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A case study analysis of thematic transformations in nondirective play therapy 1992

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A CASE STUDY ANALYSIS OF THEMATIC TRANSFORMATIONS IN NONDIRECTIVE PLAY THERAPY by SUSAN CHARLOTTE LEVIN B.A., Brandeis University, 1969 M.A., Simon Fraser University, 1980 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION in THE FACULTY OF GRADUATE STUDIES (Department of Counselling Psychology) We accept this thesis as conforming eued THE UNIVERSITY OF BRITISH COLUMBIA September 1992 Susan Charlotte Levin, 1992 in presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying ‘of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. ________________________________ Department of Counselling Psychology The University of British Columbia Vancouver, Canada Date September 14, 1992 DE-6 (2/88) Abstract A multiple case study approach was employed in this intensive thematic analysis of the process of nondirective play therapy. Using a naturalistic research paradigm, this study undertook to identify and describe the principal verbal and play themes and their transformations emergent over a course of play therapy, as well as to identify and describe similarities and differences between the themes emergent in those two domains. Play and verbalization, two types of symbolic expression, were considered routes of access to the child’s evolution of personal meaning. The research participants in this multiple case study were 4 preschoolers, aged 3 to 4. Each participant received 20 weekly play therapy sessions which were videotaped and transcribed. Running notations were made on the verbatim transcripts as to participants’ play activities. Separate coding schemes were devised for the emergent play and verbal themes. Supplemental data collection, organization, and analysis procedures included a field notebook with post hoc descriptions of the sessions, session summary sheets profiling play and verbal themes, charts, and memos. This study, discovery—oriented and exploratory in nature, yielded rich descriptions of the intricacies of therapeutic change on two symbolic levels. From these descriptions were extracted not only information on the transformations in play and verbal themes but also an understanding of the qualitative changes which denote the phases of therapy, and insight into the process of evolving meaning across these phases. ii A central finding of this study was that the arrays of play and verbal themes and their patterns of transformations were highly individualized. However, a number of themes emerged in common to all cases: Exploration, Aggression, Messing, Distress, and Caregiving or Nurturance. Participants were observed to work through contrasting themes, with preschoolers’ therapy characterized as an active struggle with such intense, oppositional forces as birth and death, injury and recovery, loss and retrieval. Typical thematic transformations included movement from infantile vulnerability to mastery, from grief toward resolution, from fear to safety and protection. The beginning phase of therapy was found to be typified by exploratory play. The middle phase was typified by intensified involvement in play and by experiences of disinhibition. The end phase was characterized by two contrasting yet not mutually exclusive tendencies, namely, the introduction of a sense of hopefulness, confidence, and integration; and an improved capacity to deal with difficult psychological material. Entry into the middle and end phases was signalled by qualitative shifts in the child’s attentional, tensional, or relational state. The theoretical implications of this study included insight into the critical role of the child’s initiative and of the therapist’s permissiveness in the unfolding of symbolic expression. Each individual case contained specific theoretical implications for such classic problem and treatment phenomena as developmental delay and play disruptions. iii The practical implications of this study include emphasizing the need for practitioners to counterbalance attention to the child’s verbal expression with attention to transformations in play activity and play material usage. It is suggested that further research extend the ramifications of this exploratory study by examining the themes occurring in treatment within homogeneous populations according to problem configuration. iv TABLE OF CONTENTS Abstract ii Table of Contents v List of Figures viii Acknowledgements ix CHAPTER I. INTRODUCTION 1 Background of the Study 1 Rationale for the Study 2 The Research Questions 4 Overview of Design and Method 5 Definition of Terms 5 CHAPTER II. REVIEW OF THE LITERATURE. SECTION I: PLAY AND THE PLAY THERAPY PROCESS 8 Background on Play Therapy 8 The Therapeutic Qualities of Play 8 Historical Overview of Play Therapy 10 Conceptualizations of the Play Therapy Process 12 Jungian/Analytic Play Therapy 13 Nondirective Play Therapy 14 Studies of Play Therapy Process 17 Empirical Studies of Nondirective Play Therapy 17 Instruments of Play Therapy Process 33 CHAPTER II. REVIEW OF THE LITERATURE. SECTION II: THE USE OF SYMBOLS TO ELUCIDATE PLAY THERAPY PROCESS 36 The Nature and Function of Symbols 36 Play and Language as Symbolic Systems 38 Their Developmental Convergence 38 Differences as Symbolic Systems 39 Similarities as Symbolic Systems 40 Empirical Support for Developmental Correspondence. . .41 Therapeutic Play as Symbolic Expression 43 Accounts of Symbolic Transformations in Child Therapy 44 Case Studies of Play and/or Art Media 44 Case Studies of Sandplay 47 CHAPTER III. METHODOLOGY. SECTION I: PRINCIPLES, RATIONALE, AND TERMS 51 Background: Considerations in Choice of Method 51 The Naturalistic Paradigm Field Research Participant Observation Case Study Method The Rationale for Multiple Cases... Criteria for Case Selection Purposeful Sampling Principles of Grounded Theory The Narrative Framework Qualitative Data Analysis Specific Data Analysis Techniques Coding Memoing Graphic Displays The Research Design 52 53 54 55 57 58 59 60 61 65 66 66 67 67 68 V CHAPTER III. METHODOLOGY. SECTION II: THE RESEARCH PROCEDURE. .69 Synopsis of Design 69 Description of Participants 69 Rationale for Participant Selection 70 Process of Participant Selection 70 The Setting and Access Issues 71 Ethical Considerations 72 The Researcher as Participant—Observer 72 The Therapist’s Intervention Style 73 The Data Collection Phase 73 The Play Therapy Sessions 74 The Field Notebook 74 Session Summary Sheets 75 The Data Preparation and Organization Phase 75 The Data Analysis Phase 76 Coding of Play Themes 76 Coding of Verbal Themes 77 The Written Accounts 78 CHAPTER IV. CASE 1. ANNA 80 CHAPTER V. CASE 2. BRAD 130 CHAPTER VI. CASE 3. CARL 182 CHAPTER VII. CASE 4. DAVE 233 CHAPTER VIII. DISCUSSION AND CONCLUSION 284 The Research Questions 284 The Research Findings 285 Individualized Paths of Change 285 Struggle with Opposites 286 Common Themes 287 Types of Transformations 290 Similarities and Differences in Domains 295 Developmental Transformations 299 Distinctions Between More/Less Verbal Participants. .300 The Play Therapy Phases 301 Phase Markers 305 Narrative Integration 306 Reflections on Choice of Method 310 Theoretical Implications of the Study 318 Limitations of the Study 329 Implications for Practice 331 Implications for Future Research 333 Summary 334 REFERENCES 337 vi APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: OUTLINE OF RESEARCH PROCEDURE 346 RESEARCH INFORMATION AND CONSENT FORMS 347 LIST OF MATERIALS AND DIAGRAM OF PLAYROOM 350 DATA ANALYSIS FORMS 352 vii LIST OF FIGURES Figure 1. Anna: Figure 2. Anna: Figure 3. Anna: Figure 4. Anna: Figure 5. Anna: Figure 6. Anna: Figure 7. Anna: Figure 8. Anna: Figure 9. Anna: Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. Overview of Play with Principal Materials....83 Play Themes with Infant Props 85 Verbal Themes Associated with Infant Birth.. .93 Verbal Themes During Other Infant Play 97 Play Themes with Doctor Materials 102 Verbal Themes Associated with Doctor Play. . . 104 Play Themes with the Whale 107 Verbal Themes Associated with Whale Play....110 Play Themes for Painting 114 Overview of Play with Principal Materials. . .135 Play Themes with Vehicles 137 Verbal Themes with Vehicles 145 Play Themes with the Doll House and Props...151 Verbal Referents Across Play Materials 159 Play Themes with Adventure People 160 Play Themes with Hospital Figures 163 Play Themes with Doctor Materials 164 PlayThemeswith Water 165 Play Themes with Sand 169 Overview of Play with Principal Materials. . .187 PlayThemeswith Vehicles 188 Examples of Verbal Themes with Vehicles 195 Play Themes with Doll House Figures 204 Examples of Verbal Themes with Doll House Figures 209 Overview of Play with Principal Materials...237 Play Themes with Doctor Materials 238 Verbal Themes with Doctor Materials 241 Play Themes with Puzzles 245 Verbal Themes with Puzzles 248 Play Themes with Puppets 251 Verbal Themes with Puppets 252 Play Themes During Play-in-the-Dark 253 Verbal Themes During Play-in-the-Dark 255 Play Themes with Miniature Animals 259 Verbal Themes with Miniature Animals 264 Play Themes with Dolls and Props 267 Verbal Themes with Dolls and Props 271 Brad: Brad: Brad: Brad: Brad: Brad: Brad: Brad: Brad: Brad: Carl: Carl: Carl: Carl: Carl: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: viii ACKNOWLEDGEMENTS I would like to express my appreciation to the teaching staff and the director of the preschool for permitting this research project to take place on site; to the participants’ parents who graciously permitted their children to take part in this project; and to the preschoolers themselves for their trust, for being so vibrantly alive, and for teaching me so much. My thanks extend to the faculty members who helped to bring this project to fruition: to Don Fisher for his warm and supportive guidance and for offering a steady hand and sound advice throughout the challenging research process; to Larry Cochran for his keen insight and for his commitment to meaningful research; and to Bill Borgen, Department Head, who although not serving on my committee, offered unwavering support and assistance throughout my program of studies. It is not possible within a few brief sentences to fully convey my feelings of deep appreciation to John Allan. As my research supervisor, program advisor, clinical supervisor, teacher, and mentor, his wonderfully compassionate and clear sighted counsel shaped each day of my studies, clinical training, and research program. I am deeply indebted to John, whose deep caring for the welfare of young children is matched by his genuine concern for his students. I would like to express my appreciation to Mike Shepard of UBC’s Education Computing Services for his invaluable, patient help and advice in the preparation of this manuscript. Doctoral Fellowship funding from the Social Sciences and Humanities Research Council of Canada is gratefully acknowledged in enabling this research to proceed. ix 1CHAPTER I. INTRODUCTION Background of the Study This intensive study of play therapy process emerged from pilot work consisting of two years of recent clinical experience with young children. During that time preschoolers receiving nondirective play therapy moved toward emotional recovery through their own self—directed play. Each child was observed to gradually settle into play with favored play media. Over time, global changes or transformations were noted in the children’s interactions with central play materials. Upon reflection, it was apparent that each child’s play material selection and play style were unique. In addition, each child’s reliance upon verbal communication was singular. While this may appear to be an obvious comment on individual differences, the varying relevance of verbal communication for each child was intriguing. The children’s patterns of communication through speech as opposed to communication through play activity appeared to be distinctive. Nevertheless, whether verbally or through their play the children were at all times communicating, expressing facets of their personalities, their emotional conflicts, and their resources for solving the problems confronting them, weaving back and forth between verbal and play expressions. The observed differences in young children’s verbal and play expressive style began to prompt questions as to how the changes in the verbal and play components of play therapy might be clarified. The researcher’s fascination with the verbal and play components of this complex form of child therapy also prompted 2additional questions about the nature of the process of change in nondirective play therapy and the child’s own experience of change within that process. Retrospective case accounts of children in play and related therapies pointed to the dynamic role of focal play materials and key play symbols in catalyzing therapeutic change (Allan, 1988; Kaiff, 1980; Sikelianos, 1979, 1986, 1990). Theoretical work on the role of symbols in human culture and in psychic development (Jung, 1954; Kubie, 1953) described how symbols bridge the conscious and unconscious realms, linking emotional experience to tangible media (Kubie, 1953), providing routes of access to inner experience. An intensive, detailed, fine—grained analysis of the child’s verbal and play expressions appeared to offer a productive avenue of inquiry for the broader process questions. By systematically attending to the child’s emergent verbal and play expressions, perhaps new understanding could be garnered about the process of nondirective play therapy, its particular components, and its meaning for the child from a phenomenological perspective. Rationale for the Study As a rich and multifaceted treatment modality, play therapy enjoys widespread clinical usage by child psychiatrists, psychologists, social workers and school counsellors. Having been adapted to many therapeutic orientations and treatment styles, from psychoanalytic to behavioral, play therapy is utilized directively or nondirectively in the treatment of the entire spectrum of childhood emotional disturbances. 3However, research into the complexities of play therapy process has not kept apace with the scope and popularity of play therapy practice. Meager process research supports the current widespread practice of play therapy. Much of the clinical literature consists of anecdotal case reports by practitioners who tend to focus on the efficacy of play therapy in specific settings (e.g., Johnson & Stockdale, 1975) or with specific populations (e.g., Nibs & Reiss, 1982). The need for ongoing research into play therapy process is widely acknowledged in the research literature (McNabb, 1975; Phillips, 1985). This study was launched in response to the scarcity of systematic process research and the pronounced lack of in—depth process work. The handful of extant process studies have for the most part conceptualized the nondirective play therapy process in terms of observable changes in the child-therapist relationship or deducible changes in the child’s emotionalized attitudes. In these studies, the perspective of the researcher, like that of the clinician, has been that of “other,” an outsider searching for observable evidence of specific changes. The child’s own experience of change has been equally objectified and distanced. Play therapy process research to date can be considered largely “third person” efforts, attempts via precategorized content analysis to classify predetermined therapeutic events. No research into the nondirective play therapy process has yet attempted to conceptualize or to study the process of therapeutic change by accessing the perspective of the child. There is an evident need for such a “first person” account of the changes which occur in nondirective play therapy. 4By not superimposing an interpretive vocabulary, by truly listening to and watching the child, this study endeavored to attune to dual aspects of the child’s evolving personal expression. By considering the child’s unfolding verbal expression and play themes as parallel narratives for analysis, this study set out to produce a rich description of the nondirective play therapy process as experienced by the child. By attending to the child’s verbal and play thematic expressions, this study attempted to isolate and identify key components of the play therapy process. The purpose of this study was to explore play therapy as a lived experience by utilizing two symbolic systems to access the child’s experience of change: the themes emergent in the child1s interaction with play materials and the child’s verbal narrative. The Research Questions This study was designed to answer the following research questions: 1. What themes emerge within play, that is, during the child’s interaction with play materials? How do these themes transform across sessions of play therapy? 2. What themes are verbally expressed during play? How do these verbally expressed themes transform across sessions of play therapy? 3. What are the similarities and differences in these themes across participants? 4. What are the similarities and differences between the themes which are expressed through play versus those which are verbally expressed by the child? 5It was anticipated that the verbal and play themes would provide routes of access into the process of change from the perspective of the child. It was further anticipated that the researcher’s immersion into the details of participants’ thematic material would lead to an elucidation of the process of play therapy as it pertains to the child’s evolving world of meaning. Overview of Design and Method This study utilized principles of naturalistic inquiry (Lincoln & Guba, 1985): a field setting; the researcher as participant observer; case study reporting; grounded theory rationale; and principles of narrative analysis. There is considerable overlap among these terms, which are often used interchangeably in the research literature. These terms share a common concern with the researcher’s immersion into lived experience for the purpose of extracting emergent, as opposed to preconceived, thematic elements. In this instance, the researcher sought play and verbal themes emergent in nondirective play therapy. This study employed a multiple case study strategy with preschool participants receiving play therapy. Participants’ play therapy sessions were videotaped and then transcribed. These transcripts were then submitted to qualitative thematic analysis, with the coding categories emergent from participants’ verbalizations and play activities. Definition of Terms This section identifies the following terms central to the study: play therapy process, play themes, verbal themes, and verbalization. 6Play Therapy Process Play therapy process was considered a composite of the transformations within the child’s verbal and play themes over time. Play Themes Based on Bishop’s (1982) definition of theme, a play theme was considered “a series of actions and events . . . which are connected through a common purpose, sequence, and consequence” (p. 39). Play themes generally pertained to patterns in participants’ interactions with play materials. Verbal Themes Verbal themes were the patterns and clusters of related meanings emergent within the child’s verbalization. Verbal themes consisted of repeated topic or content referents, their synonyms, and associated words or sounds. Verbalization Verbalization, as distinct from the rules and syntax of language, referred during the data analysis phase to the child’s entire vocal output. This included words, phrases, sentences, sounds, noises, shouts, singing, and crying. Format of the Thesis This document is organized according to the following format, Chapter II, which is divided into two sections, reviews the literature on nondirective play therapy process and the literature on play therapy as symbolic expression respectively. Chapter III, also divided into two sections, first presents the principles, rationale, and terms underlying the research methodology, and then describes the detailed steps of the 7research procedure. Chapters IV through VII are the core of the study, the case accounts of the four research participants, Anna, Brad, Carl, and Dave. The concluding Chapter VIII discusses the findings and sets them in their theoretical and practical context. 8CHAPTER II. REVIEW OF THE LITERATURE SECTION I: PLAY AND THE PLAY THERAPY PROCESS This chapter reviewing the literature is divided into two sections which present the major theoretical background of the study. Section I provides theoretical and historical background on play therapy. Section II details the theoretical rationale for using symbolic expression to elucidate play therapy process. Section II also provides background on play and language as symbolic systems, focusing on their developmental and functional similarities and differences. Sections I and II are respectively supported by reviews of empirical and/or descriptive studies, namely, play therapy process studies and representative studies describing play therapy as unfolding symbolic expression. Background on Play Therapy This section discusses the therapeutic qualities of play; a brief overview of the development of play therapy; and the principles and predominant conceptualizations of play therapy process. The Therapeutic Qualities of Play The many and varied therapeutic uses of children’s play span the entire spectrum of psychological theories. Each therapeutic application of play, such as behavioral play therapy (Russo, 1964), psychoanalytic play therapy (Klein, 1955), or group play therapy (Ginott, l982b), assumes the theoretical coloration of the psychological model which has inspired it. Yet all of these creative therapeutic approaches, including nondirective play therapy, have in common the fact that therapists are working with a medium, namely play, which is adaptable for therapeutic aims. 9Winnicott (1971) offered a compelling explanation of how and why this ordinary childhood activity is capable of accomplishing therapeutic tasks. Winnicott referred specifically to the paradoxical nature of play as an activity which does not belong exclusively to either the inner or the outer world of the child. That is, playing reflects the child’s inner psychic reality, yet it takes place in the external world of objects. Conversely, although playing occurs with objects, it is not an objective activity, but a highly involving subjective experience. Playing, therefore, constitutes a unique experience of intermediation between the child’s subjective and objective experience. As such, explained Winnicott, it characteristically offers singular opportunities for self—absorption and concentration. Children are often referred to as being “lost in play.” On the contrary, through play young children are often finding themselves, treading deeply, often unconsciously, back and forth from inner world to outer reality and again returning to inner experience. What transpires quite naturally in play is the working through of experience from feelings within to their outer portrayal, from inner experience to the symbolic expression of emotional and psychic reality by means of play materials and fantasy—-in essence, therapeutic activity. Smith, Takhvar, Gore, and Vollstedt (1985) summarized other qualities of play which contribute to its therapeutic value. Play is a naturally enjoyable activity, offering opportunities for pleasure and for positive affect. Because it is usually fun and by definition largely freed from rules, it is intrinsically motivating and engaging. 10 The mere introduction of play materials promotes conditions which are conducive to therapeutic process for several reasons: (a) the play materials convey to the child that the special playroom is a nonthreatening, child-friendly setting, thus helping to reduce the child’s anxiety; (b) the play materials provide the child with marty options for activity which can be used to bridge contact with the therapist (through shared play) or avoid such contact (in solitary play); and (c) the materials provide the therapist with a nonthreatening arsenal of enticing activities for diminishing the child’s defenses. Play is widely accepted in the literature as a stimulus and enhancer of the child’s verbalization. Within play therapy literature, play is generally understood as the symbolic language of the child, no less significant than the child’s verbalization. Although the child may not consciously intend for play behaviors to be communicative, play therapists perceive and respond to the latent communications in play. The manipulation of play materials and the resulting physical representation of experiences and emotions help the child express and ultimately integrate, often more graphically and tangibly than in words, personal conflicts and difficulties. For many young clients, the inability to verbalize is an inherent part of their difficulty. For them, play provides a tangible means of communication. Play is also kinesthetically enriching, offering opportunities for energetic movement and physical involvement (Levy, 1976). Pounding, smacking, banging, and messing with play materials are all physically engrossing. At the same time, such activities facilitate emotional catharsis. Through the physicala 11 engagement with play materials, anger can be released, anxiety dissipated, tension reduced, and calm achieved. Cumulatively then, play is a naturally familiar, pleasurable, kinesthetic activity, which encourages verbalization, motivates and elicits symbolic communication, and comprises a natively rich therapeutic medium. It is within this stimulating and prolific context that the nondirective play therapist actively strives to maximize the interpersonal conditions that will further facilitate emotional awareness, personal expression, conflict resolution, and growth. Historical Overview of Play Therapy The therapeutic use of play emerged from Freudian insight into its function. Freud wrote extensively about the function of play in human development, characterizing it within the bounds of the pleasure principle (Slobin, 1964). He identified repetitious play, nonpleasurable and often fraught with anxiety, as a form of repetition compulsion. He also identified regressive play in the service of the ego, and he cited the usefulness of play for experiences of mastery or symbolic revenge (Freud, 1920). Von Hug-Hellmuth (1921) first promoted the inclusion of play in the treatment of children under seven. With very young patients she believed that play would “enact an important part throughout the whole treatment” (Hug-Hellmuth, 1921, p. 295). However, it remained for the next generation of analysts and Freud’s daughter Anna to develop the deliberate use of play for therapeutic purposes. Anna Freud (1946) utilized play to expedite a trusting relationship with the child. She stressed the play-enhanced transference to access the unconscious. Her contemporary, 12 Melanie Klein (1955), established play as a cornerstone of child therapeutic treatment, using verbal interpretations of play as the focus of treatment. Offshoots of the psychoanalytic play technique, such as release therapy for play cathartic expression appeared in the 1930s (Levy, 1976). The use of play in child treatment remained solely in the psychoanalytic camp until Axline’s (1947) extrapolation of Rogerian (1951) principles to the child therapeutic setting. Nondirective play therapy, which offers the child a play environment conducive to emotional growth, has engendered stylistic offshoots. Ginott (1959) emphasized the play therapy environment as a re—education for life (reality testing) and favored a less permissive setting than Axline’s. Moustakas (1959) stressed the importance of building a supportive therapist—child relationship in the nondirective setting. In general, psychoanalytic applications of play and nondirective play therapy have remained the dominant divisions of contemporary play therapy practice, with newer techniques, such as filial therapy (Guerney, 1964) or theraplay (Jernberg, 1979), continually appearing. Conceptualizations of the Play Therapy Process Conceptualizations of play therapy process differ among the schools of practice. This section presents the nondirective and the analytic (Jungian) conceptualizations of play therapy process, which together comprised the theoretical basis of this study. 13 Jungian/Analytic Play Therapy Compendia of play therapy interventions (Landreth, 1982; Schaefer, 1976; Schaefer & O’Connor, 1983) have not yet denoted analytical or Jungian play therapy as a discrete area of play therapy practice. However, the work of Allan (1988) and of sand play therapists such as Kalff (1980), illustrates the practical fusion of Jungian theory and play therapy principles as an identifiable subset of play therapy practice. Jung objected to what he termed the “reductive causalism” of the Freudian outlook, and posited instead the “teleological directness which is so characteristic of everything psychic” (Jung, 1976, p. xxiii). Jung rejected Freud’s solely sexual definition of the libido and considered the libido a positive driving life force. In contrast to the Freudian unconscious which is singularly a repository of personal memory and repressed feeling, the Jungian unconscious is bipartite. The personal unconscious, similar to the Freudian unconscious, consists of repressed memories and feelings from the individual’s own experience. The nonpersonal or collective unconscious is the repository of universal images, knowledge, and awareness shared through evolution by the human species. From this collective unconscious are derived archetypal images or themes common to all cultures. These archetypes, such as “the hero,” “rebirth,” or “wholeness,” emerge in myths, ceremonies, religious observances, and other cultural symbols as well as in the dreams of the individual. The personal unconscious and the collective unconscious are interactive, and this unique interaction within each individual is responsible for the diversity of human 14 personalities. The third component of the personality, the Ego, is the experiential consciousness of the individual: memories and feelings, ideas and thoughts. The Jungian conceptualization of the personality also posits a spiritual center of the individual, beneath and beyond the Ego and the two-tiered unconscious: the Self, whose nature it is to grow and evolve toward well-being and wholeness. Applying Jungian theory to play therapy practice, Allan (1988) observed that “the task of psychological growth is to achieve a balanced communication between the Ego and the Self” (p. 5). This balanced communication between the Ego and the Self occurs through symbolic expression because symbols function as a nonverbal link between the unconscious and the conscious mind of the individual (Jung, 1976). “In order for the child to maintain contact with the inner world and feelings, the axis path between the Self and the Ego must be kept open. If the Self is to grow and the Ego is to mature, some form of symbolic expression or outlet is needed” (Allan, 1988, p.7). Play therapy process from a Jungian perspective emphasizes the child’s evolving symbolic expression. Nondirective Play Therapy Axline (1947) developed this major school of play intervention using Rogerian (1951) principles. Nondirective play therapy refers to a philosophically integrated complex of conditions which are considered by this therapeutic stance to be optimal for emotional growth (Guerney, 1983). The vocabulary of Rogers’ (1951) client-centered therapy with adults wholly applies within the nondirective play therapy 15 setting. The nondirective play therapist communicates a sense of genuine respect for the personhood of the child, as well as an implicit acknowledgement of the self—curative resources which reside within each client. The task of the therapist is to create optimal conditions for emotional growth. To that end, the therapist must be congruent with his/her own emotions, avoiding artificial responses or tone of voice. The nondirective play therapist must also provide unconditional positive regard and a consistently nonjudgmental attitude, even toward what are regarded outside the playroom as misbehaviors. Therapist empathy is the theoretical and practical cornerstone of all nondirective approaches to therapy. By Rogers’ (1951) definition, empathy, the catalytic impetus of nondirective therapy, refers to the therapist’s assuming the internal frame of reference of the client and perceiving the world as the client sees it. Gradually, through therapist empathy, congruence, and unconditional positive regard, a trust— inducing environment, a “nonthreatening psychological climate” (Rogers, 1951, p. 346), well-suited to emotional risk-taking and client growth, evolves. From the perspective of the nondirective play therapist, the hours of supporting the child’s self-directed play are neither indulgent nor unremunerative. They constitute the aim and the essence of therapeutic process. In such a milieu, self—awareness and even insight can emerge entirely from within the child (Landreth & Verhalen, 1982). Young clients unconsciously respond with increasingly expressive verbalizations and behavior in an 16 atmosphere which is permissive, not in the interests of laissez— faire for its own sake, but in the service of emotional growth. The nondirective playroom provides abundant opportunity for the child’s selection and combination of play materials as well as for the development of pretend play themes. The nondirective play therapist actively avoids verbalizations or even body language which restricts, disturbs, or otherwise directs the child, who experiences the freedom to unfold from within. The opportunity as well as the onus are on the child to select and develop play activities and to make many decisions. Thus, mini— steps along the road to growth and self-mastery are nurtured and supported. Although nondirective play therapy, like its “parent” client-centered therapy, employs a different theoretical vocabulary from Maslow’s (1968) self-actualizing hierarchy, nondirective play therapy is compatible with an existential stance which posits implicit belief in the self-actualizing potential of each human being. In sum, the nondirective therapist, through empathic and neutrally nonjudgmental reflection of the child’s play behaviors and attendant speech, creates a receptive environment that encourages trust and rapport, and permits and facilitates the child’s self-directed experiences of growth. Therapeutic process consists of this quietly powerful behavioral and emotional unfolding in the presence of an attuned, supporting therapist. The nondirective play setting, as a growth-facilitative environment, is thus an optimal context in which to observe the process of therapeutic change from the perspective of the child and to study the natural evolution of its symbolic components. 17 Studies of Play Therapy Process The handful of extant empirical studies of nondirective play therapy process are described in this section. Play therapy observational instruments, which have been devised for therapeutic or experimental settings, are included for discussion because these instruments provide additional conceptualizations of the play therapy process. Because investigators have explored varied notions of the play therapy process, these few studies are unfocused in terms of the process variables considered. Empirical Studies of Nondirective Play Process Landisberg and Snyder’s 1946 study is the conceptual and methodological antecedent of what can be considered the “first generation” of empirical process inquiries (e.g., Finke, 1947; Lebo, 1951). Landisberg and Snyder explored play therapy process multidimensionally, through the analysis of speech, actions, attitudes and child-therapist interactions, They codified the verbalization content of therapists and both the content and feeling tone of clients’ verbalizations. They further classified each client verbalization or action into a “meaning—unit,” which categorized positive, negative, or ambivalent feelings. They sought patterns in the client- therapist relationship, trends in clients’ response patterns, patterns in expressed client feelings, and indications that nondirective play therapy was truly nondirective. Inferred from their codification categories of therapist verbalization (whether positive, negative, or ambivalent statements, attitudes, and actions predominated) is a conceptualization of play therapy process as (a) intrinsically intertwined between therapist and 18 client and (b) methodologically accessible through the codification of speech, actions, and attitudes. Their prominent finding, that three-fifths of all verbalized responses were made by the child, while two—fifths were made by the therapist, is often cited in the literature as evidence that the nondirective therapist’s empathic style encourages the child’s more active emergence. Of the total number of client and therapist statements coded, 30% of all statements were nondirective therapist statements, 25% consisted of clients’ giving information, and 24% consisted of clients’ pursuing positive play action. Considering the sequel relationship between particular counsellor verbalizations and the “immediately—following” client statement or action, Landisberg and Snyder found that “nondirective responses preceded 84.5 percent of the client’s responses” (1946, p. 207). Therapist reflection of feeling preceded over half (57%) of the client responses. These two findings are generally considered as support for the nondirective nature of the therapy. To determine both therapist and child trends in the treatment process, responses for all cases (4) were combined and the entire treatment process was divided into fifths. From this procedure, the following information emerged. Recognition of Feeling, the most frequently used strategy, comprised 62% of therapist responses in the first fifth of treatment, but dropped to 40% in the next fifth. By contrast, during this second fifth, the “Restatement of Content” increased. The researchers noted that this second fifth increase in the restatement of content “occurs simultaneously with a drop in amount of Action by the 19 client and an increase in amount of clients’ Giving of Information” (1946, p. 208). Therapists were found to be slightly more directive or semi-directive in the latter three fifths of treatment than in the first two fifths. Therapists’ statements of “Simple Acceptance” more than doubled in the latter two-fifths of treatment in comparison with the first two-fifths. However, Simple Acceptance statements, overall, constituted less than 10% of therapist remarks. This latter finding is seen as antithetical to the naive perception of nondirective play therapy as simple acceptance of the child (cf. Guerney, 1983). With regard to changes within the child, Landisberg and Snyder found the rise in physical action by children in the latter three-fifths of treatment to be most important. This corresponded with “marked expression of feeling” (1946, p. 209) accompanying most of that action. Also significant, according to chi square analysis of frequency counts, was the marked rise in expression of feelings toward other persons or situations. Expression of negative feelings increased from 20% of the total in the early fifth, rising to 40% later, and leveling out at 33% at the end of treatment, while expression of positive feelings remained generally fixed at 30% of the responses. The researchers directly attributed these findings to the child’s growing sense of safety and security in the nondirective play room: “Until the child feels free to express himself without fear in the play therapy situation, he expresses himself in limited fashion by simple statements of acquiescence” (1946, p. 210). Although this study generated a large number of statements (5,751), Landisberg and Snyder relied on 4 subjects, who were 20 treated by three different therapists. In presenting the results, Landisberg and Snyder evidently presumed uniformity across therapists’ styles and responses, leaving their study vulnerable to the “myth of the uniform therapist” (Kiesler, 1967). When Landisberg and Snyder collapsed the data across therapists, they obliterated the distinctions which may have resulted from differing therapeutic styles or degrees of effectiveness. In addition, the fact that they failed to denote the number of sessions or the time span studied is a frustrating weakness of their discussion. Their observation that “nothing in the four children’s cases occurred that could be classified as insight” (1946, p. 213) cannot be properly interpreted without information about the length of the course of therapy. Finke’s (1947) noted Master’s research, carried out at the University of Chicago under Carl Rogers, is often cited as a central contribution, both conceptually and methodologically, to the literature on play therapy process. Adopting a perspective similar to Landisberg and Snyder, Finke (1947) reasoned that “predictable trends in verbalized attitudes [should] occur during a series of non-directive play therapy contacts” (p. 12) Nondirective play therapy process was conceptualized as patterns of verbalized attitudes. Finke devised 19 verbalization categories which were adapted and elaborated in subsequent research (cf. Lebo, 1955). These coding categories included: expressions of curiosity, simple descriptions of play, statements of aggression, exploration of playroom limits, negative and positive self—statements, and evidence of interest in the counsellor. In her multiple case 21 study, Finke analyzed the complete protocols of six children (ages 5 to 11), who each received from 8 to 12 nondirective play therapy sessions. Based on chi square analyses, Finke graphed significant coding categories across sessions for each child, providing a visual record of frequency changes in, for example, aggressive statements or negative self—statements across sessions. Her findings offer greater reliability than those of Landisberg and Snyder in that Finke did not presume a “uniform therapist,” but instead analyzed the emotionalized attitudes that resulted from each distinct client-therapist unit. When she collapsed the frequencies across clients in a Victor Curve, she deduced three general stages of the child’s play therapy experience: The first stage is characterized by shyness or constant talking, a great deal of aggression and testing of limits, and with some children an interest in the relationship with the counselor. Near the end of this stage the level of conversation reaches a point that is maintained for the remainder of the therapy. In the second stage aggression and testing of limits decrease slightly, imaginative stories connected with the play become marked, and the child seems to have accepted the counselor’s neutral role. The last stage is characterized by a suddenly renewed interest in the relationship with the therapist and the rapid decline of aggression, testing of limits and imaginative stories. (1947, p.49) Finke’s contribution to an understanding of play therapy process was two-fold: (a) within the individual, play therapy process refers to patterns of particular verbalized responses; (b) across individuals, global process stages can be discerned. Lebo (1955) concurred with Finke’s (1947) basic codification categories of clients’ feelings, but argued that Landisberg and Snyder’s (1946) use of a homogeneous age group (five— and six— year—olds) did not provide information about the relationship of 22 response categories in play therapy to chronological age. Lebo seconded Finke’s conceptualization of play therapy process as verbalized emotional attitudes. To that end, he expanded (to 21) and refined Finke’s coding categories, retaining a broad conception of play therapy process as a composite of self— reflectional, interactional, decisional, and play or personal descriptive elements (cf. Lebo, 1955). Lebo selected 20 children, divided into equal groups of ages four, six, eight, ten, and twelve years. Each of these normal children were offered three one—hour nondirective play therapy sessions. The fifteen pages of “verbatim style” records, representing roughly one-tenth of the statements generated, were analyzed (coded) by three experienced play therapists. Lebo found that the older the child, the greater the tendency for the child to be more independent of the play therapy situation. Older children explored the limits of the play room less, looked less to the therapist for information, and talked less than the younger participants. At the same time, the older children tended to use the playroom as an opportunity for social conversation, in contrast to the younger ones who attempted a more personal relationship with the therapist. There were methodological difficulties with Lebo’s work, some of which he acknowledged. For example, Lebo noted that (a) the statistical verification indicated that each of the three trained judges had employed the coding categories differently; and (b) the categories of Simple Description of Play versus Straight Information about outside events were often confused during coding and had to be collapsed. 23 Lebo’s attempt to study play therapy process over a course of only three sessions for each age group is questionable. Any meaningful consideration of play therapy process requires time for that process to evolve. The fact that none of the five age groups expressed any statements in the “Insight” category may be a reflection that Lebo’s work could more accurately be described as a study of therapy inception rather than of therapy process. Moustakas (1955a) considered the quality of the child’s emotional adjustment to be the essence of play therapy process. He anticipated that the child’s expression of emotion in relation to the therapist would parallel what he considered the phases of normal emotional development of the child within the family: undifferentiated positive and negative feelings becoming more focused, then becoming ambivalently anxious and hostile. From this ambivalence, Moustakas anticipated a process of emotional differentiation and intensification, with negative feelings becoming more specific and more directed at a personal or situational target. Later emotional ambivalence would include a mixture of positive and negative feelings which would, in turn, become more distinct. Toward the end of therapy, positive attitudes and expression should predominate. Moustakas’ (1955a) analysis of play therapy process as phases in emotional adjustment relied upon his thematic analyses of portions of verbatim transcripts of several clients. He concluded that “there is an apparent parallel between normal emotional development in the early years of life in the family relationship and emotional growth in a play therapy relationship” (Moustakas, l955a, p. 84). He arrived at the 24 following parallel phases observable in the child’s play: (a) expression of diffuse negative feeling; (b) ambivalent anxious or hostile feelings; (c) more focused expression of negative feelings; (d) an admixture of positive and negative ambivalent feelings; (e) the predominance of positive attitudes. Acknowledging that even well-adjusted children show negative emotion, Moustakas emphasized the increased frequency and intensity of negative emotion in the disturbed child. Above all, Moustakas stressed the role of the therapeutic relationship in facilitating emotional growth. His process description was not an experimental inquiry but a conceptual treatise based on his own clinical work. In a subsequent process study, Moustakas (l955b) compared the frequency and intensity of negative attitudes expressed in play therapy by well-adjusted and disturbed children. This study reflects a more focused conceptualization of play therapy process as the transformation of specific emotionalized attitudes (as opposed to global emotional attitude changes in Moustakas, 1955a) Nine well—adjusted and 9 disturbed preschoolers each received at least four play therapy sessions by the same therapist. The negative attitudes expressed in play therapy were evaluated according to frequency, variety and intensity (minor, moderate, or severe). When the session transcripts and accompanying notes were analyzed, Moustakas’ twin hypotheses were supported: (a) disturbed children expressed negative attitudes more frequently than well-adjusted children; and (b) disturbed children expressed negative attitudes with greater intensity than 25 well-adjusted children. Although not part of the research per Se, an interesting qualitative aspect of Moustakas’ selection of subjects was his comparison of parents’ versus teachers’ verbal description of each child’s problems. While there was definite agreement among teachers and parents that each child suffered from emotional disturbances, the parents’ descriptions reflected a near panicked perception of their youngsters’ difficulties, while the teachers framed the children’s problems in serious yet objective terms. Moustakas’ thematic classification of the types of negative attitudes which emerged (not derived from preconceived coding categories) resulted in the following themes: developmental regression; diffuse anxiety; orderliness anxiety; hostility toward others; hostility toward family (parents and siblings); hostility toward the therapist; and cleanliness anxiety. Among well-adjusted children, cleanliness anxiety and orderliness anxiety were rare, while the most frequently expressed negative attitude was hostility toward siblings. Disturbed children presented a greater percentage of diffuse hostility, hostility to home or family, cleanliness and orderliness anxiety, and developmental regression. In a later comparison of well-adjusted and disturbed children, Moustakas and Schalock (1955) analyzed therapist-child interactions. They asked whether (a) the therapist behaves differently in interaction with well-adjusted versus disturbed children; (b) there are differences in the interaction behavior of well-adjusted versus disturbed children; (c) certain therapist behaviors produce certain child reactions, and/or (d) certain 26 child behaviors produce certain therapist reactions. Using behavioral categories derived from their coincidental work (Moustakas, Sigel, & Schalock, 1956), Moustakas and Schalock assumed that the child—therapist interaction involves “reciprocal stimulation.” Each is influenced by the responses and behaviors of the other. The 82 adult behavioral categories and 72 child categories were interchangeable in that each could be applied to child or adult. The behavior of a single therapist was analyzed in relation to 16 preschool children. Statistically significant differences in frequency indicated that the therapist gave help to disturbed children twice as often as to well-adjusted children, as well as gave more information to disturbed children. Therapist forbidding and directing also occurred more frequently with the disturbed group. Regarding the child’s approach to the therapist, disturbed children more frequently evidenced “Threat of Attack” and “Physical Attack.” Incidents of hostility numbered 418 compared to 23 for the adjusted group. The adjusted group more frequently participated jointly in activity, sought help and permission, and resorted to more passive ways of expression of aggression toward the therapist (e.g., changing the topic). Dependency was more frequently expressed by the disturbed children, while the adjusted children expressed slightly more anxiety. Based on an analysis of 1,882 interaction sequences, the therapist most frequently initiated interactions with children that offered verbal information, oriented the child to time, oriented the child to his role, directed by suggestion, and offered interpretation. Based on the 771 interaction sequences 27 initiated by children toward therapists, children most frequently sought information or directed by suggestion or command. In 1950, Axline conducted a follow-up study of the play therapy experience as described by her child participants. Although not a process study per Se, her intent, to attend to the child’s perception of the play therapy experience, is of interest to this study. In the first stage of her research, she perused the verbatim case transcripts for comments made by the children about their play therapy experience. Children’s comments on feeling happy at being allowed to express all their feelings, to make a mess, or to be free of adult constraints predominated. In the second stage, Axline contacted some of the clients five years after the conclusion of their therapy to solicit their memories of the play therapy experience. In conversation with her, the children recalled, for example, feeling happy, making friends (in a group play setting), being allowed to make noise, and a general sense of freedom. Based on the children’s comments, Axline (1950) stated that the nondirective play therapy experience: raises the questions of the relative position of importance between intellectual understanding of cause and effect as determinants of present behavior and the immediate emotional experience the individual has during therapy as the essential dynamic in the process of reorganization of the self. (p. 56) Mary Brown Rogers (1964) conducted a play therapy process study which was unique in its monitoring of process using electronic recording devices. Rogers furnished two separate but nearby rooms for therapeutic play. One room contained play materials conducive to aggresssive play; the other contained materials conducive to constructive play. The 12 subjects were 28 free to wander back and forth between the rooms and to choose the materials they wished within the 50 minute sessions. The rooms and the toy shelves were electronically wired such that the time spent by each child in each room and the amount of time spent with each material could be measured precisely. This highly mechanized data collection procedure yielded the following picture of play therapy phases: First, a period of exploration and, second, the emergence of aggression, whether displaced onto play materials or expressed directly. In the final phase, the children were observed to move into more constructive play, in which productive goals became more prominent. Two studies of similar intent yielded different versions of the nondirective play therapy process. Stover and Guerney (1967) trained mothers in nondirective play therapy skills, a treatment technique known as filial therapy. The treatment group, whose mothers were trained, received 10 one—half hour play therapy sessions while the untrained mothers of the control group interacted as they normally would in play with their children over 4 observed sessions. They hypothesized that the children’s behavior would change in response to the degree of directivity or (neutral) reflectivity in their mothers’ statements. The intensity of children’s leadership, dependecy, aggression, and negative feelings were rated on a 4 point scale which ranged from “0” to intense. Over the course of therapy, Stover and Guerney found that the children of trained mothers showed increased leadership statements, decreased dependency, increased aggression, and increased negative feelings. Stollak (1968) essentially replicated this study, using 29 psychology undergraduate students rather than mothers as the play therapist substitutes. Stollak increased the number of one-half hour play therapy sessions to 10 for both experimental and control groups. He anticipated trends similar to those of Stover and Guerney (1967). Instead, it was found that (a) the children’s leadership behavior increased from sessions 1 through 5 only; (b) dependecy and aggressive behaviors remained unchanged; and (c) negativity continued to increase from sessions 1 through 10. Taking a different research approach to the question of nondirective play therapy process, Siegel (1972) studied 16 learning disabled children who were each given 16 play therapy sessions by the same therapist. She sought to determine how the degree of therapist offered conditions of accurate empathy, unconditional positive regard, and genuineness affected children’s process during therapy, as measured by the process scale first developed by Finke (1947). Contrasting the 4 children who received the highest degree of therapist-offered conditions with the 4 who received the lowest degree of therapist-offered conditions, Siegel found significant behavioral changes over time. Specifically, children receiving higher therapist—offered conditions were observed to make more insightful statements and more positive statements about themselves than the children who received the lowest degree of therapist-offered conditions. In another study carried out in the 1970s, Hendricks (1971) explored the patterns of play activities, nonverbal expressions, and verbal comments within the nondirective play therapy process. 30 She divided 10 boys, ages 8 to 10, into 2 groups which received 12 and 24 nondirective play therapy sessions respectively. Hendricks relied upon verbatim transcripts and notations of the children’s nonverbal expressions and their play activities. She devised a 30—item scale for verbalization, a 14-item scale for nonverbal expression, and a 16—item scale for play activities. These scales were similar to those previously devised by Finke (1947) and later revised by Lebo (1955). The scales enabled Hendricks to rely upon quantitative data, namely, frequency counts. Hendricks identified 4 major phases of the nondirective play therapy process. In the first, exploratory, noncommittal, and creative play predominated. She found that the children commented on their play and the playroom, and volunteered information about themselves or their families. Anxiety was most likely to appear in this phase. Creative play increased while exploratory and noncommittal play decreased in the next phase. Aggression increased as did verbal comments about self and family. In the third phase, dramatic and role play increased while creative play decreased. Subjects’ feelings of anxiety, frustration, and anger became more focused on specific concerns. In the final phase, children showed increasing interest in the relationship with the therapist. At the outset, in addition to phases of the therapy, Hendricks had sought phases of emotional and social growth. She observed, however, that the children’s feelings and attitudes overlapped to a great degree, such that no clear stages for emotional and social growth across subjects could be determined. 31 In 1975 Withee embarked upon a similar quantitative study of play therapy process in the treatment of 10 children, who were seen by 10 different therapists. Seeking to replicate and extend the work of Hendricks (1971), Withee categorized verbal patterns, play activity patterns, and patterns of other nonverbal expression for boys and for girls. Dividing the participants’ 15 sessions into five 3—session time periods, Withee calculated aggregate percentages for predetermined content categories across time periods and gender. Sessions 1 through 3 saw high levels of verbal, nonverbal, and play exploratory activity. In Sessions 4 through 6, aggressive play and verbal sound effects peaked. In 7 through 9, aggressive play ebbed while creative play peaked. In 10 through 12, relationship play peaked while noncommittal play reached a low point. In the final fifth, noncomittal play and verbal relationship with the counsellor peaked. Representative findings related to gender included noticeably more anger amongst boys, and more creative and relationship play amongst girls. Hannah’s (1986) study of play therapy marked a theoretical and methodological innovation in process research. Hannah had observed that despite good intentions in traditional play therapy process/outcome studies, results had been mixed and treatment effects small. He attributed this to the customary reliance on between—group designs and dependence on parametric statistical methods, which he perceived as obscuring meaningful individual changes. Instead, Hannah employed the time series analysis of multiple cases. His subjects were 10 normal children, who each had a particular behavior problem, according to parent or teacher 32 reports. “Target” problem behaviors, such as aggressive acts, poor peer interaction, noncommunicative behavior, or off—task behaviors, were identified as unique criterion outcome variables for each child. Behavioral observations for each child were carried out before and during eight 50-minute nondirective play therapy sessions. Standardized interviews of parents and teachers were held at the end of treatment to account for changes due to client history. In addition, the subjective observations of parents and teachers were used as comparison data with the time series analysis results. When the tenth child was withdrawn from treatment due to parental request, that child was used as a nontreatment “rough check” for historical changes. Play therapy process consisted of behavioral changes over time. The strength of Hannah’s methodological breakthrough lay in his use of time series procedures, which allowed, statistically, for the inclusion of time as an experimental variable. However, a major weaknesses of that study may be attributed to that statistical approach as well, Hannah reported that 8 of the 9 participants exhibited a significant and positive change in their targeted behavior. Closer reading of his dissertation revealed that the statistically significant results corresponded to parents’ and teachers’ subjective impressions of change in only one—third of the subjects. One-third of the observations were antithetical to the statistically derived results (i.e., parents perceived a behavioral change, while the time series analysis found no statistically significant change). The latter third were mixed or ambivalent (i.e., parental observations were ambivalent in comparison to statistically—evidenced changes). 33 Four of the ten time series analyses required sophisticated ARIMA procedures to verify statistical significance. In general, Hannah’s use of time series raised questions as to the weight to be given to personal perceptions of change in comparison to statistical evidence. An additional complication arises from the fact that Hannah employed four different therapists in working with the 9 subjects, each of whom would have differed in levels of skill, efficacy, and impact with the children. This study is vulnerable to the “myth of the uniform therapist” (Kiesler, 1967). The impact of the therapist would be no less important than the impact of passage of time. Instruments of Play Therapy Process Seeking a method to analyze child-adult interaction in play therapy contexts, Moustakas, Sigel, and Schalock (1956) developed coding categories such as Attentional Behaviors (e.g., recognition of others or offering help), Stimulus Behaviors (attempts to elicit particular responses, such as reassurance or affection), Orienting and Directing Behaviors (directing or restricting), Criticism or Rejection Behaviors (ranging from praise to physical attack), Cooperation and Compliance expressions, and Interpretation. The resulting interaction observation instrument of 82 adult behavioral categories and 72 child behavioral categories was utilized by Moustakas and Schalock in their 1955 study. (The description of the instrument and its development was published after the study.) The varied categories of this instrument suggest a conceptualization of play therapy process as a composite of interactional events. Although a later Play Therapy Observation Instrument (PTOI; 34 Howe & Silvern, 1981) was developed as a research tool, its genesis is considered here because the authors carried out an exhaustive theoretical formulation of play therapy process in developing it. Howe and Silvern intended for the PTOI to depict and analyze the play therapy process more efficiently than any previous play interaction instrument (e.g., Dana & Dana, 1969; Guerney, Burton, Silverberg, & Shapiro, 1965). Concerned that “most [play therapy] studies have focused only on therapy outcome, not process,” and that these outcome studies “have been largely irrelevant to concerns about playroom indicators of pathology and change” (Howe & Silvern, 1981, p. 169), Howe and Silvern painstakingly set about to develop an observation instrument of superior construct validity, capable of “classifying every child behavior or càmment, regardless of its purported significance” (Howe & Silvern, 1981, p. 169). To that end, the authors embarked upon an exhaustive review of the play therapy literature to determine the universalities of child clients’ responses. Ultimately, they ascertained four major components of play therapy experience: Emotional Discomfort, Competency, Defensiveness or Maladaptive Coping Strategies, and Fantasy Play. These were subdivided into 31 coding categories such as frequency and degree of play disruption, frequency of coherent talk, frequency of regression or withdrawal, or inventive use of structured or creative toys. Of the original 31 experimental categories, 13, after testing, were deemed reliable observational criteria of play therapy process. To date, however, Howe and Silvern’s contribution to the conceptualization of play therapy 35 process lies in the isolation of the four major experiential categories identified above. Examination of the Social Sciences Citation Indices since 1981 revealed no published applications of the PTOI. One dissertation study used the Fantasy, Social Inadequacy, and Emotional Discomfort scales of the PTOI for diagnostic purposes only, in order to distinguish adjusted from maladjusted children (Perry, 1989). Summary The extant studies of nondirective play therapy process encompass a range of research intentions, variables, and methodologies. The small number of studies, each with a disparate research focus, offer virtually no overlapping or corroborative findings, thus confounding realistic cross—study comparisons. The paucity of the existing literature provides a spare context for the current study which, rather than replicating earlier research methodologies and/or research foci, chose to proceed in a new direction, using qualitative analyses of children’s symblic expression. 36 CHAPTER II. REVIEW OF THE LITERATURE SECTION II: SYMBOLIC EXPRESSION AND THE PLAY THERAPY PROCESS This section links theoretical background on symbolic expression with accounts of child therapy that have focused on the child’s symbolic expression. It begins with a brief overview of the Jungian conception of symbols, proceeds to outline the similarities and differences between play and language as symbolic systems, and concludes with a review of representative clinical literature which has focused on therapeutic change as a process of transformations in symbolic expression. The Nature and Function of Symbols Jung (1976) equated the symbolic expression of human beings with the teleological life of the unconscious, describing symbols as “transformers” which serve to convert the libido or psychic energy from a lower form to a higher or spiritual form. His unique contribution to therapeutic process was the insight that the personal unconscious unfolds and evolves through symbolic expression. Conversely, symbolic expression provides channels for psychic and emotional growth. Jung concentrated on identifying archetypal images, such as the hero and the foe, and on exploring fundamental themes of destruction and wholeness, death and rebirth. He linked images occurring in nature to ancient and primal meanings: repressed instinctual violence as well as fertility and the positive life force. At the same time he cautioned against any simplistic analysis of the meaning of the symbol, focusing instead on the depth of the psychic mystery a symbol brings into focus. Symbols cannot be simply defined or unidimensionally interpreted. 37 Rather, symbols are complex “images of contents” (Jung, 1976, p. 77) with many potential meanings. Symbols are not signs corresponding to what is known. Symbols “seek rather to express something that is little known or completely unknown” (Jung, 1976, p. 222). Symbols do not signify a definite action or event. They represent and express deep personal meaning. Jung’s corroborative case material (1976) as well as subsequent work by analytical therapists (e.g., Kalff, 1980) affirm that symbols appearing in a client’s art, play, or dreams commonly reflect or portend important personal changes. Symbols are capable of representing personal meaning because they link objective (tangible) with subjective (emotional and psychic) experience. Symbols link the conscious and the unconscious (Segal, 1975). Symbolization occurs when “abstract intangible states of affairs are realized in a concrete medium” (Kaplan, 1979, p. 220). By Kaplan’s description, symbols act as a “mediator” between the realms of the mental or emotional and the physical or material. According to Kaplan, symbols perform a fluid or a moving and interactive function between these two domains. They intimate unseen meanings while retaining physical dimensions. As similarly characterized by Kubie (1953): It is the dual anchorage of the symbol . . . which is the bridge over which these processes take place, i.e., the internalization and externalization, introjection and somatization. Without this dual anchorage of the symbolic process these familiar transmutations of experience could not take place either consciously or unconsciously. (p. 73) Whether conceptualized as “transformers,” “mediators,” or “bridges,” symbols offer tools of access and insight to inner and outer experience. In this study, the selected symbolic systems 38 of play and language were understood to offer access to the interplay between the material and the mental, the seen and the unseen, the conscious and the unconscious, the child’s observable activities with a play object and the intangible yet comprehensible meanings these objects and activities represent. Play and Language as Symbolic Systems Both play and language are symbolic or representational systems (Wolf & Gardner, 1981) which have been shown within a wide range of psychological literature to share commonalities in their development and in their expressive functions. Play and Language: Their Developmental Convergence Vygotsky’s theories (1966, 1978) on the interrelated developmental course of play and language underlie this study. According to Vygotsky, the development of language and the development of symbolic play are interrelated and interactive in the young child. Vygotsky observed that the development of language and activity in the infant at first proceed on independent, parallel paths. Physical explorations of the infant’s world are not linked to specific articulations. Conversely, the spontaneous vocalizations of “baby talk” are not initially associated with the identification of objects. Early speech is not symbolic. It does not represent anything. However, at a critical point in development, the infant’s sounds acquire meaning. At this developmental crossroads, language and physical exploration become linked. Language becomes symbolically, representationally, associated with objects, activities, and events: “The most significant moment in the course of intellectual development, which gives birth to the 39 purely human forms of practical and abstract intelligence, occurs when speech and practical activity, two previously independent lines of development, converge” (Vygotsky, 1978, p. 24). The crucial feature of Vygotsky’s developmental theory is that this critical developmental event, the point at which language becomes fused with intentional activity, occurs in a relational context. Specifically, according to Vygotsky (1978), speech or expressive language derives from the child’s relationship with the mother, in particular, from playful interaction with her. Vygotsky proposed that the infant’s speech at first functions interpersonally, to establish contact with the mother. Only later, following successful expressive contact, does language take on the intrapersonal function of reflection or thought. That is, the child’s social communicative experience precedes the development of internalized self-talk. This is in contradistinction to Piaget’s (1962) related theories, which considered internal speech an early form of thought and a precursor to expressive, interpersonal language. According to Vygotsky, the developmental process of speech and activity may be summarized as follows: The child’s speech is at first separate from activity. Later speech accompanies activity in a relational context, and, finally, it precedes activity (i.e., the thought of the event precedes the action). Play and Language: Differences as Symbolic Systems Play and language are related though not identical symbolic systems (Sinclair, 1970). Specifying the differences, Sinclair (1970) noted, first, that play occurs in the tangible world, 40 while spoken language is an intangible representative system. Second, play and language differ in the manner in which they permit the expression of meaning. The meanings of a given play act are highly individualized. Play with blocks, for example, can occur in myriad forms, styles, and emotional coloration, indicating meanings unique to each child. The words that comprise language, in contrast, are a conventionally assumed system of shared meanings. A final difference concerns the fact that through play the child can spontaneously and loosely link materials, themes, and events together. In contrast, words cannot be joined together haphazardly. Language is governed by rules of syntax, grammar, and convention, while a child’s spontaneous play is free of any pre—ordained form. Play and Language: Similarities as Symbolic Systems Play and language share functional and conceptual features as symbolic systems (Smith, 1979). Both are representational systems, enabling the individual to externalize and portray thoughts and emotions. Play materials are representational in that they act, in Vygotskian terms (1978), as a “pivot,” an object which carries meaning related to, but independent of, the object it is meant to represent. When a child uses a wooden block as a car, the block acts as such a pivot. It bears the essential meaning of “car.” In play with this object, the child demonstrates (a) an understanding of a symbolic object, which can stand for or represent a real object removed in time and space, and (b) a facility with the representational nature of language, whereby the word “car” contains meaning which links yet distinguishes the real object and its representation. Play 41 objects as pivots assist the child to separate objects from their essential meanings. As similarly described by El’Konin (1971), “In play the child operates with things as things having meaning; he operates with the meanings of words which substitute for the thing; therefore, in play there occurs the emancipation of the word from the thing” (p. 230). As symbolic systems, both play and language permit decentration. The ability to decenter, identified in the pretend play literature as a developmental turning point (Fenson, 1984), refers to the child’s capacity to play at levels of experience increasingly removed from the self. Early attempts at pretense in late infancy are directed toward the self (Lowe, 1975). Later, the child animates and directs objects, investing them with the potential for independent action. At a more complex level of abstraction and decentration, the child is able to adopt a role or engage in pretend play independent of the qualities or presence of physical props (Elder & Pederson, 1978; Jackowitz & Watson, 1980; Ungerer, Zelazo, Kearsley, & O’Leary, 1981). Language similarly permits decentration by enabling the child to conceptualize, describe, and verbally manipulate persons, objects, and events removed in time and space. Empirical Support for Developmental Correspondence Empirical studies from the field of cognitive psychology confirm the synchronous onset, interrelated abilities, and associated deficits in the child’s play and language development. Group comparative studies with autistic children, whose deficits in both symbolic play and language capabilities are acknowledged as extreme (Rutter & Schopler, 1978) has shown that impairment in 42 the capacity for symbolic play is associated with impairment in expressive language abilities and vice versa (Mundy, Sigman, Ungerer, & Sherman, 1987; Sigman & Mundy, 1987; Ungerer & Sigman, 1981). Other studies confirm the correspondence of language and symbolic play capacities in normal development. Free play with make—believe content has been positively associated with verbal fluency (Dansky, 1980). Functional and symbolic play competencies at age 13 1/2 months have positively correlated with language competencies 9 months later (Ungerer & Sigman, 1984). Reviewing an extended body of the related cognitive literature, McCune-Nicolich (1981) noted that symbolic play measures frequently correlated positively with language acquisition in normal infants. She noted a developmental correspondence between the young child’s capacity to represent events in symbolic play and in speech and she cited the literature as supporting the following synchronous events: “(1) presymbolic behaviors in both domains, (2) initial pretending and first referential words, (3) the emergence of combinatorial behaviors in both domains, and (4) hierarchically organized language and symbolic play” (p. 795). McCune-Nicolich suggested that “symbolic play might provide a useful converging operation for identifying structural turning points in language” (1981, p. 795). An appreciation of the conceptual commonalities of play and language as symbolic systems, their differences as symbolic modalities, and their developmental interrelationship underlies this inquiry. 43 Therapeutic Play as Symbolic Expression Play in therapeutic settings has long been regarded as a vital symbolic language of the child. Ginott (1982a) observed: Child therapists . . . make use of toys and play materials in the . . . treatment of emotionally disturbed children. The rationale for this practice is the belief that play is the child’s symbolic language of self-expression. Through the manipulation of toys the child can state more adequately than in words how he feels about himself and the significant people and events of his life. To a considerable extent, the child’s play is his talk and the toys are his words. (p. 145) Play therapy has also been defined as “symbolic action” (Sikelianos, 1990): “Different mediums . . . are used to create arrangements and rearrangements, creation and recreation symbolically . . . . Through symbolic action of bringing about changes, transformations, the child also gains confidence in his ability to find resolutions” (p. 5). According to her, the child’s “symbolic action” is both a highly personal language and the essence of therapeutic change. Allan and Berry (1987) observed that children in treatment seem to gravitate toward particular play materials which at first appear to be merely a function of object preference. “It is common for many children to be attracted to one key symbol that will, appear, disappear, and reappear throughout their treatment” (Allan & Berry, 1987, p. 306). More than a function of preference, the experience of these therapists indicated that these objects are often a unique symbolic expression of the child’s difficulty, or a symbol of the child’s capacity for growth and recovery. 44 Accounts of Symbolic Transformation in Child Therapy Case studies which trace the transformations of children’s central play symbols are often found on the margins of the established body of play therapy literature, namely, in the expressive arts or sand play literature. These studies, which encompass play, art, sand, or other expressive media, illustrate the critical role of play symbols in treatment and demonstrate the transformation of these symbols as therapy progresses. Case Studies of Play and/or Art Media Clegg (1984) explored the evolution of a particular symbolic theme in play therapy process, “the reparative motif,” or the theme of rescue, help, and restoration. He observed that the emergence of this theme marked a significant phase in therapy and presaged a generally successful therapeutic result. In his in— depth study of two cases, Clegg (1984) documented how this motif emerged, evolved, and moved these children toward recovery. He noted that nascent forms of the reparative motif, barely discernible at first, crystallized into fuller form as therapy continued. Clegg considered play a “holographic sampling” (1984, p. 121) of the personality processes of the child: “It is as if the child were initially teaching the therapist the language of her own unconscious” (Clegg, 1984, p. 92). Also working from a Jungian perspective and emphasizing the curative transformation that can occur as a child works symbolically through expressive arts media, Allan (1988) has contributed numerous case studies which document the interplay between therapeutic movement and symbolic expression. According to Allan (1988), “In play therapy, children will often 45 spontaneously work on fantasy themes that have direct relevance to their psychological struggles” (p.21). As children progress in therapy, Allan has observed that they use play materials differently, often with compelling significance which parallels and symbolically expresses their inner experience. For example, one child achieved emotional growth which was both catalyzed by and reflected in successive drawings of a tree as a symbol of the Self——decaying, rotten, eaten away, and sprouting new life (Allan, 1988) In a case study of adapted play therapy treatment (Allan, 1988), a five—year-old’s progress from psychosis to emotional well-being was expressed symbolically through dual media, drawing and fantasy enactment. The themes of the child’s fantasy play (specifically, her dramatic enactments) and the graphic representations of her inner emotional life followed an intermingled course. Her early psychotic insistence that she was a sea gull was mirrored in her drawings of herself as a sea gull (a feathered creature). As she became emotionally stronger, her preoccupation with the sea gull receded while images of feathers remained. In a later stage of therapy, the feather was evident on the headband of a healthier, graphically represented persona, an Indian princess. In her fantasy enactments as in her drawings, she adopted different, successive identities which transformed across her therapy. Allan’s case study accounts suggest that therapy is a continuous movement of symbolic transformations, a stream of consciousness! unconsciousness that utilizes a variety of symbolic media as it wends toward emotional recovery. He observed that “the language of the Self is that of 46 pictures, images, metaphors, and feelings” (Allan, 1988, p. 7), Sikelianos, a therapist who has used play media but who emphasized graphic arts representations in the case study reports of her psychoanalytically-oriented therapy, has contributed similar accounts (1975, 1979, 1986) documenting the role and the interplay of symbolic changes in therapeutic process. In 1979 she described the course of successful treatment of a severely disturbed boy. This child embarked on a two-year course of therapy in which symbolic transformations presaged, paralleled, and summarized his progress. The boy “made substantial steps toward integration through the creation of visual symbols” (1979, p. 43). Initially, his drawings of a trailer (which are linked to sources of power and, in his case, were loaded with food) reflected his preoccupation and sense of safety with mechanical objects while at the same time presaging his need for nurturance. “To delineate the trailers and the hook—up, [he] used two opposing lines: these may symbolize the opposing forces —-good and bad, positive and negative--whose immobilizing power [he] showed in his bearing and continued to represent in his drawings” (Sikelianos, 1979, p. 45). Other graphic symbols emerging and transforming in his therapy were keys, coin phones, and light bulbs. In another case study (1975; revised in 1986), Sikelianos described the symbolic transformations, in this case persistent graphic symbols, which characterized the progress of a five—year— old girl. Sikelianos specified that “symbolic expression played a central role in this [therapeutic] process since the core of [her] disturbance was at levels of feelings she could not express 47 overtly in words” (1986, P. 53). Although Sikelianos employed play media, the case account focused on three persistent graphic symbols which transformed over the three—and—a—half year course of therapy. Two vertical parallel lines, an abstruse early symbolic communication, eventually merged into a cross. This graphic transformation mirrored the child’s personal transformation from emotional isolation (parallel and distant) to her later capacity for human contact and relationship (later represented by intersecting lines). A figure 8, initially upside-down and falling into space, gained stability, human features (eyes, nose, mouth), and ultimately (post-therapy) became an S-shaped mandala, a symbol of wholeness in the Jungian framework. The V, associated early in her therapy with images of aggression (“Monster V”), developed into a diamond, another symbol of wholeness (radiance). Sikelianos understood the “8” and the “V” as symbolic of the girl’s “infantile splitting and aggressive tendencies” (1986, p. 59). These graphic representations underwent transformation as her ego and personality became stronger and healthier. In general, “each of the forms had a particular psychological significance for her, and over time the forms were modified and combined in ever—changing ways that reflected her struggle through the basic developmental tasks of the young child” (Sikelianos, 1986, p. 53). Case Studies of Sandplay Sandplay, an adjunct and an acknowledged component of play therapy, constitutes a therapeutic medium in itself. Intended as a nonverbal or minimally verbal, noninterpretive therapeutic 48 modality (Kalff, 1980; Lowenfeld, 1939), descriptive case studies of sandplay emphasize the transformations of three—dimensional, tactile representations, and serve as further illustrations of the conceptualization of therapy process as a course of transforming symbolic expression. Buhler’s (1951) “World Test,” an early analysis of sandplay symbolism, was a projective technique to distinguish for diagnostic purposes the sandplay of well-adjusted from disturbed children. Of interest are the basic styles or themes of sandplay which she identified, and her conviction in their symbolic function as representative of inner emotional states. Buhler identified disorderly versus orderly, schematic versus scattered, and open versus enclosed arrangements. She elaborated other basic styles and the affective dimension they represent as follows: violent play (symbolizing aggression); sparse play configurations (dearth of ideas; escape, rejection); repetitive play (preoccupation or fixation); no people (hostility or escape wishes); enclosed formations (protection or isolation); chaos (inner confusion, dissolution, ego breakdown); and patterns (primitive or perfectionistic; after Buhler, 1951, p.14). The Jungian psychotherapist Kalff considered the sand tray a temenos, a safe container for the child’s unfolding psyche. In her work, she paid particular attention to symbols of wholeness and well-being: “The manifestation of the self . . . is the most important moment in the development of the personality” (Kaiff, 1980, p. 29). Kalff’s (1980) Sandplay is a compendium of case studies illustrating the curative influence of symbols central to each child. A child who suffered from a learning inhibition 49 symbolized feelings of hopelessness with a crashed airplane in the sand tray. Another symbolized the beginning of a feeling of wholeness and completeness within herself using tiny trees. Two halves of her Self were symbolized by fir trees (the West) and tiny blossoming trees (the East). Allan and Berry (1987) noted that the physical properties of sand allow the child to tangibly resolve difficulties through the externalization of fantasies. Sand provides opportunities for mastery and impulse control over the material, and, in parallel and symbolic fashion, over real life difficulties. Because emotional resolution occurs on the unconscious, symbolic level, verbal interpretation is usually neither necessary nor recommended (cf. Kaiff, 1980) The many miniature play objects available to the child each has “its own physical structure and symbolic meaning, and each tends to trigger a fantasy reaction” (Allan & Berry, 1987, p. 301). In their case study, cars, trucks, arid jets, symbolized “adaptive movements in the outer world,” (p. 305); snakes symbolized “negative external forces” (p. 305); and crocodiles symbolized aggressive forces. A figure of Pegasus, identified as a “symbol of inner strength” (p. 305), underwent a transformation which paralleled the boy’s progress: at first buried by heaps of vehicles, later ridden by a magic helper, and finally emerging with figures representing the child’s family members seated in a circle, a symbolic representation of wholeness. 50 Summary The case accounts by the above therapists and theorists have in common the retrospective inspection of salient shifts in young children’s play symbolic expression. The notion that children’s therapeutic process would be evident in their symbolic expression was central to the present study. This study set out not only to highlight key events within the child’s symbolic expression but also to capture as much as possible the rich details of the microscopic changes in the child’s symbolic expression. The present study, then, differs from these case accounts in the degree of detail of symbolic expression, and in extending the scope of symbolic expression to include verbalization. This study differs from previous empirical process research, considered earlier, in its departure from a quantitative research paradigm and in its adoption of an intensive, qualitative research design. Previous empirical process research focused primarily on shifts in verbal function, content, and intent. By tracking transformations in both verbalization and play, this study has attempted to straddle and even to integrate aspects of both the content analytical (verbal) focus of previous emprical studies and the symbolic expressionist domains of the play therapy process literature. 51 CHAPTER III. METHODOLOGY SECTION I: PRINCIPLES, RATIONALE, AND TERMS Chapter II describes the methodology employed in this study. The chapter is divided into two sections. Section I discusses the theoretical principles and rationale underlying the methodology. A brief introduction is followed by explanations of the major terms pertinent to the study: the naturalistic paradigm, field research, participant observation, case study method, principles of grounded theory, and the narrative analytic framework. Section II describes the research procedure employed: the subjects and selection issues; setting and access issues; ethical considerations; data collection methods, and data analysis techniques. Background: Considerations in Choice of Method Predating current burgeoning interest in qualitative research (e.g., Lincoln & Guba, 1985; Lof land & Lof land, 1984; Miles & Huberman, 1984), Vygotsky, whose work of the l930s was published in English forty years later, noted the tendency of researchers to “treat the processes it analyzes as stable, fixed objects” (1978, p. 61). He broke new methodological ground in psychology with his ingenious problem-solving experiments, advocating that “a complex reaction must be studied as a living process, not as an object” (1978, p. 69). Method must not be dissociated from the essence of the phenomenon under study: The search for method becomes one of the most important problems of the entire enterprise of understanding the uniquely human forms of psychological activity. In this case, the method is simultaneously prerequisite and product, the tool and the result of the study. (Vygotsky, 1978, p. 65) 52 According to Vygotsky, research must give priority to what he termed the “unit of analysis.” “Unit of analysis” does not refer to an operationalized definition in the empirical research tradition. Rather, a unit of analysis is a living micro-facet of the process under investigation. Vygotsky cautioned that psychological processes of cognitive learning, emotional growth, and human interactions should not become so particularized into objective components in the process of research that they lose the essence of the whole to which they belong. Research units of analysis should retain the essence of the process under investigation. A reductivist study of water, which analyzes the disparate hydrogen and oxygen molecules, fails to capture the moving, living reality and taste of water (after Vygotsky, 1978). This study considered participants’ play and language, facets of their symbolic expression, as the units of analysis, methodologically accessible through a field research strategy and qualitative data analytic approaches. The Naturalistic Paradigm In contrast to the dominant research paradigm in which reality is considered determinate, linearly causal, and objective, the emergent paradigm of naturalistic inquiry construes experience as holistically complex, mutually interactive and causal, indeterminate and subjective (Lincoln & Guba, 1985). Naturalistic inquiry attempts to minimize “the presuppositions with which one approaches the empirical world” (Lof land & Lof land, 1984, p.3) and to become attuned to the events and themes which emerge from the site under study. Terms such as “ethnographic research,” “case study 53 research,” “field research,” and “qualitative research” have been used synonymously with “naturalistic inquiry” to describe a research strategy which seeks to know and understand human experience by immersion in it, followed by description of its emergent themes (Bogdan & Bikien, 1982; Burgess, 1984; Lincoln & Guba, 1985; Lof land & Lof land, 1984). Despite the proliferation of terms, what the Lof lands (1984) have called a “terminological jungle,” there is an essential unity of purpose and overlap in actual ideology among these research strategists. Usually, the differences among terms can be reduced to a matter of degree and emphasis. In this study, the term “naturalistic inquiry,” as explicated by Lincoln and Guba (1985), was used as the overarching paradigmatic expression which encompassed the theoretical and practical components of this study: field research, participant observation, the case study method, principles of grounded theory, and the narrative framework. Field Research Naturalistic inquiry takes place in a natural or applied setting (Lincoln & Guba, 1985). The term “field research” emphasizes the fact that the researcher departs from experimentally controlled environments and enters human contexts, the field, in order to study them (Burgess, 1984). Field research relies upon the researcher’s observations of human experience as lived and the subsequent description and analysis of that experience. Fieldwork, as described by Burgess, is detailed and intensive. It utilizes the researcher as the principal research instrument in the formulation of research questions, which are elaborated and developed as the research 54 proceeds. The researcher enters the context to be studied with a minimum of disturbance to its natural functioning and devises methods of data analysis which remain true to experience as observed and which at the same time offer explanatory or analytic insight. Acoording to Bogdan and Biklen (1982), “Becoming a [field] researcher means internalizing the research goal while collecting data in the field” (p. 129). Participant Observation Participant observation has been described under a variety of related research rubrics, as an aspect of field work (Burgess, 1984), qualitative research (Bogdan & Bikien, 1982), and naturalistic inquiry (Lincoln & Guba, 1985; Lof land & Lof land, 1984). Participant observation is a means of data collection by which the researcher functions in a dual capacity: as a participant in the actual processes and contexts under study and as an observer of those processes. It is through participation that “the researcher [can] focus on the process whereby behavior is constructed, and not simply the means or the ends” (Fisher, 1990, p. 127). Depending upon the degree of detachment or involvement within the context under study, there exists a role continuum in participant observation (Bogdan & Bikien, 1982; Burgess, 1984). At one end of the continuum is the complete observer, who functions discretely from the research subjects and who observes events from a distance. At the other end is the complete participant, whose appearance and behavior differ little from the research participants in the setting. The distance and detachment required by the complete observer can hamper the ease of communication with participants. Likewise, the complete 55 participant risks losing sight of the research objective and “going native.” The challenge in carrying out participant observation research is to find a balance between these extremes which is appropriate to each specific study (Bogdan &c Bikien, 1982; Lofland & Lofland, 1984). Case Study Method The case study is a process of research which “describe[sJ and analyze[s] some entity in qualitative, complex, and comprehensive terms, not infrequently as it unfolds over a period of time” (Wilson, 1979, p. 448). The entity under study can be an event, a setting, an institution, or, as in the present study, a process within an individual. The capability of the case study to examine events over a period of time is an important advantage of this research approach. Descriptions of real life events and explanatory or analytic commentaries based on these descriptions are the results which enable the researcher “to begin determining the outer limits and internal workings of functional relationships, to find out the possible symbolic meanings of various objects, and the different ways in which objects can be used in relating to the world outside” (Baas & Brown, 1973). Another strength of this method of inquiry is its “ability to deal with interwoven complexity, multiplicity, [and] details of concrete daily life” (Wilson, 1979, p. 450). With the intensive focus on the individual, case studies are ideally suited as a means of probing the particular in the pursuit of widely generalizable principles of human behavior. Case studies offer understanding of the particular, the detailed extension of experience, and an in—depth basis for the increased conviction in 56 that which is known (Stake, 1978). Case study research in the field of psychology is advantageous because it is closely allied to clinical practice, which is largely concerned with changes within individuals. The case study approach has been central to the development of psychology (Kazdin, 1980). The foundational contributors to the discipline, Freud and Piaget among others, utilized a small number of case examples in conjunction with the force of their own subjective insights and inductive reasoning, in establishing the basic tenets of psychoanalytic and cognitive psychology. According to Dukes (1965): A few studies, each in impact like the single pebble which starts an avalanche, have been the impetus for major developments in research and theory. Others, more like missing pieces from nearly finished jigsaw puzzles, have provided timely data on various controversies. (p. 76) The case study method is appropriate when, as in this study, the research question asks “how” or “why” and when the researcher has little control over the behavioral events involved (Yin, 1984). By contrast, when the research requires control over events to be studied, as in a laboratory setting, and/or the research questions concern incidence and frequencies, the “how many” and “when” questions, group comparative or survey approaches are preferable. Within contemporary psychology, a reliance on group comparative research has resulted in a negative prejudice toward the study of the individual, according to Rosenwald (1988). Rosenwald observed that “with the jettisoning of the unique, the particular was lost as well. This leaves us with the definition of human items by their deviation from the mean” (1988, p. 240). 57 Rosenwald’s claim that “the study of cases—-of lives——is an approach to the better understanding of social life, not a retreat from it” (1988, p. 240) conveys the motivation for the use of case study methodology in this study. The Rationale for Multiple Cases Multiple case studies are not merely aggregates of single case studies (Kazdin, 1980). They are qualitatively richer than an average of the component cases (Rosenwald, 1988) because they are capable of answering wider—ranging theoretical questions. As explained by Kazdin (1980): Although each case is studied individually, the information may be aggregated in an attempt to reveal relationships that extend beyond more than one individual. . . . Conclusions drawn from several individuals seem to rule out the possibility of idiosyncratic findings characteristic of one person. (p.13) Yin (1984) maintained that of the five levels of questions which can be answered by case study research, only “questions to specific interviewees” and “questions asked of an individual” can be answered by a single case study. However, the multiple case study is capable of additionally answering “questions asked of the findings across the cases,” “questions asked of the entire study in relation to the literature,” and “normative questions leading to general conclusions.” From Yin’s perspective, “the evidence from multiple case studies is often considered more compelling, and the overall study is therefore more robust” (1984, p. 48) because each case is considered a literal replication of the other. 58 Criteria for Case Selection From the perspective of Shapiro (1966), “The first step in the investigation of processes must logically consist of investigation in a number of individual cases” (p. 5). The use of logical, theoretical criteria in the selection of multiple cases is necessary. Patton (1980) identified six strategies of case selection in multiple case research, namely, the selection of extreme or deviant cases for contrast, typical cases, critical cases, politically sensitive cases, convenience sampling, and maximum variation sampling, which documents unique variations emergent under varied conditions. Yin’s (1984) two strategies for case study subject selection synthesize the above options. Yin suggested selecting (a) a highly typical case, the analysis of which can be considered representative of many others in the field; or (b) a highly atypical case, which by contrast illumines cases closer to the norm (Yin, 1984). Findings of commonalities which arise from highly diverse cases can be considered more robust because of the diverse base from which they emerge. The number of cases utilized in a multiple case study should also be based on logical, theoretical principles: The number of cases one chooses to observe depends for its scientific credibility on the conceptualization of the problem, the structure of the observation, the significance of the case chosen, and the use to which the results are to be put. (Brown, 1974, p. 3) The number of cases in this study (4) permitted some diversity for thematic comparisons and contrasts. At the same time, the number was small enough that intensive, even microscopic, analysis could be carried out. 59 Purposeful Sampling Multiple case studies rely upon replication logic (Yin, 1984) and utilize purposeful sampling rather than random sampling. According to replication logic, each case is considered a literal replication of the entire study. An individual in case study research is considered not merely a single unit, but a universe of responses. The sampling logic of naturalistic inquiry differs from that of empirical, experimental research. In that tradition, sampling is based on the statistical premise that the selected group of subjects represents a random selection from the population at large. In case study research, with a small N or an N of 1, sampling logic does not apply. The data resulting from these 4 subjects were not intended to represent the population at large but rather to provide insight into and generalize to the theories underlying the study. Purposeful sampling is based upon informational rather than statistical factors. Participants are selected for their capacity to generate and maximize information rather than for facilitating generalizations to the population at large (Lincoln & Guba, 1985). Principles of purposeful sampling apply not only to the selection of subjects but also to the data which are selected for analysis. That is, portions of the data to be analyzed may be selected by theoretical rather than statistical criteria. Purposeful sampling is dependent upon the theory driven needs of the study. That is, it serves a purpose in the enhancement of existing theory or in the development of new theory. 60 Glaser and Strauss (1967) used a similar term, “theoretical sampling.” Their term emphasized that a theoretical rationale must underlie subject selection. In their view, the term “theoretical rationale” encompassed not only subject selection but also the criteria by which the qualitative researcher decides which data is to be analyzed, how, and when. In “theoretical sampling,” the sampling of cases, of responses, and of themes continually undergoes focusing and revision. Principles of Grounded Theory The purpose of naturalistic or qualitative research varies from providing rich descriptions, at one end of the continuum, to providing explanations, to the generation of new or expanded theory. Glaser and Strauss (1967) asserted that the purpose of qualitative inquiry is to go beyond description to generate new theory which is anchored, or grounded, in the themes and the evidence which emerge from the data. Grounded theory utilizes research strategies common to most qualitative research, such as coding, memos, and continual written commentaries and analysis. However, the research vocabulary which Glaser and Strauss introduced emphasizes theory creation. Coding categories, they maintained, should be more than adequate descriptions. They should be “conceptually dense,” in that the categories provide analytical and sensitizing handles for understanding the data. They identified “core categories” as those conceptual categories which have the most explanatory power. These categories are meant to be the theoretical nuclei from which new theories evolve. In formulating new categories, the researcher working from a grounded theory perspective uses 61 the method of “constant comparisons” whereby new categories, their rationale, and their properties are continually compared with existing ones. No conceptual detail is presumed. The categories and their conceptual justifications undergo continual comparative analysis. This study set as a primary aim the rich description of thematic transformations within the play therapy process. From these rich descriptions, it was anticipated that explanatory insights into the process of play therapy and possibly even new theoretical understanding of that process might emerge. The Narrative Framework Principles of narrative knowing underlie the data analytic strategy of this study. That is, this study considered participants’ play and their verbalizations as two forms of emergent narrative, two forms of text or story. As well, the study employed principles of narrative analysis in the identification of emergent verbal and play themes. Narrative as a means of knowing and as a creative qualitative research perspective rests on the premise that human beings are continually telling stories replete with personal meaning through their words, their actions, and their lives. Polkinghorne (1988, 1990), who has advanced the understanding of narrative, has developed a more complex conceptualization of narrative than the ordinary comprehension of narrative as “just” a story: Narrative is the continual unfolding and expression of meaning. As such, narrative expression is the essence of human culture and an on—going process within the individual. If words, actions, and lives are considered as a vital story, a living 62 context of meaning, the meaning of that story, life, action, or words, can then be accessed in the same manner as with a literary work, namely, through the identification of plots and themes. To describe a plot in a narrative is to ascertain the meaning of that plot for the individual. Narrative as a perspective in clinical practice is not foreign to the field of psychology. The psychoanalytic and psychodynamic literature is composed of numerous client stories retold by the clinician. Freud was continually searching for decisive moments in his patients’ experience to ascertain repetitive themes, their significant transformations, and their meaning in depth (Polkinghorne, 1988). His case studies are illustrations of insights acquired through what was essentially narrative analysis of his patients’ discourse and dreams. According to Polkinghorne, Freud contributed two significant insights into the analytic use of narrative. Both are relevant to this study. First, meaning usually depends upon what happens later. That is, meaning occurs in a temporal context. At times, it may be immediately clear; at other times, understanding may occur only in retrospect. Second, the expression of meaning is not equivalent to the expression of factual experience. The client who fabricates the content of a dream, the child who tells a fanciful story, are still providing expressions of personal meaning. Whether or not the dream or the story is factual does not interfere with the validity of its meaning. The narrative framework presupposes that human meaning, purpose, and intention are knowable and accessible through both the words and the actions of the individual. As Polkinghorne 63 (1990) elaborated, just as words in a series link to assume meaning greater than the sum of the parts, actions in a series form meaningful episodes and plots. Although experience as it is being lived may appear segmented and disjointed, over time these segments create a whole of meaningful plots and patterns. Small segments when connected become larger episodes which, in turn, depict overarching themes. A beginning, a middle, and an end of certain themes may emerge, and the series of disjointed experience forms into a more coherent and meaningful whole. Individual events in the narrative thus become “comprehensible by identifying the whole to which they contribute” (Polkinghorne, 1990, p. 94). This thematic identification is accomplished largely by retrospective reflection upon the narrative material. Adopting a narrative framework for research provides “a descriptive structure for integrating themes into a whole” (Cochran, 1990, p. 80). As a research strategy, narrative can be used to provide both descriptions and explanations. Descriptive narrative research attempts to accurately portray emergent themes and plots. The descriptive analysis of a narrative text can be complex because plots and sub—plots intermingle, requiring the discernment of latent meanings. Polkinghorne maintained that the use of narrative can accomplish causal explanations because the narrative perspective delves beneath statistical probabilities to the level of the intricacies of human motive and purpose. This study endeavoured to provide essential descriptions of emergent themes and their transformations in children’s verbalizations and in their play. The actual interpretation of a narrative text can be 64 accomplished with scientific rigor (Van Manen, 1990): In the quantitative sciences precision and exactness are usually seen to be indications of refinement of measurement and perfection of research design. In contrast, human science strives for precision and exactness by aiming for interpretive descriptions that exact fullness and completeness of detail, and that explore to a degree of perfection the fundamental nature of the notion being addressed in the text. (p. 17) Extracting the themes, scripts, or guiding messages embedded in a narrative can be accomplished by two primary methods: (a) letting the data reveal itself, and (b) asking the data a question (Alexander, 1988). “Letting the data reveal itself” is not a passive process. It requires attunement on the part of the researcher to discern emergent themes. Alexander (1988) identified nine “principle avenues” for determining salient themes in a text. By attending to primacy, the researcher probes the narrative for initial themes, assuming that first themes or expressions are meaningful to the individual. Frequency of expression is another means of identifying salient themes. “When frequency is coupled with other salience indicators it may reveal less conscious schemas” (Alexander, 1988, p. 271). Unique or unusual expression and content can indicate salient themes within a narrative, and the individual’s negation of meaning can also be significant. Words like “always,” “absolutely,” and “never” indicate salience through emphasis. Salience can also be indicated through omission, a lack of affect or lack of cognitive clarity in the stream of narrative. Statements which reflect error or distortion can signal important gaps in understanding or the individual’s self—image. Nonsequitors, or statements in 65 isolation, can signal salient themes, as can incomplete statements. In the latter two strategies the narrative researcher seeks to uncover the motivation for the isolated or incomplete statements. After employing these principles to identify salient themes, the initial data are sorted and reduced. Salient units in their completed form are “microscopic stories with an introduction, an action, and an outcome” (Alexander, 1988, p. 278): My assumption is simply that what is expressed in imagery and the manner in which it is expressed indicates the repertoire of that subject . . . To find repeated fixed instances of a sequential pattern, despite changes of context, characters, and time, alerts the observer to the power, in the sense of importance, of that sequence in the experience of the subject. (Alexander, 1988, p. 281) A comparable method by Giorgi (1985) for extracting meaning from narrative protocols is to (a) read the entire protocol to get a general sense of the whole; (b) identify “meaning units”; (c) apply psychological insight to these meaning units; and (d) synthesize the meaning units into a “consistent statement” of the subject’s experience. Giorgi noted that the researcher must be particularly alert to points of change in meaning within the text. Qualitative Data Analysis Qualitative data analysis is a continual process of data reduction and organization (Miles & Huberman, 1984). Data reduction refers to the ongoing task of “selecting, focusing, simplifying, abstracting, and transforming the ‘raw’ data that appear in written-up field notes” (Miles & Huberman, 1984, p. 21). Data reduction occurs through systematic, methodical tools which begin to streamline a large quantity of data (words) into 66 smaller and increasingly manageable and meaningful units. Data reduction and data focusing occur during both the data collection and the data analysis phases. Within this research method, reliability and validity are dependent upon the accuracy of the reporting, the generation of rich descriptions with a wealth of detail. The construction of a chain of evidence depends upon this abundant and accurate reporting. Specific Data Analysis Techniques The principal data analytic technique utilized in this proposed study was that of coding. Coding was carried out following data collection. Memos, or analytic notes, were completed during the data collection and data analysis phases. Diagrams and displays (after Miles & Huberman, 1984) were also used. Coding Coding is the process of conceptualizing the data and categorizing them according to emergent themes. Coding categories in this research paradigm are devised from the data, not superimposed upon them. Open coding (Glaser and Strauss, 1967), like the “first-level coding” of Miles and Huberman (1984), is an early attempt to organize the data through thematic categorization. In open coding, the researcher approaches the data with preconceptions and prejudgments suspended (bracketed). Later, axial coding, or intensive analysis around particular coding categories by breaking them into component dimensions, can be carried out (Strauss, 1987). Axial coding is similar to the dimensional coding suggested by Miles and Huberman (1984). Pattern codes (Miles & Huberman, 1984) link the more 67 particularistic open codes into categories of overarching themes and interrelationships. Coding categories may be descriptive, explanatory, and/or interpretive. They may refer to motifs, themes, patterns, and/or causal links (Strauss, 1987). In this study, two coding systems were devised: one for the child’s verbal themes and one for the child’s play themes. Memo ing Memos are analytic notes written by the researcher throughout the research process (Miles & Huberman, 1984; Strauss, 1987). Memos serve a variety of purposes in qualitative research, such as orienting the researcher to a new problem, raising a question, recording an insight, or substantiating the rationale for a new coding category (Strauss, 1987). optimally, these notes are intended to be tagged to the data which prompted them. They consist of comments, observations, ideas, questions, clarifications, and analytic insights which arise at any point in the research: before, during, and after data collection. The purpose of writing analytic notes is to amass a quantity of analytic comments which can be sorted, even coded, and utilized for building theory. Graphic Displays Displays of the qualitative data, as recommended by Miles and Huberman (1984), can include charts, graphs, tables, and any other creative diagrams which depict, organize, clarify, and explain the data. This study relied primarily upon the charting of coding categories across sessions. 68 The Research Design In naturalistic inquiry the research design evolves from the focusing question which motivates investigation. The design “deals with a logical problem and not a logistical problem” (Yin, 1984, P. 29). The research design is less a form and more a direction. Early data analysis and emergent evidence for theory building provide the theoretical scaffold for later data analysis. Prevalent themes or theories emergent early in the research are modified or replaced and new questions formulated as additional data become available (Miles & Huberxnan, 1984). Although analysis of the data takes place throughout all stages of the study, the more formal and intensive analysis and theory building occur in the later stages (Bogdan & Biklen, 1982). The principle feature of the qualitative research design is its flexibility to adapt as new data and theoretical constructs emerge (Bogdan & Biklen, 1982). In qualitative research it is important to avoid “going into a study with hypotheses to test or specific questions to answer, [since] . . . finding the questions should be one of the products of data collection rather than assumed a priori. The study itself structures the research, not preconceived ideas or any precise research design” (Bogdan & Biklen, 1982, p. 55). Because naturalistic research endeavors to generate rather than to test hypotheses (Marshall & Rossman, 1989), guiding questions rather than specific hypotheses were formulated at the outset of this inquiry. Additional questions were anticipated throughout the process of data collection and analysis. A description of the research procedure follows. 69 CHAPTER III. METHODOLOGY SECTION II: THE RESEARCH PROCEDURE This section describes the steps of the research procedure. It begins with a synopsis of the design, then proceeds to describe the phases of subject selection, data collection, data analysis, and write-up. Appendix A outlines the steps of the research procedure which are described in summary form in this section. Synopsis of Design A multiple case study design was employed, with each case considered a literal replication of the inquiry. Preschool participants received a course of nondirective play therapy from the therapist/researcher. From the transcriptions of their sessions, emergent coding categories for the verbal and play components of the entire course of therapy were devised. Data analysis consisted of a process of continual re—organization, reduction, and charting of the codes and supplementary descriptive material until themes or patterns were identified. Description of Participants Four preschoolers ranging in age (at outset) from 3.1 to 3.10 years participated in this study. Preschoolers with diverse presenting problems were selected for participation. Participants’ presenting problems ranged from severe developmental delay to a variety of adjustment, behavioral, and emotional difficulties. With one exception, participants were able at the outset of therapy to play and to communicate verbally. None of the participants had been diagnosed as suffering from any physical handicap or mental disorder. All 70 children attended the same preschool and were able to receive play therapy on site from the therapist/researcher. Rationale for Participant Selection Preschoolers were selected because this age group generally possesses the capacity for both expressive language and symbolic play. Important developmental capabilities in language and symbolic play converge between ages 2 1/2 and 3 (Lowe, 1975; Ungerer & Sigman, 1984). By the preschool age of 3 1/2 to 5, basic play and language competencies are considered the developmental norm. Older latency age children tend to be less spontaneously self-disclosing (cf., Lebo, 1951) and, in Piagetian terms, depart from a symbolic play focus to concrete operational interaction with materials. Participants with diverse presenting problems were selected in accord with the rationale for participant selection described by Yin (1984), namely, that commonalities found across highly diverse cases may be considered more robust. Process of Participant Selection The process of participant selection began with the therapist/researcher’s observation of the entire preschool population to identify children in need of and believed to be capable of responding to play therapy intervention. The therapist/researcher carried out these observations from behind a two—way mirror. Observations took place over a period of 4 weeks. To supplement the researcher’s observations, the children’s preschool intake records were also consulted in determining the subject pool. Children who, it was believed, would benefit more from the classroom peer milieu or from group 71 music therapy were not included in the subject pool. Other factors, such as consultation with the preschool staff and/or consideration of parental request, were also taken into account in the determination of the subject pool. Letters of initial contact were sent by the director of the preschool to the parents of the children in the subject pool. These letters described the opportunity for their child to receive individual play therapy and requested that interested parents phone the school to set up a meeting with the play therapist for the purpose of exploring this possibility further. In the meeting, the therapist! researcher began by describing the principles of play therapy and the possible benefits of play therapy for their child. The therapist/researcher described the research that would derive from the play therapy intervention and provided parents with a letter outlining the research purpose and basic procedure. The purpose of this personal meeting was to answer any questions or concerns the parents may have had about play therapy and/or the research purposes and methods. The children’s availability was a factor in participant selection. Only those children whose parents, subsequent to or during the meeting, provided written consent were selected for participation. Copies of the letter to parents describing the research objectives and the form for parental consent can be found in Appendix B. The Setting and Access Issues Subjects were selected from a reputable British Columbia preschool which included both typical and atypical children in its student population. The play therapy sessions took place at 72 this preschool. Because the researcher had completed two years of clinical work at the preschool during the pilot work for this study, she was already known to and accepted by the preschool director and teachers. Several months before the start of the school year, a written document, outlining the purpose of the research, was submitted to the board of the preschool who granted informed consent for the study to proceed in the fall. Ethical Considerations In accordance with university ethics regulations for research with human participants, a synopsis of the research and methods was submitted to the UBC Behavioural Sciences Screening Committee for Research and other Studies Involving Human Subjects. Approval was received before play therapy sessions commenced. Informed consent for participation in the study was secured in writing by the parent or legal guardian of each child, as described above. The children’s confidentiality and anonymity were scrupulously ensured throughout the write—up of the project through the use of pseudonyms, the masking of background details, and protecting the anonymity of the setting. The Researcher as Participant—Observer In this study, the therapist/researcher functioned as a participant—observer as follows. The role and function of the therapist/researcher was well-defined and discrete within the data collection and data analysis stages. In the data collection phase of the project, the researcher maintained a participatory role as the nondirective play therapist, conveying a specific nonjudgmental, noninterpretive, and empathic attitude toward the 73 participants in order for the therapy to proceed. Reliance on electronic means of data recording (audio- and videotapes) freed the therapist/researcher from the need for during—session field notes which would have disrupted the therapeutic focus. After the sessions, the therapist assumed the observer function, completing the field notebook and reflective, retrospective notes or memos. The observation function——data reduction and analysis, via the transcription and examination of videotapes——occurred after all the play therapy sessions had concluded. The Therapist’s Intervention Style During the play therapy sessions, the therapist worked according to the principles of nondirective play therapy, as explicated in Chapter II, allowing the children to determine their play initiatives. Within the nondirective approach to play therapy, the therapist adopted a highly permissive style of intervention. Children were permitted to engage in messing and aggressive behaviors well beyond the limits of socially accepted behavior. The therapist operated from a belief that, within the contained therapeutic setting, (a) the expression of negative affect and behavior diminishes its destructive force and (b) the child’s positive, self-actualizing energies can ultimately override the experiences of dissolution and regression. The Data Collection Phase The videotaping and audiotaping of each child’s course of nondirective play therapy sessions constituted the data collection phase. All sessions were videotaped with an audiotaped back—up. The video camera was placed on top of a 3— tiered shelf within the playroom. In general, it did not prove 74 to be a distraction to participants. A field notebook and session summary sheets (described below) were additional features of the data collection process. The Play Therapy Sessions Each participant received a course of weekly individual nondirective play therapy sessions. The sessions were conducted on—site at the preschool during school hours in a small room which had been equipped by the therapist/researcher for that purpose. The therapist accompanied each child from and to their respective classrooms. Three of the participants received 20 sessions, while the fourth child, whose therapy ended at parental request, received 17 sessions. The course of therapy spanned roughly 6 months of the school year, from October through March. Each session lasted from 35 to 45 minutes. A diagram of the therapeutic playroom as well as a listing of the play materials provided to participants can be found in Appendix C. The Field Notebook During the course of the play therapy sessions, the therapist/researcher kept a field notebook. The field notebook or field journal is an indispensable technique of field research (cf. Bogdan & Biklen, 1982; Burgess, 1984; Lincoln & Guba, 1984). The field notebook contained the therapist/researcher’s notes on each of the play therapy sessions. The notes were in prose form and attempted to provide a literal record, as recalled as soon after the session as possible, of what transpired within the sessions. Personal comments, reactions, insights, and analytic comments were included in the field notebook but were set off from the session descriptive notes in brackets. 75 Session Summary Sheets The researcher filled out post-session summary sheets for each session. Session Summary Sheets (Appendix D) were a secondary aspect of the data collection process, as adapted from the Contact Summary Sheets recommended by Miles and Huberman (1984). The purpose of the Session Summary Sheets was to highlight the main verbal and play themes for each session. These summaries served to focus the researcher’s thoughts along the lines of the inquiry but they were not instrumental in the data analysis phase. In a separate file, the researcher kept memos or analytic notes related to the research procedure as well as other general observations, questions, insights, and reflections on the research in process. The Data Preparation and Organization Phase Before emergent verbal and play themes could be identified and analyzed, the researcher followed a series of steps intended to methodically organize the vast amount of material generated by the 77 play therapy sessions of the participants. Working on one case at a time, the researcher first prepared verbatim transcripts of that child’s sessions. The transcript page was arranged with the verbatim verbal material in the left- hand column. In the right-hand column of the protocols, the therapist noted the play activities synchronous with the verbalizations. “Pivots” and “elaborations” in play activities were noted. “Pivots” were major shifts in the chi1ds choice of play materials, which marked entry into new play. “Elaborations” were additions of play materials to on-going play activity. One- minute intervals were noted on the pages of transcript. A sample 76 of a transcripted page from the therapy of Anna, showing verbatim verbalization, play pivots and elaborations, and time notations, can be found in Appendix D. The notation of pivots and elaborations proved necessary for the next step, the construction of “time lines” for each session. Time lines showed in summary form per session all of the major attentional breaks or pivots as well as play elaborations. Above the time line, the therapist noted key play activities. Below the time line, the therapist noted key verbalizations. The construction of time lines enabled the researcher (a) to see at a glance the progression of play activities within sessions, (b) to compare trends in play across sessions, and (c) to identify the child’s principal play materials. A sample of a portion of a time line is found in Appendix D. The Data Analysis Phase The data analysis phase consisted of the coding of play themes followed by the coding of verbal themes. Coding of Play Themes Coding of the play themes, or patterns in the child’s play activities, began with the construction of the time lines. Through the construction of the session time lines the researcher was able to identify the child’s principal play materials. The primary criterion for determining the child’s principal play materials was the comparative frequency of play with materials across sessions. Using the information on principal play materials generated by the time lines, the researcher compiled for each play material a chronological listing within and across sessions of all of the 77 child’s interactions with that material. These were called event listings, of which a sample excerpt from Anna’s therapy may be found in Appendix D. As is evident from the example, corresponding verbal highlights were also noted. With the complex web of the child’s play activities thus broken down according to play material and chronology of usage, the researcher then sorted each event listing into themes for each principal material. To determine the themes, the researcher used a two-fold strategy of letting the data reveal itself and asking the data a question. Specifically, the therapist poured over the chronologies, attuning to the types of distinctions in play material usage. The therapist repeatedly asked of these data the question: How does the child’s use of a given play material differ from preceding use? For each child, the answers to this repeatedly asked question differed. The answers to this basic underlying question determined the designation of play categories. The coding categories for play themes had a behavioral focus, noting the shifts in the child’s interaction with a given material. The resulting categories were then charted across sessions in order to portray the succession of the themes and their transformations over time. The reader is advised that within the four case accounts nonoperationalized terms such as aspects, dimensions, facets, and so on, are used interchangeably to denote the components of a given code. Coding of Verbal Themes Verbal themes were coded for each principal play material. To determine the verbal themes, the researcher consulted the event listings and continually referred to the verbatim session 78 protocols to ensure that all verbalizations were considered. The strategy for ascertaining the principal verbal themes varied according to the degree of verbal sophistication of the participant. For participants with limited verbal faculties, the researcher was able to compile for each material a straight vocabulary listing across sessions. For more talkative participants, the researcher perused the event listings and the transcripts for clusters of related referents occurring in association with a given play material. To ascertain a given theme, the researcher adopted the strategy identified above: (a) letting the data reveal itself by reading and rereading the transcripts and the event listings; and (b) asking the data the question: How are these referents related or alike? To determine transformations within a given theme, the researcher asked the data the question: How do these referents differ from previous referents within the same thematic category? Charting the verbal themes and their transformations across sessions revealed their general progression over time. The Written Accounts The next 4 chapters contain the case study accounts of the 4 participants. Each chapter begins with a case profile, which gives a brief developmental history and the basic reason for the child’s play therapy referral. In order to safeguard participant confidentiality and anonymity, only that background which was necessary for the reader to make sense of the child’s play and verbal themes has been included. All names have been changed, and certain details have been modified to protect the identities of the children and their families. 79 Each introductory case profile is followed by the identification of the phases of the child’s play therapy and their principal play materials. This is followed by a detailed description of the transformations in the play themes with the principal materials. The verbal themes associated with the principal materials are then identified and their transformations detailed. In this study, the phases of data collection, data analysis, and write-up overlapped and were interactive. Throughout the process of writing the accounts and the intricacies of the play and verbal themes, the researcher found that consideration of the thematic trends led to a further understanding of each child’s experience of play therapy. A summary narrative concludes each chapter. This concluding narrative utilizes the child’s play and verbal themes as tools of understanding to refract and explicate each child’s experience of play therapy. The reader is advised of the following stylistic convention in these accounts: The figures given in parentheses, e.g., (6) or (5 through 9), refer to the session number. 80 CHAPTER IV. CASE 1 ANNA: THE REEXPERIENCING OF INFANT LIFE Anna’s play therapy sessions were replete with the detailed and often dramatic reenactments of aspects of infant life, from birth through toddlerhood. Anna was nearly 4 at the outset of play therapy. Her presenting difficulties had perplexed several specialists, who had advanced several diagnoses in an attempt to explain some problematic behavior patterns, such as tantrums, a tendency toward hyperactivity, and occasional sleep disturbances. Anna sometimes avoided her peers, preferring solitary play. Anna’s family was very concerned about the difficulties their youngest child was encountering. Anna presented as a highly verbal child, with a well- developed and, as this analysis will later illustrate, sophisticated vocabulary. Anna possessed a number of other strengths. An active and energetic child, she enjoyed a range of age—appropriate play activities. Her play in the classroom was often characterized by elaborate fantasy sequences, such as dress—up or solitary house play, evidence of her creative abilities. With regard to her developmental history, Anna’s birth had been perilous and difficult. Her presenting breech position had threatened her life. Throughout her early childhood, Anna had suffered frequent upper respiratory infections. She had required ongoing medical treatment, which included frequent visits to several doctors, repeated medical tests, many of which were painful and intrusive, and, on a few occasions, brief hospitalizations. Health difficulties, both minor and major, 81 persisted to some degree throughout her play therapy. Overview of Anna’s Play Therapy From the first session, Anna responded happily and enthusiastically to the nondirective play therapy setting, which gave virtually free rein to her creative and impulsive energies. Anna quickly established a level of comfort in the playroom and basic trust with the therapist. By the third session, she had begun to surface in her play consequential psychological material, namely, enacting the birth of the infant. Anna filled the next 12 sessions with the recreation of many aspects of infant life: birth, sleeping, feeding, messing, washing, aggression, and the infant at play. The concluding 4 sessions saw a decrease in the intensity, frequency, and duration of her enactments of infant life. In these latter sessions, Anna began to use other play materials in the symbolic representation of her current real—life struggles. Specifically, Anna utilized the figure of a small whale as a patient, while Anna as the doctor tended him with painful injections, comforting bandaids, and verbal warnings of death. Although Anna’s enactments of infancy still recurred, they now alternated within sessions with segments of whale doctor play. Positive developmental gains began to accrue outside the playroom. Her progress in school and at home proceeded in spurts. Considerable behavioral improvement manifested shortly after the first 5 sessions, as Anna began to calm at home and to participate without behavioral outbursts at some family outings. Behavioral and emotional changes generally followed a “two steps forward, one step back” pattern throughout her therapy. 82 “Best ever” adjustments at home and at school, as reported by her parents or teachers, were usually followed immediately by troubled periods, during which behavioral difficulties such as tantrums or sleep disturbances recurred. Midway through her therapy Anna was required to undergo a battery of medical tests in hospital. This potentially traumatic event proved to be a positive test of her progress to date. In contrast to earlier hospital experiences, Anna, with the active support of her family, was able to tolerate the medical procedures without incident. The fact that her return home was not followed by serious regression into acting out behaviors was an achievement for her, suggesting some enduring emotional gains. Ultimately, through her therapy, Anna succeeded in remediating some of the effects of her difficult birth. By late spring, Anna had moved slowly but steadily into a new and stronger relationship with herself, her peers, and her family. She was happier and more resilient emotionally. She was less susceptible to tantrums or to bouts of anxiety, and she had begun to seek out and to enjoy play with peers. The Phases of Anna’s Therapy Anna’s play therapy advanced in three broad phases. In the brief Beginning Phase (Sessions 1 and 2), Anna engaged in a number of activities, which included sustained care-giving sequences, such as preparing food (playdoh, sand, and water) for the therapist (1) and giving the therapist a medical check-up (2). Session 3 marked the beginning of the Middle Phase, the Enactment of Infant Life, in which Anna herself was usually the recipient of care. These enactments of birth, feeding, sleeping, 83 messing, aggression, and infant—at—play continued in rich elaboration through Session 15. Representations of Hurt and Healing thematically dominated the End Phase (Sessions 16 through 20), alternating with enactments of infant life. In this final phase, a small whale, which had appeared throughout Anna’s therapy, figured prominently. The Principal Play Materials The recurrence of play materials across sessions served as the principal criterion in determining the play materials central to Anna’s therapy. Their appearance across sessions is summarized in Figure 1. Infant—related props were the primary materials of Anna’s Infant Play. A simple cotton sheet served as the infant’s receiving blanket, an essential prop throughout this play. Other props included the doll cradle, baby bottles and soothers, the tea set, a bib, and assorted objects which Anna used as the “baby’s toys.” The Doctor Kit, Paints, and the Whale were also central to Anna’s therapy. Her play with these materials was also submitted to thematic analysis. Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Material INFANT PROPS * * * * * * * * * * * * * * * * * * * * DOCTOR MATERIALS * * * * * * * * PAINT * * * * * * * * * * * * WHALE * * * * * * * * * * * * * * Ficure 1. Anna: Overview of Play with Principal Materials 84 Infant Play: The Play Themes The play themes comprising Anna’s Infant Play were determined according to the natural life activities they represented: Birth, Sleeping (in bed and in a crib), Infant Aggression, Eating, Drinking, Infant-at-Play, Messing, and Washing. As Figure 2 depicts, Infant activities were added incrementally to her play repertoire, until, over time, Anna was enacting a wide spectrum of infant life. Within each session, infant activities overlapped and interwove in a seamless whole, with the hungry infant Anna pausing to play, then drinking from her bottle, then climbing into her crib to read a book, and so on. For the purposes of this study, these thematic threads have been teased apart and subjected to discrete analysis for play and for verbalization components. Precursors of infant play. Anna’s infant play began with two fleeting and, at first glance, almost trifling incidents in the Beginning Phase. In the first (1), Anna simply handled the tiny crib from the doll house and wordlessly placed it on the playroom table. In the next (2), she buried the same crib and in it a small baby figure in the sand tray. These segments, though brief, are consequential as thematic precursors to Anna’s later well-elaborated infant play. 85 Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Theme PRECURSORS * * MESSING * * * * * * * * * * * * * * * * * * BIRTH * * * * * * * * * * * * * SLEEPING Bed * * * * * * * Crib * * * * * * * AGGRESSION * * * * * * * * EATING * * * * * * * DRINKING! BOTTLE Water * * * * * uice * * * * * * INFANTPLAY * * * * * * * * * * * WASHING * * * * * * * * * * * * Figure 2. Anna: Play Themes with Infant Props Birth. The dynamic theme which characterized Anna’s therapy for months was the enactment of the birth of the baby (3 through 14; reprised in 19). Her first enactment of an infant’s birth was preceded by the spilling of water. After making a huge water mess on the floor, Anna crawled into the therapist’s lap and asked to be wrapped in a blanket. A brightly colored flowered sheet was adapted for this purpose. Curled in the therapist’s lap in a breech (head up) fetal position, and wrapped in her “flowered blanket,” Anna squirmed inside the blanket and made faint squeaks and infant sounds. From this enclosed posture, Anna tentatively reached out a hand or a foot, and then withdrew it into her blanket cave. Anna then lifted the blanket from off her head and, looking radiant and happy, exclaimed, “It’s a baby 86 girl!” This was the genesis of the birth enactments which constituted the thematic core of Anna’s primal play therapy. Within sessions and across sessions, Anna repeated the Infant Birth sequence many times. In its most dramatic variation (3, 4), Anna repeated what appeared to be an enactment of a breech birth. She extended her legs first, uncovered the rest of her body, emerged feet first from beneath the blanket, and glowingly announced the birth of the baby. In other variations (4 through 9; 11), fetal Anna remained enwrapped for long periods, not wanting to come out. Sometimes Anna played a game of neonatal peek-a-boo, slowly lifting her blanket, or permitting the therapist to do so, and glancing at the therapist with a look of happiness mingled with fear. At these times in her play, Anna’s face had the soft and vulnerable cast of a newborn. Often Anna emerged glowing, playful, and interested in pursuing other infant—related activities, sometimes returning to more birth enactments following sleeping, washing, or feeding sequences. Anna became attached to the flowered sheet in which she first enacted a birth sequence (3). She used this favorite “flowered blanket” throughout her therapy for birth play or adapted it for use in other infant enactments. It became a transitional object of critical importance (Winnicott, 1971), and it figured prominently in the next dimension of infant life to emerge, Sleeping in Bed. Sleeping in bed. Moving of f the therapist’s lap following her first birth enactments (3), Anna crawled onto the nearby table and asked the therapist to provide more blankets so that she could create a bed for herself on the table surface. Still 87 referring to herself as the “baby,” Anna paradoxically bound off the table and capably arranged and rearranged the layers of blankets on the table, eventually crawling under these covers for a pretend sleep (3, 5, 6, 8, 9, 11, 14). She usually retained the “flowered blanket” from the birth sequences as her cover. Her bed-making activity was initially carried out with nervous even anxious movements (3). Increasingly, calmness infused this activity (e.g., 8). In one transformation, Anna, once in bed, asked for the playroom light to be turned off (6, 11, 14). She soon became anxious in the dark and asked for the light to be turned on again. In another variation of the Sleeping in Bed theme, Anna incorporated sequences of being fed imaginary food (9) or a real bottle (11). In Session 9 Anna felt particularly playful upon awakening. She frolicked on her bed/table, engaging the therapist in a game of mimicked babbling. The Sleeping in Bed activity overlapped with and was ultimately replaced by another neonatal subtheme, that of the infant sleeping in a crib. Sleeping in a crib. Anna enjoyed the confines of the small wooden cradle (11, 12, 13, 15, 16, 18, 20). Intended for large dolls, this cradle was large and sturdy enough to accommodate her seated upright in it. Wrapped in her original flowered blanket, Anna usually spent her time in her “crib” drinking a bottle of water (10 to 14) or juice (after 15). Across sessions, Anna’s crib time was consistently linked to bottle drinking. A few additions to this basic activity occurred across sessions, with some developmental progression discernible: wearing baby “pajamas” (a piece of cloth); holding smaller play 88 materials as the infant’s toys (e.g., 10); requesting the light to be turned off (11); listening to a storybook (13); paging through the book herself (15); and watching the therapist draw her a picture of “baby Anna” (16). Eating. The activities of Infant Eating and Infant Drinking both emerged following birth sequences in Session 4. For the purposes of analysis, Infant Eating was distinguished from Infant Drinking as follows: When Anna drank or pretended to drink liquids from her bottle, the activity was identified as Infant Drinking. When she used tiny cutlery to spoonfeed herself, the activity was identified as Infant Eating, even if she were spooning the mixture from her bottle. This distinction was made in response to the degree of developmental regression which she permitted herself through play, i.e., whether she was enacting an infant (drinking) or a toddler (eating). The Infant Eating activity recurred throughout her therapy (4, 5, 6, 8, 9, 10, 20). Neonate Anna’s food was sand, which she prepared for herself in a baby bottle. During Infant Eating, Anna spooned tiny portions of sand from the bottle and either ate it, pretended to eat it, or fed the therapist the mixture. Usually this activity took place with Anna seated on the therapist’s lap, with the flowered blanket wrapped around her. In an above—cited exception, Anna ate and was fed sand while on her bed/table (9). When the Infant Eating activity reprised at the end of her therapy (20), it contained a number of changes. Anna no longer used the bottle or sand as play props. Instead, she set the table with the tiny teaset and cutlery, sat in the “baby’s chair” and fed herself, a “nice baby,” a water and juice “dinner.” 89 Drinking. Anna shifted from the imaginary or actual ingesting of sand to drinking water from a bottle in Session 10. Anna usually drank her bottle of water while seated in the therapist’s lap or when ensconced in her crib. In both cases, she remained covered in her flowered blanket. Anna enjoyed this bottle drinking activity, sucking on the bottles at length and/or returning to drink from her bottle between other infant activities. This activity remained consistent, with no transformations across sessions other than the therapist’s providing juice for baby Anna (15 and following). Once juice became available, Anna often enjoyed having two bottles (one of water and one of juice). She held one while drinking from the other in turn, or she sometimes playfully drank from both at the same time. A fleeting transformation of the drinking activity occurred (18) when Anna used a soother for several seconds. Infant—at—Play. Anna’s Infant—at—Play sequences varied across sessions and were embellished with unique details. Lighthearted and even mischievous elements often permeated Anna’s infant play, which began at the prenatal level and gradually became more developmentally advanced. Anna’s playful sequences began as she moved and squirmed from within the blanket womb or uttered tiny squeaks and sounds to get the therapist’s attention (e.g., 4). Complex, sustained, exuberant, and interactive sound play later comprised her neonatal infant play (9). In this sequence, Anna knelt on the table and wobbled back and forth, as is characteristic of a baby learning to creep or crawl. As she moved, she uttered a range of babbling sounds. The therapist imitated her playful sounds, and 90 Anna enjoyed this mirrored baby play with the therapist/maternal figure. In later infant play Anna incorporated various play materials as the infant’s toys. Early in her therapy (5), Anna cuddled in the therapist’s lap, still wrapped in her flowered blanket, and elicited the therapist’s help in completing a puzzle. In a central session (10), she climbed on top of the shelves and proudly showed the therapist how well the baby could pound the cobbler’s bench by “himself.” In the latter half of her therapy, Anna incorporated objects as the infant’s toys, which she usually held as she drank her bottle(s) in her crib or on the therapist’s lap. These objects included a book, a small doll, and, in later sessions, the small whale. In one instance (15), Anna clutched a small alligator as an infant’s toy. While she drank from her bottle, the alligator pretended to “bite” the therapist. Anna was capable of cooperative play with the therapist! maternal figure. In a unique play sequence (12), Anna, as infant, sat on the therapist’s lap and enjoyed painting the table with her. Anna handed the therapist “the big mommy brush” while Anna used the “little baby brush.” The infant’s play was sometimes kinesthetic, involving energetic movement or the physical immersion in materials. Digging in the sand was one example of such play. In Session 6, for example, Anna sat in the sand tray, completely covering herself with sand. After climbing out of the sand tray, she lay calmly on a small piece of carpet, grabbing her toes and rocking on her back like a baby. In another example of kinesthetic play 91 (20), Anna repeatedly jumped from a basin of water onto the therapist’s lap, dousing the therapist with water. Messing. Anna engaged in some type of messing activity in every session. In the role of infant, she used several tactile materials for her messing activities: painting herself with water colors; overturning the basin of water onto the floor; or, as noted under Infant-at-Play, climbing into the sand tray and messing in sand. Washing. Anna denoted the plastic basin of water as the “baby’s bathtub.” Her bathing activity, in which she stood or sat in the basin, recurred in most sessions (6 through 9; 11 through 16; 18, 20). Most commonly, Anna took one or two such baths within a sequence of infant activities. However, in one central session (11), she returned to the washing activity 6 times. Occasionally, Anna elaborated the Infant Washing activity by climbing out of the basin and making wet footprints on the floor (8) or by painting her feet as she sat in her bath (11). Infant aggression. Anna’s infant persona engaged in a number of aggressive acts. Some of these, such as spilling water or throwing sand, overlapped with the Messing activities described above. The subcategory of Infant Aggression included aggression directed against the therapist. At first, this took the form of smearing playdoh on the therapist’s hands and occasionally on her clothing (3 through 6). In Session 9, the smearing of playdoh on the therapist’s hands served as a pretense for Anna’s hitting the therapist’s hands. In the next phase (12 through 15), Infant Aggression escalated. Following a birth enactment, Anna wriggled out of her blanket and, lying in the 92 therapist’s lap, kicked the therapist’s arms vigorously. When Anna’s attack of the therapist was particularly intense in Session 14, Anna retreated to the sand tray. Reassured that her anger would not harm the therapist, Anna resumed her attack. Soon after, she burst into tears. Infant Play: The Verbal Themes The most abundant and varied verbalization occurred in the context of Infant Birth enactments. This analysis focuses first on the categories of referents emergent in Birth play. Many of the categories, which first emerged in birth play, persisted across all aspects of infant portrayals as indicated below. This analysis then highlights the principal verbal themes emergent in other infant play categories. Songs and Embedded Stories are discussed as special verbal phenomena. Infant Birth: The Verbal Themes Verbalizations associated with Infant Birth clustered around the following thematic categories, which are described below and depicted across play phases in Figure 3: Infant Sounds; Infant Identity; Prenatal/Perinatal Experience; Neonatal Emotional States; and Neonatal Physical States. Infant sounds. Infant Sounds predominated before, during, and immediately after Birth sequences and recurred intermittently in most of her infant play. This thematic category comprised 3 levels of preverbal communication: squeaks, babbling, and crying. 93 Phase Beginning Middle End Theme SOUNDS * * IDENTITY Baby * * PRE/ PERINATAL EXPERI ENCE Movement * Covered * Ambivalence * Birth process * PRE/NEONATAL EMOTIONS Excited * Safe * Fearful * NEONATAL PHYSICAL STATE Sick * Hungry * Tired * Clean * Figure 3. Anna: Verbal Themes Associated with Infant Birth Anna emitted faint squeaks from within her flowered blanket, in an attempt at prenatal communication. Babbling or baby talk consisted of syllables like “goo goo” or “puppa puppa pup.” Sometimes Anna babbled or used baby talk while still inside the flowered blanket. Often, after being “born,” she snuggled in the therapist’s lap and babbled happily in this way. Anna also occasionally pretended to cry (“waaah!”). Cries usually communicated the infant’s hunger or distress. These aspects of preverbal communication intermingled comfortably with ordinary verbal communication: “Wah bah bah! . . . But he’s just talking 94 for a little while. Ba kaka puutata” (10). Infant identity. Throughout her infant play, Anna identified herself as a “little baby.” Her verbalizations related to identity consistently depicted a positive and happy infant persona. Anna referred to herself as a “laughing baby” (9), a “magical” baby (11), a “cute” (13) baby, and a “surprise baby” (14, 19). In unique instances, she also referred to herself as older than an infant: “sweet little girl” (5) or “a bigger baby” (7, 8). In general, references to an infant identity (“baby”) predominated. Following her first birth sequence (3), she glowingly announced, “It’s a baby girl.” With only two exceptions, in which she referred to herself as a “baby boy” (10) and a “baby dinosaur” (11), Anna otherwise referred to herself as a girl baby throughout her therapy. However, when describing the infant in the third person, she often referred to the baby as masculine, e.g., “Baby is making a bed with his mommy right now” or “He doesn’t need it on him” (3). At times, feminine and masculine referents occurred within successive sentences: “He wants to curl up in his mummy’s tummy. • . She’s not coming out!” (4) Paralleling and complementing her self—depiction as a “baby” were her continuing references to the therapist as mother. Anna unfailingly called the therapist “mama.” This concept was deeply embedded in her infant play: “You’re the mummy and I’m the baby” (4). Even in the final session (20), Anna commented, “Susan has a new baby.” At the same time, Anna was keenly aware that she was engaged in a dramatized play relationship. During her first 95 infant enactment (3), she informed the therapist: “You’re not my real mommy. Carol S. is my real mommy.” Prenatal/perinatal experience. Descriptions of prenatal experience were associated with sequences of birth play. Although these referents varied across sessions, cumulatively they provided a striking picture of her play persona’s prenatal life and birth experience. A number of referents clustered around the notion of fetal movement. Anna described herself as “moving” (4), “wiggling” (6), and “turns around” (8). As well, Anna appeared to be intensely aware of the infant’s position: “She’s curl on her mommy; curl curl curl. . . . He wants to curl up in his mummy’s tummy” (4). The concept of being covered was also verbally expressed. The baby was described as “hiding” (3, 11) and “covered” (7, 8,). In a similar vein, the flowered blanket was referred to as the baby’s “cocoon” (3) as well as her “cage” (11). Evidently struggling between a sense of prenatal comfort and safety (“cocoon”) and entrapment (“cage”), infant Anna expressed ambivalence about emerging from the flowered womb. The infant was “peeking out” (4). She often alternated between “coming out” and “she not gonna come out again” (e.g., 4, 5). Anna’s descriptions of the process of birth were especially vivid: “It’s crunching out. Crunch crunch crunch” (4). Similarly, as she lifted the flowered blanket to emerge, she commented, “The baby went out of there” (4) and “This is opening up” (11) Prenatal/neonatal emotional states. In her play of prenatal 96 experience, Anna expressed a range of conflicting emotions. She felt safe (3) in her cocoon, and she was excited: “Baby’s in your tummy ‘cause she’s excited” (4). The infant within the blanket also experienced some serious, and well—identified, fears: “She’s hiding ‘cause there’s monsters” (3). She further elaborated this sense of intermingled distress, fear, as well as some possible solutions to these states (3): “The baby was so upset about something, so the baby went fast a fast asleep. ‘Cause something killed him. He’s with his mummy now. He’s not scared any more. He’s in his little cocoon.” References to fear recurred: “She wants to go back in ‘cause she’s too scared” (5). Neonatal physical states. Anna verbally described the neonate as experiencing a range of physical conditions. The newborn was first described as feeling sick (3, 4): “He has a cold” (3), and “The baby’s really sick. She has to have some medicine” (4). When the newborn was hungry, she sometimes made articulate requests for food: “some dinogettis ‘cause he’s really hungry” (4) and “breakfast” (10). On occasion, the newborn was tired and wanted to take a “nap” (10, 12). Anna even “napped” while still inside the blanket/womb: “He’s gonna have a little sleep now ‘cause he’s too tired” (10). In one instance, Anna referred to the newborn baby as feeling clean following a birth enactment: “Now the baby feel all clean now” (8). Verbal Themes Associated with Other Infant Play The verbal themes emergent during other aspects of Infant Play are summarized by play category in Figure 4. External Referents, Songs, and Embedded Stories are also discussed. 97 Play Category Theme MESSING SLEEPING ANGRY EATING DRINKING WASHING PLAY Muck Mess N/A Tired Sick Hungry Good food Good food Bad food P00/Dirt Dirty Clean Remorse Pride Delight Pleasure Pleasure Pleasure Fear Fear Anger Hit Bite Storm Figure 4. Anna: Verbal Themes During Other Infant Play Sleeping in bed. When Anna enacted the infant in bed, referents to tiredness, wanting to go to sleep or to have a little “nap,” dotted her discourse. These were the only referents related to this activity which saw some repetition across sessions (3, 5, 6, 9). Referents to feeling sick (“cold,” 3) or being hungry (“ice cube” dinner, 9) were sparse. Generally, the referents clustered around the notion of physical state or condition. As for emotional states, although Anna appeared anxious whenever the lights were turned off during this play, she verbalized this fear only once: “He is scared. Would you turn on the light?” (6). Enioyxnent typified this play. Generally, Anna seemed to enjoy the bedmaking process as much if not more than the “sleeping” aspect. She appeared quite proud of herself making her own little bed: “Baby, let’s get you nice, nice covered up. That’s good. It’s nighttime now and time for sleep. 98 Time for having a nice sleep. That’s it. You’re all in your nice little bed” (6). Sleeping in a crib. Perhaps because her crib time was usually linked to bottle drinking, there were few referents distinctive to this play. A few related remarks appeared to indicate a positive feeling about this activity, e.g., her stressing that the crib was “fly bed” (11,12), “I like in my crib” (11), and the fact that it was “cozy” (13). Unique infant- related referents concerned a request for “pajamas” (11) and a “diaper” (13). On one occasion, with the lights off, she struggled with fear: “There’s no monsters in here? . . . There’s some, there’s, I’m in my bed” (11). Eating. Anna first introduced the topic of food and hunger following a birth sequence (4), translating her baby talk for the therapist: “Gaga! Food!” Particularly during the first half of her therapy, before Anna began prolonged bottle drinking, Anna most often referred to her sand food in appealing terms: “Baby likes his food,” which was also identified as “good” (5). Positive references predominated in Session 8, when she described the sand food as: “breakfast,” “cherry juice,” “dinner,” and “restaurant.” However, to a lesser degree her sand food was also described in distasteful terms. It was “yukky” (4), “gukky” (5), “p00” (4) and just “dirt” (8) Drinking. When Anna shifted to drinking water (rather than spooning sand) from her bottle, her verbal referents consistently expressed pleasure, e.g.: “I want some milk. . . The baby like her bottle. . . . I have a drink. I think it’s good” (11). References related to oral aggression surfaced in the unique 99 instance of her drinking from the bottle while playing with a small alligator figure (15). While Anna happily drank from her bottle, she put the alligator in the therapist’s shirt pocket, commenting: “He goes inside and he eats something. Yummy. That was warm. . . He drinks some. . . . Now you have bites all over you. . ‘Cause he’s only a monster.” Messing. Anna repeatedly referred to her sand and/or water messes as her mucky mess of which she was clearly proud. References to “mucky mucky messes” persisted throughout her therapy. In a unique instance, she smeared her hands and the therapist’s clothing with blue playdoh, warning the therapist that she would “never get away” from Anna’s “gooey hands” (3). Washing. Anna consistently verbalized feelings of pleasure and delight in her bath and in being clean. The water basin was her “special water,” (8), the “baby bath” (9), and once “my swimming pool” (11). Preceding her baths, Anna was aware of being “so dirty” (11, 13). During and afterwards, she was happy to be “nice and washed” (11) and “all washed up” (12). Her pleasure was epitomized in the following self-description: “She played in her bath and clapped her hands like this” (11). Infant-at-Play. No particular verbal theme emerged during infant play. Anna generally described herself as infant in the process of playing: “Baby found a puzzle,” (5), “The baby’s playing sand!” (6); “This a dry place for him to play” (10); “Baby this is his toy” (11). In Session 9, preverbal sounds constituted the play, as Anna and the therapist played an interactive game of mirroring each other’s vocalizations. Infant aggression. Mess—making overlapped with Anna’s 100 aggressive play. Usually she referred to the results of her aggressive actions simply as a “mucky mess.” Later in her therapy, when she began to physically attack the therapist, her expressions of aggression and anger became more direct. She called the therapist “you sweater” and told the therapist, “I’m gonna hit you!” (12). She also wanted to “bonk” her and then, troubled by this action, added, “I’m so sorry, mommy, ‘cause it was just when I was just, when I was little” (13). In her most intense attack on the therapist (14), she told the therapist that she wanted to “bonk you” but that “I’m afraid you might get hurt.” Informed that her anger would not hurt the therapist, she responded, “I’m glad to hear that,” and resumed her attack, followed by tears. External referents. Anna’s sessions were dotted with a number of informational and/or self-disclosing statements related to her life outside the playroom. These included her disclosing or describing (a) being hungry after medical tests; (b) the time she broke her arm (5); (c) her video movies at home (6, 8); and (d) her dislike of spankings (16). Usually her tone during these disclosures was one of intimacy. Songs. Throughout her therapy, Anna interwove within her play no fewer than 53 little songs. Only a handful were repetitions of popular children’s songs (e.g., Puff the Magic Dragon; 3). Most were her own creations; and most were brief sung or chanted descriptions of the play at hand or cheerful musical embellishments to her play. Simple examples related to infant play, included: “Baby baby bottle. Baby baby bottle. Baby body” (10) or “I took my bath and I had big” (11). 101 Her most elaborate song related to infant play occurred as Anna prepared to lie down for a little sleep. The composition was rich in imagery (8): “The little whale, and in the morning when it’s dry, little baby. When it’s nighttime, in the falling rain, I’ll sleep in flowers. I want my. I went in to my mum. Hmhmhm. And then the waterfall. Hmhmhm.” Embedded stories. Embedded Stories characterized Anna’s discourse. These stories, 20 in all, differed from descriptions of her activities (e.g., “I’m gonna put this one here”). Rather, for these narratives Anna adopted a special “story telling” voice. She added characters and imaginary events. She seemed carried away, talking partly to the therapist and partly to herself. Embedded in the larger sequence of her play, these stories often contained elements of narrative structure, phrases like “and then” or “one day” or other verbal markers to denote a beginning, a middle, and/or an end to the tale she created. The following are representative examples associated with infant play: 1. While making her bed: “When baby’s making his bed one day. Over the hills and far away, and he like to” (5); 2. While sitting in the sand tray, covered with sand (6): The baby’s playing sand. And that’s for my Gramma. When she see that. My Gramma and Nan. And Grandpa will come to pick me up and my Mumma too. Yup. And they all hug me and kiss me. And they they come and do. Remember? 3. After emerging from her flowered blanket (11): I’m a baby dinosaur. I’m Little Foot. Little Foot was so happy to see his girlfriend named Sara. Sara was so heavy [sic] too. So be careful. So she had to just. Ah. I’ll save you, Sara. Ooh. His mother didn’t know what to do with him so he put him in her bathtub. 102 In general, Anna’s Embedded Stories mirrored and encapsulated certain themes emergent throughout her therapy, such as fear, neediness, vulnerability, and pleasure. Doctor Materials: The Play Themes Doctor Play was second to Infant Play in frequency across sessions and as a dynamic factor in Anna’s therapy. It began fleetingly, lay dormant for several sessions, and reemerged as an important and well—developed component of her play in Sessions 16 through 20. In virtually all doctor play, Anna retained the role of doctor, ministering at first to the therapist and later to the small whale as her patient. Figure 5 charts the emergence of the principal doctor play themes across sessions. Session Middle Phase 1 2 3 4 5 6 7 8 910111213 1415 1617 181920 Theme EXAMINES INSTRUMENTS * * THERAPIST AS PATIENT * SELF AS PATIENT * * WHALE AS PATIENT * * * * * Figure 5. Anna: Play Themes with Doctor Materials Examining instruments. Doctor play appeared initially in several distinct and isolated incidents. In the introductory doctor play sequence (2), Anna as the doctor spent a full 10 minutes exploring the doctor kit materials: syringe, stethoscope, blood pressure implement, reflex hammer, medical chart and others. 103 Treating therapist and self. Anna treated the therapist with 4 injections, each followed by a bandaid (2). In the next brief segment of doctor play (8), Anna required treatment for her own hurt. Almost in tears, she complained of hurt fingers and sought bandaids from the doctor kit. (The hurt may have been real or reflective of emotional hurt, as she had been upset and anxious from the beginning of the session.) She calmed and was able to resume play with other materials as soon as bandaids were applied. The power of bandaids to comfort and to ease pain was particularly conspicuous in the concluding, recurrent segments of her doctor play. Whale as patient. Doctor Play emerged as a sustained and well—elaborated play scenario in Session 16, lasting 17 minutes, or one third of the session. Anna repeatedly gave her new patient, the whale, injections followed by bandaids. She took his temperature and blood pressure, and read him his prognosis from the medical chart. This sustained, intense examination and treatment of the whale constituted the core of her doctor play in all successive sessions. Minor variations or additions to this basic play activity were discerned. These variations suggested the notion of recovery. First, the whale was permitted to return between injections to his water basin to swim (18), suggesting that his treatment over two sessions was beginning to have curative force, restoring him to his normal activities. Next (19), playful elements emerged as Anna tickled the whale when she finished treating him. Finally (20), she kissed him when concluding his treatment. These latter examples (tickling, kissing) contained 104 an affectionate tone. Doctor Materials: The Verbal Themes Anna’s initial Doctor Play (2) introduced the nuclei of the principal verbal themes——”hurt,” “crying,” “shots,” and “getting better”—— which received elaboration and detailed development in the final 5 sessions. To these central thematic concepts of Hurt or Pain, and Recovery were added the themes of Fear and Death as well as Help through Friendship (of. Figure 6). Session Middle Phase 12345678 91011121314151617181920 Theme HURT! PAIN * * * * * * * * RECOVERY (*) * * * * * DEATH * * * * FRIENDSHIP * * FEAR * Ficiure 6. Anna: Verbal Themes Associated with Doctor Play Hurt. Anna as doctor was shocked at Roo’s “hurt tail” (16). Roo was “hurt, she can’t swim” (16) and “sometimes [he] get hurt” (20). Many references to his Hurt condition interwove this play. Sometimes the notion of hurt related to the treatment itself, which was usually a “shot” or “owie” (16, 17, 19, 20). Anna vacillated within sessions and across sessions as to the degree of hurt the injections might cause Roo. Injections “hurt a little bit I think” (16), they “really hurt” (16), and it “doesn’t hurt” (16, 17, 19). They also contained “poison medicine” (18). Sometimes “hurt” reached the whale’s imaginary extended family: “Your mommy’s hurt, she can’t swim” (16). 105 Fear. Though few, Anna’s references to fear are significant, as references to fear had dotted other elements of her play (Cf. “monsters” during infant play). Anna expressed a sense of her own fears around the whale’s hurt: “I’m afraid you might get hurt” (16). Paralleling her contradictory comments around the concept of “hurt” and “doesn’t hurt,” Anna’s direct admission of fear was expressed together with its negation: “It’s not afraid. I’m afraid” (16). Death. The theme of Death appeared dramatically in her Doctor Play. Pretending to read the medical chart (16), Anna suddenly read Roo the news that he was going to die (16). References to Death recurred, and the topic appeared to be fraught with fear and often confusion for Anna: “You gotta die ‘cause you might get hurt”; “She doesn’t feel when she’s dead. She, when she’s dead. That’s when you die” (16); “When Roo dies, she’ll be sick” (17). “Remember something of dying? . . Roo when she’s dying, and Roo’s hurt, she dies. All about Roo when she dies” (20). She gave him terrifying news: “Your mommy died,” (16) “poor little whale, his mommy dead. She can’t swim. She’s hurt” (16); and “doctors kill you” (17). Friendship. Some references to Death were linked to attempts at solutions to this problem: “When you die, I’m gonna help your and you some bandaids to make you better.” Bandaids appeared to offer some hope to these persistent fears, as did Friendship. Involving the small fish figure in this play, Anna told Roo, “You gotta die, Roo, ‘cause you might get hurt. Your friend will help you” (16). When the little fish arrived, Anna remarked, “No more dying, Roo” (16). On the other hand, the 106 whale’s friend remained vulnerable: “I’m gonna make you a friend. . . . Now your friend is hurt too” (20). Recovery. The notion of Recovery was composed of a number of thematic strands. This was evident in Anna’s role. She referred to herself as the healer, the “doctor whale,” (16), a “good doctor” (16), and “the nurse” (20). Injections were followed by bandaids, which were invariably described as a “special treat” or a Ilsurprise.H There was evidence of affection, as when she kissed her patient (18, 20) on his “cute little eye” (20). She referred to the recovery process itself. Anna told Roo “you’re fixed” (16). She reassured him, “That’s much better now, Roo” (17), and told him she was making him “better” (20). At the same time, Anna was not completely certain that he was better. Some anxiety about his condition persisted. Many times throughout her medical care of him, she asked him with intermingled hope and fear, “Are you all right?” or “Are you much better now, Roo?” The Whale: The Play Themes Play with the whale interwove much of Anna’s play therapy. At first, its incorporation in her play was brief and subtle, but in later sessions, whale play surfaced into prominence, strongly linked to both Doctor Play and Infant Play. In general, the whale underwent the following metamorphosis: Introductory Play Object; Marine Creature; the Doctor’s Patient; the Infant’s Toy; and the Focus of the Mural. Figure 7 depicts this progression, in which there was some overlap amongst these thematic elements. 107 Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Theme HELD OBJECT * * * * * * MARINE CREATURE * * * * * * * * * * * * * * MEDICAL PATIENT * * * * * INFANT’S TOY * * * * MURAL FOCUS * Figure 7. Anna: Play Themes with the Whale Introductory play oblect. Across 6 early sessions (1; 3 through 7) Anna consistently sought out the whale immediately upon her entry into the playroom. She usually placed him in water and did not return to play with him for the remainder of these sessions. These brief contacts with the figure of the whale, overlooked by the therapist during the therapy, acted as precursors to her later extensive use of that figure. Marine creature. This subcategory refers to the whale’s natural identity as a swimmer. In every session in which the whale figured in her play, Anna animated the whale, having him swim in the basin of water. There were two variations within this theme. First, in the early sessions (to 7) the whale swam only in clear water. In later sessions (13 and following) Anna added sand to the basin, creating a murky habitat for him. Second, in later sessions (13 and following) the whale was occasionally joined by the figure of the little fish, who functioned as a companion for him. 108 Medical patient. The whale shifted from being a literal, biological creature to acquiring an anthropomorphic, fantasy identity. As doctor Anna’s patient, the whale was the recipient of sustained, intensive medical care, as elaborated above, throughout the concluding sessions (16 through 20). He was subjected to painful treatments as well as care, comfort, and affection. Sometimes the painting of his tail, as cited above, appeared to be part of the recovery process. Infant’s toy. Infant Play alternated with Doctor Play in the final play phase (16 through 20). The whale functioned in both these major thematic categories, accompanying Anna back and forth from her infant persona into doctor play. Anna simply held the whale as the infant’s toy, as she cuddled in the therapist’s lap and drank from her bottle. In one variation, she clutched him playfully between her feet while she drank. In another variation, Anna treated him as a playmate, sharing her bottle with him (18) or spoonfeeding him some juice (19). These latter instances of cuddling and offering nurturance to the whale paralleled Anna’s simultaneous activity of receiving physical and emotional nurturance herself. Focus of the mural. The theme of the whale began and concluded Anna’s therapy. The penultimate play act of her therapy was to paint the playroom wall. Anna identified some of her large purple swirls as a whale, getting “bigger and bigger.” In this activity, Anna did not utilize the physical object of the whale. His two-dimensional depiction was sufficient for her to keep the essence of the whale active and alive. 109 The Whale: The Verbal Themes Verbal themes related to play with the whale assorted under the following categories, as depicted across play phases in Figure 8: Identity; Attributes; Setting; Hurt, Death, and Treatment; Relationship; and Nurturance. Embedded Stories and Songs recurred in all phases of whale play. Whale identity. The whale was first identified as a “baby whale” (1) and at the end of therapy was still (20) a “nice little baby whale.” During the Middle Phase, he was occasionally “Mr. Whale” (5, 13). However, when whale play resurfaced in the Final Phase, he received a more personal name, “Roo,” which persisted in Sessions 16 through 20. Even when Anna in one instance assigned Roo the role of mother, it was superimposed upon his basic identity of “Roo”: “Roo, you’re the mommy” (19). Whale attributes. In his first appearance (1), the whale was described as “black,” “hungry” and “thirsty.” He was “all right” and had to “be good.” Anna also called him a “poor whale,” denoting suffering or misfortune. This single referent precursed later references to the whale as “poor”: “poor little stuff” (14), “poor little whale” (16, 19), “poor little thing” (18). The aspect of smallness embedded in these referents also saw some repetition: “little small whale” (14); “be a good little fellow” (16). Phase Beginning Middle End Theme IDENTITY Baby * * * Mr. Whale * Roo * ATTRIBUTES Poor * * * Hungry! Thirsty * Little * * SETT ING Aquarium * * Pool * Dark water * * Bathtub * HURT * * * RECOVERY * DEATH * RELATIONSHIP Offspring * * Friend * * Sister * NURTURANCE * STORIES * * * SONGS * * * 110 Figure 8. Anna: Verbal Themes Associated with Whale Play The whale, like Anna, experienced a sense of conflict between wanting to express anger and having to be good: “Well, I don’t think I can get mad because I’m a whale. I always be a good whale” (13). Other descriptors of the whale ran a complete gamut of human attributes, with virtually no repetition: “happy” (13), “scared” (13), “has big teeth” (13), “only a whale” (15), “so happy she can swim,” “silly” (16), “beautiful” (17), “dirty” (18, 19), “the greatest” (20), and “a dirty little animal” (20). She also referred to Roo as “a girl” (16). 111 Perhaps the most unique verbalized referents concerned the way in which Anna verbally brought the whale to life. In Session 13, Anna picked up the whale and told the therapist: “Mr. Whale’s gonna say something.” However, he was not quite ready to speak, as Anna moved on to other play materials. Later (15), Anna conunanded him, “Come alive!” In Session 16, the whale at last functioned as a dynamic, interactional character. Anna handed the whale to the therapist and asked her, “Would you help her talk, and the whale song is gonna come.” This time Anna pursued extensive play and verbal interaction with the whale, with the therapist speaking for Roo. Setting. Roo’s natural habitat was a basin of water which was referred to as his “aquarium” (1, 14), his “swimming pool” (16), and his “bathtub” (18). However, Anna most often referred to the basin of water to which she had added sand as his “dark water” (15 through 19). Hurt, death, and medical treatment. Verbal references to hurt, death, and medical treatment proliferated when the whale served as a prop within doctor play. The description of these referents has been considered under Doctor Play. Relationship. A string of assorted referents suggested a thematic cluster around interpersonal relationships, particularly during the End Phase. There were repeated references to the little fish as Roo’s “friend” (16, 17, 20) who would “help you.” Roo learned that the little fish was his “baby sister” (19). There were consistent references to Roo’s mother: “Hello, I’m a little small whale. Do you know where my big mother is?” (14); “He has to have more dark water, so he can make his mother” (15). 112 Nurturance. Referents which suggested varying degrees of nurturance toward the whale involved affection and food. Anna offered him “a big hug” (16) and a “kiss” (17, 20). She playfully “tickled” him (17, 19). Sometimes, her care of him included tasty food: “juice” (17, 18), “dinner” (18), “soup” (19), “cake” and “whale food” (20). Roo was also offered a toxic substance, “poison” (19). Embedded stories. A number of Embedded Stories interwove Anna’s play with the whale, of which the examples below are representative. An early story emerged when Anna handled the whale for the first time (1). This story contained precursors of the themes of Whale, Mother, Baby, and Fear which were to unfold in greater detail as her therapy advanced: One day the mother took the little baby somewhere. And the baby said, “WahI I’m just a little baby. I’m in here somewhere. Get me out of here!” This one was next. And big bad. Grrr! Me too, me too, little whale. A later story highlighted the whale in his struggle between dirtiness and cleanliness (15): “Yippee!” he said. My, he wants. He’s going to get some mud. Erh erh erh. So he jump inside the mud and he just all dirty. And he had to get him all clean in some tub of water to make him all clean. A final example contained themes of hurt and recovery (16): Roo was so hurt. She went out of the swimming pool. Oh right here. And Roo was so happy. She wasn’t hurt any more. She got a fish. She was way up into the sky, ok. And Roo didn’t come down. There’s Susan. Songs. Songs interwove Anna’s whale play from the outset to the conclusion of her therapy. Like the Embedded Stories, her songs about the whale reflected the themes of her own play. Her first whale song was very brief (1): “Up we go. Up the whale.” 113 Another example reprised her doctor play themes (16): “I won’t believe the no whales. And then then Roo hurts her tail. She gets a bandaid and a shot. She swims.” The following song, an adaptation of a contemporary children’s song, described a playful Roo (17) It’s the way for Roo. It’s the way for her. It’s the whale are home. Nice, so heavy. It’s the whale. Do—do—do. Swim so wild and swim so free. It time for her to have some water. Wo-wo-wo. Whale all full of mud. Do-do-do. A song near the end of therapy (20) distinguished between creatures (whale and fish) which were “hurt” or “not hurt”: “Swimming little Roo. Swimming on her bum. Swimming swimming swimming swimming, swim two whale. One has bandaids and one doesn’t. Swim swim swim.” Painting: The Play Themes During the course of therapy, Anna’s painting activities appeared to be play interludes of minor importance. However, thematic analysis of these activities (cf. Figure 9) revealed interesting transformations reflecting developmental changes. Painting changed from being a body- or self-focused to an object or other—focused activity, and, ultimately, to a representational activity. Painting also progressed from being an autonomous, to an associative, then to an independent yet cooperative activity. Virtually all of Anna’s painting, throughout her therapy, was carried out in purple. Anna’s painting was initially highly tactile and self focused. In its earliest and most frequent manifestation, Anna painted her arms, legs, feet, and sometimes stomach with the water colors (1, 2, 3, 10, 11, 20). In the middle phase of 114 therapy, Anna began painting objects other than her own body. She painted the table with the water colors, smearing circles on its surface. In one instance (11), this painting occurred in interaction with the therapist. As noted under Infant Play, this sequence was noteworthy for her inclusion of the therapist in sustained, interactional fashion. Session Middle Phase 1 2 3 4 5 6 7 8 9101112 131415 1617181920 Theme PAINT Self * * * * * * Table * * * Whale * * Paper * * Wall * Ficrnre 9. Anna: Play Themes for Painting In the end phase, when treating the whale as the doctor’s patient, she occasionally painted the whale’s tail (17, 20) and/or (17) a “happy face” for him. The painting of the whale seemed to be part of the whale’s medical treatment (much like the application of mercurochrome) and at the same time an aspect of his improvement or beautification. Also in the end phase (18, 19), Anna initiated two art activities which at first appeared to be mundane. She began by painting (18) and by colouring with crayons (19) on paper on the floor. However, in both instances, destruction immediately followed creation, as she poured water on one drawing (18) and ripped the other in pieces which she then floated in the whale’s water basin (19). 115 Anna’s culminating painting activity, occurring in the final session (20), was the creation of a large mural on the playroom wall. This activity was unique in terms of the size and scope of her work with the paints; large circular swirls filled one section of the playroom wall. Anna verbally explained that she intended this mural to be a representation of marine life. Anna identified herself as the infant as she painted with the therapist. Yet this painting sequence differed from her earlier cooperative painting activity with the therapist at the table. In that case, Anna had acted the dependent and attached infant, seated on the therapist’s lap. In this final painting sequence, Anna still played the baby, but she was no longer the infant attached to the maternal figures. She worked apart from the therapist, taking turns painting the mural with her in cooperative yet independent fashion. The therapist was enlisted here more as a partner and playmate than as a maternal figure. Painting: The Verbal Themes Relatively meager verbalizations occurred in association with painting. Perhaps this was due in part to the fluidity of the medium and the calmness and concentration it induced. Nevertheless, the scant verbalizations still covered a wide range of topics. These formed only two thematic clusters with any consistency of repetition: Calls for Attention and References to Mother. There was some overlap between these two categories. There were also unique references to Fears as well as a verbal elaboration of the play theme of the Whale and other marine life. As Anna painted her hands, feet, and sometimes her stomach, Calls for Attention were often repeated within sessions: “My 116 mommy see this” (1, 2, 11), “mommy will look” (10), and “everybody see me” (2). Suggesting ambivalence about receiving attention, Anna also claimed that “Mommy won’t see this” (10). When the theme of Attention later recurred, it was directed to the whale. Specifically, after having painted the whale’s tail purple (20), Anna painted herself, “just like you do,” whale. “What do you think of me?” she asked him. A few verbal referents suggested that during the body- painting activity, Anna perceived the paints as enhancing her appearance. She referred to the paints as her “polish” (2). They made her look “so beautiful” (11). However, in one instance (3), she called her painted hands “gooey” and “mucky,” and she threatened to smear the therapist with them, telling her, “You will never get away.” At the same time (3), “They’re not gooey. They have paint on them, and they’re pink.” References to Mother, sometimes overlapping with these calls for attention, also constituted a thematic category in itself. In the beginning phase, as Anna painted herself, she remarked that “mommy wash this” (2, 11). In the middle phase, while seated on the therapist’s lap and painting with her (10), sometimes hand over hand, Anna persistently addressed the therapist as mother. She invited the therapist to join her by saying, “Paint with me, mama.” She repeatedly offered the therapist the “big mommy brush” while Anna took the “little baby brush.” She sustained the activity with such comments as, “Now it’s your turn, mommy.” Later in her therapy (19), when she created the picture which she then tore in pieces, she called it a “picture for my mommy.” 117 During a central session (10), having climbed on top of the toy shelf, using it as a perch on which to play, Anna expressed some intense fears. While painting, she commented that the baby “likes spankings.” Anna then threatened to “spank your [therapist’s] bum” and “paint you” and soon after asked the therapist, “Monsters coming out? . . . I get scared when they have claws on them.” Other unique verbal referents clustered around the theme of the whale and other marine life. As Anna painted the playroom wall in the final session (20), she first called her creation “a design” and “a giraffe neck.” But she soon identified the circles as “whale! . . . a really big whale. It’s so fat that it makes too much fish.” The marine theme continued: “Let’s make one little tiny little fish. . . . It’s getting bigger and bigger and bigger and bigger. . . because it ate the starfish. You see. This is a starfish. . . . You make a nemone [sic]? . . . I’m in a net.” Thematic Comparison and Contrast There was strong thematic consistency and overlap between Anna’s play themes and the attendant verbal themes. That is, Anna’s verbalizations elaborated and advanced the play at hand. Whether in the context of infant, doctor, whale play, or a painting activity, Anna for the most part tended to talk about and describe the play in which she was involved. In general, the major categories of play tended to generate discrete clusters of thematic material. Anna’s Infant Play centered around verbal and play themes related to Infant Life, Neediness, and Pleasure. Doctor Play generated play and verbal 118 themes of Hurt and Healing. Sparse but consequential references to Fear dotted these two principal play activities. Painting produced a cluster of referents descriptive of relationships. Through all of these activities, references to the whale were interwoven. Contribution of Play Activity to Therapeutic Process Anna created a complete, multifaceted, and realistic play identity for herself as the Infant. She gave birth to that identity in play and proceeded to elaborate many details of infant life: eating, drinking, messing, washing, sleeping, aggression, and playing. Anna also created a play persona for the therapist, as mother. The playroom itself became Anna’s nursery, the infant’s home, complete with crib, bottles, and food. In creating infant life, Anna was able to do more than enact the infant. She became the infant and as such in her play she reexperienced infant life. This reexperiencing encompassed not only the physical but also the emotional sensations of infancy and babyhood. Specific infant-related activities yielded specific therapeutic benefits. Through the birth activity, Anna had access to sustained physical closeness and cuddling and the sense of security that provided against fears. Drinking from a bottle gave her actual nurturance (the juice), emotional nurturance through cuddling, as well as physical pleasure in the sensations of drinking. Sleeping in a bed or in a crib provided opportunities for movement between states of anxiety and calmness. The aspect of infant-at—play enabled the safe 119 expression of aggression toward the therapist/maternal figure. Anna benefitted from the kinesthetic properties of play materials. She literally immersed herself in their tactile properties. She experienced absolute messiness, being covered in sand or paints, as well as the pleasure of feeling washed clean in her infant bath. Anna benefitted from the regressive experiences which the infant persona enabled. At times, her descent into developmental regression could be perceived with striking clarity in her play activities. For example, play in the crib developed after play in the bed. Drinking from a bottle occurred after eating activities. In these cases, the developmentally less mature activity followed a developmentally more advanced activity. Anna used her doctor play with the whale for the depiction and representation of real life experience. Anna as the whale’s doctor was no longer the vulnerable infant. She assumed the role of helper and healer, as well as one of control, power, and the ability to inflict hurt. In her treatment of the whale, she was able to depict current real life concerns of repeated trips to the doctor, receiving medical treatment, and so on. The whale, through the mechanism of projection, now carried the vulnerability, the fears, the helplessness, and the pain, giving Anna some symbolic distance from her persistent medical difficulties. Contribution of Verbalization to Therapeutic Process On the level of verbalization, Anna spanned a complete developmental range. The authenticity of the sequence of her infantile verbal development was striking. She began as a 120 preverbal, prenatal being, making imaginative approximations of fetal communication--faint squeaks from within her blanket in order to capture the mother’s attention. Later, Anna, like any developing infant, used sound itself as play and this served the specific purpose of forming the relationship with the maternal figure. Vygotsky (1978) has stated that the impetus for infant speech derives from the mother-child relationship, and that the play between mother and child serves to stimulate and enhance that development. As Anna rocked back and forth on the table and enjoyed mirrored sounds with the therapist, this circular interrelationship between playful mother-child contact, the enhanced motivation for infant speech, and the strengthening of mother-child rapport was vividly portrayed. Anna proceeded into overlapping infant and babyhood stage phases of babbling and baby talk, all of which were interwoven with her own age appropriate discourse. During later doctor play, Anna moved to the third—person description of difficult topics, such as hurt, death, and mother’s death as well as topics indicative of recovery, healing, help, and friendship. Anna was fluent on the verbal level, not only in terms of her vocabulary, which was often quite precocious (cf. the “excited” and “upset” baby). She also functioned verbally very capably, advancing the play on overlapping and sometimes simultaneous levels. That is, she was able to speak as the infant, while concurrently describing her infant activity in the third person. She interacted directly with the whale, talking to him and creating his personality as she did so. In addition, there were Songs and Embedded Stories which mirrored and which 121 captured in encapsulated form the themes and concerns which interwove her own first—person play. Her songs and stories, noteworthy for their rich and creative detail as well as for the sense of wholeness (beginning, middle, and end) they conveyed, provided windows of insight into Anna’s development. There were instances when Anna verbally departed from the play before her and raised topics related to her life outside the playroom. Such external referents, elements of self—disclosure, are an underlying goal of play therapy (Reams, 1987). Over the course of her therapy, Anna referred to a number of external topics, telling the therapist about her home, friends, doctors, injuries, and classroom life. Following these brief and personal disclosures, Anna was able to return to her play without a sense of interruption. A number of nonsequitors persisted in Anna’s speech. These verbal inconsistencies did not elaborate the play at hand nor were they restricted to a particular category of play. Often a string of related referents were followed by one which was unusual and sounded out of place, e.g., “my daddy come and all the fairies.” Her repeated contradictory references to herself as both a feminine and a masculine infant are another example of this verbal inconsistency. Anna also seemed to experience difficulty with the relationship between cause and effect. For example, her statement that “baby’s in his mommy’s tummy ‘cause he’s excited” is representative of this sort. Anna likely meant the reverse, that the baby was excited “because.” These types of verbal nonsequitors are seen as indications of a degree of inner struggle. 122 On the level of verbalization, the naming of the whale can be considered a positive critical incident. In naming him “Roo,” Anna for the first time bestowed upon him a specific, rather than a generic (cf. “Mr. Whale”) identity. This identity was dynamic in that the whale, following his naming, underwent a number of trials, adventures, healings, and relationships, including an active and interactional relationship with Anna. The whale’s identity was consistent in that he retained his persona and his name for the remainder of Anna’s therapy. Anna’s ability to verbally bestow a consistent identity upon this play material reflected her own growth toward a stronger and more integrated identity. Summary Narrative The following narrative uses the play and verbal themes analyzed above as the basis for a summary story of Anna’s therapy. Beginning phase. Anna entered the play room for the first time as if she had already intuited its purpose--to immerse herself in play of a deeply personal nature. Anna displayed neither shyness nor tentativeness in her approach to the play materials. She was active, energetic, and thoroughly involved with whatever material she chose. At times, her play seemed impelled by nervous energy. Yet she also appeared happy and excited to have a play arena in which she could indulge her play wishes. She involved the therapist in her play almost immediately and actively sought relationship with her. The play materials were at least in part Anna’s tools for the formation of contact 123 and closeness with the therapist. Using sand, water, and playdoh, she set about in an extremely busy and officious manner to provide “yummy” food for the therapist. Here, Anna enacted the maternal role of caregiver, of nurturer, a role which for her was to be short—lived. Anna used the doctor materials to examine the therapist, treating her with shots and bandaids, an activity that became prominent much later in her therapy. As busy mother and as doctor, Anna retained the element of control in her play interaction with the therapist. From the outset, Anna exhibited delight in the physical interaction with messy materials. She enjoyed handling the sand and water during her preparation of the therapist’s food. She stirred, mixed, and dumped the mixture and revelled in the pleasurable sensations of the materials. She similarly enjoyed painting herself with water colours and overturning the basin of water on the playroom floor. The beginning phase contained only the faintest precursors of the themes of the infant and the whale. Anna simply placed the doll house crib on the playroom table. By the simple act of transferring the crib from the margins of the playroom (the doll house) to the focal point of the playroom (the table) Anna appeared to be unconsciously, if microscopically, through a play symbol, raising the topic of infant life. She barely touched the whale. Yet extensive thematic changes burgeoned from both these minute play incidents. Middle phase. Anna’s enactment of the birth of the infant dramatically marked the beginning of the prolonged Middle Phase. In this phase Anna gave birth to the principal play identity from 124 which the rest of her therapy evolved. The reign of Anna as the controlling caregiver had ended. Anna as the infant drank in physical and emotional nurturance just as she drew physical comfort from her bottles. She epitomized gentleness and vulnerability. Cuddled in the therapist’s lap, secure in her flowered blanket and hidden from view, Anna was free to explore and to express fetal sensations. The physical sensations included “curling” and “moving.” Anna even attempted prenatal communication with the maternal figure. She emitted faint squeaks from within her blanket womb. The as yet unborn Anna experienced deep fears, of “monsters” and of being killed, as well as the “excitement” of being born. Between her fears and her excitement, Anna was suspended in a deep-seated ambivalence about being born. Her birth play afforded her the opportunity to completely immerse herself in and play out the extremes of that ambivalence. In her enactments of birth, Anna could enjoy the luxury of a biological impossibility, returning to the womb. She previewed the world she would be born into, lifting the flowered blanket to peek at the therapist. Free of any biological imperative, Anna was then able to withdraw again into her blanket to enjoy the security of prenatal life. The playful imitation of birth could advance unhurried and by degrees, with the tentative extension of an arm or a leg followed by its withdrawal. Her birth play often seemed to be a rehearsal of that event, as she repeatedly emerged into and withdrew from the world. Most striking were the details of her birth play which corresponded to Anna’s own breech birth. On more than one 125 occasion, Anna thrust herself feet first out of her blanket. Her comments on the baby as being “born” only strengthened this impression of Anna’s play as a deep—seated reworking of her own birth experience. Indeed, Anna seemed less to be playing at birth than to be thoroughly reexperiencing it. Often she emerged from her blanket looking radiant, with cheeks flushed and eyes gleaming. The rest of this phase of her therapy flowed quite naturally from this core birth experience. Anna as the “magical baby” claimed the playroom as her nursery, with the therapist functioning extensively as the maternal figure. The flowered blanket, which had served as the symbolic womb, accompanied her play in bed, in the crib, and on the therapist’s lap. The blanket functioned as a transitional object of critical importance, carrying the sense of security she had experienced “prenatally” into the expanded world of the neonate. Themes of comfort, care, physical and emotional nurturance, and relationship with the maternal figure infused this phase. Most of Anna’s infant experience was pleasurable. She experienced a sense of security in her bed and in her crib, nurturance and pleasure through her bottles. She delighted in the sheer physicality of messing and washing, and she enjoyed enacting--being--the active infant at play with mother. She sang happy little songs and embroidered her play with short stories. Anna also explored nonpleasurable and difficult aspects of infant experience. Anxiety and fears, particularly of “monsters,” surfaced in her infant play. Anna as infant also expressed considerable aggression toward the therapist in the 126 form of physical attacks. The “magical baby” and the angry baby were equally at home in the playroom nursery. End phase. The whale, who had lain dormant during the Middle Phase, suddenly came to life. Asking the therapist to “talk for him,” Anna gave him a name, and in that act of naming him launched the final phase of her therapy. Anna created in the whale named Roo a peer, a friend, an infant toy, a child, a companion, and a confidante. However, the whale primarily served as her medical patient, such that whale play in this phase was substantially fused with doctor play. In a sudden shift of roles and identities, Anna the infant assumed the role of Anna the “doctor whale [whale doctor]” and as such ministered to Roo. He was subjected to injections, and he received bandaids, tickles, cuddles, and kisses. Anna was no longer solely the vulnerable infant, afraid of monsters or needy of sustained care. As the doctor, she administered pain and comfort, and regulated their amount and frequency. Anna had become the dispenser, the subject of experience, both positive and negative. Roo had assumed, at least in part and for the interim, the role of object, recipient, and victim. Anna’s doctor and whale play fluctuated between themes of hurt and healing. The topic of hurt was elaborated and associated with the theme of death and the terrifying notion that “doctors kill you.” At the other extreme, healing was elaborated to include not only literal solutions (cf. bandaids) but also a relationship component, friendship. Anna created for Roo a little fish friend who would “save” him and ensure “no more 127 dying.” Anna’s journey between the dimensions of hurt and healing was not an easy one. Her doctor play with the whale was often charged with tension, especially when references to death surfaced. Whale play fused with doctor play did not supplant infant play. Scenes of infant life continued in this final phase. They did so in a striking and almost rhythmic oscillation with the whale and doctor play. Anna moved back and forth between the roles of the infant and the doctor. In one role, she personified vulnerability and neediness; in the other, control, agency, and authority. She enjoyed regression in the reexperiencing of infant life, and she raised topics pertinent to her current life experience——trips to the doctor, and all the associations of fear, pain, and need for comfort that those visits entailed. Anna appeared to be using the retreats into infant life (birth, feeding, and so on) as respites for emotional nurturance from which she drew the psychological strength to deal with these concerns. In the final minutes of the last session, Anna abandoned doctor play and turned to the creation of a large purple mural on the playroom wall. She filled the wall with whales, an emblem of her therapy. As she painted, she retained the role of the infant; however, she appeared a more capable and self—confident, even mature, baby, painting cooperatively with the therapist! maternal figure. The mural concentrated many of the key themes and activities which had recurred throughout her therapy: her love of painting and messes, her involvement in the infant role, the recapitulation of the whale theme. In that respect, the 128 mural seemed a fitting, creative closure to her therapy. However, before leaving the playroom, Anna sought a final foray into infant life. Finishing her mural, she sat on the “baby’s chair” and greedily sipped juice from a tiny cup. In taking a final sip of juice, Anna seemed to be conveying that she wanted to take with her one last symbolic gulp of nurturance as she ventured forth from the room. Summary Anna’s play therapy was characterized by her complete and enthusiastic immersion into play experience. She was fully involved both with the therapist and with the play materials from the first moments of her therapy. Anna plunged into the reexperiencing of infant life. She gave birth to a play identity, and the playroom became her nursery. By degrees, Anna descended into regressive play in which the myriad facets of infant experience came to life. Anna as the newborn experienced comfort, nurturance, joy, and pleasure as well as anxiety, fear, and intense aggression. Finally, Anna shifted into new play depictions, new themes, and new developmental challenges. In doctor play, themes of hurt and healing were elaborated. In perhaps the key verbal communication of her therapy, Anna broached her fear of death and brought to light the worries and even terror that had likely underlain her own frequent medical care. Moving through virtually all of Anna’s play therapy was the often silent, but ultimately vocal, figure of the whale. Anna’s attachment and commitment to the whale throughout her therapy represented an intriguing choice of a play material, for whales 129 travel at the ocean floor and at its surface. In the Jungian framework, the ocean may symbolize the depths of unconscious life. The whale served Anna as a strong, friendly mammalian companion who was comfortable at the surface and at the depths. 130 CHAPTER V. CASE 2 BRAD: THE EMERGENCE OF PLAY AND VERBAL COMMUNICATION Brad’s play therapy was marked by the synchronous emergence of play and verbal capacities, which developed from an initial state of severely impoverished functioning in both domains. At the outset of play therapy, Brad was 3 years and 9 months old. His presenting difficulties perplexed his parents and his teachers. Although Brad was normal in appearance, irregularities in motor coordination were sometimes evident. His gait was occasionally unsteady, and his fine motor skills were inconsistent. Brad often looked pale, and he suffered from frequent and prolonged colds. Most worrisome to his parents and his teachers was his lack of speech. However, although quiet, Brad was not mute. He was capable of emitting sounds, such as crying and screaming. In general, his attempts to vocalize were so unclear and so poorly formed that his teachers feared he lacked the capacity for speech. They had begun to teach him a few basic signs, which Brad began to employ. Within the classroom, Brad at first did not and, apparently, could not play. He appeared unfamiliar with many of the play materials. During the first few weeks of preschool, Brad seemed overwhelmed with both the range of stimulating activities and the social structure of the classroom. For example, the first time that the therapist observed Brad in his classroom, all of the other children were seated in a circle on the floor, listening to the teacher. Brad, in contrast, scampered around the room. Preschool was Brad’s first experience in a peer setting, and he 131 was unfamiliar with the demands and requirements of this social milieu. A family doctor had suggested that Brad was mentally handicapped, an untested assessment which had greatly disturbed his parents. Brad lived with both parents, who were hard working and sincere individuals. Brad’s mother suffered from chronic health problems which had seriously affected her vision. Brad’s birth had been normal, although his mother expressed concern that some over—the—counter medications that she had taken during pregnancy may have affected his prenatal development. Developmental milestones had been delayed. Brad walked at 14 months and was toilet trained very late, at age 3, several months before entering preschool. Speech had not yet emerged. Although a congenital mental handicap had been suggested by one doctor, a developmental delay of unknown etiology and extent appeared a more plausible assessment. An Overview of Brad’s Play Therapy In the early play therapy sessions, Brad neither played nor spoke. However, gradually, Brad attuned to the safety and the relaxed behavioral limits of the therapeutic playroom. He began to become involved with play materials and to elaborate activities with them. Gradually, too, phonemes, syllables, words, and short phrases emerged by degree from his presenting unclear and unformed vocalizations. In the final sessions of play therapy, Brad took an important step in his play, with the emergence of person—action sequences in which Brad played out, and commented on, a fantasy scenario. This emergence of fantasy play was a critical and 132 culminating developmental event within his therapy. Brad’s treatment began in the fall and spanned six months. During that time, he made important social-relational gains at home and at school. As Brad began to communicate his wants and needs at home, his tantrums diminished, and his parents, in turn, felt more relaxed and less frustrated in their contacts with their son. At school, his teachers invested much time and energy to meet and assist his emergent capacities for play and language. Brad made two strong friendships during the school year. The first friendship, which began early in the school year and lasted throughout, was with a highly verbal child, Ray. Despite Brad’s few and unclear vocalizations, Ray seemed to understand Brad, and the two were virtually inseparable. Toward the end of the school year, Brad, who by this time had begun to speak discernably, befriended a moderately autistic boy who did not speak. When a team of specialists assessed Brad in the early spring, Brad tested above the range of mentally handicapped. A definitive diagnosis was deferred as the specialists considered Brad’s abilities to be just emerging from his developmental delay. The Phases of Therapy Three phases were discerned within Brad’s course of 20 individual play sessions. The Beginning Phase, consisting of Sessions 1, 2, and part of 3, was characterized by the total absence of both play and speech. A breakthrough in Session 3, in which Brad simultaneously began to play and to emit sounds, marked the beginning of the Middle Phase of increasingly focused play and emergent speech which continued through Session 20. The 133 latter three sessions (18, 19, 20), the emergence of fantasy play, constitute the End Phase. During this phase, rudimentary sentences typified Brad’s speech. The following analysis describes the major transformations that occurred in Brad’s activities with focal play materials across his therapy. This analysis then identifies the verbal themes which attached to these focal materials and activities and, in addition, considers the development of Brad’s verbal capabilities. Brad’s increasingly focused play and verbalization were all the more striking, given his severely impoverished play and language functioning at the outset of therapy. The First Session: The Absence of Play and Speech Brad, who had been fearful of leaving his classroom, held the therapist’s hand limply as he walked down the hall with the therapist for his first play therapy session. There was a striking absence of muscle tone and responsivity in his physical contact. However, within the playroom, the depth and the extent of Brad’s developmental difficulties soon manifested with an intensity that overwhelmed the therapist. For the entire first two sessions of 40 minutes each, Brad stood silently, virtually immobile, rooted to a position in the playroom that was midway between the therapist and the shelves laden with toys—-a total distance of about 20 inches. He did not touch any play material, nor did he utter a sound throughout these two sessions. His behavior appeared to communicate a combination of fear coupled with unfamiliarity as to what was required of him. The result was essentially a paralysis of all play and communicative functions. 134 Normally, the colorful appeal of the play materials serves to override or neutralize young clients’ early session anxiety. However, Brad remained standing throughout these sessions, not venturing even to touch the materials. The only variations during the second session were slight changes in posture. For example, having stood for most of Session 1 with his back to the therapist, he varied his stance slightly in Session 2: turning to peek shyly at the therapist and then ever so slowly and subtly rotating his body so that he could face the toy shelf. At this point, Brad gazed with interest at the toys. He slowly bent his knees to get a closer look at them but did not reach out his hand to explore. At the end of both sessions, Brad responded readily when the therapist announced that it was time to leave. By the slight start of his body when the therapist spoke, it appeared that he understood the therapist’s verbal message. The therapist contemplated allowing these presenting behaviors to continue until Brad’s inner tension peaked and impelled him to take a risk. However, the therapist decided instead to initiate blowing bubbles in the third session in the hope that the shimmering bubbles would attract Brad and gently induce him to begin to play. When the third session began much as the first two, with Brad only marginally less frozen in one place, the therapist took a jar of bubbles and silently began blowing bubbles away from Brad. Intently, he watched them float across the room. Gradually, as the therapist blew the bubbles nearer to Brad, his frozen posture appeared to thaw. Ever so tentatively he reached out one finger to burst a nearby bubble. In this simple motion, two therapeutic breakthroughs 135 occurred. Brad had begun to play, and the therapist, through the medium of bubbles, had made contact with Brad. Within minutes, Brad was scampering around the room, waving his arms wildly and stomping on the floor, trying to burst as many bubbles as he could. His first vocalizations accompanied this first play activity. Brad laughed and yelped with delight. Soon after, he began to play with other materials. The Principal Play Materials Across Sessions 3 through 20, with few and brief exceptions, Brad utilized the following materials in his play therapy: Vehicles, the Doll House and Furniture, the Doctor Kit, the Hospital Bed and Figures, Adventure People, Sand, and Water. Figure 10 summarizes the occurrence of play with these materials across sessions. This analysis will focus on the transformations in play themes and associated verbalizations in Brad’s play with these materials. Brad’s unique Sound and Activity Mimics are Session Middle Phase 1 2 3 4 5 6 7 8 9101112131415 1617 181920 Theme VEHICLE * * * * * * * * * * * * * * * * * * PLAY WATER * * * * * * * * * * * * * * * * * * SAND * * * * * * * * * * * * * * * * DOLL HOUSE * * * * * * * * * * * * * * DOCTOR * * * * * * HOSPITAL * * * * * * * * * ADV. PEOPLE * * * * * * * * * * Figure 10. Brad: Overview of Play with Principal Materials considered as a singular play manifestation, incorporating his 136 play and verbal capacities and facilitating both. Vehicles: The Play Themes The playroom selection of Vehicles included several small cars, a motorbike, a tow truck, a fire engine, a plane, a dump truck, a backhoe, and a set composed of a larger wooden helicopter, train, and flatbed truck. Brad’s play with these Vehicles was a prominent (salient) play activity in that it spanned the 18 active sessions of his therapy, while many other play materials and themes appeared only intermittently across sessions. Similarly, within sessions, Play with Vehicles was salient in (a) frequency (with Brad often returning to play with vehicles), (b) duration (with vehicle play constituting the major portion of object play in Sessions 3 through 20, and (c) quality of involvement (with Brad clearly familiar with, comfortable with, and enjoying these materials). Figure 11 summarizes the play themes which emerged in play with Vehicles and their occurrence across sessions. In order of their initial appearance the Vehicle play themes were: Vehicles on the Floor; Vehicles in Water; Vehicles on the Table; Lines of Traffic; Collisions; Throwing Vehicles; Parking; Vehicles in the Sand; Brinkmanship; and Fantasy Play. The earlier-occurring play themes were discerned from the location of his play and the selection of other materials used with the Vehicles. Later play themes were distinguished by the type of organized activity associated with Vehicle usage. A description of these themes with representative session examples follows. Session Middle Phase 1 2 3 4 5 6 7 8 910111213 1415 1617 181920 Theme HANDLE Floor * * * * * Table * * * * * * * * * * * Water * * * * * * * * * * * Sand * * TRAFFIC Lines * * Crash * * * * * * Park * * TOSS * * * * BRINK * * PUZZLES * * * * w/ HUMAN FIGURES * * * * 137 Figure 11. Brad: Play Themes with Vehicles Vehicles on the floor: Motion and kinesthesia. Immediately following the critical turning point in Session 3 when Brad exuberantly began bursting bubbles, Brad turned to the toy shelf and without hesitation selected one of the vehicles. Seated on the floor, Brad tried several vehicles, holding them and moving them along the floor, and clearly enjoying the motor noises which the wheels made in friction with the floor. He sat midway between the therapist and the toy shelf, exactly where he had stood rooted in the first 2 sessions. His position in respect to the therapist, whether facing, avoiding, or slightly turned, was variable and appeared flexible. Play with Vehicles on the Floor in this format spanned Sessions 3 through 7. With only a brief exception in Session 8, Brad’s play with vehicles shifted to other locations and more varied activities, never to return to the floor. 138 Vehicles on the table: The emergence of patterns. Brad’s decision in Session 6 to bring some of the vehicles to the table marked an important transformation in his play. Brad had relocated from the floor, apart from and lower than the therapist, to the small play table, very near and level to her. His play with Vehicles on the Table continued through Session 14, with recurrences in Sessions 16 and 17. From this base beside the therapist, a range of activities evolved: Lines of Traffic, Parking, Collisions, and Brinkmanship. While some of these activities appeared aimless, they actually contained the germ of emergent play organization. Play with Vehicles on the Table transformed from casual interaction with the vehicles to highly purposive, focused, detailed, and realistic play, constituting rudimentary representational play. In its least organized form, Brad’s play with Vehicles at the Table consisted of Brad idly touching and handling the vehicles (6) and/or moving them across the table surface, appreciating the noises the vehicles made and the engine noises he vocalized. In a slightly more developed version, Brad explored various vehicles one at a time, pointing out with great interest to the therapist the vehicles’ doors and windows, and, by the tone of his vocalizations, clearly hoping to find parts that would open and close realistically (7). In Session 7, Brad arranged a number of vehicles on the table in a first distinct Line of Traffic. From one end of the small table to the other, the vehicles moved slowly or simply idled, bumper to bumper. This first realistic representation of vehicles organized in relation to others contrasts with another 139 vehicle play transformation which originated in this session; for 6 minutes, Brad caused some of the vehicles to travel fast and crash in a head—on Collision. Such Collisions recurred in Sessions B and 13. The relatively calm and contained activity of Lines of Traffic recurred only once, in Session 13. Comparable in noise level and emotional tone to the Collisions, Brad’s Throwing of Vehicles was characterized by angry movements. This variation in vehicle play first appeared in Session 8, continued through Session 11, and recurred in Sessions 13 and 17. Within sessions, Vehicle Throwing was intermittent. That is, it followed or was contained within segments of Brad’s calmer exploration of vehicle parts or Traffic play. Typically, Brad would sit quietly, calmly handling or lining up vehicles, then suddenly, impulsively, and angrily toss one or two to the floor. Ordinarily, Brad would return to his previous activity at the table, minus one or two vehicles. Sometimes, however, he stretched his arm across the table and swept all the vehicles to the floor in a noisy clutter and then moved on to another activity. Play which reflected even more intentionality on his part, and which involved contact via the Vehicles with the therapist, emerged in Session 11 with a recurrence in Session 13. In the Parking activity, Brad had each vehicle, in turn, travel to the therapist’s edge of the table. He parked many vehicles side by side, in parking lot fashion, facing the therapist. Sensing Brad’s symbolic approach to her, the therapist gently touched each vehicle as he parked it and commented, “Hi, jeep,” “Hi, backhoe,” or “Hi, truck.” Brad parked each vehicle with care 140 and listened intently as each one was acknowledged. Brinkmanship was a unique yet rich subtheme of Brad’s play with Vehicles on the Table, reflecting well-developed motor control and containing new emotional coloration. In this activity, Brad would use only a single vehicle. Sometimes this would be an ordinary car, and at other times a larger vehicle, such as the tow truck or the fire truck. He made the vehicle race to the edge of the table and then held it teetering on the edge of the abyss. The vehicle then raced forward, or in reverse, evidently in retreat from this danger, only to crash into the wall at the opposite edge of the table. In the sole occurrences of Brinkmanship in Sessions 13 and 17, Brad’s vehicles sped back and forth from these two perils, with Brad providing realistic brake screeching sounds and comments on the car “cash.” Vehicles in sand and water. At the outset of therapy, Brad disliked getting his hands dirty. Not surprisingly, his use of Vehicles in Sand was sparing. In Sessions 11, 12, and 16 Brad manipulated the backhoe to dig briefly, but realistically, in the sand. In Session 17, the dump truck momentarily visited the sand tray. By contrast, Brad’s play with Vehicles in Water emerged early in his therapy (3) and spanned his course of therapy (cf. Figure 11). In its earliest occurrences (3, 5), play with Vehicles in Water was literally contained within the water: Brad dumped dozens of small objects into the plastic water basin. Vehicles were included in this confusion of objects in the basin but were by no means the focus of this activity. Water was associated with vehicle play when Brad momentarily had a vehicle 141 travel from the table, sometimes through the air, into water spilled on the floor, and back to the table (12). Sand and Water in combination figured prominently in the Fantasy Play with Vehicles considered below. Transportation puzzles. Brad’s interest in vehicles was so transcendent throughout his therapy that it influenced his selection of a seemingly unrelated material——puzzles. With few exceptions, Brad chose puzzles of vehicles. For that reason, his puzzle play is considered herein as a facet of the Vehicle theme. In Sessions 11 and 14 through 16, Brad sat in rapt absorption placing the large depictions of train, plane, car, bike, and so on, in their respective depressions of the wooden puzzles. With increasing clarity, he named the vehicles as he did so. Vehicles and human figures. A number of unique events not readily categorizable within the above thematic divisions arose within Brad’s Vehicle Play. In Session 11, while engaged with Vehicles on the Table, Brad, for the first time in his therapy, incorporated human figures into his vehicle play. He put a man, a woman, and a child figure from the doll house into the jeep and gave them a brief ride, with one of the figures functioning as the driver. A similar example of a unique play event with Vehicles occurred in Session 17, when Brad placed the nurse and patient (Hospital Figures) in the large dump truck and took them for a ride on the table. These events suggest that, although lacking age-appropriate verbal skills to verbally communicate his understanding, Brad was, nevertheless, a keen and intelligent observer of his world, capable of communicating his perception of certain person-object relationships (e.g., rider-vehicle) through 142 play. In Session 13, two unique events occurred which exemplified Brad’s capacity for attention to detail. In one instance, Brad carefully and realistically hooked a small car onto the tow truck mechanism and towed it across the table. In the second, Brad played with the backhoe in a remarkably detailed and realistic manner. In precise imitation of a backhoe at a construction site, Brad had the backhoe (on the table) scoop imaginary shovelfuls of earth from one direction, then slowly pivot on its base and scoop from the other side, repeating this sequence for several minutes. These unique events constituted rudimentary segments of representational play. Within the context of play with Vehicles on the Table, where play involving spatial/movement patterns predominated (Parking, Traffic, Collisions, Brinkmanship), the above play events of precision, reflecting attention to subtle detail, were sporadically embedded. Further, within the context of global kinesthetic interest in the vehicles, human figures began fleetingly, but significantly, to be incorporated. Cumulatively, these events are seen as rudimentary segments of representational play and precursors to the culminating activity of his vehicular play, an elaborated person—action—object sequence that constituted his first fantasy play. Vehicle fantasy play. The appearance of fantasy play, a protracted scenario incorporating human figures, a vehicle, and a repeated activity sequence, occurred in the final 12 minutes of Brad’s last play therapy session (20). In this singular play vignette, Brad knelt on the floor beside a plastic basin which 143 contained his self—concocted silty mixture of water and sand. Selecting the man, woman, and child adventure people from the shelf, Brad placed them on a small plastic boat in the basin. The figures travelled on the boat until suddenly a “cash” [sic] occurred and it tipped, spilling the figures into the silt, which covered their bodies. These figures occasionally cried, “Huip!” Brad then retrieved them from the water, brushed the sand off their bodies, and placed the plastic family unit on the boat again. He repeated this sequence 5 times with great absorption, while at the same time looking at the therapist and verbally describing this scene. The developmental import of this play activity is manifold. First, this person—object—action sequence constituted the most complex representational play of his therapy: The miniature actors were realistically tossed from the boat, covered with silt, and survived to repeat the experience. Second, these 3 miniature figures authentically duplicated his own family constellation. Third, this segment contained the consequential addition of fantasy to his representational play. That is, the boat crash and rescue activity did not stem from Brad’s own literal experience. It required imagination. Lastly, this play activity was significant in that it contained the most varied emotional content of all his play. In previous representational segments with the vehicles, emotional coloration was generally absent. With regard to thematic progression, this segment contained elements of earlier Vehicle Play. It recapitulated, in much elaborated form, Brad’s initial interest in the boat in the basin 144 (4). At that time, he barely ventured to touch the boat. This segment is also mindful of two earlier unique events in which small human figures rode in various vehicles. However, this Fantasy Play segment with vehicles reassembled these elements—— interest in the boat and people as passengers——and elaborated them. No longer simply a fleeting representational activity, Brad’s vehicle Fantasy Play told a simple but clear story of danger and rescue. The ensuing analysis of the verbal themes associated with Vehicle Play will illustrate that this segment was equally consequential, developmentally and therapeutically, not only on the level of play activity but on the verbal level as well. While his play depicted and in a sense defined a literal danger, his words communicated more than the figures’ need for “hulp.” Repeatedly, Brad observed with horror, “Oh, no. Papa gone. Whus boat?” Vehicles: The Verbal Themes The gradual emergence of verbal themes, in fact, Brad’s very capacity for verbalization, underwent painstakingly slow development, which evolved from his presenting total silence to rudimentary sentences. An outpouring of amorphous and largely incomprehensible sounds surfaced, following his play breakthrough with bubbles. This ambiguous jumble of sounds, a virtual word salad, which nevertheless uncannily bore the inflections, intonations, and cadence of language, was the elemental vocal material from which verbal clarity and, eventually, verbal themes emerged. The following verbal themes, summarized in Figure 12, emerged in association with vehicle play: Vehicle Noises, Names of Vehicles, Negation, Names of Parents, and Loss and Danger. 145 Session Middle Phase 1234567891011121314151617181920 Theme ENGINE SOUNDS * * * * * * * * * * * * SPECIAL VEHICLE SOUNDS * * * * * * * * VEHICLE NAMES * * * * * * * * * NEGATION! ABSENCE * * * * * * * LOSS! DANGER * * Figure 12, Brad: Verbal Themes with Vehicles Vehicle noises. Vehicle noises were the first unit of communicative currency between the therapist and Brad. As Brad energetically rolled a number of vehicles along the floor (3), the therapist provided an accompanying motor sound: “Rhhnnn.” In response to the therapist’s primitive vocal addition to his play, Brad ran the cars along the floor even more energetically, clearly seeking more “verbal” commentary from the therapist. This type of contrapuntal dialogue, between Brad’s play with the vehicles and the therapist’s provision of the motor sound, was common within the first few sessions. Not surprisingly, given Brad’s enjoyment of and engrossment with vehicle play, his first discernible syllables were his own versions of car engine noises (3, and ensuing), hereafter referred to as Vehicle Noises. The sounds of motors constituted the basis of Brad’s playroom language. Gradually, these Vehicle Noises evolved and transformed in detail and complexity, edging 146 toward the formulation of syllables, words, and sentences. Specialized vehicle noises. When Brad’s play with vehicles transferred from grossly defined movements on the floor to patterned play at the table, a roughly corresponding development occurred on the verbal level, with the emergence of detailed Specialized Vehicle Noises. From Brad’s first play with vehicles at the table (6), he began to emit a range of very realistic vehicle—related noises. The “eerrk!” screech of brakes as one vehicle neared the edge of the table and the whine of the fire engine siren were the first such sounds to emerge (6). Later, Brad added such accurate vocalizations as water gushing from the fire engine’s imaginary fire hose (8), and realistic train (10), rocket ship (11), and airplane (13) sounds. Brad’s vocalization of Specialized Vehicle Sounds culminated in Session 16, with Brad emitting a generous range of vehicle noises, and introducing one of greater sophistication: the rhythmic, monotonous “beep beep beep” of a truck’s back-up signal. This particular Specialized Vehicle Noise was yet another indication of Brad’s capacity for keen observation and his emerging capacity for detailed, intelligent representation. Names of vehicles. Emerging from this richly variant range of vehicle noises, crude yet comprehensible approximations of the Names of Vehicles followed. Brad’s first comprehensible word, although it was related to play with a vehicle, was not a vehicle name. Pausing in his play with vehicles on the floor (7), Brad pointed out to the therapist a car’s “door, on door” with great interest. Later that session, Brad uttered “car” as he swished some vehicles in the water basin. 147 From this simple beginning (7), Brad began to verbalize a limited number of vehicle names, which recurred throughout his therapy. Ordinarily, pronunciation was very poor and barely understandable: “huck” [truck], “hwain” [train], “ham” [plane], “hike” [bike), “boh” [boat]. Interestingly, Brad’s verbalization of vehicle nouns proliferated not during actual vehicle play, but as he sat absorbedly removing and replacing the transportation puzzle pieces, accurately naming each one. Brad’s general vocabulary gradually expanded from this basic core of vehicles names. However, virtually all of Brad’s emergent vocabulary involved vehicle—related topics. For example, “cash” [crash] and such phrases as “oh no” and “boh gone” were all associated with vehicle play. Even Brad’s expression of “cow” involved a puzzle piece of a freight car, which when removed, revealed cows on board. Negation and absence. Following the emergence of Names of Vehicles, which indicated a comprehension of tangible (present) objects, a theme reflecting the opposite, Negation and Absence emerged. The word “no” first appeared as early as Session 6. Until much later in his therapy, Brads “no’s” always occurred in the context of a favoured phrase, “Oh no!” which conveyed the element of surprise. As a totality, this phrase idiomatically conveyed a sense of worry and concern. “No” as a dynamic conveyor of negation did not emerge until Session 13. As his cars crashed into the wall by the table, Brad commented, “No go hey is houn” [latter segment indecipherable]. In a successive transformation of the negation theme, Brad’s “no” by Session 14 conveyed a comprehension of the concept of lack or absence. 148 Removing representations of vehicles from a wooden puzzle frame, Brad observed “no hoe” [tractor), “no ike,” “no huck.” A subtle and more complex transformation occurred subsequently (16) as Brad, again during the puzzle activity, elaborated the concept of “no” in crude phrases: “No huh cow,” “Not uh train.” This theme of Negation and Absence culminated with a more generalized assertion of absence: “Gone.” As various vehicles disappeared under water (16, 19, and 20), Brad observed, “Oh no. Gone kane [plane] .“ The emergence of the theme of negation was a critical developmental occurrence. A two—year—old’s first “no” commonly marks the onset of a rebellious phase. A positive developmental milestone, this “no” marks the rudimentary comprehension of ego boundaries and the ability to distinguish between self and other (nonself). As the child’s emergent ego boundaries clarify the self, as actor and agent, from the nonself, as object and other, the child verbalizes this distinction in a generic but powerful “No!” If Brad’s focal play symbol of the vehicles is taken as a representation of the self, then his verbal commentary of “no ham” or “no hike” indicates his emergent developmental awareness of self and other boundaries. That is, just as there is “ham” and “no ham,” there is self and nonself. Further, Brad’s expression of “gone,” an important extension of the Negation Theme, was accompanied by play in which vanished objects later reappeared, signalled his comprehension of the enduring existence of objects removed from sight. Brad, within this play and corroborated by his verbalization, had edged toward the 149 developmental capacity for decentration. Names of parents. Brad first elaborated his vehicle play with the Names of Parents during the same session in which “no” as a dynamic negative first occurred (13). As his (driverless) vehicles repeatedly crashed into the wall in the Brinkmanship activity, Brad commented enigmatically, “Mama ha ho mama” and later “Iya papa hung.” Throughout his entire therapy, “mama” and “papa,” his own name, and a crude approximation of what may have been “lady” or “Heidi” [an adult friend] were the only names of people that Brad ever uttered. He never identified other play figures as “boy” or “man,” for example, as is common for children in play therapy. Loss and danger. Precursors to the culminating verbal theme of Loss and Danger can be discerned as early as Session 6 in Brad’s anxious comment, “Oh no,” a phrase which recurred throughout his therapy. This simple phrase subtly conveyed worry, anxiety, and a sense of pending loss or danger. It often occurred when vehicles crashed or toys were broken. Later (19), in a slightly more elaborate expression of this theme, Brad, upon submerging an airplane in water, offered, “Oh no. Gone kane!” The verbal theme of Loss and Danger appeared in its most compelling and lucid form in the last 9 minutes of the final session (20). As Brad engaged in his sophisticated fantasy sequence of the family members being repeatedly tossed from the little boat, he verbally described the action: Guh guh. . . . Oh no. Haish mama?. . . Unna go boh. . . Un haigh goh. . . Oh no. No go boh. Go boh. Phhnn. Cash! . On boh. Hulp! . . . Whuh mama? . . . Whuh papa? . . . No papa. Papa gone! Gone gone papa. . . . Mama, no mama! Rhhnn. Cash! Oh, ah, oh no! 150 Although his verbal facility is terribly impoverished for a child of 4.2 years, this story represented a developmental achievement for Brad. At a fundamental level, it encompassed the themes of danger and recovery, loss and retrieval. However, for the first time in his therapy, the protagonists experiencing danger and loss in a play sequence were not mechanical, but human. Further, they were not merely any people, but parental figures. At a deeper level, then, this story is fraught with emotional force and essential object relations content: The entire family suffered repeated dangers but were repeatedly recovered; mother and father were repeatedly lost and retrieved. Brad’s Improved Verbal Functioning Although not the direct concern of this study, both progress and a progression within Brad’s capacity for verbal communication and the structure of his language were noted in the process of analyzing his verbal themes. A mass of prevocal sounds (3, 4, 5) first emerged: laughter, shouts, yelps, and, later, vehicle noises. Subsequently, nonspecific syllables and single words emerged (6), followed by such two—word strings as “oh no” (6) and simple phrases, “on boat” (7). Virtually unintelligible sentences began to proliferate in Session 9 and continued throughout his therapy. Intelligible noun—verb sequences emerged in Session 19 (“kane gone”) and proliferated in the final session (20) with his commentary on the boat crash. Doll House and Props: The Play Themes A second focal object in Brad’s play was the doll house, its furniture, and the 3 or sometimes 4 resident characters (cf. Appendix C). Four major play themes, summarized in Figure 13-- 151 Exploratory, Bathroom Play, General Play, and Throwing Objects-- as well as a series of Unique Events evolved in his doll house play. Brad played with the doll house in some fashion in Sessions 4 through 13 and 16 through 20. Session Middle Phase 1 2 3 4 5 6 7 8 9101112 1314151617 181920 Theme HOUSE Touch * Climb * * * Deface * * * FURNITURE Handle * * Throw * * * * * * * * BATHROOM PLAY Athouse * * * * * * Attable * * * OTHER ROOMS * * * Figure 13, Brad: Play Themes with the Doll House and Props Exploratory play. Even during his inactive and silent sessions (1, 2, and part of 3), Brad had looked with interest at the doll house but had not ventured to approach it. His first play at the doll house (4) epitomized subtlety and tentativeness as he explored its features and props before moving on in later sessions to engage the materials in limited representative fashion. In 2 brief segments (less than 30 seconds each), Brad simply touched some of the furniture, including the toilet, an object which figured prominently in later representative play. Subsequently, he handled some of the furniture briefly, and then, as if testing the strength of the structure, climbed on top of the doll house for a few seconds. During this session (4) he 152 tried to deface the doll house, by pulling off the tape which held some of the wooden molding together. He eventually succeeded in breaking off a piece of the molding. These four subthemes of Exploratory Doll House Play--Touching, Handling, Climbing, and Defacing--rarely recurred throughout his therapy. Bathroom play. A conspicuous theme within Brad’s doll house play was Bathroom Play, which occurred at two locations: the Doll House and the Table. The miniature bathroom fixtures which appealed to Brad included a shower stall, a basin with attached mirror, a tub, and a toilet with attached counter and basin. The toilet was realistically equipped with a liftable toilet seat and a toilet paper dispenser. Bathroom Play at the Doll House ranged from simple handling of the fixtures to including a human figure in a representational play segment. For example, Brad merely handled the shower stall in Session 4 and 5 and banged the small toilet on the doll house’s bathroom floor (6). In subsequent sessions (7, 8, 9), he put a small baby figure in the bathtub. Later, he placed a boy figure on the toilet (8, 9). Bathroom Play at the Doll House appeared in its most intricate and complex manifestation when Brad utilized all of the fixtures in a related sequence, giving the baby a bath, putting it on the toilet, and giving it a shower (12). In the following session (13), Brad repeated a similar sequence with utmost calm and absorption with the variation of using a figure of a boy rather than a baby. The subtheme of Bathroom Play at the Table emerged in Session 8, several sessions after the appearance of Bathroom Play at the Doll House. As the boy figure sat on the toilet in this 153 session (8), Brad provided the sounds of exertion associated with defecation and the sounds of water flushing. The boy called out “Huip” and “Mama.” Brad then tossed these objects angrily to the floor. In a subsequent transformation of this play (9), the boy figure climbed all over the fixture, its toilet, counter, and basin. When the therapist responded, “Now the boy is standing here,” Brad moved the figure to a new location and asked her, “Ungh now?” In the final occurrence of Bathroom Play at the Table (11), Brad gave the mother, father, and boy figures showers in the shower stall. Although there is minimal difference in the content of play with bathroom fixtures (i.e., it always concerned washing or toilet needs), the transfer of Bathroom Play from the doll house to the table, nearer the therapist, is seen as a significant transformation on several levels. First, independent of the play materials, Brad, it is inferred, felt generally more comfortable to bring his play closer to the therapist. Second, related generally to the materials, Brad appeared to be symbolically bringing the contained and private inner world of the doll house to the open setting of the playroom table. Finally, Brad’s bringing specifically the bathroom fixtures from the house to the table is seen as an important play symbolic communication. Brad was portraying sensitive body and toilet training issues and, literally, bringing them to the therapist’s attention via the materials. General doll house play. This play theme encompassed doll house play with furniture props other than bathroom fixtures. More generalized play with a range of doll house furniture first 154 appeared in Session 10, several sessions after the emergence of Bathroom Play. Brad played with these props at the Doll House or, alternatively, brought selected items to the Table. At the Table, Brad’s General Doll House Play was limited in that he tended to focus on a single object with minimal activity elaboration. For example, when he placed the mother and father figures on the couch (12), the figures simply sat there. However, when kneeling before the Doll House (with his back to the therapist), Brad was capable of sustained, absorbed, and complex play with an assortment of props and figures. General Doll House Play reached its richest elaboration during Sessions 12 and 13. A comparison of this subtheme across these two sessions reveals that in Session 12 Brad focused on the baby asleep in the crib, commenting “Shshsh.” He also handled the kitchen appliances. He then went on to a sustained sequence of Bathroom Play with the baby figure. However, in the next session, Brad engaged in Bathroom Play with the boy figure rather than the baby and then sat calmly and intently arranging and rearranging many household furnishings, placing bathroom, dining room, kitchen, bedroom, and living room props within a single room of the doll house. He appeared to be attempting to concentrate the essentials of an entire household into one small and manageable space. His deep and impressive concentration during this activity was regrettably spoiled by the therapist’s verbalization, “That’s the shower.” Brad reacted to her neutrally descriptive comment as a serious intrusion to his calm and silence. In response, he angrily swept the doll house furniture to the floor and moved on to other play. 155 Throwing furniture. Throwing Doll House Furniture constituted a distinguishable, recurring play theme in itself. In its initial manifestation (6), Brad tossed ]J of the doll house furniture down the doll house staircase, leaving it in a jumbled and confused pile at the bottom of the ground floor. More commonly (6 through 11, 13, 16), Brad scattered or flung the pieces one at a time from the doll house onto the playroom floor. Sometimes, this throwing activity followed calm and engrossed play at the doll house (e.g., 13). The resounding crashes and the resulting chaos served as an angry and abrupt conclusion to his preceding calm. At other times, Brad simply enjoyed the activity for its own sake (i.e., throwing was not preceded by focused play), tossing the furniture all over the room. Throwing Furniture represented Brad’s least structured or focused doll house play and one of his most aggressive behaviors within the playroom. Unigue events. A number of Unique Events, not readily categorizable within the above themes, occurred in association with doll house play. In Session 10, Brad dumped the water from the miniature toilet bowl into the therapist’s lap, an action that concurrently suggested a desire to punish, dirty, provoke—— and trust——the therapist. In an unrelated unique event later that same session, Brad included in his doll house play the figure of a boy with a bandaged head. Brad’s inclusion of this Hospital Figure with the doll house materials was unusual. In Session 11, Brad selected a square piece of doll house furniture with many open sides, a type of cupboard, and lifted it off the table, straight into the air. He provided mechanical sounds as 156 he did so. Only during the data analysis did the therapist realize that Brad was depicting an elevator, an act which reflected his perceptive and his imaginative capabilities. In the last session (20), Brad sat quietly at the table near the therapist playing with the doll house’s standing lamp. He quietly and deliberately broke it in two. The therapist wondered at the significance of this occurrence in the last session. Brad was likely angry at the ending of these sessions, and it is plausible that the breaking of the light unconsciously symbolized the disruption he felt with the pending break in therapy. Brad’s doll house play culminated in a richly developed Unique Event in Session 16, when, for the first time in his therapy, characters functioned in rudimentary relationship. Brad began the sequence by dragging the heavy doll house to the center of the playroom, bringing the world of the entire doll house nearer the therapist, and allowing him access to all sides of the house. Repeatedly, Brad made the boy and the mother figures move to and through the doll house windows and door. Sometimes these two figures took turns going to the windows to look outside or inside. At other times, it appeared that one figure was looking for the other, as if they were engaged in a subdued chase. Once, the boy said “Boyboy” [bye-bye] to the mother. Later, the mother figure climbed the doll house chimney twice, falling off both times. Following this complex activity, Brad abandoned the figures and became absorbed in defacing the house by removing all traces of masking tape from its window ledges. This sustained 11 minute Unique Event was developmentally significant. Brad, for the first time, had portrayed characters 157 in relationship. Further, the relationship was multi dimensional, with the figures functioning as a unit (looking out the windows), in association (chasing each other), and as individuals (searching for each other, saying “bye bye”). The mother figure alone was depicted as experiencing danger (falling from the chimney.) Brad’s subsequent attention to pulling off bits of masking tape was seen as an emotional retreat, perhaps in reaction to what for him had been an enormously expressive play activity. Doll House Play: The Verbal Themes In contrast to Brad’s vehicle play, in which associated verbalizations were observed to coalesce into discernible, if unrefined, themes, the verbalizations associated with Brad’s doll house play were minimal and fragmentary. Figure 14, which summarizes all identifiable words which emerged during play with materials other than vehicles, includes a listing for the Doll House. The table distinguishes between clearly formed verbal efforts and those which were unclear, but reasonably distinguishable in context through tone and inflection. Assorted noises (toilet flushing, shower water, defecation, refrigerator sounds) appear to be the only loosely associated grouping of sounds. They are only qualifiedly advanced herein as a theme per se. The remaining words appearing in the Table essentially comprise a vocabulary list typical of an impoverished 18-month- old child. In the absence of any consistent thematic material, this section of the analysis comments on the inconsistencies and the impoverishment of Brad’s verbalizations during Doll House Play. 158 The paucity of vocabulary associated with the doll house is striking. One explanation may be that Brad was often quiet, even silent, during such play. Nevertheless, he just as often emitted a range of sounds, syllables, and words, most of which were undecipherable. Yet the lack of any continuity of even single words across sessions is perplexing. For once Brad had shown that he could pronounce a word, the question arises as to what prevented him from repeating it in subsequent sessions. As well, there was at least a sampling of names, nouns, prepositions, and verbal participles. Having shown himself to be capable of pronouncing these units of communication, the question also arises as to why Brad rarely assembled these into phrases or short sentences. Adventure Peoile: The Play Themes Brad first incorporated the Adventure People, as distinct from the Doll House figures, into his play in Session 9. The 11 3—inch high plastic Adventure People represented a range of male and female characters (cf. Appendix C). A “black man,” which figured prominently in Brad’s Adventure People play, actually had Caucasian features, but his black hair, black moustache, and black clothing lent him a sinister appearance. An inspection of Figure 15, which summarizes all of Brad’s play with the Adventure People, reveals minimal play with these human characters across the entire 20 sessions. Play Material Doctor Sand Hospital Adventure Doll Water Figures People House Referent * 159 door * car * * boh [boat] * * cash [crash] * * * go * * * ouch * * ohoh * * ohno * * * * no * mama * * * * papa * * * * in * * high * * out * ook [look] * oke [broke] * * done * gone * * * * * ung-ung [all gone] * no hi—eel hi—ee gone * * hon [sand] * * * * won /wong/ wa—eh/wuh [water] * * esh [splash] * whunna go? [where’d it go?] * * hink hun [drink some] * no want out * huip [help] * * * nie—nie * bye bye * nine [mine] * now * on/off * house * light * eyes * bye-bye * SOUND EFFECTS vehicles * * toilet flushing * * shower * defecation * fridge * sh sh sh [hush] * Figure 14. Brad: Verbal Referents Across Play Materials The four major play themes were the following: Handling, Toileting, Submerging in Sand or Water, and Riding in Vehicles. These themes were so limited in occurrence and development that 160 they do not require any further description other than the listing provided in Figure 15. Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Theme HANDLE * * TOILET * WIVEHICLES * * * SUBMERGE Sand/Water * * * * * SCENES * * * * Figure 15. Brad: Play Themes with Adventure People Brad’s play with the Adventure People was not only infrequent and brief but, for the most part, it lacked any complexity. The figures were the passive victims of a simple event: burying, dumping, or submerging. Even when they were active, such as sitting or riding, their activities were restricted representational segments lacking in play development. Brad generally tended to engage these figures in simple, unvarying, and literal representations. Scenes. However, within this general context of simple usage, devoid of distinctive movements and even emotional coloration, a number of scenes, or unique events, stand out. Brad’s making one figure jump from the back of a playroom chair into the water basin (17) represented a unique and even imaginative departure in play material usage. In the following session (18), an event occurred in play with Adventure People that was unique on the verbal dimension as well. Brad sat at the table, not playing at all but holding a female (presumed mother) 161 figure, who appeared to be the topic of his conversation, as follows: “Oh no, unna ho. [Vocalized sounds of running water.]! Oh no, oh oh. Oh no, ub oh.! Hon.! Gun.” In the next session (19), the nurse figure jumped into the sand and was buried, Subsequently, Brad engaged in a sustained and completely engrossed play segment with the “black man.” In absolute and absorbed silence, Brad repeatedly had the black man jump from the back of a chair into the water basin, buried the black man in the silt in the basin, and then brushed off the figure to repeat the segment many times, sometimes including the nurse figure in the same pattern of activity. Intermittently, he tried to pull the legs of the black man apart, apparently trying to break the toy. He also appeared interested in hurting the figure. When the therapist responded “ouch!” as the figure’s legs were pulled, Brad laughed somewhat sadistically. The final session (20) contained a series of unique events with the Adventure People, each with different emotional coloration. Having observed the therapist (directively) use a family grouping to enact a scene of a boy receiving a spanking, Brad had the boy figure spank the mother figure and then bury her in the sand. Later (19), Brad repeated the activity of delightedly pulling the black man’s legs apart and then burying him in silt. In Session 20, he engaged in the boat crash scene so rich in emotional coloration, as described in detail under Vehicle Play. Interestingly, all unique events with the Adventure People occurred in the final 4 sessions. As well, most play with single Adventure People involved male figures. 162 Adventure People: The Verbal Themes The reader is referred to Figure 14, which summarizes all decipherable vocabulary, whether clearly formed or reasonably deduced in context, which occurred throughout his therapy with these figures. No consistent thematic material was discerned, with the exception of his verbalizations during the boat crash scene in Session 20. This first, and only, verbalized story told of danger and loss, “Oh no. Gone. Whus mama? Papa gone!” Most verbalization associated with Adventure People occurred during play with vehicles. Hospital Figures: The Play Themes Brad, who had never been hospitalized, seemed intrigued with the white plastic set of a nurse, boy patient (with detachable head bandage), and wheeled hospital bed (with removable blanket). As with the adventure people, play with the Hospital Figures clustered around the most elementary of activities: Handling (on the floor, at the table, or in water); Throwing on the Floor, and Burying in Sand. A subcategory of More Elaborate Handling refers to Brad’s placing the boy figure in the bed, covering him with the blanket, and wheeling the bed and/or giving the nurse a turn in the bed. The “More Elaborate” activities were still severely limited representational play segments. Within this general context of restricted play representation, the few unique events which can be discerned in Brad’s Hospital Play were less developed than in his play with Adventure People. The Nurse, for example, simply walked across Brad’s puzzle (14). The Boy Patient lay in bed, entered the water, and briefly rode a boat in the water basin (17). In Session 17, a slight progression was 163 discerned in the play with these materials as together the two figures rode in a dump truck, were immersed in water, and, in turn, took showers. Figure 16 lists these themes and cites their occurrence. Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Theme HANDLE Floor * Water * Table * * * * BURY Sand * THROW * * * * SCENES * * * * * Figure 16. Brad: Play Themes with Hospital Figures Hospital Figures: The Verbal Themes Figure 14 reveals that there were few intelligible verbalizations and no clear verbal themes during play with these figures. As the figures rode in the dump truck (17), Brad commented: “No. oh no. Gone. Hon [sand?]. Whunna go [Where’d it go?]. Car cash [crash].” This constituted the largest cluster of verbalizations during play with Hospital Figures. It is significant that this occurred in conjunction with Vehicle Play. Doctor Materials: The Play Themes Brad’s play with the Doctor Materials generally involved Exploratory Handling of the plastic instruments. Once, he briefly placed a pencil behind his ear while looking at the medical chart, a play detail which the therapist interpreted as an indication of his perceptive and imitative capacities. 164 In addition to Handling the instruments, Brad occasionally Examined the therapist briefly. His two examinations of the therapist indicate some thematic progression. In the first examination (6), he used the syringe to inject the therapist’s watch. Later in his therapy (18), Brad ventured to inject the therapist’s mouth and to place the thermometer in her mouth. The occurrence of these themes is summarized in Figure 17. Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Theme HANDLE * EXPLORE INSTRUMENTS * * * * INJECT THERAPIST * * Figure 17. Brad: Play Themes with Doctor Materials Doctor Materials: The Verbal Themes No verbal thematic material emerged throughout this play (cf. Figure 14). Only minimal and unclear verbalizations accompanied his doctor play. Water: The Play Themes Play with Water occurred in each of Brad’s active sessions (3 through 20). Figure 18 summarizes the kinds of activities which emerged in association with water. These clustered around the themes of Handling Materials in Water; Mess-Making; Representational Play; Pouring; and Feeding. 165 Session Middle Phase 1 2 3 4 5 6 7 8 9 101112 131415 1617 181920 Theme HANDLE OBJECTS * * * * * * * * * * * * * * MESS Spill * * * Splash * * Dump * * * * * * * * * * * w/HUMAN FIGURES * * * * POUR * * DRINK Cup * * Bottle * Figure 18. Brad: Play Themes with Water Handling. Brad’s play with water began in most tentative fashion as one of his vehicles skimmed the water in the basin (3). In the next session, the water basin became a focus of play activity. Brad tossed many play materials into the basin, filling it with a chaotic jumble of toys (3 through 9, 14, 15). A transformation occurred when Brad knelt by the basin full of toys and calmly handled them (5, 7, 9, 13, and 15 through 19). Mess-making. Mess-Making involved Spilling, Splashing, and Dumping. Brad Spilled water on the doll house (7), on the therapist’s feet (12), and on 2 large baby dolls (18). He also Splashed water in the basin (7) and on the therapist (11). The most dramatic messes occurred when Brad Dumped the entire basin of water with the small toys onto the playroom floor, creating a wet, colorful flood (8 through 11 and 13 through 19). Representational play. In his early sessions, Brad used the 166 water basin as a container for an indiscriminate jumble of toys. In later sessions, he selectively dipped a small number of human figures into the water, occasionally with a vehicle prop, playing with them in the basin in representational fashion (as vehicle passengers). These scenarios, which have been already been elaborated, included the hospital figures going for a ride in the water (16), and the hospital figures and adventure people being immersed in the water (17). In the final instances of representational play, Brad added sand to the water, creating a silty mixture. The black man and the nurse figure jumped into and disappeared in this silt (19). The extended boat crash scene (20) was the finale of representational play involving water. Pouring. The therapist introduced the water wheel late in Brad’s therapy in an attempt to intensify his play with water. He used it in two sessions (16, 17), pouring the water from the tea set pitcher and other containers into its funnel, and watching the trickling water set the plastic gear wheels in motion. His brief use of the pitcher here led him to use it in the preparation of make-believe food. Drinking. From the above simple pouring activity with the tea set pitcher, Brad shifted to incorporate the tiny tea cups in his water play as well (17). He drank from the cups. In the first nurturing activity of his therapy, he poured water into a tiny cup for the therapist to drink. In the following session (18), this transformed into Brad’s only instance of play with the baby bottles. As Brad poured water into tea cups for himself and the therapist, the therapist placed a baby bottle on the table. Brad quickly grabbed it, filled it with water, and then filled 167 another bottle for the therapist. He not only drank from the bottle, but he also bit off the tip of the nipple from his bottle. Momentarily, he tried a soother as well, trading soothers with the therapist. Water Play: The Verbal Themes Figure 14 summarizes Brad’s verbalization during play with water. These verbalizations are classified according to sounds which were clear, or unclear but reasonably deduced within context. Within the listing of more clearly formed words, the following clusters, qualifiedly advanced as actual themes, included: Vehicle related words (vehicle noises, “my car” “doors”); names of parents (“mama,” “papa”); referents suggesting loss or worry (“gone,” “oh oh”). A preponderance of self— conscious and even nervous laughter during water play, especially during Mess-Making activities, was observed. Similarly, a preponderance of Sound Mimics (described below) were also noted during his water play. The number of unclear but comprehensible words which emerged during Water Play far exceeded the number of comparable words emerging during play with adventure people, hospital figures, the doctor kit, or sand respectively. There were several verbalizations unique to water play: (a) “esh,” a rendition of “splash”; (b) “won,” “wuh,” “wong,” and “wa—eh,” believed to be renditions of “water”; (c) a repeated expression of “ung ung,” believed to mean “all gone”; (d) a command to the therapist to “hink hun” (presumed “drink some”) water from a cup; and (e) Brad’s reference to the baby bottle as “nine” (“mine”). 168 Sand: The Play Themes The progression of sand play themes is summarized in Figure 19. Brad’s Sand Play encompassed Shoveling (Solitary and Associative), Mess-Making, and Representational Play. Brad usually Shoveled Sand, digging and transferring it within the sandtray (3, 4, 6, 8 through 14). This Shoveling activity underwent a subtle but significant transformation from Solitary to Associative Play with the therapist. In Sessions 15 and 16 Brad invited the therapist to join him in a parallel shoveling activity in which the therapist functioned as a play companion. Brad enjoyed taking turns with the therapist in lifting shovelfuls of sand and digging out portions of the sandtray. Brad was relating to the therapist throughout, pausing to engage the therapist’s shovel in a mock duel, then returning to the turn-taking activity. In the next session (16) Brad moved the sandtray to the middle of the playroom so that both could shovel together at that central location. His moving the sandtray from the periphery to the center of the room is seen as an expression not only of his confidence within the playroom but the importance he attributed to this activity. Moving closer to the therapist may also have been a factor. His moving of the sandtray to the center of the playroom corresponds to his similar transfer of the doll house to the middle of the room (16, 17). Representational Play associated with sand involved dirtying Bobo (9); placing or burying Adventure People (10, 15, 19, 20); and the transportation of Vehicles (11, 12, 16). Later more complex segments, incorporating water as well, included: (a) burying the nurse and the black man (19); and (b) burying the 169 family group in the sand followed by the boat crash scene (20). Session Middle Phase 1234567891011121314151617181920 Theme SHOVEL Alone * * * * * * * * * * Assoc. * * MESS * * * * * W/ HUMAN FIGURES * * * * * * * Figure 19. Brad: Play Themes with Sand Sand Play: The Verbal Themes Inspection of Figure 14 indicates that clusters of verbal referents rather than clear thematic consolidation occurred. As with most of Brad’s play, these verbalizations included names of parents; expression of loss (“gone”) and a few references to vehicles. Nervous or self—conscious laughter as well as Sound Mimics occurred sporadically during sand play. Brad’s clear comment that “mama” was “okay” (19) was a singular and significant verbalization, expressing both concern and relief. His unclear expressions of “hon,” which recurred during Sand Play appeared to be an approximation of “sand.” The narrow range of comprehensible speech during sand play is striking. Activity Mimics and Sound Mimics Brad engaged throughout his therapy in a unique and dynamic type of communicative activity. Brad’s Activity Mimics and Sound Mimics, gross motor activity and energetic vocalizations mutually mirrored by the therapist and child, were pertinent and unique play and verbalization phenomena. Although these did not involve 170 play with specific materials nor did they (directly) generate discernable words, they constituted a developmental basis for and a link between these two domains. In Activity Mimics, the therapist mirrored Brad’s actions. This included a range of activities initiated by Brad: stamping feet on the floor, rocking one’s chair, pounding the table, jumping, and so on. In Sound Mimics, Brad would yell out a syllable, such as “Dah dah dah!!” From Brad’s tone, it was evident that the therapist was to respond. She did so by playfully duplicating (mimicking) the syllable, sometimes changing the volume. Brad and the therapist would repeat these syllables to each other in conversational fashion. Brad sometimes (5, 11) manufactured burps for Sound Mimics, which the therapist also duplicated. Occasionally, Activity and Sound Mimics occurred in unison, with the therapist imitating both Brad’s activities and associated vocalizations. Sound Mimic production peaked in Session 6. In general, Sound Mimics and Activity Mimics were more frequent in Sessions 5 through 12, then tapered off sharply. These two types of imitative behavior are seen as Brad’s most basic and fundamental, even primitive, assertion of play and verbal behavior. At the same time, they were also vitally relational events, connecting Brad in pleasurable, boisterous, even aggressive play and/or sound with the therapist. Thematic Comparison and Contrast Analysis thus far has attended to within-theme transformations for play and for verbalization, considered independently. The analysis turns now to the interrelationship 171 among the themes generated in both domains and, following, a consideration of the unique contributions of play and verbalization to his play therapeutic process. One of the questions posed at the outset of this study concerned the contrast and comparison between the themes generated in play and in verbalization. In Brad’s case, a comparison is discerned, first of all, on the more fundamental level of functioning in his play and verbal capacities. There was a striking parallel between the evolution of organization and clarity in his play and the increasing organization and clarity in his speech. Although not a one—to—one correspondence, with patterned play necessarily accompanied by clear speech, in both domains, there was a parallel movement from amorphous to clearer functioning. Brad’s verbalizations tended to cluster around the objects and activities before him. With the possible exception of play with the telephones (not analyzed herein), in which Brad “caw mama” and spoke, through pretense, to his parents at home, Brad’s verbalizations, although limited, commonly centered around the concrete objects and activities with which he was directly involved. In other words, there was no thematic tension, no particular contradiction, between the verbalization associated with his play activity. Further thematic comparison yielded general but credible correspondences between a small number of play activities and verbal themes which formed an interrelated cluster: Apprehension and Concern, Loss and Absence, Danger and Need for Help/Rescue. In the verbal domain, the sense of Apprehension and Concern as 172 well as Loss and Absence were initially expressed in exclamations of “oh no” and “gone.” Later, more dramatic cries of “Whus mama? Papa gone!” and “Hulp!” revealed that this Apprehension and Loss had intensified to a sense of Danger. Within his play, portrayals of the dynamics of Loss and Absence were slow to evolve, with humans participating only later and intermittently in his play scenes. These figures were, on limited occasions, buried or otherwise removed from sight (tossed). The Vehicles, in the perilous Brinkmanship activity, first introduced a played portrait of true danger, with the boat crash scene a climactic play illustration of this theme. In sum, a corresponding development between the played portrayal of an overarching theme of Loss and Danger and its associated verbal commentary is discerned. Both the played and the verbal aspects of this theme underwent an evolution in clarity, complexity and detail. Contributions of Play and Verbalization to Process An analysis of Brad’s verbalization alone would have yielded little understanding of Brad, his problems and his potential. At best, it could be considered limited and unclear. Brad’s verbalization was impaired and impoverished. Even by the end of the therapy, Brad could produce only a severely limited range of names of people and objects. These provided few clues to Brad’s understanding of the world and his relationship to it, for Brad never verbally expressed a liking for particular play materials, identified an emotion, or directly told about himself in any fashion. While many children chatter happily during play, mechanical and other sounds were the basis of Brad’s verbal “commentary” on his play. 173 Brad’s play activities, however, communicated in three— dimensional clarity what his verbalizations could not yet achieve. Brad’s play served as an eloquent substitute for the verbal skills he lacked. The few and restricted activity elaborations, the limited presence of human figures, and the restricted functions assigned to figures bespoke of serious developmental, emotional, and relational impoverishment. For Brad, play was a unique and critical alternative mode of communication for his verbal language deficiencies, with play activities communicating in rich detail his understanding, relationships, and emotions. Brad’s examination of the therapist through doctor play, for example, was an eloquent expression of his interest in the person of the therapist. No comprehensible verbalizations elaborated his interest or revealed concerns around plausibly related issues, such as hurt, sickness, healing, or recovery. Brad’s doll house play conveyed his intense interest in the bathroom and vividly depicted his perception of the bathroom as a focal relational setting for the family figures. Yet this play was usually carried out in engrossed silence, interspersed only with a range of water and bathroom sounds. Similarly, Brinkmanship with Vehicles portrayed the dynamic tension of near disaster, but only engine sounds, with no elaboration through language, accompanied this play. Perhaps the most pertinent example of the capacity of Brad’s play to elucidate what his verbalizations could not achieve occurred in Brad’s culminating play activity, the boat crash scene. During that play in the final session, his verbalizations 174 alone, his calls of “Whus mama?” and “Papa gone!,” conveyed a general emotional undercurrent of concern, worry, and fear and the more specific dread of loss of parents. However, in his play the dimension of these feelings assumed explicit reality. The boat crash scene depicted in engrossing detail that this was not an ordinary loss which Brad felt he was facing. It was related to a struggle which placed the family figures in mortal danger. These dangers were compounded: The figures were threatened by the catastrophes of crashing and drowning. However, his play also revealed that Brad possessed a ray of hope and a sense of the possibility that rescue could be achieved. Brad’s play, in general, revealed the extent to which a single play material can simultaneously serve as a focus of meaning and a catalyst for therapeutic change. Specifically, Brad loved the vehicles. They were familiar to him, and he enjoyed playing with them. These mechanical metal objects appeared to represent an emotionally safe, perhaps even familiar, uninhabited world. Like Brad, they moved and emitted particular sounds. Through his fascination and predilection for these materials, Brad could also be said to have moved, that is, progressed, in therapy. Vehicles accompanied Brad through every session of his therapy. It was through play with the vehicles that Brad ultimately achieved the developmental and therapeutic step of depicting peril and human loss. The contribution of Brad’s verbalization to an understanding of therapeutic process is complex because in some ways, as the following example will illustrate, Brad appeared to be using language to conceal expression as much as to reveal it. Brad’s 175 unintelligible sentences, as mentioned earlier, uncannily retained the cadence, inflections, and intonation of language. The therapist often responded to what she presumed Brad was communicating in his terribly unclear “sentences,” basing her response solely on the rhythm and tone of the unintelligible components. On more than one occasion, as corroborated by Brad’s subsequent actions and behavior, the therapist’s comprehension proved accurate. In one instance (13), for example, Brad stood opposite the therapist at the table, leaned toward her and commented: “Nogo heyis houn.” To which the therapist replied, “It’s not time to go back to your classroom yet. I will take you back a little later.” Brad responded by pulling up a chair near the therapist and engaging in play. Brad’s very motivation to communicate appeared to be intricately associated with specific play materials. Vehicles, for example, triggered the production of mechanical sounds and, later, Brad’s rudimentary commentary on their activities. Similarly, unclear verbalizations, critical attempts at speech, proliferated during water play. Brad’s verbalizations conveyed only the scantiest specific information, such as the names of his parents, an interest in doors, or a pervading sense of loss (“gone”). Because his vocabulary was so restricted and verbal formulations were so poor, Brad’s feelings were communicated through intonation and inflection. Increasingly, Brad’s intonation and inflection relayed emotional nuances and coloration, which can be grouped as clusters of feelings: worry, concern, anxiety; aggression and tension; excitement and pleasure. 176 Brad’s verbalizations also provided subtle cues to his cognitive potential. Brad’s adeptness in reproducing a range of mechanical sounds, for example, served as an important clue to the therapist of the cognitive skills of attention and memory that he possessed. In a few but significant instances, Brad’s verbalization revealed an emergent capacity for abstraction, the capacity to refer to people or events beyond the play setting. For example, Brad announced that he was going to “caw mama” on the play phone, expressing intention and a nascent ability to plan. On another occasion, Brad informed the therapist that the truck pictured in a puzzle held cows inside. His single word “cow,” when pointing to the truck, was evidence of an emergent ability to generalize from his knowledge of what vehicles outside the playroom hold and apply this knowledge to this particular example. This single word also indicated the ability to imagine and, therefore, suggested an emergent capacity for abstraction. Summary Narrative The preceding thematic analysis has identified Brad’s prominent play materials, resulting play activities, and associated verbalizations. The following narrative reweaves these thematic strands into a story of Brad’s play therapy as an experiential whole. Beginning phase. Brad presented in the play therapy room in a state of virtual paralysis of play and communicative functions. He stood in fearful silence, not venturing to touch a single toy. When the therapist reached out through nonthreatening materials, Brad ever so tentatively reached out a finger to burst one bubble. This was his first experience of initiative within the 177 playroom, and his bubble bursting activity was accompanied by his first excited vocalizations. Turning to materials which appealed to him, the miniature vehicles, Brad began to touch, handle, and explore these vehicles, moving them at a distance from, and then closer to the therapist, and providing them with realistic motor sounds. Brad, like the vehicles, had come to life in motion and in sound. Brad’s beginning phase of therapy, then, was characterized by movement from paralysis to involvement in play and speech. A most tentative emergence of initiative was followed by rudimentary interactions with materials. Brad embarked upon a painstakingly slow evolution toward speech by breaking his silence with energetic sounds. Middle phase. Brad became more confident within the playroom. His presenting impairment with initiative faded as he selected play materials with increasing interest and interacted with them energetically. He played as if more assured of his right to do so. He moved around in and began to explore all aspects of the tiny room. This increased movement and more self— assured entry into play suggested that Brad was beginning to feel that the play materials, indeed the room itself, truly were his own. In this phase, Brad not only interacted in constructive fashion with the play materials, but he also began to upset, overturn, undo, and even mildly attack the playroom parts. This seemed to be an adjunct to making the playroom his own. By undoing, rearranging, and upsetting the playroom, he was putting his own expressive stamp on his surroundings. There was both an 178 unloosening and a release, as well as brief but intense flashes of anger, as when his calm play at the table was followed by a hasty sweep of the play materials onto the floor in a noisy clutter. Brad’s favoring or preference for certain materials came into clearer focus. The vehicles and the doll house captivated his interest, although with a qualitative difference. He often returned to vehicle play as if returning to an old friend, providing a range of highly detailed and realistic sounds to enliven them. By contrast, when playing at the doll house, he was often quiet. He appeared not so much to choose the doll house with delight but rather to submit himself to its fascination, as if having been drawn into a mysterious orb. Not only preferences, but certain patterns now appeared in his play. The vehicles lined up and parked. Realistic bathroom activities predominated at the doll house. The adventure people went for rides in the vehicles. Brad tried the puzzles and successfully completed them. From the earlier amorphous melange of vocalizations, a limited range of names of vehicles and people began to emerge, as well as a small number of other words. The patterned play and the unsettled play did not form two parallel and discrete streams. On the contrary, this phase was characterized by a sense of struggle and a seething intermingling of varied and oppositional elements. Brad played calmly and then overturned things. He tossed materials into the container of the water basin, handled them calmly, and then dumped the water and toys onto the floor. He played near the therapist and then turned his back on her to play at the doll house. His attention 179 span was sometimes sustained, sometimes evanescent. A general unloosening was occurring, in his play, in his speech, and in his emotional and relational capacities. Out of the unsettled play, with its expressions of aggression, anger, and chaos, formulations of his psychological needs and struggles became better clarified in his play and in his speech. In particular, thematic threads of loss and danger emerged and wound through his play. Cars tended to “cash.” He often called out “gone” and “oh no!” during play. His anger spilled over in dumping and tossing activities as well as in hitting Bobo. Revealing interpersonal interests and understanding, miniature human forms began to literally travel through his play. In general, there was ongoing evidence of inner struggle in this phase, as Brad moved from often raucous kinesthetic play to emergent fragments of the portrayal of human experience. End phase. A sense of emergent clarity marked the final phase of Brad’s therapy. Although messes, dumping, and other unchannelled hyperkinetic physical activity still occurred, these abated in frequency and duration. There were increasingly more frequent islets of calm and sustained play. Within those islets of calm, Brad was no longer paralyzed. On the contrary, there was a sense of his actively working through the mess and the near chaos to achieve clarity in play and verbal expression. Indeed, Brad seemed to be groping for the tools with which to portray and communicate his understanding. His capacity to utilize concrete forms and verbal tools to communicate what he saw, felt, and understood, honed and strengthened. The earlier fragments of representational play, which he had so guardedly and 180 fleetingly circumscribed to restricted roles of riding and driving in vehicles, became more elaborate in activity and play sequence. Figures looked out the doll house window, jumped into a basin of silt, or repeatedly crashed and were rescued. A sense of the formulation of nascent identity also infused this phase. Brad enlivened the small figures with the attributes of identity, a range of emotional or relational characteristics which, although limited, were critical emergent features. The boy, for example, said “bye bye” to the mother. The family grouping together endured repeated peril in the boat crash. Whereas the miniature figures had previously moved through his play in virtual anonymity, there was evidence now that their identities and personalities were emerging from that anonymity and assuming names and qualities. They could even take risks and endure with identities intact. Brad’s own identity appeared stronger, more dynamic, and far less tentative. It was he who puppeteered the figures to more daring actions, animated them with relational qualities, and vitalized them with his own projected emotions. This projected play reflected his improving capacity to actively experience life and to draw more deeply from this well of personal experience during play. He had moved from a world inhabited mainly by vehicles, to a rather two—dimensional inclusion of human figures, to the rapt representation of human events. He now took an embryonic yet consequential step from projected play to the enactment of experience. His singular play with the baby bottle, drinking from it and then biting off the nipple, was a signal that the barriers to Brad’s experiencing his own infant identity 181 had loosened to the degree that Brad could experience oral pleasure and anger at its source. In a concise yet elegant statement of emergent sense of self, he added that the bottle was “mine” [“nine”]. Summary. Brad initially experienced the playroom as a place where his fears intensified to a crippling degree. However, the appeal of play materials soon invited him into a world of movement and sound. The relaxed limits of the room tacitly encouraged his descent into mess, aggression, and inner struggle. With virtually unbridled self-expression permitted, Brad became immersed in an intense experience of oppositional forces, vividly portrayed in his play and transmitted in his speech: loud and quiet, raucous and calm, messy and clean, chaotic and ordered, loss and recovery, danger and rescue. Clarity and elaboration of verbal expression as well as clarity and elaboration in play gradually evolved. By the final session, Brad’s more confident presence in the playroom, his improved verbal communication, and his more personal and projective play betokened that the phase of dissolution was beginning to give way to, and was enabling, reconstruction. 182 CHAPTER VI. CASE 3 CARL: TRAUMATIC PLAY DISRUPTION AND RECOVERY Carl’s play therapy was characterized by traumatic play disruptions during which Carl sat and cried, overwhelmed by pain. Carl, aged three at the outset of therapy, was the only child of a couple in their early forties who were considered mildly mentally handicapped. For that reason, social services support had been available to Carl’s biological parents even before his birth. The pregnancy and delivery had been unremarkable. Developmental milestones of the onset of sitting, walking, and talking had occurred within normal range. Carl enjoyed excellent physical health and suffered no physical impairments. He was sturdily built and well-coordinated. However, Carl’s limited vocabulary and his poorly formulated speech, with infantile pronunciation, made him difficult to understand and suggested a lack of verbal stimulation and interaction from an early age. At the outset of therapy, he was not yet toilet trained. His tense physiognomy, with lips almost pursed and eyes nearly squinting with tension, suggested withheld emotions. Yet it was Carl’s family situation that prompted his need for play therapy. Several months before his third birthday, Carl’s biological parents voluntarily gave Carl up for adoption to family friends. The adoptive couple had known Carl since his birth. His biological parents felt that this couple would be better able to care for their son. Carl had often spent time in the home of these friends and, in the months before he entered preschool, had gone to live with them. Carl was accepted for play therapy because an adoption, which challenges and endangers the 183 emotional/relational capacities of most children, was pending. In the fall, shortly after Carl’s first play session, the legalities of the private adoption were completed. The fact that Carl’s biological parents signed the original consent for play therapy and that, soon after, his adoptive parents signed the consent for its continuation, accentuates the dramatic developments that were occurring in Carl’s life. Young enough to be an appealing prospective adoptee, Carl was old enough to know and remember his biological parents. Play therapy provided him with the opportunity to work through the dual stress of the separation from his natural parents and the new attachment to the adoptive couple. An Overview of Carl’s Play Therapy Carl experienced the long walk down the hail from his classroom to the therapeutic playroom as an emotionally wrenching ordeal. Accompanied by the therapist, who carried him or held his hand, Carl usually cried as he was taken from the secure base of his familiar classroom to the tiny playroom. Once inside the playroom, his capacity to recover from the enforced separation from his teachers and peers varied. In some sessions, the appeal of the play materials soon enticed Carl from his sense of loss and despair, and he quickly immersed himself in enjoyable play with favorite materials. In other sessions, Carl was inconsolably overwhelmed with pain and rage and, in his despair, uninterested in and incapable of playing. Carl wept and protested “No!” as the therapist closed the door of the playroom for his first play therapy session. However, Carl’s stress subsided when he caught sight of the 184 miniature vehicles. Running these along the floor, he placed them in the sandbox and was soon involved in calm play with them for the remainder of the session. Similar play with vehicles in the sand typified the ensuing sessions (2, 3, 4, and part of 5). A series of novel play events (5), such as Carl’s angry tossing of a real chair onto the playroom doll house and then spending nearly 20 minutes dousing the therapist and the playroom with water, signalled that a new therapeutic phase loomed. In fact, a serious play disruption developed, spanning 3 sessions (6 through 8). Carl cried and screamed throughout these sessions. Ensconced in the therapist’s lap, he sobbed as the therapist used miniature human figures to repeatedly enact a scenario of his adoption, leaving his natural parents to go live in a new home. Carl was able to recover enough to return to sustained play following the Christmas holidays (10 through 13). He favored playing in the sand with the backhoe and other vehicles, but he also intermittently used the miniature doll house people to enact aspects of the separation from his parents, e.g., having a little boy figure kiss mother or father “goobye,” or putting the mother or father figure in a crib and lovingly wish them “nie nie.” However, pain, rage, and a sense of despair again overwhelmed him during the second major play disruption (14, 15). Inconsolable and in even deeper pain than in the first play disruption, Carl occasionally left the therapist’s lap to stand by the door and demonstrate his intense desire to leave the room. “Time go back now?” he sobbed again and again. Carl’s distress, anxiety, and pain reverberated throughout his entire social system. His teachers feared that play therapy, 185 having become so painful, was harmful to Carl. At home, following the more stressful sessions, Carl suffered sleep disturbances and nightmares. The adoptive couple attributed his difficulties to the play therapy and suddenly asked that it be discontinued. A three-week hiatus ensued, during which the therapist met with Carl’s teachers and the adoptive couple to reassure them and to persuade them to reconsider additional sessions so that the therapist-child relationship could terminate gracefully and with notification to Carl. An additional two sessions were agreed to, and these comprised Carl’s most positive and productive therapeutic play. Carl enjoyed calm, sustained, cooperative play with the therapist (16, 17). Seated on the therapist’s lap near the sandbox, Carl directed the therapist to “dump San” or to “park” and “race” vehicles with him. The three— week hiatus during which he had recovered somewhat from his distress, and his awareness that there were “no more playtimes” served to calm Carl enough to achieve this new level of play and relationship. Carl’s play therapy terminated after 17 sessions. Outside the playroom, his teachers had initially observed an increase in aggressive behavior toward his peers. This gradually diminished. Carl’s tense physiognomy appeared much more relaxed by the end of his therapy. His speech was clearer; and he was more present, active, and confident in relationships with peers and teachers. The Phases of Carl’s Therapy Five phases are discerned in Carl’s play therapy. These consisted of three principal play phases, interrupted by two play disruptions. The Beginning Play Phase (1 through 5) consisted 186 primarily of Carl’s play with vehicles in sand and water, with some exploratory play with other incidental materials. The First Play Disruption (6 through 8) was marked by Carl’s sobbing expression of pain and rage. During this play disruption, the therapist utilized small figures to depict the real life events which Carl had recently undergone. In the Middle Play Phase, Carl remained on the therapist’s lap while he played with vehicles in sand and water, sometimes engaging human figures in his play. The Second Play Disruption (14, 15) was marked by Carl’s intense despair, as he sobbed and cried to leave the room. In the End Play Phase, typified by cooperative play with the therapist, Carl was calm, affectionate, and enjoyed playing with the therapist, maneuvering vehicles with her in sand and water. The Princiral Play Materials Carl played with a limited range of play materials, with his attention and interest dominated by two principal materials: Vehicles and Doll House People. Their appearance across sessions is charted in Figure 20. Vehicle play conspicuously dominated Carl’s interest and attention, predominating within and across sessions in frequency and in duration (cf. Appendix C for vehicle listing). A family grouping of Doll House People, representing Carl, his biological parents, and the new adoptive couple, comprised the other principal play materials. Although Carl occasionally explored other play materials, such as the paint brush and the magic wand, his interest in them was fleeting and usually never repeated. The exception, a sustained play segment with the baby dolls, is discussed within the context of a unique pivotal session (5). 187 Session Beginning Disruption Middle Phase Disruption End 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Theme VEHICLES * * * * * * * * * * * * DOLL HOUSE FIGURES * * * * * Figure 20. Carl: Overview of Play with Principal Materials Vehicles: The Play Themes Carl’s Vehicle play themes were determined by two criteria. The first criterion was the setting where Vehicle play occurred: On the Floor, At the Table, In Water, and In Sand. Vehicle Play in Sand contained numerous subthemes of Handling and Moving, Burying, Digging, Getting Stuck, and Special Vehicle Maneuvers. The second thematic criterion concerned the degree of human representation or involvement attached to the Vehicle play, i.e., using human figures in conjunction with the vehicles. In later human-related Vehicle play, Carl played directly with the therapist, Directing the Therapist’s Vehicles and engaging in Cooperative Vehicle Play. Figure 21 summarizes the themes and subthemes across sessions. Vehicles on the floor, on the table and in water. Carl’s initial Vehicle Play began On the Floor (1, 2). Carl energetically ran a vehicle along the floor, enjoying the noise the wheels made in friction with the floor. As he moved the truck or car back and forth, the therapist moved playfully to the sound, stopping whenever Carl stopped moving his vehicle. Carl enjoyed this game, and alternately raced the vehicles or brought them to a sudden stop, thereby indirectly controlling the 188 Session Beginning Middle Phase End 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Theme HANDLE Sand * * * * * * * * * * * * Floor * * Water * * * * * * Table * * * MANEUVER Dig/dump * * * * * Bury * * Stuck * * * * * Complex * * w/HUMAN FIGURES * * * W/Therapist * * * * Figure 21. Carl: Play Themes with Vehicles therapist’s movements as well. Through this little game of mirrored activity, a kind of nonverbal kinetic dialogue between the therapist and Carl’s moving vehicles, therapist and child made their first relational contact. Carl did not return to the floor for vehicle play after Session 2. The Table served primarily as a momentary way station for Carl’s vehicles (3, 4, 5, 9). In only one session (13) Carl engaged in sustained play with the vehicles at the table (using human figures). Running vehicles for a matter of seconds across the table, Carl preferred to settle into play with vehicles at the sandtray. Likewise, Carl’s play with Vehicles in Water (2 to 4; 11 to 13) was limited to his quickly dipping them or moving them under water before returning them to the sandtray which he favored. Vehicles in the sand. Carl loved the sandtray. Sometimes gritty and abrasive, sometimes smooth and soothing, wet or dry, flowing through his fingers or resisting the attempts of his 189 vehicles to traverse it, sand was a medium which thoroughly engrossed Carl. He loved to shovel it, pile it, pat it, fling it out of the sandtray, watch a pool of water disappear in its depths and, above all, maneuver his vehicles through it. His vehicle play, in fact, usually alternated in an almost palpable rhythm with sand play. Carl would maneuver his vehicles for a minute or two, then dig a bit, make a vehicle pick up a load of sand, and then pause to shovel sand onto the therapist’s hand. Carl’s Vehicle Play and his play with sand were, in fact, interrelated. For that reason, sand play has not been analyzed herein as a separate play medium. The varied aspects of his sand play were encompassed in his play with vehicles, which travelled, worked, and were buried in its dunes. Handling and moving. As Figure 21 depicts, Carl began his Vehicle play by Handling and/or Moving the Vehicles, activities which recurred throughout all of Carl’s nondisrupted sessions. Handling consisted of Carl’s simply placing the vehicles in the sand or holding them while listening to the therapist. Moving Vehicles consisted of Carl’s driving them along the sand, sometimes providing motor noises. In the Beginning Play Phase, Carl’s Vehicle Play consisted solely of these rudimentary activities. In subsequent sessions, more complex activities were added. Ordinarily, Carl interspersed this vehicle play with a few moments of play with the sand, as described above, returning repeatedly to the vehicles. Digging arid dumping. Digging as a subcategory of Vehicle Play refers to what Carl called the “wook [work]” in which the backhoe was engaged. In the Middle Play Phase, when Digging and 190 Dumping activities first appeared, Carl enjoyed making the backhoe “pick up” and “dump” loads of wet sand. In the End Play Phase, he designated the backhoe for the therapist’s use and took the new playroom dump truck for himself, shoveling a “load” of sand into its container, moving it to the dump site, and “dumping dis” in another corner of the “sanbok.” The Digging subtheme represented a more complex and purposeful activity transformation than simply moving vehicles through the sand, as the backhoe and dump truck vehicles realistically fulfilled details of their mechanical functions. Burying. Although Carl fleetingly buried the “fie tuck” in sand in the first session (“Seh gone”), Burying Vehicles did not occur again until the Middle Play Phase. Burying a truck in the sand (11), Carl understood what he had done, observing, “No truck.” Later in this session, when he buried a car in the sand (“No car”), he called out, “Help pees, Mommy!” In all three instances of Burying Vehicles, Carl did not leave the vehicles buried but eventually uncovered them. Getting stuck. From the Middle Play Phase (11 through 13) to the conclusion of his therapy (16, 17), Carl’s vehicles often got “stuck” in the sand. In the introduction of this subtheme (11), the backhoe “fah duh” [fall down] and got “stuck.” In the following session (12), the subtheme of Getting Stuck was intensely repeated, with an assortment of vehicles getting stuck in the sand 24 different times. The backhoe, a truck, several cars, and even the boat took turns becoming lodged in the sand. At one point during this play Carl commented that it was “snowing now.” His comment suggested that Carl may have been imagining 191 the vehicles to be stuck in snow. Special vehicle maneuvers. In the End Play Phase (16, 17), Carl’s Vehicles engaged in several specialized maneuvers, Parking, Backing—up, and a complex play scenario involving blocks as additional props. Although Parking and Backing-up had been introduced in his vehicle play earlier (11 and 12 respectively), Carl repeated these activities with particular interest in the final 2 sessions. While “parking” and “backing-up” may appear to be minute and even superficial activity distinctions, on closer inspection they denote important, if subtle, play transformations. A Vehicle which is “parked” is not in difficulty, as is a vehicle which is “stuck.” A parked vehicle is simply carrying out one of its ordinary functions, in a sense pausing or resting before resuming activity. “Parking,” which usually takes place in designated and demarcated areas, also suggests rules, boundaries, and limits. In depicting this realistic functions of vehicles, Carl was also depicting an emergent awareness of the realities of bounds and limits. Carl’s vehicle play culminated with a calm and sustained intricate play sequence. With intense concentration and great pleasure, he engaged in a sustained 14 minute play scenario which reprised many thematic elements of his previous vehicle play and generated new ones. Assigning a truck and later the backhoe to the therapist, Carl handled the dump truck. For a while, largely at Carl’s command and direction, the vehicles together or in turn “dumped” sand and travelled along the sand over “bumps.” Suddenly requesting “wocks [rocks],” Carl added a bucketful of 192 small, colorful blocks to the sandtray. The addition of these play props served to thoroughly engross Carl. He loaded his dump truck with “logs” and directed the therapist to do the same with her vehicle. They took turns “dumping” their “loads” and occasionally getting stuck in the sand, menaced by the “logs” which Carl had buried in the sand. However, their vehicles also travelled (“drive!”), raced (“set go”), and parked (“set park”). They backed up (“beep beep beep”), got stuck in the “deep” sand, and one even “tip[ped) over.” The vehicles had difficult work to complete (“move dat log!”). Seated on the therapist’s lap throughout this segment, Carl spent the final minutes of his play therapy as he had at the outset, in play with Vehicles. Human figures in vehicle play. The addition of human figures comprised the final theme of his vehicle play to be considered. Carl’s use of human figures as props or adjuncts to vehicle play was minimal across sessions (1, 11, 12, 13). However, within those few sessions (11 to 13), his use of miniature human figures was extensive and consequential. Children commonly use human figures as drivers or passengers for the playroom vehicles, and, in fact, Carl had done this briefly in Session 1, placing a small figure on the boat in the sand. Human figures did not participate in his Vehicle Play again until Session 11 when Carl, seated on the therapist’s lap at the table, used the backhoe to pick up the figure of one adoptive adult. Querying “Dis pick up Daddy?”, Carl used the backhoe to pick up a woman instead. In the following session (12), the incorporation of human figures was more elaborate. Still on the therapist’s lap, but 193 now seated beside the sandtray, Carl had the backhoe “pick mommy” and then himself up and, in turn, “dump” them. Telling the therapist, “I wan Daddy now,” he retrieved from the table the other 3 figures of his extended family grouping and added them to the sand. This time he buried the adoptive woman in the sand, with her body becoming an obstacle to his vehicle, a train. With apparently sardonic humour, Carl commented on the buried figure, “[She] makin’ happy face? . . . [She s]top train?” Finally (12), this same female figure, evidently undergoing punishing treatment, was later picked up and dumped by the backhoe, as Carl commented, “Where [she] go?” In the final appearance of human figures with vehicles (13), the backhoe, the focal vehicle, functioned not only as a piece of working machinery and as a moving transport, but also as an enclosing container, a kind of moving home, for the miniature people. Playing near the table while on the therapist’s lap, Carl had one adoptive parent, himself, and then the father figure take turns driving the backhoe. He tried to bend the rubber figures so that they would sit and even lie down in the cab of the backhoe: “Look! Carl driving! Two people! . . . Duh sit down der. . . . Daddy’s driving it! . . . I wuh can seep seep [sleep].” The Carl figure also joined one and then both adoptive parents in driving the vehicle together. The fact that the figures were now riding not singly but in varying groupings of 2 and 3 people in the cabin of the backhoe was a significant play transformation. Carl appeared to be grappling with reassembling the human participants in his world into a coherent and meaningful unit, a unit which travelled, worked, and even slept 194 together in the confines of his backhoe. Vehicle play with the therapist. At the end of the Middle Play Phase (12, 13), Carl began to direct the therapist to play with vehicles. Still on her lap, Carl ordered her to “Pay [play with] dis one! . . . Dump down! . . . Pick up.” As she carried out his instructions with the vehicle(s) he had designated, Carl generally sat quietly and watched the activity in the sandbox. He would then take a brief turn in similar activity with his own vehicles, pausing soon after to again direct the therapist. According to Carl’s directives, either the therapist or Carl took turns moving the “stuck” vehicles so that they could continue motoring over the sand. Carl enjoyed this play activity with the therapist and was both calm and affectionate: “I like boo [blue] car. . . . I like that truck. . . . I like Susan.” In the End Play Phase, which followed the Second Play Disruption and a three-week hiatus from therapy, a significant transformation in the theme of Vehicle Play with the Therapist occurred. Carl’ began to engage in cooperative play with her. Still directing the therapist to “drive,” “park,” “back—up,” and race (“set go!”), Carl now often joined the therapist, carrying loads of logs on their respective vehicles, driving alongside her vehicle, and parking nearby. When Carl was most involved in cooperative play with the therapist (16, 17), he did not use human figures even once in his vehicle play. This detail of the play transformation would appear to represent an important developmental event. When Carl first directed the therapist in play (12, 13), he was still using human figures in his vehicle play during these same sessions. 195 When he subsequently joined the therapist in cooperative vehicle play (16, 17), play in direct association with an adult supplanted his use of adult likenesses. Vehicles: The Verbal Themes The following verbal themes emerged during Carl’s play with vehicles: Vehicle Noises; Names of Vehicles; Vehicle Activities; Vehicle Qualities; Expression of Wants; Expression of Liking; Absence; Relational Phrases; and Calls for Help. Because verbalization was minimal, Figure 22 provides representative examples of the verbal themes across play phases. The following Session Beginning Middle Phase End 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 dumptruck (11) mack truck (12) front loader (13) Die is lots? (12) Dis car door open? It dump. (12) No go. (3) What backhoe doing? (12) Dah fah down? (16) [consistent across phases] No car. (12) I wanna pay in the sandbox. (11) Help pees, mudder. (12) Dit need help. (13) Daddy’s driving it. (13) Figure 22. Carl: Examples of Verbal Themes with Vehicles discussion focuses on the across-session thematic developments and trends. Theme VEHICLE NAMES fie huck (3) choo choo (4) QUALITIES clean bQh (3) moh car (3) WORK didig (1) dumptruck (16) (13) No moh wookin.(16) OTHER ACTIONS STUCK ABSENCE / LACK WANTS HELP Car gone. (1) I wan more cars. (3) Hup dis. (2) RELATING Bye didig. (1) LIKES I needa work oer der.(17) Pay dis one. (17) I like boo car. (17) 196 Vehicle noises. Carl provided realistic noises for his vehicles, such as motor noises, sirens, and back—up signals. These occurred in most of his nondisrupted play sessions. Yet his speech rather than vehicular noises predominated during his vehicle play. Across sessions there was no remarkable change in the production of these sounds. Carl appeared to enjoy making the noises, and he used them selectively and appropriately when vehicles were driving, backing up, and so on. Vehicle names. Carl knew the names of many vehicles, including specialized ones, and he frequently identified them during his play: “Der boat!” or “Dah truck.” As his therapy progressed, a tendency toward more specific and even sophisticated terms was discerned. In the Beginning Play Phase, Carl’s verbal repertoire of names comprised “car,” boat,” “fie— tuck,” “tuck,” and “choo—choo.” By the Middle Play Phase, Carl had added “backhoe,” dump truck,” “wusing [racing) car,” and even “macktruck” and “frontloader.” Vehicle activities. Carl provided an increasingly rich and elaborate commentary about his vehicles, which were almost always in motion. Verbal subthemes included: Work, and the Description of Vehicle Movements. In the first session, Carl commented that his vehicle was “didig [digging],” introducing the subtheme of Vehicles at Work. This was amply elaborated in subsequent sessions: “Moh didig,” “I making tunnuh,” (2); “Moh wook,” “Dump” (3); “Picks the big dirt up,” “Pick the wock up” (12); “Working finished. No moh wookin’” (16); “I move dat rock,” “Dis carry logs” (17). It is noteworthy that not only did this subtheme of Work persist 197 throughout his therapy, but also, as even these few examples illustrate, Carl’s capacity for verbal description improved markedly from his first one—word commentary (“didig”). A second subtheme of vehicle activity was the more literal Description of Vehicle Movements: “Stop,” “No go” (2); “There going” (4); “What backhoe doing?” “Car come” (12); “Dih go drive,” “Is going in sand” (13); “Beep beep backing up!” “Carl tip over,” “Dis stan’ up?” (17). A particular subfacet of Vehicle Movements was the notion of the vehicles as “stuck” (“can’t move”). The concept of the vehicles as “stuck” initiated in Session 3 and recurred many times throughout Carl’s therapy. Vehicle qualities. Carl possessed a versatile range of adjectives which he applied to the vehicles. He was aware of size (“big backhoe,” “little car”) and place or position (“High now?” “Low down”). He expressed interest in additional or greater quantities (“Nudduh car” [[2]; “Dis is lots” [12]; “Moh park” [16]). He was aware that one vehicle was “bokin [broken]” (4). He commented that “Dis car door open” (13) and “Boat loud [allowed] get wet?” Carl used the first person possessive only once in relation to the vehicles, “My boh!” (3). Also in one instance he used the word “better,” a somewhat sophisticated comparative: “It bedduh put up der?” In general, as these examples illustrate, Carl’s verbalizations of Vehicle Qualities clustered around certain descriptors (size, location, and other details). However, repetition of these words was so sporadic that they cannot be said to constitute consistent thematic material. An exception, 198 however, was Carl’s sustained interest in the concept of “dirty.” In the first session, he described a vehicle in the sand as “duhtee.” Such references proliferated throughout his therapy. Although he could pronounce its opposite accurately (cf. “clean boh”), Carl was much more excited when commenting on “duhty water” (16) or the “duhty wheel” (17). Absence or lack. Verbalizations of the concept of objects being hidden, missing, or absent were meager throughout his therapy. Carl expressed this concept in most elemental form. In the Beginning Play Phase, he commented “Car gone” (1) and “Dih dih [digging] gone” (3). In the Middle Play Phase, he formulated this concept differently, commenting “No truck!” (11), “No car!” (12) when he buried them in the sand. This verbal theme did not recur in the End Play Phase. Expression of wants. Carl was able to express what he wanted using the first person, “I,” from the outset of therapy. This Expression of Wants transformed across play phases and occurred even during play disruptions. In the Beginning Play Phase, Carl was able to communicate what he wanted to do and with which object he wished to play: “I wuh ride dat boat” (1); “I wuh more cars” (2). In the Middle Play Phase, a number of transformations occurred. In addition to designating the object he desired, Carl more frequently announced what he wanted to play before engaging in play, “I wanna pay in the sandbox” (11); “I wan boat in ner san” (12); “I wuh pay airpane” (13). He was able to express his wants even at the risk of being limited by the therapist: “ I wan bing dis [backhoe back to the classroom]” (10). He also conveyed 199 a wish to attempt an activity: “1 wuh try [using a particular vehicle]” (13) Carl’s most emotionally charged Expression of Wants was his eloquent request for help during play with the vehicles (“I wuh help” [12, 13]). At the end of the Middle Play Phase, while trying to dislodge a stuck vehicle from the sand, Carl commented, “I wuh tow truck [to] help.” This latter example is considered a more sophisticated expression of wants. It is more complex than a request for an object, and it is more intricate than a statement of wishing to play. It described Carl’s wish to have the tow truck assume a particular function or quality. In assigning or attributing the function of helping to this vehicle, Carl’s ostensibly simple statement actually represented progress toward rudimentary fantasy play. Not only he or the therapist could free the stuck vehicles, but the vehicles themselves could adopt this helpful quality. (Carl’s requests for help assumed other formulations and are considered in further detail under the Theme of Help, below.) In the final play session (17), he expressed his wanting to play with the vehicle in a new way: “I need a work o’er der!” This was Carl’s first and only first—person expression of need throughout his entire therapy. This expression of need is seen as an extension of and a transformation of the theme of the Expression of Wants. His expression of Need encompassed and overshadowed the notion of request (“want”), intensifying it to the level of deeper demands. Carl’s most vehement Expressions of Wants were worded in the 200 negative. During both play disruptions, as he cried and repeatedly asked, “Time go back now?” Carl often yelled loudly and unequivocally, “No wan payroom!” It is likely that this intense negative expression of his wants during play disruptions actually enabled him to formulate more clearly and securely the expression of positive wants during the latter play phases. Expression of liking. Carl expressed a positive liking for objects/people in the playroom in only one session (16). Having been informed by the adoptive couple, his teachers, and the play therapist that he had only “two more playtimes,” Carl recovered quickly from his initial distress at being in the playroom. As well, pleased to see a new dump truck in the room, Carl settled into contented play at the sandbox, nestled in the therapist’s lap. “I like boo [blue] car,” “I like that truck!” and, later, “I like Susan,” he commented. Although on one level, the therapist was certain that Carl did, in fact, like both the play materials and the therapist, she also believed that he was able to express this liking at this time because he was relieved that the sessions were ending soon. Calls for help. The theme of Help was introduced briefly in the Beginning Play Phase, elaborated in the Middle Play Phase, and completely absent from the End Play Phase. This theme assumed two forms: indirect and direct calls for help. The Help theme in its indirect form first emerged briefly in Session 2. Carl commented that one vehicle would “hup dis” other one. This verbal expression is considered indirect in that the need for help was projected onto the play material, and worded impersonally in the third person. When this theme next recurred 201 during the Middle Play Phase, Carl intensified the call for help, adding the concept of need, again projected onto a vehicle: “Truck need help” (12) and “Dih need help” (13). The call for Help in its direct form was worded as a direct personal appeal in the second person. In both Sessions 11 and 12, as Carl endeavoured to free the “stuck” vehicles, he repeatedly called out, “Help mommy. Help pees, Mommy. Help pees, Mudder.” Although an element of projection was involved in this expression, as Carl clearly intended to be speaking for the (invisible) driver of the stalled vehicles, the sincerity of his tone conveyed the depth of his own wish and need for help. Settled on the therapist’s lap, he was simultaneously expressing an admission of his need for help, his wish for help from his mother (perhaps both biological and adoptive), and at the same time asking for help from the maternal substitute, the therapist. Relational. To a degree of course, all of Carl’s speech was relational. However, this verbal thematic category refers to those verbalizations which either (a) directly addressed the play materials (vehicles) as respondents in a personal relationship with Carl, (b) referred to his relationship with individuals outside the playroom, or (c) directly engaged the therapist in relational contact. The first subcategory occurred only once. As Carl left the playroom after his first session, he called out to the backhoe in the sandbox, “Bye didig [digging].” The second (11 through 13) conveyed Carl’s biological and adoptive parents as either objects to be carried by or drivers of the vehicles: “Dis pick up Daddy” (11); “Daddy’s driving car!” (13). 202 The third category proliferated in the latter two Play Phases. Carl frequently addressed the therapist directly, in tones that implied both friend and playmate, beginning with a simple call for her attention, “Look, truck!” (10). Later, Carl began to verbally direct the therapist to play: “Pay with backhoe,” “Try again” (12); “Pay dis one!” (13). His comment in Session 12, “Let’s pick mommy daddy. Pick ‘em up,” was a particularly clear expression of mutual interest and effort (cf. “let’s”). Similar directives continued throughout the Final Play Phase. To these directives, Carl verbally added the element of competition, inviting the therapist’s vehicle to race his own (“Set go!”) and even compete in parking (“Set park!”). Human Figures: The Play Themes Carl played with the following sets of human figures: the Adventure People, the Hospital Grouping, Baby Dolls, and the Doll House Figures (cf. Appendix C). The Adventure People figured only cursorily in his play, with Carl placing one of them (unidentified) on the boat in the sand (1), biting the head of the “black man” (3), and holding an unidentified female figure (6). The Hospital Grouping were handled only twice, with Carl banging the hospital bed on the table (2), and floating the little boy patient in the water (3). Toward the end of pivotal Session 5, Carl played with Baby Dolls once, in a series of unique play activities. Taking a table knife, he tried to “cut” the eyes of one doll. Removing the bedding from the large playroom cradle, Carl put two dolls into the cradle, rocking them so vigorously that they almost fell out. Undressing another small doll, he put her into her own tiny 203 cradle; but just after exploring other baby clothes on the shelf, he suddenly ran from the playroom. After the therapist brought him back, he played with a small doll for another minute before the session ended. Although the Adventure People, Hospital Grouping, and Baby Dolls did not undergo thematic development across sessions, these few details are included here because Carl’s play with these materials served as a rudimentary introduction or as precursors to his later more involved play with the Doll House Figures. Once Carl had gravitated to the Doll House Figures, following the First Play Disruption, he never returned to play with the other human figures. Carl’s interest in the Doll House Figures may have been influenced by the therapist’s having used these five figures to depict Carl’s leaving his biological parents to go to live with the adoptive couple, referred to in this discussion as A and B. In this scenario, the therapist had the small “Carl” figure hug and kiss the figures of the biological parents good-bye, as the adoptive parents came to walk Carl over to the corner of the table which represented their home. In variations, the therapist had the small Carl figure “speak” to both couples about what he felt about being adopted. In addition to playing out fragments of the scenarios the therapist had enacted in the First Play Disruption, Carl utilized the Doll House figures, often very touchingly, to enact the elements of his primary relationships that were important from his three—year—old perspective. 204 Session Beginning Middle Phase End 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Theme Carl OBSERVES THERAPIST * * TOUCHES * EXPLORES BODIES * * TOSSES * * BURIES * Figures SLEEP * SEPARATE * HUG/KISS * * * TOILET * * * DRIVE/RIDE VEHICLES * * * Figure 23. Carl: Play Themes with Doll House Figures Carl began his involvement with the Doll House Figures as an observer. Sobbing as he sat on the therapist’s lap throughout Sessions 7 and 8, he Calmed noticeably, if briefly, whenever the therapist enacted, for example, the child figure hugging the mother or father goodbye. This precocious figure also asked his parents why they had given him up for adoption. He told the adoptive couple how frightened he was and that they must take particularly patient care of him. Toward the end of Session 8, the therapist brought several Doll House furnishings to the table and had the child figure jump from the crib into the bathtub full of water. For the first time in 3 sessions, Carl smiled. He 205 touched the water in the tiny tub and toilet. From this embryonic interest in the doll house furnishings, a number of play themes evolved in play with the Doll House family figures: Expressions of Affection, Sleeping, Bathroom Activity, Separation, Exploring Body Parts, Tossing, Burying, and Vehicle Related. Carl carried out all play with human figures while seated on the therapist’s lap near the table. His play with them occurred solely within the Middle Play Phase (9 through 13). Carl did not return to play with human figures after the Second Play Disruption. Expression of affection. As Figure 23 illustrates, Session 9, immediately following the First Play Disruption, was particularly suffused with Doll House Figure themes, with Expressions of Affection predominating. Generally, Expression of Affection took the form of the figures kissing. Repeatedly, the child figure hugged and kissed the mother and father figures. The child returned to kiss the father twice more. The mother kissed the child and the father. Later, the father kissed one of the adoptive parents. The child figure kissed her as well. This activity recurred with diminished frequency (10 and 13 only). Once Carl expressed affection toward a human figure in another way. The father figure’s head was covered with sand. Lovingly, Carl wiped the sand off “daddy.” Sleeping. With great absorption and tenderness, Carl repeatedly put several of the figures to bed (9 only). Pertinently, he used only the figures representing his natural family. First, he put the child into the crib, and then put child and father in the crib together. Next, the child lay down 206 with the mother on a bed. Finally, the mother slept in a bed while the child climbed into his crib. Separation. Enactments of separation between the child and the parents occurred in association with the Sleeping theme. As the child figure lay down in the crib (see above), Carl had the father walk away from the crib, saying “Bye.” Later, the roles reversed, and when the child put the father into the crib, he, too, walked away from the figure, saying “Nie nie, Daddy.” These instances were the only depictions of Separation which Carl initiated. However, in the next session (10), as he finished playing with the Doll House figures, he pushed all the figures away from him and said, “Bye, A. Go home, Daddy.” Bathroom activity. Enactments of Bathroom Activities at first consisted of the child repeatedly jumping into the little tub full of water (9). Carl particularly enjoyed having the child jump from his crib directly into the tub. Carl also put A in the tub. In the next recurrence of this theme (11), Carl focused on other bathroom furnishings, having the child sit on the toilet and then jump into the basin. After this session, Carl never returned to bathroom play with these figures. However, he showed minimal, intermittent interest in the toilet fixture itself, adding it to the sand (12, 16). Exploring bodies. Carl was curious about the anatomy of the Doll House figures. Although this exploration occurred only twice in his therapy, his strong curiosity about the figures’ bodies reflected an important developmental interest. In the first appearance of this theme (10), Carl held the mother and father figures in turn and tried to remove their clothes. He was 207 aware of “der body” and particularly interested in seeing their “bum.” In the other occurrence of this activity (13), Carl tried to take the clothes off the mother and father figures as well as the adoptive parental figures. Carl was concerned with determining which of the figures had a penis. Tossing. Although Carl tossed the Doll House Figures onto the floor only twice (11, 13), this activity is considered as a separate theme for two reasons. First, in contrast to Brad, Carl did not carry out this tossing activity with overt aggression. Rather, he would slowly and almost delicately sweep them of f the table onto the floor, as if he were simply tired of being confronted with the complex relationships they represented. He did not appear to be acting from impulse but rather from a quiet determination to clear the table of their presence. Second, and significantly, on both occasions he retrieved the figures from the floor, either resuming play with them (10) or intently checking that they were unharmed from the fall (13). His actions suggested care and concern for the figures as well as the need for distance from them. Burying. The theme of Burying Human Figures did not undergo thematic transformation. Rather, this activity was a unique event in Carl’s play with the figures: He buried B in the sand, using her body as an obstacle to stop his train (13), introducing, through this depiction, associations of punishment and perhaps death. Vehicle related. Doll house people figured in association with Carl’s vehicle play during the Middle Play Phase only, in three successive sessions (11 to 13). This theme began with one 208 brief segment (11), with the backhoe picking up B and dumping her on the table. In its next instance (12), this theme subtly transformed in that, in addition to picking up and dumping B with the backhoe, Carl used the backhoe to pick B and the child figure up together. In this same session, he also buried B and used her to “[s]top the train.” The third and final instance of this theme (13) was sustained and elaborated with variations of drivers and passengers. First, B drove the backhoe along the table, soon joined by the child. Then a series of human figures, mother, child, and B, were each picked up by the backhoe and dumped. Finally, the adoptive couple, A and B, joined the child in driving the backhoe together. In this brief but significant sequence, the biological mother was ultimately replaced by A in the cab of the backhoe, a symbolic depiction of obvious relevance to Carl. The backhoe here represented much more than a vehicle. For during every active session, Carl had played intently with the vehicles, and within his play therapy sessions, the vehicles were very much “his.” Therefore, in having the adult figures join him for the first time in the cab of the backhoe, the seat of control, Carl appeared to be inviting the adults to join him in the miniature world of which he was owner and master. This was in clear contrast to the reality of his life outside the playroom, where he no doubt felt powerless in the face of adult decisions which had radically changed his life. Doll House Figures: The Verbal Themes Verbalizations associated with the Doll House figures Middle Phase Theme Examples SEPARATION Bye bye, Daddy. (9) Dis goobye mommy? (13) AFFECTION [kissing sounds; 9, 10) ATTRIBUTES He’s frying. (9) A dirty. (11) BATHROOM Daddy pee up there. (9) Der pee. (11) OTHER Up high. (9) Dis pick up Daddy? (11) ACTIVITIES SLEEP Nie nie, mama. (9) RELATIONAL Toy mommy. (10) EXPLORE BODIES Der bum der. (10) VEHICLE RELATED A top train. (12) Figure 24. Carl: Examples of Verbal Themes with Doll House Figures Expressions of affection. Carl’s Expressions of Affection when using human figures were actually prevocal but highly expressive. He simply provided realistic kissing sounds as the small figures embraced (9, 10, 13). Sleep. Here, Carl’s vocabulary was very limited. However, his tone of voice communicated tenderness as he put the figures 209 clustered around the following themes: Expression of Affection, Sleeping, Bathroom Activity, the Vehicles, Separation, Relationships, Exploring Bodies, Activity Descriptions, and Projected Attributes. With the exception of the Bathroom category, all of these themes were expressed solely during the Middle Play Phase. None of these themes recurred in the End Play Phase. Because verbalization within phases was minimal, Figure 24 provides examples of verbal referents which illustrate the improved clarity and specificity in Carl’s verbalizations around these themes. I wuh can seep. (13) I wun daddy now. (12) Mummy has a penis too? (13) Daddy’s driving it. (13) 210 into their beds and wished them, “Nie nie, Mama. Nie nie, Dada” (9). He was able to minimally describe the activity of these figures as well: “Daddy seeping. Lying down couts. Nuthuh bed” (9). The only other reference to sleep occurred several sessions later (13) when Carl tried to settle several figures in the cab of his backhoe: “I wuh [that they] can seep.” Bathroom. Again within the range of a limited vocabulary, Carl was able to adequately describe bathroom interest, fixtures, and activities. This verbal theme initiated in the first session as Carl identified the contents of the doll house bathroom: “Dis wah wah. Dah basroom? Pee dah. Pee!” In the most elaborate expression of this theme (9), Carl described his figures jumping into the tub and using the toilet: “Wah wah jump. Dad in duh wah wah. Hot. Dad ah wet. Daddy pee up there! Smell dat.” The final occurrence of this theme (11) was very limited (“toilet,” “water,” “der pee”), suggesting that Carl’s interest in the bathroom, at least for the moment, had diminished. Vehicle related. When Carl played with the human figures in association with the vehicles, he verbalized freely, describing aptly the actions of the people as drivers, passengers, or victims of the vehicles. Representative examples of such descriptive speech from the two principal sessions (12, 13) where these referents occurred include: “Let’s pick mommy daddy.” “B [s]top train?” “Daddy’s driving it. He fell off.” “I wuh pick Carl up.” “B driving in the sandbox.” Separation. Using only a handful of words, Carl was able to effectively express an understanding of the process of parting in a relationship, telling the figures “Bye, Daddy. Go home, 211 Daddy,” (10) or asking, “Wheh mama?” Where B go?” Carl’s most poignant verbalization around the theme of Separation occurred in Session 13. Holding the child and the mother figure, one in each hand, Carl had them kiss, as the Carl figure said, “Goodbye. Dis goodbye, Mommy?” These few words signalled to the therapist that Carl had comprehended her depicted scenes during the play disruption, that he was actively trying to grapple with the reality of this separation from his parents, and at the same time that he was not entirely overwhelmed by the separation. He was able to depict and vocalize an expression of love for mother (the figures’ embrace and kiss) and to verbalize “goodbye.” Relationships. This category includes references to Carl’s feelings toward and relationships with people, during play with the doll house figures. A brief but compelling example arose in Session 12. Playing with some of the human figures at the sandbox, Carl realized several were missing. “I wan Daddy now,” he told the therapist. While ostensibly referring to the small plastic figures, Carl was also accurately expressing how he felt at a deeper level, missing his father. In this same session, as Carl buried adoptive parent B in the sand, he commented, “B makin’ happy face?” On the surface, the question appears genuine, a simple query. However, the remark insinuated aspects of his relationship with that adult. The therapist sensed that Carl knew well that someone being buried would not be making a happy face. With few words, but in rather sophisticated fashion, Carl was expressing intermingled anger, resentment, worry, concern, and guilt toward that figure. 212 Carl’s most powerful verbalization surrounding relationships was his remarkably clear comment regarding the role of his adoptive mother. This dramatic and therapeutically critical discourse occurred in Session 12. Noting the various miniature figures on the table, Carl first identified them: “Dah Mommy. Dah Papa.” In a statement which indicates that he comprehended the figures’ projective function, he then commented, “Toy mommy.” Finally, he partly stated and partly inquired, “Is A’s duh mommy? Dah A mommy?” Carl was actively grappling with what was perhaps the most difficult question in his life: “Is A my mommy?” Exploring bodies. Carl initiated this verbal theme while trying to pull the clothing off the figures (10): “Dah [clothes] open up? Der bum der? Der body!” Several sessions later, when this theme arose for the second and final time, it underwent an important transformation. From an interest in the “bum” of these figures, Carl was now more interested in determining which figures had a penis: “Dah look [I look at that]. Duh penis. Dis bum, too. B penis too? Mommy has a penis too? No toes? I see penis too. I wan see.” Description of actions. As with his play with vehicles, Carl’s play with the doll house figures was usually accompanied by literal descriptions of their activities. His verbalizations in this regard were abundant, spanning all play phases. The following are representative examples: “Hey, walking!” (3); “Up high,” “Fall,” (9); “Dis pick up Daddy?” (11). Prolected attributes. Carl comprehended that the miniature doll house figures could be animated and enlivened through actions which recapitulated and/or reworked the basic activities 213 of his life. Verbally, he offered two important elaborations on their activity. Holding the Carl and the father figure so they could embrace and kiss (9), Carl commented, “He’s frying [crying].” It was not clear from this statement which of the figures Carl was describing. Nevertheless, this brief verbal description of emotion was significant in its parallel to his crying in the playroom. In the next session (10), Carl seemed pleased as he manipulated the small figures that “Dose walk.” While on the surface these brief comments appear to be little more than activity descriptions, they are significant in that they indicate that Carl comprehended the element of pretense. He knew, for example, that the figures were not really crying or walking, that it was he who added these qualities to the figures. In verbally admitting comprehension of and comfort with the mechanism of pretense, Carl’s difficulties were becoming accessible to two realms, depiction and discussion. The verbal projection of attributes culminated in Carl’s comment that one figure was a “Toy mommy” (10). He had moved from the assigning of attributes (crying, walking) to the designation of identity (“toy mommy”). Carl was then able to begin to work through the most difficult identity issue confronting him, namely, who was his real mother: “Dis A Mommy?” The Play Disruptions Five of Carl’s 17 sessions were characterized by his complete or nearly complete desisting from play activity. Although analysis has thus far focused on thematic progression during play specifically in interaction with an object, Carl’s play disruptions provided a unique opportunity to explore 214 thematic changes in the absence of such person—object interactions. These five sessions were far from being a therapeutic void. On the contrary, nonverbal (albeit nonplay) and verbal transformations continued to unfold. As this brief summary of those thematic changes illustrates, even when deepest distress overwhelmed Carl’s interest in play, the process of play therapy was still dynamically transmuting, working and wending toward recovery. Nonverbal changes. A number of emotionally—charged unique play events in pivotal Session 5 forewarned that a qualitative shift in Carl’s play was looming: He doused the therapist with water, threw a chair on the doll house, played with baby dolls, tried to cut a doll’s eyes, and ran from the room. In the first session of the ensuing 3—session disruption (6), a period of play with water, sand, vehicles, and the shark (a unique choice) was compressed between two prolonged bouts of crying. Carl’s crying and distress lasted throughout the next session (7), with the significant change that Carl sat on the therapist’s lap, where he spent most of the remainder of his therapy. Whenever the therapist initiated using Bobo as a target for Carl’s projected distress, Carl calmed: “Bobo, please don’t bother Carl today, because he’s very sad.” Carl seemed unable and unwilling to listen to the therapist talk to him about the difficult changes that had occurred in his life. Her talking to him directly aggravated his upset state. By contrast, the therapist’s introduction of human figures to depict the adoption (8) helped Carl to calm considerably. By the end of that session, he watched quietly as the therapist used 215 the 5 figures to enact Carl leaving his natural parents to live with the new couple. In the next session (9), although he cried upon entry to the room, he recovered and spent most of that session in calm, absorbed play with the human figures. In summary, in this first play disruption, the incorporation by the therapist of the human figures provided Carl with a tangible representation of the causes of his distress. He first watched the figures, then touched them, and, ultimately began to engage them in play. The therapist’s use of the human figures served as a bridge which gradually led Carl back to the world of play (Middle Play Phase, Sessions 9 to 13). Carl’s rising anxiety as he played during Session 13 foreshadowed another difficult period. In the ensuing second disruption (14, 15), Carl’s anger, pain, anxiety, and distress were intense and sustained. He spent virtually the entire sessions on the therapist’s lap sobbing, while the therapist talked to him about the adoption and his feelings. A slight behavioral transformation occurred (15) as Carl repeatedly left the therapist’s lap to stand by the door, as if to emphasize his need to leave the room. However, he returned each time to the therapist’s lap, crying and miserable. He seemed caught between his intense despair and grief, his need for comfort from the therapist, and his wish to flee the pain which she and the playroom represented to him. Verbal themes. Carl’s fundamental communications throughout the first play disruption were his vehement Dislike of the playroom and his Wish to Leave: “No wan payroom. Open door. Ah done now!” Within this general context, two singular 216 communications stand out. The first was a consequential Communication of Affect, Carl’s admission, “I’m not happy,” (7, 8). The second suggested the theme of Feeling Abandoned: “Miri coming now?” (Miri was Carl’s favorite teacher.) This single question conveyed a deep sense of loss and aloneness and a wish to be rescued from his intense pain. The verbal theme of Dislike of the playroom and his strong Wish to Leave continued with deepened intensity in this second play disruption. “Time go back now?” was his almost continual verbal refrain. From amidst this persistently repeated cry, several unique communications not only elaborated the earlier theme of Feeling Abandoned but also introduced new and significant therapeutic material: 1. Recapping and elaborating the earlier verbal theme of being left alone, abandoned, and needy, he sobbed, “Diane [a teacher] pick Carl up!” Through racking sobs, he often added “big hug,” “big big hug,” an expression of his need for love. 2. Carl began to verbally assert himself in relation to the therapist. When the therapist verbally interpreted his anguish (14, 15), Carl silenced her with a determined and angry: “No wan talk! No talking!” 3. Some verbalizations suggested that Carl was a personality capable of complex emotional defenses and sophisticated reasoning. Still sobbing, he insisted on 4 separate occasions, “I happy now” (15). Carl, hoping to leave, had evidently reasoned that he would be kept in the playroom until he felt better. 4. To the refrain of “time go back now, time go back now” 217 he added instead (15), “Time go home now. Time go home.” The words seemed to well from deep within him, expressing deep pain. The therapist believed that this feeling of wanting to go home lay at the root of Carl’s anguish, yet it was not clear from his statement which home Carl meant. The therapist attempted to determine which home by formulating a question: “Who do you want to see at home?” Carl replied that he wanted to see the adoptive couple. Thematic Comparison and Contrast The themes which emerged in Carl’s play and in his verbalization can be said to coalesce into two major clusters of meaning: vehicle activities and elements of human relationships. In both the verbal and the play domains, these themes were well developed. Carl was capable of expressive detail in both play and verbalization. With the vehicles, for example, he developed play sequences of getting stuck and being freed, elaborating them with appropriate descriptive vocabulary. With the human figures, Carl depicted certain details of relationship, such as kissing or parting. Although his descriptive vocabulary for relationships was less developed than for vehicles, Carl was nevertheless able to verbally process difficult details of relationships using his elemental vocabulary: “Toy mommy,” “Dis A Mommy?” There was strong concordance between Carl’s play themes and his verbal themes. That is, Carl generally tended to talk about the play at hand, with his verbalizations elaborating and explaining the vehicles’ or the figures’ actions. There were, however, some exceptions to this general tendency: 218 1. Certain actions, such as burying vehicles, tossing sand, or tossing the figures on the floor, were never accompanied by any verbal commentary. Perhaps the anger associated with these actions overshadowed his capacity for verbal expression. Alternatively, Carl may have lacked anger—related words. 2. Carl occasionally introduced verbal referents to objects, events, or people outside the playroom. These could be either immediate (related to the preschool) or remote (related to home). In the latter category, Carl’s comments about snow, his desperate cry for someone to come and pick him up, and his telling the therapist about his car at home, “My boo [blue] car bown [brown],” are illustrative. During human figure play, Carl’s verbal comments on play were far less elaborate than during vehicle play. The emotional intensity of the human figure play may have been a factor in limiting his speech, or, again, attributable to the lack of related vocabulary for emotions and relationships. He could verbally describe in rudimentary fashion the figures’ actions (jump, go, sleep), but it was his play portrayal with the figures (kissing, walking away, driving the backhoe together) which conveyed the deeper dimensions of these human relationships. Contributions of Play and Verbalization to Process Carl possessed adequate and at times even sophisticated capacities for play and for verbalization. These modalities offered Carl qualitatively different opportunities for self— expression. Carl verbally elaborated his play activities with rich and appropriate descriptions of play activity and object identity. 219 Through verbalization, Carl’s play activities were given clarity and specificity through detail. Carl verbally added to his play references to events or people outside the playroom. Through verbalization, connections with other settings, events, objects, and people were brought into the playroom. Carl’s speech was dotted with precocious vocabulary (e.g., “mack truck” and “frontloader”). He occasionally verbalized unique associations or made imaginative comments (e.g., his reference to the car stuck in the “snow” or a comment that the fine dust from the sandbox was “smoke”). Carl’s verbalizations reflected capacities for awareness, intelligence, and imagination not revealed in the literalness of play activities. Carl used verbal communication to express wishes, wants, likes, and dislikes with a range of intensity. Through verbalization, Carl was able to announce and to plan his play, telling the therapist what he wanted to do next. Through verbalization, Carl gained control over the therapist’s play actions. Carl verbally expressed and even discussed psychologically pertinent material: sounding a call for help, expressing an interest in body parts and gender identity, questioning the role of an adoptive adult. Through verbalization, Carl was able to express his core pain, wanting to go home. Carl possessed a particular capacity for ironic, subtle, and psychologically complex verbal communication. As Carl buried one adoptive figure and ran her over with a vehicle, he commented in a tone both innocent and insinuating, “[She] makin’ happy face?” 220 These few words suggested a capacity for precociously wry humor. They also reflected his awareness of emotional extremes, of contradictions. Perhaps Carl wanted to preserve the illusion of “happy face”; at the same time, his questioning tone indicated that he knew that under the circumstances (being buried and run over) this was unlikely. A second example concerned Carl’s insistence during a play disruption that he was “happy now.” Taking the comment at face value, Carl no doubt wanted to feel happy. At the cognitive level, his comment reflects a capacity for rudimentary abstract thinking and reasoning about his situation: “I believe I am supposed to be helped in some way in this room. Perhaps if I convey that I no longer need help, I can leave this terrible place.” On an emotional level, the statement reflected Carl’s capacity for verbal denial. He would have preferred to wipe his misery away with words. At the outset of this analysis, the researcher, recalling Carl’s infantile speech and limited vocabulary, considered Carl a nonverbal child. Data analysis exposed the inaccuracy of that impression and revealed that despite a limited vocabulary, Carl was a highly expressive child. The two major groupings of play materials contributed different play benefits to the course of Carl’s therapy. The vehicles initially offered Carl a focus for industrious play activity and involvement. In drawing his attention, they served as a distraction from and a defense against rising anxiety. In the Middle Phase, the vehicles advanced from a kinesthetic role to an expressive role. They enacted Getting Stuck and Needing 221 Help. The actions of the vehicles were eloquently elucidating Carl’s own problems. Like the vehicles, Carl, too, sometimes got stuck (cf. play disruptions) and needed help to free himself. Ultimately, the vehicles became tools of trust and friendship. Carl used them to invite the therapist’s participation in his play world. When painful feelings eventually overwhelmed him, it was a second grouping of play materials, not the therapist’s words, which first reached Carl and helped draw him toward emotional recovery. Carl was profoundly helped by the presence of the human figures. The likenesses of these figures lent a tangible and a comprehensible form to his jumbled, frightened feelings of love and pain. They were extraordinarily real to him. He sobbed as the therapist had the child say goodbye to the father. He bade the father good night with great tenderness. These small figures offered Carl the opportunity to control and manipulate relational events. Through them, he was able to extract and enact the aspects of human experience most important to him (kissing, sleeping, parting, toileting). The actions of the figures afforded him concrete proof that the child’s affection endured. In portraying the expression of affection toward mother he could affirm and validate the survival of that affection. By literally holding on to their image, Carl could begin to grasp the reality of his relationship with them. With regard to developmental needs and interests, play with these figures afforded Carl the opportunity to explore areas that are often subject to adult limits and hence repression——toilet use and gender identity. Through human representative materials 222 (the baby dolls), Carl explored infant needs and infant identity. With regard to his emotional/relational difficulties, the opportunity to depict the traumatic separation he had undergone lent him psychological distance from these overwhelming events. Through play with human figures, Carl by degrees became less a victim and more a witness to real life events. When Carl, in one of his last play scenarios with them, had the child and mother figure kiss, the therapist sensed that Carl had crossed a threshold of understanding. In manipulating these figures to relate with affection, he was gaining symbolic control over the devastating separation from his mother. Carl possessed a wonderful capacity for eloquence through the sequence of play activities. That is, Carl was capable of utilizing play materials to create a story. Although the sequence was sometimes inexact from an adult perspective, the constituent activities nevertheless formed plausible, coherent stories. The human figures, for example, went to bed, walked away from each other, took baths, and slept together. Although the sequence was awkward, the components of family life were reasonably strung together, revealing an extended picture of aspects of family life. Similarly, in vehicle play, the figures took turns driving, riding in, and being picked up by the backhoe. While this play reflected more imaginative content (i.e., people do not get picked up by backhoes or drive them together), Carl was portraying a detailed sequence that told a loosely constructed story: The child, joined by a number of adults important to him, enjoys driving a wonderful, powerful machine. This capacity for constructing expressive sequences 223 with play materials culminated in his final session. Carl’s vehicles loaded logs, dumped them, repeatedly freed themselves from obstructions, parked, raced, backed up, and moved in relation to other vehicles. In examining the play progression overall, a global play transformation from a focus on vehicles (Beginning Phase), to a focus on human figures (Middle), and a return to vehicles (End) is discerned. That is, as his therapy drew to a close, Carl returned to the play with vehicles. Although Carl was capable of verbal referents to external events, objects, and people, it is noteworthy that when Carl returned to the concluding phase of vehicle play, he made no verbal referents to any of the relational themes which had emerged in the Middle Play Phase. When not engaged in play with the human figures, no verbal referents about them arose. This fact reflects the power of the physical presence of play materials to facilitate therapeutically relevant discourse. At the same time, it is likely that the pending end to the therapy induced Carl to close the painful chapter of relationships. Carl exploited the expressive capabilities of both play and verbalization to synergistic benefit. Sometimes he worked simultaneously in both domains, verbally embellishing his play activities, with play and language richly enhancing each other. Sometimes these two domains unfolded in a kind of contrapuntal sequence: Carl would play quietly, then describe his actions verbally; or, in opposite sequence, Carl would announce his plans to play, then seek out the objects and materials he needed to actualize his verbal intentions. 224 The synergistic benefits of play and language were particularly evident in the development of Carl’s relationship with the therapist. Carl utilized both to form a relationship with her, first through verbalization and later through play. Earlier in therapy, he directed negative and angry verbalizations at the therapist, which nevertheless denoted an emergent relationship with her, “No like payroom! Go pees!” By the end of the therapy, he verbally directed her play actions and sought her full participation in his play activities. Contributions of the Play Disruptions to Process The play disruptions interrupted Carl’s play and verbal capacities. Tears and screams predominated. At the same time, critical events occurred in both domains, which were integral to his therapeutic progress. On the level of play, the materials were pivotal during the first disruption. Although Carl’s own willingness and even capacity to play were disrupted, he could still watch the human figures, decipher their actions, and gradually achieve calm. On the verbal level, it was during the play disruptions that Carl communicated his deepest pain, of feeling left and abandoned, of wanting to go home to his biological parents. With his emotional defenses against pain crumbling, Carl felt the overwhelming hurt of separation from them. During this terribly vulnerable state, important core communications gushed out. Like his tears, his words were beyond his conscious control (“Miri come get me,” “Time go home now,” “Big big hug”), but they were of deepest psychological relevance. 225 Summary Narrative As with the analyses of Anna and of Brad, a summary narrative concludes the chapter on Carl. This narrative reweaves and reworks the verbal and play thematic material, analyzed in depth above, into an integrating story of Carl’s play therapy experience. Beginning phase. Carl initially experienced the playroom as a frightening place. As the playroom door closed and his teacher walked away, Carl burst into tears of intermingled fear, sadness, anger, and protest. Far from his peers and teachers, uncertain when he would see them again, and left in the care of a stranger, Carl shouted a desperate “No!” However, the presence of the play materials offered solace. As soon as he caught sight of the vehicles on the shelf, his fear, anger, and sadness lifted. He approached them happily, as if they were familiar friends and, without hesitation, he engaged them in play. Carl played energetically, with a sense of involvement and commitment. He was busy and so were his vehicles. He added water to the sand, stirring, digging, and preparing the area for his vehicles. The vehicles, too, had work to do, digging tunnels and burrows, travelling, and dumping miniature loads of sand. The sandtray churned with movement and industry. Carl delighted in the physical interaction with the raw materials of sand and water. The contrasting properties of these materials challenged and stimulated him to create, to do, and simultaneously they soothed and engrossed him. Carl was fascinated with the notion that the sand was “dirty,” a feature which seemed to enhance its attraction for him. 226 He tolerated, accepted, and even enjoyed the therapist as an observer or spectator to his play. Aware of and open to her presence, Carl continually chattered to her as he played, describing in adequate vocabulary, if infantile and unclear pronunciation, the names and the activities of his vehicles. Yet Carl was an independent player. On occasion he touched the therapist, but he did not invite her to join his play nor did he seek out sustained physical closeness with her. Carl relished the opportunities for initiative within the playroom. He was familiar with the play purposes of sand, water, and vehicles, and he did not await the therapist’s permission to engage them in play. He moved happily and busily, almost rushing from one play material to the next. When his interest in one vehicle began to wane, he went quickly to the toy shelf and chose another one. His play with the vehicles advanced in a cyclic rhythm, a little time with the tow truck, then the backhoe, then another vehicle. At the ebb of each cycle of interest, Carl seemed almost impelled to seek out a new vehicle. There was the faintest hint of anxiety in his voice as he sought “moh car.” In fact, these pauses, microscopic play disruptions, were pregnant with anxiety, which dissipated as soon as he resumed play with the next vehicle. Like a play “fix,” the novelty and the unique functions of each new vehicle allayed his uncomfortable feelings, which lurked just below the surface. Ultimately, Carl could not control the feelings which had begun to well within him. They broke through; and Carl burst the bounds of accepted social behavior, flooding the playroom and the therapist, and attacking the doll house. He barely looked at his 227 cherished vehicles during this pivotal transition and chose to play with baby dolls. His play with them was characterized by a deep and touching sense of vulnerability and, at the same time, rage, as he attempted to cut the eyes of one baby and almost rocked others out of their cradle. Overcome by inner tensions created by these extremes of vulnerability and rage, Carl fled from the playroom. First disruption. Carl’s experience during play disruptions was that of a child living a waking nightmare. He screamed and sobbed on entry into the playroom. Waves of pain, sadness, and anger flooded him. At first, Carl was able to temporarily muster his attention to the play materials, which offered him distraction from the frightening feelings which had erupted with such intensity. He chose the materials that had brought him so much pleasure in the past——the vehicles, the sand, and the water. Yet these trusted and familiar play companions did not provide the same captivation or comfort. The unsettled feelings welling within Carl induced him to seek a new play diversion. He chose the shark, a sinister and less than comforting play figure, which glided through the water and the sand. The diversions of play had served as a buffer and a wall of defense from the pain which was beginning to surface, but these diversions could no longer withstand the waves of sorrow which flooded him again. He dissolved in anxious and angry tears. The novelties of play materials no longer sustained his interest or mitigated his anxiety. Carl was overwhelmed with anguish and despair. From the perspective of the therapist, the permissive atmosphere of the playroom and Carl’s immersion in play activity had enabled 228 the loosening of his defenses to the extent that deeper feelings had become dislodged and surfaced. However, from Carl’s perspective, the playroom itself was the terrifying and cruel source of his pain. Carried to the playroom against his will, Carl wanted no part of it nor of the therapist. Separated from his friends and teachers, he experienced the playroom as a punishment cell and the therapist as the jailer. “Open door!” he screamed. Ultimately, play materials came to his aid, leading Carl out of the abyss of this disruption. Small human figures enacted scenarios of a child leaving his mother and father. Through his tears, Carl was interested in the portrayal of the feelings and experiences of the tiny child. Something about the activities of that little figure, as he hugged his mother and father and then walked away with other adult figures, made sense to him. This miniature human world was comprehensible. The tiny figures who inhabited it were small enough that Carl could see and absorb the entire scope of their actions and interactions. The figures were maneuverable and controllable. The tiny child could speak and describe all the wrenching feelings he experienced on leaving his parents. Calm, clarity, and understanding were possible in the presence of these figures. A profound change marked his relationship to the therapist. Throughout the disruption, despite his fiercest protestations to leave, Carl never struggled to leave the therapist’s lap. Carl was not simply seated on her lap, he remained rooted there. Middle phase. The wave of despair lifted as suddenly as it had descended. Carl entered a period of more detailed and 229 complex play with his vehicles and of touching personal scenes with the small human figures. Themes of work and industry prevailed in the vehicle play, but the vehicles began to encounter serious difficulties. They became stuck in the sand and repeatedly needed help to become dislodged. The therapist was intermittently engaged to help free the vehicles. From amongst his verbal descriptions of the vehicles’ activities, a distinct call for help sounded: “Help pees, Mommy.” This phase was marked by the emergence of representations of human interaction. Carl controlled the relationships, the identities, and the destinies of the miniature figures. He portrayed vivid but simple expressions of love and tenderness, with the family figures hugging and kissing, and sleeping together. He verbalized profoundly tender wishes of “nie nie” to the father and vocalized gentle kisses. He enacted scenes of parting and farewell, with the child walking away and telling his father “goodbye.” He depicted positive and playful facets of the tiny child’s personality, with the figure happily “jumping” into the tub. Carl expressed fascination with the toilet. After the figures “used” it, he touched and smelled the “pee der.” He used the figures to explore his curiosity about the biological givens of gender identity, attempting to comprehend who has a penis. He grappled with the gnawing question of the identity of his mother. Like his vehicles churning through the sand, Carl in this play phase was working and churning through layers of emotion and understanding. He was able to depict the components of his life with clarity and to use language, simply yet eloquently, to 230 express difficult issues. After a time, nonspecific anxiety, discernible in his voice, threatened the relative calm and emergent strength he had achieved in this play phase. Second disruption. The emotions of the second play disruption washed over Carl like a tidal wave. The sadness, rage, and despair of the first disruption intensified to a sense of inconsolable grief. His verbal protestations to leave escalated. He repeated almost without cessation, “Time go back now? Time go!” This refrain was both a question and a demand, a plea for help from and an expression of anger at the noncompliant therapist. At the height of his pain, Carl refused to even look at the therapist. She had become the enemy, the symbol of adult power to control, direct, and contain forces which had so radically disturbed his life. At the same time, he remained grounded in her lap, breaking down in comprehending sobs when she commented in words which simultaneously troubled and helped him: “You’re so sad. You love and miss Daddy so much.” At times, Carl did not so much as sit on the therapist’s lap as lie across her lap like a limp rag doll, battered by grief. Carl felt alone, forgotten, even abandoned. “Time go home now,” he wailed. Racked with sobs, his deepest pain had surfaced. Desperate to leave the playroom, he tried to bargain with and to manipulate the therapist. “I happy now,” he repeated, hoping to convince her to return him to his classroom. Carl’s play disruptions bring to mind the metaphorical image of tunnels, like those his backhoe carved in the sand. In one sense, troubling emotions bored beneath Carl’s conscious 231 faculties, causing him pain and distress. In another sense, while apparently confining Carl to an interminable darkness of despair, the play disruptions actually led toward light, toward recovery. Final phase. The intensity and trauma of the second play disruption yielded to a sense of calm and resolution. There was an optimistic sense of “after the storm” as Carl returned to greater enjoyment and pleasure in his play than ever before. Carl’s vehicles moved and worked with a sense of purpose. They enjoyed their power, moving real loads, and freeing themselves from tangible obstacles. They maneuvered in complex and detailed ways. Carl’s ability to comprehend the vehicles in a more rule—bound world of lanes and parking stalls suggested the faint emergence of superego functions. The therapist emerged as a playmate and a friend. A feeling of intimacy, rapport, and even love suffused emergent cooperative play. Carl verbalized feelings of liking the vehicles and the therapist. Carl enjoyed controlling and directing the therapist, ordering her how, where, and with what to play. By the conclusion of his therapy, the tension had largely disappeared from Carl’s face. Part of his ease must be attributed to the fact that he knew the sessions would soon end. Nevertheless, throughout his therapy Carl had experienced an intense storm of emotions, and there was evidence that he was beginning to emerge from that difficult period. He seemed happy, content, and, for the first time, at home in the playroom. Summary. The three Play Phases, in which Carl enjoyed the simple play pleasures of cars and trucks, sand and water, were 232 punctuated or, more precisely, rent asunder by two deeply distressing and painful Play Disruptions. During these disruptions, Carl initiated no play. He was reduced to the sentience of profound hurt and anger. Miniature human figures were the decisive play tools of his recovery. When he could not play or even speak due to overwhelming emotions, he was able to quietly integrate the essence of the child-adult depictions he observed. Later, in the depths of his pain, he verbalized a wish to go home, an expression which marked a turning point in his therapy. Carl’s play and verbal capacities worked in tandem to advance him toward recovery. Carl began to recover, in part, because of his ability to portray particular motifs of the child adult relationship; and he began to recover, in part, because of his verbal capacity to express difficult issues with simple clarity and force. 233 CHAPTER VII. CASE 4 DAVE: THE WORKING THROUGH OF FEAR Dave’s play therapy followed an intricate course through a series of creative and imaginative play activities, leading ultimately to the early stages of the working through of fear. Three years and 9 months old at the outset of therapy, Dave did not suffer from any severe behavioral or emotional difficulties. A highly verbal, bright, and active child, Dave usually participated well and enthusiastically in his school activities. He engaged his peers in play and was generally cooperative with his teachers. During his first year at preschool, however, intermittent tantrums had troubled Dave and his teachers. Although he seemed to be settling well into his second year at preschool, the recollection of his angry and unhappy outbursts, which had occasionally affected his relationships with peers, suggested that Dave would benefit from individual therapeutic play. Dave’s adjustment difficulties had never required psychological assessment. No formal diagnosis was associated with his referral to play therapy. Rather, play therapy was offered to Dave as a developmental assist, both supportive and preventive in nature. Dave lived in a single-parent household. During the initial parent-therapist meeting, his mother pointed out that Dave preferred action—oriented play, which often involved superhero themes. Dave’s developmental milestones had all occurred within normal range. However, toilet—training had been difficult; Dave was still prone to accidents at night and sometimes at school. Physically, Dave appeared small for his age but was 234 nevertheless a well—coordinated and energetic child. Aside from the occasional cold, he did not suffer from any health problems; he had never been hospitalized. Intellectually, he was quick and alert, with a good memory for detail. He also possessed an impressive vocabulary and verbal facility. He used these faculties to verbally reason, argue, and negotiate with adults. While his size suggested a younger child, his verbal abilities were typical of a much older child. An Overview of Dave’s Play Therapy From the outset, Dave showed interest and curiosity in many play materials. He played with a cheerful eagerness. However, he did not immediately experience a sense of comfort and ease in the therapeutic playroom. Typically, he played with sustained attention with a particular material or a series of materials and then suddenly asked, or demanded, to leave the playroom. Anxiety seemed to lurk just below the surface. It emerged during attentional breaks or shifts, troubling him and prompting him to seek to return to his classroom. The therapist did not comply with his requests to leave. It was not until well into his therapy that Dave’s level of involvement in play deepened and intensified, granting him distance from this anxiety. Involvement and delight in play emerged during several consecutive sessions when Dave initiated play in the dark. Enveloped in the darkness, Dave began to thoroughly enjoy the playroom as a setting in which he could launch a number of creative play scenarios. When the phase of play in the dark ended, Dave turned to depicting scenes of fearful animals threatening small, vulnerable 235 creatures. In the final 6 sessions, he repeatedly constructed miniaturized scenes of such intimidation. Dave’s play therapy ended just as he had begun to work through the fears which were likely responsible for his earlier anxious behavior. Outside of the playroom, Dave’s progress was slow and not immediately evident. During the first half of his therapy, no appreciable change in his behavior was noted in his classroom. Midway through the year, however, he began to have an increasing number of toileting accidents both at home and at school. Changes in home and school routines may have partly contributed to his stress, precipitating the “accidents.” However, the therapist interpreted this regressive behavior as a positive sign, signalling a dissolution of certain controls and inhibitions, and expressive of a need for infantile care. After a number of weeks, these accidents diminished. The changes in Dave at the end of the 20 sessions in play therapy were definite, although not dramatic. His teachers found him more resilient, better able to accommodate to changes in routines. He had begun to occasionally settle into their laps for affectionate cuddles. From beneath his facile verbal demeanor, which had veiled his emotional neediness, a vulnerable and affectionate little boy was beginning to emerge. At the conclusion of his therapy, Dave still favored “tough guy” scenarios on the playground, often leading several peers in such activities. This indicated to the therapist that the fears which drove his anxiety were not entirely resolved. His tantrums had not completely disappeared; however, at school they were far less frequent, occurring usually when he was feeling very tired or 236 unwell. In general, Dave’s progress in play therapy was positive though incomplete. He had gained incremental strength in the safe confines of the playroom and had begun to apply his considerable creative resources to work on underlying fears. The Phases of Dave’s Therapy The three phases of Dave’s play therapy were much more fragmented, overlapping, and interwoven than those of the other participants in this study. The Beginning Phase of Unsettled Play was composed of a series of overlapping subphases, namely, of Doctor Play, Doll House! Puzzle combinations, and Play with the Witch Puppet. In contrast to the early play phases of the other 3 participants, Dave’s Beginning Phase contained only minimal exploratory play, as he quickly became involved with a range of play materials. Play in the Dark (9 through 13) constituted the Middle Phase, dividing the Beginning Phase from the End Phase of Representations of Fear. In addition to Representations of Fear, this later phase also contained a Subphase of Juxtaposed Infantile/Macho play. The Principal Play Materials Dave was a prolific player who utilized a wide range of materials, which, either singly or in combination, dominated the many subphases of his therapy. This analysis of play and verbal themes attends to the following play materials: Doctor Materials; Puzzles; Puppets; Miniature Animals; and Baby Dolls, Bottles, and Soothers. Play in the Dark, which involved several unique props, is also analyzed. The occurrence across sessions 237 of play with all cited materials is summarized in Figure 25. Session Middle Phase 1 2 3 4 5 6 7 8 91011121314151617181920 Material DOCTOR * * * * * * * * * PUZZLES * * * * * * * * ANIMALS * * * * * * * * * DOLLS * * * * * * * * * PUPPETS * * * * * * * * * * * DARK * * * * * Figure 25. Dave: Overview of Play with Principal Materials Doctor Materials: The Play Themes Dave chose the Doctor Materials upon his first entry into the playroom. Dave’s play with these materials clustered around the following activity and event themes (cf. Figure 26): Exploratory/Handling; Identity of Patient; Inclusion of Other Characters; and Type of Examination and Treatment. Exploratory/handling. Exploration and Handling of the various instruments in the Doctor Kit took place intermittently during Dave’s doctor play across the first 4 sessions. Once familiar with the medical instruments, Dave moved on to their application in patient examination and treatment. Patient identity. The figure of a large “baby boy,” with anatomically correct genitals, served as Dave’s first patient (1, 2, 3). Additionally, Dave himself functioned self-reflexively as both doctor and his own patient (3), examining his stomach with the stethoscope and asking the therapist to examine him in this 238 way as well. Dave never again enacted the role of patient. Dave retained the doctor role and utilized the therapist as patient for the remainder of his therapy (5, 6, 7, 11, 19, 20). Session Middle Phase 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Theme EXPLORE / HANDLE * * * * PATIENT IDENTITY Doll * * * * Self * Therapist * * * * * * PUPPETS Help * Hurt * * TREATMENT Brief exam * * * Hurtful * * * * Caring * * Figure 26. Dave: Play Themes with Doctor Materials Inclusion of other characters. Puppets were the only other props to be incorporated in Dave’s doctor play. Although infrequent, Dave’s inclusion of puppets as props to the doctor play is noteworthy because their usage reflects contrasting thematic elements of caring versus harming. Initially (1), an (unidentified) puppet grabbed the baby boy, with Dave indicating contradictorily that “He [the puppet] just said ‘hello.’ He scratched him.” Later (6), the dog, duck, cat, frog, and princess puppets appeared as helpers. In turn, each assisted the therapist, as patient, in removing a bandaid which Dave, the doctor, had applied to her hand. In the final inclusion of puppets in doctor play, caring and 239 harming elements were juxtaposed. Initially, Dave tended the therapist’s dog puppet by applying a bandaid to its eye. Using the duck puppet, Dave at first helped the dog remove the bandaid, but then insisted that the dog ingest the bandaid. When the dog choked on the material, Dave’s puppet forced the therapist’s puppet to repeatedly ingest (and choke on) more bandaids. Type of examination and treatment. In early doctor play (1, 2), Dave undressed the male infant and gave him only a cursory examination with the instruments, with a more detailed check—up involving several instruments occurring later (3). However, when the therapist served as the patient, she was subjected to a brief physical exam and then given treatment which included oral discomfort. This took two forms: Dave’s pretending to squirt a variety of substances into the therapist’s mouth (“medicine,” “milk,” “juice,