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A case study analysis of thematic transformations in nondirective play therapy Levin, Susan Charlotte 1992

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A CASE STUDY ANALYSIS OF THEMATIC TRANSFORMATIONS IN NONDIRECTIVE PLAY THERAPY  by  SUSAN CHARLOTTE LEVIN  Brandeis University, 1969 B.A., 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  DE-6 (2/88)  September 14, 1992  Abstract A multiple case study approach was employed in this intensive thematic analysis of the process of nondirective play Using a naturalistic research paradigm, this study  therapy.  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. common to all cases:  However, a number of themes emerged in 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, and retrieval.  injury and recovery,  loss  Typical thematic transformations included  movement from infantile vulnerability to mastery, toward resolution,  from grief  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 ii v viii ix  Abstract Table of Contents List of Figures Acknowledgements  1 1 2 4 5 5  INTRODUCTION CHAPTER I. Background of the Study Rationale for the Study The Research Questions Overview of Design and Method Definition of Terms SECTION I: REVIEW OF THE LITERATURE. CHAPTER II. PLAY AND THE PLAY THERAPY PROCESS Background on Play Therapy The Therapeutic Qualities of Play Historical Overview of Play Therapy Conceptualizations of the Play Therapy Process Jungian/Analytic Play Therapy Nondirective Play Therapy Studies of Play Therapy Process Empirical Studies of Nondirective Play Therapy Instruments of Play Therapy Process SECTION II: REVIEW OF THE LITERATURE. CHAPTER II. THE USE OF SYMBOLS TO ELUCIDATE PLAY THERAPY PROCESS The Nature and Function of Symbols Play and Language as Symbolic Systems Their Developmental Convergence Differences as Symbolic Systems Similarities as Symbolic Systems Empirical Support for Developmental Correspondence. Therapeutic Play as Symbolic Expression Accounts of Symbolic Transformations in Child Therapy Case Studies of Play and/or Art Media Case Studies of Sandplay SECTION I: METHODOLOGY. CHAPTER III. PRINCIPLES, RATIONALE, AND TERMS Considerations in Choice of Method Background: 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 V  8 8 8 10 12 13 14 17 17 33  .  36 36 38 38 39 40 .41 43 44 44 47  51 51 52 53 54 55 57 58 59 60 61 65 66 66 67 67 68  SECTION II: THE RESEARCH PROCEDURE. .69 CHAPTER III. METHODOLOGY. 69 Synopsis of Design 69 Description of Participants 70 Rationale for Participant Selection 70 Process of Participant Selection 71 The Setting and Access Issues Ethical Considerations 72 The Researcher as Participant—Observer 72 73 The Therapist’s Intervention Style 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 76 Coding of Play Themes 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  DISCUSSION AND CONCLUSION 284 CHAPTER VIII. 284 The Research Questions 285 The Research Findings Individualized Paths of Change 285 Struggle with Opposites 286 Common Themes 287 290 Types of Transformations 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 333 334 Summary  REFERENCES  337  vi  APPENDIX A:  OUTLINE OF RESEARCH PROCEDURE  346  APPENDIX B:  RESEARCH INFORMATION AND CONSENT FORMS  347  APPENDIX C:  LIST OF MATERIALS AND DIAGRAM OF PLAYROOM  350  APPENDIX D:  DATA ANALYSIS FORMS  352  vii  LIST OF FIGURES Figure Figure Figure Figure Figure Figure Figure Figure Figure  1. 2. 3. 4. 5. 6. 7. 8. 9.  Anna: Anna: Anna: Anna: Anna: Anna: Anna: Anna: Anna:  Overview of Play with Principal Materials....83 85 Play Themes with Inf ant Props Verbal Themes Associated with Infant Birth.. .93 97 Verbal Themes During Other Infant Play 102 Play Themes with Doctor Materials Verbal Themes Associated with Doctor Play. . . 104 107 Play Themes with the Whale Verbal Themes Associated with Whale Play....110 114 Play Themes for Painting  Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure  10. 11. 12. 13. 14. 15. 16. 17. 18. 19.  Brad: Brad: Brad: Brad: Brad: Brad: Brad: Brad: Brad: Brad:  Overview of Play with Principal Materials. . .135 Play Themes with Vehicles 137 Verbal Themes with Vehicles 145 House Props...151 Play Themes with the Doll and 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  Figure Figure Figure Figure Figure  20. 21. 22. 23. 24.  Carl: Carl: Carl: Carl: Carl:  Overview of Play with Principal Materials. PlayThemeswith Vehicles Examples of Verbal Themes with Vehicles Play Themes with Doll House Figures Examples of Verbal Themes with Doll House Figures  Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure  25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37.  Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave: Dave:  .  .187 188 195 204 209  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  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  1 CHAPTER 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,  child’s reliance upon verbal communication was singular.  each  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  2 additional 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 Kaiff,  1980; Sikelianos,  1979,  1986,  1990).  (Allan,  1988;  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, tangible media experience.  (Kubie,  linking emotional experience to  1953), providing routes of access to inner  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, components,  its particular  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.  3 However,  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,  populations  (e.g., Nibs & Reiss,  1975)  1982).  or with specific 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. these studies,  the perspective of the researcher,  In  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.  4 By 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  s interaction with play materials 1 themes emergent in the child 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?  5 It 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.  6 Play 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, was considered “a series of actions and events connected through a common purpose, (p.  sequence,  .  .  a play theme .  which are  and consequence”  Play themes generally pertained to patterns in  39).  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, synonyms,  their  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. sounds,  noises,  This included words, phrases,  shouts,  singing,  sentences,  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, principles, methodology,  also divided into two sections,  first presents the  rationale, and terms underlying the research and then describes the detailed steps of the  7 research procedure. study, Brad,  Chapters IV through VII are the core of the  the case accounts of the four research participants, Anna, Carl,  and Dave.  The concluding Chapter VIII discusses the  findings and sets them in their theoretical and practical context.  8 CHAPTER II. SECTION I:  REVIEW OF THE LITERATURE  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. application of play, 1964), therapy  such as behavioral play therapy  psychoanalytic play therapy (Ginott,  Each therapeutic  l982b),  (Klein,  1955),  (Russo,  or group play  assumes the theoretical coloration of  the psychological model which has inspired it. creative therapeutic approaches,  Yet all of these  including nondirective play  therapy, have in common the fact that therapists are working with a medium,  namely play,  which is adaptable for therapeutic aims.  9 Winnicott  (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. although playing occurs with objects,  Conversely,  it is not an objective  activity, but a highly involving subjective experience. therefore,  Playing,  constitutes a unique experience of intermediation  between the child’s subjective and objective experience. such,  explained Winnicott,  As  it characteristically offers singular  opportunities for self—absorption and concentration. are often referred to as being “lost in play.”  Children  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, motivating and engaging.  it is intrinsically  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, helping to reduce the child’s anxiety;  thus  the play materials  (b)  provide the child with marty options for activity which can be used to bridge contact with the therapist or avoid such contact  (through shared play)  (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 Within play therapy  enhancer of the child’s verbalization.  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,  materials are all physically engrossing. activities facilitate emotional catharsis.  and messing with play  At the same time,  such  Through the physical a  11 engagement with play materials,  anger can be released,  dissipated, tension reduced, and calm achieved.  anxiety  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, repetition compulsion. service of the ego,  as a form of  He also identified regressive play in the  and he cited the usefulness of play for  experiences of mastery or symbolic revenge Von Hug-Hellmuth (1921)  (Freud,  1920).  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” However,  (Hug-Hellmuth,  1921, p.  295).  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. technique,  Offshoots of the psychoanalytic play  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 Rogerian  (1947)  extrapolation of  (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) favored a less permissive setting than Axline’s. (1959)  and  Moustakas  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, therapy  (Guerney,  1964)  such as filial  or theraplay (Jernberg,  1979),  continually appearing. Conceptualizations of the Play Therapy Process Conceptualizations of play therapy process differ among the schools of practice. the analytic  (Jungian)  This section presents the nondirective and 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, Schaefer,  1976; Schaefer & O’Connor,  1982;  1983) have not yet denoted  analytical or Jungian play therapy as a discrete area of play therapy practice.  However, the work of Allan  play therapists such as Kalff (1980),  (1988)  and of sand  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. unconscious,  The personal  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,  is the experiential consciousness of the individual: and feelings,  ideas and thoughts.  the Ego,  memories  The Jungian conceptualization  of the personality also posits a spiritual center of the individual,  beneath and beyond the Ego and the two-tiered the Self, whose nature it is to grow and evolve  unconscious:  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. and the Ego is to mature, outlet is needed”  (Allan,  If the Self is to grow  some form of symbolic expression or 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, The vocabulary of Rogers’  (1951)  1983). 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 To that end, the therapist must be  for emotional growth.  congruent with his/her own emotions, responses or tone of voice.  avoiding artificial  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. Rogers’  (1951)  By  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. empathy,  congruence,  inducing environment, (Rogers,  1951, p.  Gradually,  through therapist  and unconditional positive regard,  a trust—  a “nonthreatening psychological climate”  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 They constitute the aim and the  indulgent nor unremunerative. 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 The nondirective  as for the development of pretend play themes.  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 Lebo,  1951).  (e.g.,  Finke,  1947;  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  They sought patterns in the client-  ambivalent feelings.  therapist relationship,  trends in clients’  response patterns,  patterns in expressed client feelings, and indications that nondirective play therapy was truly nondirective.  Inf erred from  their codification categories of therapist verbalization (whether positive,  negative,  or ambivalent statements,  actions predominated) process as  (a)  attitudes, and  is a conceptualization of play therapy  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. therapist statements coded,  Of the total number of client and  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”  reflection of feeling preceded over half responses.  207).  (1946, p.  (57%)  Therapist  of the client  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. procedure, the following information emerged. Feeling, the most frequently used strategy,  From this  Recognition of  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,  than 10% of therapist remarks.  constituted less  This latter finding is seen as  antithetical to the naive perception of nondirective play therapy as simple acceptance of the child (cf. Guerney, With regard to changes within the child,  1983).  Landisberg and  Snyder found the rise in physical action by children in the latter three-fifths of treatment to be most important. corresponded with “marked expression of feeling” accompanying most of that action.  This  (1946, p.  209)  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. results,  In presenting the  Landisberg and Snyder evidently presumed uniformity  across therapists’  styles and responses,  leaving their study  vulnerable to the “myth of the uniform therapist” 1967).  (Kiesler,  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. similar to Landisberg and Snyder,  Finke  Adopting a perspective (1947)  reasoned that  “predictable trends in verbalized attitudes [should]  occur during  a series of non-directive play therapy contacts”  12)  (p.  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. coding categories included: descriptions of play,  Lebo,  1955).  expressions of curiosity,  statements of aggression,  simple  exploration of  playroom limits, negative and positive self—statements, evidence of interest in the counsellor.  These  and  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, visual record of frequency changes in,  providing a  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 Near the end of this stage the level of with the counselor. conversation reaches a point that is maintained for the In the second stage aggression remainder of the therapy. and testing of limits decrease slightly, imaginative stories connected with the play become marked, and the child seems The last to have accepted the counselor’s neutral role. 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)  categories of clients’ Snyder’s  (1946)  year—olds)  basic codification  feelings, but argued that Landisberg and  use of a homogeneous age group  (five— and six—  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,  descriptive elements  (cf. Lebo,  and play or personal  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. less,  Older children explored the limits of the play room  looked less to the therapist for information,  less than the younger participants.  and talked  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, become more distinct.  in turn,  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: expression of diffuse negative feeling; hostile feelings;  (b)  (a)  ambivalent anxious or  (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’ supported:  (a)  twin hypotheses were  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. Se,  Although not part of the research per  an interesting qualitative aspect of Moustakas’  selection  of subjects was his comparison of parents’ versus teachers’ While there was  verbal description of each child’s problems.  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, orderliness anxiety,  cleanliness and  and developmental regression.  In a later comparison of well-adjusted and disturbed children, Moustakas and Schalock (1955) interactions.  They asked whether (a)  analyzed therapist-child  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; behaviors produce certain child reactions,  (c)  certain therapist  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, offered interpretation.  and  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, to this study.  In the first stage of her research,  is of interest 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. children recalled,  for example,  a group play setting), sense of freedom. (1950)  In conversation with her, the feeling happy, making friends  being allowed to make noise,  (in  and a general  Based on the children’s comments, Axline  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: and,  First,  a period of exploration  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, technique known as filial therapy.  a treatment  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.  intensity of children’s leadership, dependecy,  The  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. and Guerney  He anticipated trends similar to those of Stover  (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 She sought to determine how the  sessions by the same therapist.  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, changes over time.  Siegel found significant behavioral  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. devised a 30—item scale for verbalization, nonverbal expression,  She  a 14-item scale for  and a 16—item scale for play activities.  These scales were similar to those previously devised by Finke (1947)  The scales enabled  and later revised by Lebo (1955).  Hendricks to rely upon quantitative data,  frequency  namely,  counts. Hendricks identified 4 major phases of the nondirective play therapy process.  In the first,  exploratory, noncommittal, and  She found that the children  creative play predominated.  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,  focused on specific concerns.  frustration, and anger became more 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. the work of Hendricks  Seeking to replicate and extend  (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. verbal,  nonverbal,  Sessions 1 through 3 saw high levels of  and play exploratory activity.  In Sessions 4  through 6,  aggressive play and verbal sound effects peaked.  through 9,  aggressive play ebbed while creative play peaked.  In 7 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,  poor peer interaction,  such as aggressive acts,  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 In general,  procedures to verify statistical significance.  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,  vulnerable to the “myth of the uniform therapist” 1967).  This study is  and impact with the children.  (Kiesler,  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  coding categories such as Attentional Behaviors recognition of others or offering help),  (1956)  developed  (e.g.,  Stimulus Behaviors  (attempts to elicit particular responses, such as reassurance or affection), Orienting and Directing Behaviors restricting), Criticism or Rejection Behaviors praise to physical attack), expressions,  (directing or (ranging from  Cooperation and Compliance  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,  its  1981) was developed as a research tool,  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 Guerney,  Burton,  Silverberg,  (e.g.,  Dana & Dana,  1969;  1965).  & Shapiro,  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, “classifying every child behavior or càmment, purported significance”  (Howe & Silvern,  1981,  capable of  regardless of its 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, structured or creative toys. categories,  13,  or inventive use of  Of the original 31 experimental  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,  Inadequacy,  Social  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,  disparate research focus,  each with a  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. SECTION II:  REVIEW OF THE LITERATURE  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, the hero and the foe,  such as  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. cannot be simply defined or unidimensionally interpreted.  Symbols  37 Rather, 77)  symbols are complex “images of contents”  Symbols “seek rather to express  something that is little known or completely unknown” 1976, p. event.  222).  1976, p.  Symbols are not signs  with many potential meanings.  corresponding to what is known.  (Jung,  (Jung,  Symbols do not signify a definite action or  They represent and express deep personal meaning.  corroborative case material analytical therapists  (1976)  (e.g., Kalff,  appearing in a client’s art, play,  Jung’s  as well as subsequent work by 1980)  affirm that symbols  or dreams commonly reflect or  portend important personal changes. Symbols are capable of representing personal meaning because (tangible) with subjective  they link objective psychic)  experience.  unconscious  (Segal,  (emotional and  Symbols link the conscious and the 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):  which is the It is the dual anchorage of the symbol . . . bridge over which these processes take place, i.e., the internalization and externalization, introjection and Without this dual anchorage of the symbolic somatization. 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 parallel paths.  independent,  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. speech is not symbolic. However,  Early  It does not represent anything.  at a critical point in development, the infant’s sounds  acquire meaning.  At this developmental crossroads,  physical exploration become linked. symbolically, activities,  language and  Language becomes  representationally, associated with objects,  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 converge”  lines of development,  (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, Specifically,  relational context.  occurs in a  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 That is,  thought.  the child’s social communicative experience  precedes the development of internalized self-talk. contradistinction to Piaget’s  (1962)  This is in  related theories, which  considered internal speech an early form of thought and a interpersonal language.  precursor to expressive, Vygotsky,  the developmental process of speech and activity may be  summarized as follows: from activity. context,  According to  and,  The child’s speech is at first separate  Later speech accompanies activity in a relational 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 (1970)  (Sinclair, noted,  1970).  Specifying the differences,  Sinclair  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. act are highly individualized. can occur in myriad forms,  The meanings of a given play  styles,  and emotional coloration, The words that  indicating meanings unique to each child. comprise language,  in contrast,  system of shared meanings.  for example,  Play with blocks,  are a conventionally assumed  A final difference concerns the fact  that through play the child can spontaneously and loosely link materials,  themes,  and events together.  cannot be joined together haphazardly. rules of syntax,  In contrast,  words  Language is governed by  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 systems,  (Smith,  1979).  Both are representational  enabling the individual to externalize and portray  thoughts and emotions. that they act,  Play materials are representational in  in Vygotskian terms  (1978),  object which carries meaning related to, object it is meant to represent.  as a “pivot,” an  but independent of, the  When a child uses a wooden  block as a car, the block acts as such a pivot. essential meaning of “car.” demonstrates  (a)  It bears the  In play with this object,  the child  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, decentration.  both play and language permit  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 (Lowe,  in late infancy are directed toward the self Later,  the child animates and directs objects,  with the potential for independent action.  1975).  investing them  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 Watson,  1980; Ungerer,  (Elder & Pederson,  Zelazo, Kearsley,  1978; Jackowitz &  & O’Leary,  1981).  Language similarly permits decentration by enabling the child to conceptualize, objects,  describe, and verbally manipulate persons,  and events removed in time and space.  Empirical Support f or 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 Ungerer,  & Sherman,  1987; Sigman & Mundy,  (Mundy,  Sigman,  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: presymbolic behaviors in both domains, first referential words,  (3)  behaviors in both domains, language and symbolic play”  (2)  “(1)  initial pretending and  the emergence of combinatorial  and (p.  (4)  hierarchically organized  795).  McCune-Nicolich suggested  that “symbolic play might provide a useful converging operation for identifying structural turning points in language” 795).  (1981, p.  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 changes,  .  .  .  .  Through symbolic action of bringing about  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,  (Allan & Berry,  1987, p.  and reappear throughout their treatment” 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, growth and recovery.  or a symbol of the child’s capacity for  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, expressive arts or sand play literature. encompass play, art,  sand,  namely,  in the  These studies, which  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, theme of rescue, help,  “the reparative motif,” or the  and restoration.  He observed that the  emergence of this theme marked a significant phase in therapy and presaged a generally successful therapeutic result. depth study of two cases, Clegg (1984) emerged,  evolved,  In his in—  documented how this motif  and moved these children toward recovery.  He  noted that nascent forms of the reparative motif, barely discernible at first, continued. (1984, p.  crystallized into fuller form as therapy  Clegg considered play a “holographic sampling” 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. to Allan  (1988),  “In play therapy, children will often  According  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, (Allan,  eaten away,  and sprouting new life  1988)  In a case study of adapted play therapy treatment 1988),  (Allan,  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. drawings,  In her fantasy enactments as in her  she adopted different,  transformed across her therapy.  successive identities which 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,  Sikelianos,  and feelings”  (Allan,  1988, p.  7),  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, food)  in his case, were loaded with  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), described the symbolic transformations,  Sikelianos  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. parallel lines,  Two vertical  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)  contact and relationship lines).  A figure 8,  to her later capacity for human  (later represented by intersecting  initially upside-down and falling into  space, gained stability, human features ultimately (post-therapy)  (eyes,  nose, mouth), and  became an S-shaped mandala,  wholeness in the Jungian framework.  The V,  a symbol of  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” 59).  (1986, p.  These graphic representations underwent transformation as  her ego and personality became stronger and healthier. general,  In  “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 1980; Lowenfeld,  modality (Kalff,  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, versus scattered,  schematic  and open versus enclosed arrangements.  She  elaborated other basic styles and the affective dimension they represent as follows:  violent play  sparse play configurations repetitive play  (symbolizing aggression);  (dearth of ideas; escape,  (preoccupation or fixation); no people  or escape wishes); enclosed formations chaos  rejection); (hostility  (protection or isolation);  (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, her work,  a safe container for the child’s unfolding psyche.  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” 1980, p.  In  29).  Kalff’s  (1980)  (Kaiff,  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. halves of her Self were symbolized by fir trees tiny blossoming trees  (the West)  Two and  (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 symbolic fashion,  and,  over real life difficulties.  emotional resolution occurs on the unconscious,  in parallel Because  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, tends to trigger a fantasy reaction” 301).  (Allan & Berry,  In their case study, cars, trucks,  “adaptive movements in the outer world,” symbolized “negative external forces” symbolized aggressive forces. a “symbol of inner strength”  (p.  arid jets, (p.  1987, p. symbolized  305); snakes  305); and crocodiles  A figure of Pegasus, (p.  and each  identified as  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.  tracking transformations in both verbalization and play,  By  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  PRINCIPLES, RATIONALE, AND TERMS  SECTION I:  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  field research, participant observation, case study  paradigm,  method, principles of grounded theory, framework.  and the narrative analytic  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, Miles & Huberman,  1985; Lof land & Lof land,  1984;  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, objects”  (1978, p.  61).  fixed  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, (Vygotsky, 1978, the tool and the result of the study. 65) p.  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, moving,  living reality and taste of water  fails to capture the (after Vygotsky,  This study considered participants’ play and language,  1978).  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, (Lincoln & Guba,  1985).  indeterminate and subjective 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, emergent themes Guba,  followed by description of its  (Bogdan & Bikien,  1985; Lof land & Lof land,  of terms, what the Lof lands  1982; Burgess,  1984).  (1984)  1984; Lincoln &  Despite the proliferation  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,  The term “field research”  1985).  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,  detailed and intensive.  as described by Burgess,  is  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, 1984),  as an aspect of field work  qualitative research (Bogdan & Bikien,  naturalistic inquiry (Lincoln & Guba, 1984).  1982),  (Burgess,  and  1985; Lof land & Lof land,  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. that “the researcher [can]  It is through participation  focus on the process whereby behavior  is constructed, and not simply the means or the ends” 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, Burgess,  1984).  (Fisher,  1982;  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 1982; Lofland & Lofland,  &c  Bikien,  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” an event,  (Wilson,  1979, p.  a setting,  448).  The entity under study can be  an institution,  a process within an individual.  or,  as in the present study,  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, of concrete daily life”  (Wilson,  1979, p.  intensive focus on the individual,  450).  [and] details With the  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 discipline,  (Kazdin,  1980).  The foundational contributors to the  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 Others, more like developments in research and theory. 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, retreat from it”  (1988, p.  240)  not a  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 (p.13) person. 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, (1984, p.  and the overall study is therefore more robust”  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, cases, politically sensitive cases,  typical cases,  critical  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 (Brown, 1974, p. 3) be put. 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,  and utilize purposeful sampling rather than random  1984)  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.  sampling  In that tradition,  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 & Guba,  1985).  (Lincoln  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 sampling.”  (1967)  used a similar term,  “theoretical  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, sampling,” the sampling of cases,  In “theoretical  and when.  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 Glaser and Strauss  theory.  (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,  written commentaries and analysis.  However,  and continual the research  vocabulary which Glaser and Strauss introduced emphasizes theory creation.  Coding categories, they maintained,  than adequate descriptions.  should be more  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 No conceptual detail is presumed.  with existing ones.  The  categories and their conceptual justifications undergo continual This study set as a primary aim the rich  comparative analysis.  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, Polkinghorne  (1988,  their actions,  and their lives.  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. actions,  and lives are considered as a vital story,  If words,  a living  62 context of meaning, words,  life,  the meaning of that story,  action, or  can then be accessed in the same manner as with a literary namely, through the identification of plots and themes.  work,  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’ repetitive themes,  experience to ascertain  their significant transformations,  meaning in depth (Polkinghorne,  1988).  and their  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. to this study. later.  Both are relevant  First, meaning usually depends upon what happens  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. client who fabricates the content of a dream, a fanciful story, meaning.  The  the child who tells  are still providing expressions of personal  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, form meaningful episodes and plots.  actions in a series  Although experience as it is  being lived may appear segmented and disjointed, over time these segments create a whole of meaningful plots and patterns. segments when connected become larger episodes which, depict overarching themes. certain themes may emerge,  A beginning,  a middle,  Small  in turn,  and an end of  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” 1990, p.  94).  (Polkinghorne,  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 In contrast, human and perfection of research design. 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) scripts,  Extracting the themes,  or guiding messages embedded in a  narrative can be accomplished by two primary methods: the data reveal itself, (Alexander,  letting  asking the data a question  “Letting the data reveal itself” is not a  1988).  passive process.  and (b)  (a)  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. omission,  Salience can also be indicated through  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, statements.  can signal salient themes, as can incomplete 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, action, and an outcome”  (Alexander,  1988, p.  an  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 (Alexander, 1988, p. 281) experience of the subject. A comparable method by Giorgi from narrative protocols is to (a) get a general sense of the whole; (c)  (1985)  for extracting meaning  read the entire protocol to (b)  identify “meaning units”;  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).  reduction refers to the ongoing task of “selecting, simplifying, abstracting, and transforming the appear in written-up field notes” 21).  Data focusing,  ‘raw’ data that  (Miles & Huberman,  1984, p.  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 Within this research method,  and the data analysis phases.  reliability and validity are dependent upon the accuracy of the reporting, detail.  the generation of rich descriptions with a wealth of  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  Memos,  or analytic notes, were  following data collection.  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. 1967), (1984),  Open coding (Glaser and Strauss,  like the “first-level coding” of Miles and Huberman is an early attempt to organize the data through thematic  categorization.  In open coding, the researcher approaches the  data with preconceptions and prejudgments suspended Later,  axial coding,  (bracketed).  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, They may refer to motifs,  interpretive. causal links  (Strauss,  1987).  explanatory,  and/or  themes, patterns, and/or  In this study,  two coding systems  one for the child’s verbal themes and one for the  were devised:  child’s play themes. Memo ing Memos are analytic notes written by the researcher (Miles & Huberman,  throughout the research process 1987).  1984; Strauss,  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,  ideas, questions,  and analytic insights which arise at any point in  clarifications, the research:  observations,  before, during,  The  and after data collection.  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, and Huberman  (1984),  can include charts, graphs, tables,  other creative diagrams which depict, explain the data.  as recommended by Miles  organize,  and any  clarify, and  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” 1984, P.  (Yin,  a direction.  The research design is less a form and more  29).  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” Biklen,  1982, p.  55).  Because naturalistic research endeavors to  generate rather than to test hypotheses 1989),  (Bogdan &  (Marshall & Rossman,  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. SECTION II:  METHODOLOGY  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 Appendix A outlines the steps of the  analysis, and write-up.  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. sessions,  From the transcriptions of their  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) 3.10 years participated in this study.  from 3.1 to  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 Important developmental capabilities in language and  play.  symbolic play converge between ages 2 1/2 and 3 Ungerer & Sigman,  1984).  (Lowe,  1975;  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 terms,  (cf., Lebo,  1951)  and,  in Piagetian  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. weeks.  Observations took place over a period of 4  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. factors,  Other  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. commenced.  Approval was received before play therapy sessions 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. phase of the project,  In the data collection  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 freed  electronic means of data recording (audio- and videotapes)  the therapist/researcher from the need for during—session field notes which would have disrupted the therapeutic focus. the sessions,  the therapist assumed the observer function,  completing the field notebook and reflective, or memos.  After  retrospective notes  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 as  according to the principles of nondirective play therapy,  explicated in Chapter II, allowing the children to determine their play initiatives. therapy,  Within the nondirective approach to play  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 child’s positive,  (b)  the  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. audiotaped back—up.  All sessions were videotaped with an 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. session summary sheets  A field notebook and  (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, therapist/researcher kept a field notebook.  the  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, after the session as possible, sessions.  Personal comments,  as recalled as soon  of what transpired within the 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 Session Summary Sheets  each session.  (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 lefthand column.  In the right-hand column of the protocols, the  therapist noted the play activities synchronous with the verbalizations. were noted.  “Pivots” and “elaborations” in play activities  “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. minute intervals were noted on the pages of transcript.  One-  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 Above  attentional breaks or pivots as well as play elaborations. the time line, the therapist noted key play activities. the time line, the therapist noted key verbalizations. construction of time lines enabled the researcher  (a)  Below The  to see at a  glance the progression of play activities within sessions, compare trends in play across sessions, child’s principal play materials.  and (c)  (b)  to  to identify the  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. listings,  These were called event  of which a sample excerpt from Anna’s therapy may be As is evident from the example,  found in Appendix D.  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 The therapist repeatedly asked of these  play material usage. data the question:  How does the child’s use of a given play  material differ from preceding use?  For each child,  to this repeatedly asked question differed.  the answers  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. participants,  For more talkative  the researcher perused the event listings and the  transcripts for clusters of related referents occurring in association with a given play material. theme,  To ascertain a given  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) question:  asking the data the  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 In order to safeguard participant  child’s play therapy referral. 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. chapter.  A summary narrative concludes each  This concluding narrative utilizes the child’s play and  verbal themes as tools of understanding to refract and explicate The reader is advised  each child’s experience of play therapy.  of the following stylistic convention in these accounts: figures given in parentheses, to the session number.  e.g.,  (6)  or  The  (5 through 9), refer  80 CHAPTER IV. ANNA:  CASE 1  THE REEXPERIENCING OF INFANT LIFE  Anna’s play therapy sessions were replete with the detailed and often dramatic reenactments of aspects of infant life,  Anna was nearly 4 at the outset of  birth through toddlerhood. play therapy.  from  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 welldeveloped and,  as this analysis will later illustrate,  sophisticated vocabulary. strengths.  Anna possessed a number of other  An active and energetic child,  age—appropriate play activities.  she enjoyed a range of  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. threatened her life.  Her presenting breech position had  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, hospitalizations.  and,  on a few occasions, brief  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 By the third session,  basic trust with the therapist.  she had  begun to surface in her play consequential psychological namely,  material,  enacting the birth of the infant.  Anna filled  the next 12 sessions with the recreation of many aspects of birth,  infant life: aggression,  sleeping,  feeding, messing, washing,  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. spurts.  Her progress in school and at home proceeded in 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 Midway through her  tantrums or sleep disturbances recurred.  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 The fact that her return home was not followed by  incident.  serious regression into acting out behaviors was an achievement for her,  suggesting some enduring emotional gains.  Ultimately,  through her therapy, Anna succeeded in By late  remediating some of the effects of her difficult birth. spring, Anna had moved slowly but steadily into a new and stronger relationship with herself, her peers,  and her family. She was less  She was happier and more resilient emotionally.  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 In the  Anna’s play therapy advanced in three broad phases. 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,  the therapist (1) (2).  sand,  and water)  for  and giving the therapist a medical check-up  Session 3 marked the beginning of the Middle Phase, the  Enactment of Inf ant Life, recipient of care.  in which Anna herself was usually the  These enactments of birth,  feeding,  sleeping,  83 aggression, and infant—at—play continued in rich  messing,  elaboration through Session 15.  Representations of Hurt and  Healing thematically dominated the End Phase 20),  (Sessions 16 through In this final  alternating with enactments of infant life.  phase,  a small whale, which had appeared throughout Anna’s figured prominently.  therapy,  The Principal Play Materials The recurrence of play materials across sessions served as the principal criterion in determining the play materials central Their appearance across sessions is  to Anna’s therapy.  Infant—related props were the primary  summarized in Figure 1.  A simple cotton sheet served as  materials of Anna’s Infant Play.  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 1  2  3  4  5  6  7  *  *  *  *  *  *  *  Middle Phase 91011121314151617181920 8  Material INFANT PROPS  DOCTOR MATERIALS *  WHALE  *  Ficure 1.  *  *  *  *  *  *  Anna:  *  *  *  *  *  *  *  *  *  *  *  *  PAINT  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  Overview of Play with Principal Materials  84 Infant Play:  The Play Themes  The play themes comprising Anna’s Inf ant Play were determined according to the natural life activities they represented: Aggression, Washing.  Birth, Eating,  Sleeping (in bed and in a crib), Drinking,  Inf ant  Infant-at-Play, Messing,  As Figure 2 depicts,  and  Infant activities were added  incrementally to her play repertoire, until, enacting a wide spectrum of infant life.  over time, Anna was  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, on.  then climbing into her crib to read a book,  and so  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. two fleeting and,  Anna’s infant play began with  at first glance,  almost trifling incidents in  In the first  (1), Anna simply handled the  the Beginning Phase.  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. brief,  These segments, though  are consequential as thematic precursors to Anna’s later  well-elaborated infant play.  85 Session 1  2  *  *  Middle Phase 91011121314151617181920  3  4  5  6  7  8  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  Theme PRECURSORS  *  MESSING BIRTH  *  *  *  *  *  *  SLEEPING *  Bed  *  AGGRESSION  *  *  *  EATING  *  *  *  *  *  *  DRINKING! BOTTLE Water uice  *  *  *  *  *  *  *  * *  *  *  WASHING  Anna:  Birth.  *  *  *  *  *  *  *  *  *  INFANTPLAY  Figure 2.  *  *  Crib  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  Play Themes with Infant Props  The dynamic theme which characterized Anna’s therapy  for months was the enactment of the birth of the baby 14; reprised in 19).  (3 through  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 A brightly colored flowered  asked to be wrapped in a blanket. sheet was adapted for this purpose. lap in a breech (head up)  Curled in the therapist’s  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. her head and,  Anna then lifted the blanket from off  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 In its most dramatic variation  Infant Birth sequence many times. (3,  4), Anna repeated what appeared to be an enactment of a  breech birth. her body,  She extended her legs first, uncovered the rest of  emerged feet first from beneath the blanket, and  glowingly announced the birth of the baby. (4 through 9; periods,  11),  In other variations  fetal Anna remained enwrapped for long Sometimes Anna played a game  not wanting to come out.  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. Anna emerged glowing, playful,  Often  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 of f the table and capably arranged and rearranged the layers of blankets on the table, a pretend sleep  (3,  5,  eventually crawling under these covers for 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 infused this activity (e.g., once in bed, 11,  14).  Increasingly, calmness  (3).  8).  In one transformation, Anna,  asked for the playroom light to be turned off  (6,  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 (11).  or a real bottle  imaginary food (9)  particularly playful upon awakening. bed/table,  In Session 9 Anna felt  She frolicked on her  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. wooden cradle  (11,  12,  13,  Anna enjoyed the confines of the small 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 to be turned off  (11);  10); requesting the light  listening to a storybook (13); paging  through the book herself  (15); and watching the therapist draw  her a picture of “baby Anna” Eating.  (e.g.,  (16).  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  This distinction was made  spooning the mixture from her bottle.  in response to the degree of developmental regression which she permitted herself through play, infant  (drinking)  i.e., whether she was enacting an The Inf ant Eating  or a toddler (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 Inf ant 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 she set the  used the bottle or sand as play props.  Instead,  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 Anna shifted from the imaginary or actual  Drinking.  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. she remained covered in her flowered blanket. bottle drinking activity,  In both cases, Anna enjoyed this  sucking on the bottles at length and/or  returning to drink from her bottle between other infant This activity remained consistent, with no  activities.  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 water and one of juice).  (one of  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., exuberant,  4).  Complex,  sustained,  and interactive sound play later comprised her  neonatal infant play (9).  In this sequence, Anna knelt on the  table and wobbled back and forth, learning to creep or crawl. babbling sounds.  as is characteristic of a baby  As she moved,  she uttered a range of  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. cuddled in the therapist’s lap,  Early in her therapy  (5), Anna  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.  included a book, whale.  a small doll,  In one instance  an infant’s toy.  and,  These objects  in later sessions,  the small  (15), Anna clutched a small alligator as  While she drank from her bottle, the alligator  pretended to “bite” the therapist. Anna was capable of cooperative play with the therapist! maternal figure. infant,  In a unique play sequence  (12), Anna,  as  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. Anna engaged in some type of messing activity in  Messing.  In the role of infant,  every session.  materials for her messing activities:  she used several tactile 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. Anna denoted the plastic basin of water as the  Washing.  “baby’s bathtub.”  Her bathing activity,  in which she stood or  sat in the basin, recurred in most sessions through 16;  18,  20).  (6 through 9; 11  Most commonly, Anna took one or two such  baths within a sequence of infant activities. central session (11), times.  However,  in one  she returned to the washing activity 6  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  Inf ant Aggression escalated.  Following a birth  through 15),  enactment, Anna wriggled out of her blanket and,  lying in the  (12  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.  Inf ant 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. Inf ant Birth:  The Verbal Themes  Verbalizations associated with Inf ant 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. Inf ant 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: crying.  squeaks, babbling, and  93  Phase Beginning  End  Middle  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, Babbling or baby talk  in an attempt at prenatal communication.  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. occasionally pretended to cry  Anna also  Cries usually  (“waaah!”).  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.  (10).  Ba kaka puutata”  Throughout her infant play, Anna  Infant identity.  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 baby”  (14,  19).  (11), a “cute”  (7,  identity (“baby”)  8).  (5)  or “a  In general, references to an infant  predominated.  “It’s a baby girl.”  (3),  she glowingly  With only two exceptions,  which she referred to herself as a “baby boy” dinosaur”  and a “surprise  “sweet little girl”  Following her first birth sequence announced,  baby,  In unique instances, she also referred to  herself as older than an infant: bigger baby”  (13)  (10)  in  and a “baby  (11), Anna otherwise referred to herself as a girl baby  throughout her therapy. she  However, when describing the infant in the third person, 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” At times,  feminine and masculine referents occurred within  successive sentences: •  .  (3).  “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. unfailingly called the therapist “mama.” embedded in her inf ant play: (4).  This concept was deeply  “You’re the mummy and I’m the baby”  Even in the final session (20), Anna commented,  a new baby.”  Anna  “Susan has  At the same time, Anna was keenly aware that she  was engaged in a dramatized play relationship.  During her first  95 (3),  infant enactment real mommy.  Carol S.  she informed the therapist:  “You’re not my  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. (6),  Anna described herself as “moving”  and “turns around”  (8).  tummy”  .  .  .  “wiggling”  As well, Anna appeared to be “She’s curl on her  intensely aware of the infant’s position: mommy; curl curl curl.  (4),  He wants to curl up in his mummy’s  (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”)  infant Anna expressed  and entrapment (“cage”),  ambivalence about emerging from the flowered womb. was “peeking out”  (4).  The infant  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, commented, up”  “The baby went out of there”  (4)  she  and “This is opening  (11) Prenatal/neonatal emotional states.  In her play of prenatal  96 experience, Anna expressed a range of conflicting emotions. felt safe your tummy  (3)  in her cocoon,  and she was excited:  ‘cause she’s excited”  (4).  blanket also experienced some serious, fears:  “She’s hiding  and well—identified,  ‘cause there’s monsters”  some possible solutions to these states  recurred:  (3):  She further  (3).  as well as  fear,  “The baby was so  so the baby went fast a fast asleep.  ‘Cause something killed him.  He’s with his mummy now.  He’s not  References to fear  He’s in his little cocoon.”  scared any more.  “Baby’s in  The infant within the  elaborated this sense of intermingled distress,  upset about something,  “She wants to go back in ‘cause she’s too scared”  Neonatal physical states.  newborn was first described as feeling sick (3, (3),  medicine”  and “The baby’s really sick.  articulate requests for food: really hungry”  (4)  (10).  “He has a  she sometimes made  “some dinogettis  and “breakfast”  4):  The  She has to have some  When the newborn was hungry,  (4).  (5).  Anna verbally described the  neonate as experiencing a range of physical conditions.  cold”  She  ‘cause he’s  On occasion,  newborn was tired and wanted to take a “nap”  (10,  the  12).  Anna even  “napped” while still inside the blanket/womb:  “He’s gonna have a  little sleep now ‘cause he’s too tired”  In one instance,  (10).  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. Referents,  External  Songs, and Embedded Stories are also discussed.  97  Play Category SLEEPING Theme MESSING  ANGRY  Muck  EATING  DRINKING  WASHING  PLAY  Mess  N/A  Tired Sick Hungry  Good food Bad food P00/Dirt  Good food Dirty Clean  Remorse Pride Pleasure Fear Fear Hit Storm  Anger  Figure 4.  Anna:  Pleasure  Delight Pleasure  Bite  Verbal Themes During Other Infant Play  Sleeping in bed. referents to tiredness,  When Anna enacted the infant in bed, 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)  (3,  or being hungry  Generally,  5,  6,  9).  Referents to feeling sick  (“ice cube” dinner,  9)  (“cold,”  were sparse.  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, verbalized this fear only once: the light?”  (6).  “He is scared.  Enioyxnent typified this play.  she  Would you turn on 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: covered up.  That’s good.  “Baby,  let’s get you nice,  nice  It’s nighttime now and time for sleep.  98 That’s it.  Time for having a nice sleep.  You’re all in your  (6).  nice little bed”  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 e.g., her  indicate a positive feeling about this activity, stressing that the crib was “fly bed” crib”  (11),  “I like in my  (11,12),  and the fact that it was “cozy”  Unique infant-  (13).  related referents concerned a request for “pajamas” “diaper”  On one occasion, with the lights off,  (13).  struggled with fear: some,  “There’s no monsters in here?  I’m in my bed”  there’s,  and a  (11)  .  she .  There’s  .  (11).  Anna first introduced the topic of food and hunger  Eating.  following a birth sequence (4), translating her baby talk for the Food!”  “Gaga!  therapist:  Particularly during the first half of  before Anna began prolonged bottle drinking, Anna  her therapy,  most often referred to her sand food in appealing terms: likes his food,” which was also identified as “good”  “Baby  (5).  Positive references predominated in Session 8, when she described “breakfast,” “cherry juice,” “dinner,” and  the sand food as:  However, to a lesser degree her sand food was also  “restaurant.”  described in distasteful terms. “p00”  (4)  and just “dirt”  “gukky”  (5),  (8) (rather than  from her bottle, her verbal referents consistently  spooning sand)  expressed pleasure, .  (4),  When Anna shifted to drinking water  Drinking.  her bottle.  It was “yukky”  .  .  e.g.:  “I want some milk.  I have a drink.  .  .  The baby like  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 (15).  small alligator figure  she put the alligator in the therapist’s shirt pocket,  bottle,  “He goes inside and he eats something.  commenting: was warm. you.  While Anna happily drank from her  .  He drinks some.  .  .  .  .  .  Yummy.  That  Now you have bites all over  ‘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” Washing.  Anna consistently verbalized feelings of pleasure  and delight in her bath and in being clean.  The water basin was  (9), and once “my  Preceding her baths, Anna was aware of  (11).  being “so dirty”  the “baby bath”  (8),  her “special water,” swimming pool”  (3).  13).  (11,  to be “nice and washed”  (11)  During and afterwards, and “all washed up”  she was happy  (12).  Her  pleasure was epitomized in the following self-description: played in her bath and clapped her hands like this”  Anna generally described herself as infant in the “Baby found a puzzle,”  process of playing: playing sand!”  (11).  No particular verbal theme emerged during  Infant-at-Play. infant play.  “She  (6);  (5),  “The baby’s  “This a dry place for him to play” (11).  “Baby this is his toy” constituted the play,  In Session 9,  (10);  preverbal sounds  as Anna and the therapist played an  interactive game of mirroring each other’s vocalizations. Inf ant aggression.  Mess—making overlapped with Anna’s  100 Usually she referred to the results of her  aggressive play.  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, gonna hit you!”  (12).  “I’m  She also wanted to “bonk” her and then,  troubled by this action, added,  “I’m so sorry, mommy,  was just when I was just, when I was little” intense attack on the therapist (14),  ‘cause it  In her most  (13).  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. Anna’s sessions were dotted with a  External referents.  number of informational and/or self-disclosing statements related to her life outside the playroom. or describing (a)  being hungry after medical tests;  (b)  the time  her video movies at home  (6,  8); and  she broke her arm (5); (d)  These included her disclosing  (c)  her dislike of spankings (16).  Usually her tone during these  disclosures was one of intimacy. Throughout her therapy, Anna interwove within her  Songs.  play no fewer than 53 little songs.  Only a handful were  repetitions of popular children’s songs Dragon;  (e.g., Puff the Magic  Most were her own creations; and most were brief  3).  sung or chanted descriptions of the play at hand or cheerful musical embellishments to her play. infant play, Baby body”  included:  (10)  Simple examples related to  “Baby baby bottle.  Baby baby bottle.  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 little whale,  was rich in imagery (8): when it’s dry,  Hmhmhm.  discourse.  Hmhmhm.”  Embedded Stories characterized Anna’s  These stories,  of her activities (e.g.,  in the falling  I went in to my mum.  I want my.  And then the waterfall.  Embedded stories.  and in the morning  When it’s nighttime,  little baby.  I’ll sleep in flowers.  rain,  The composition  20 in all, differed from descriptions  “I’m gonna put this one here”).  Rather,  for these narratives Anna adopted a special “story telling” She added characters and imaginary events.  voice.  carried away,  She seemed  talking partly to the therapist and partly to  Embedded in the larger sequence of her play,  herself.  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. day.  While making her bed:  “When baby’s making his bed one  Over the hills and far away, 2.  and he like to”  While sitting in the sand tray,  (5);  covered with sand (6):  When And that’s for my Gramma. The baby’s playing sand. come to And Grandpa will she see that. My Gramma and Nan. and me hug And they all Yup. pick me up and my Mumma too. Remember? And they they come and do. kiss me. 3.  After emerging from her flowered blanket  (11):  Little Foot was so I’m Little Foot. I’m a baby dinosaur. Sara was so heavy happy to see his girlfriend named Sara. Ah. I’ll So she had to just. So be careful. [sic] too. His mother didn’t know what to do Ooh. save you, Sara. 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, neediness, vulnerability, Doctor Materials:  such as fear,  and pleasure.  The Play Themes  Doctor Play was second to Inf ant Play in frequency across sessions and as a dynamic factor in Anna’s therapy. fleetingly,  lay dormant for several sessions,  It began  and reemerged as an  important and well—developed component of her play in Sessions 16 In virtually all doctor play, Anna retained the role  through 20.  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 1  2  3  4  5  6  7  8  Middle Phase 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 Anna treated the therapist  Treating therapist and self.  with 4 injections, each followed by a bandaid  (2).  In the next  brief segment of doctor play (8), Anna required treatment for her Almost in tears,  own hurt.  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 She calmed and was  anxious from the beginning of the session.)  able to resume play with other materials as soon as bandaids were The power of bandaids to comfort and to ease pain was  applied.  particularly conspicuous in the concluding,  recurrent segments of  her doctor play. Whale as patient.  Doctor Play emerged as a sustained and lasting 17 minutes,  well—elaborated play scenario in Session 16, or one third of the session. patient,  the whale,  Anna repeatedly gave her new  injections followed by bandaids.  his temperature and blood pressure, from the medical chart.  She took  and read him his prognosis  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. recovery.  These variations suggested the notion of  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. treatment.  Finally (20),  she kissed him when concluding his  These latter examples  (tickling, kissing)  contained  104 an affectionate tone. The Verbal Themes  Doctor Materials:  Anna’s initial Doctor Play  (2)  introduced the nuclei of the  “crying,”  principal verbal themes——”hurt,”  “shots,” and “getting  better”—— which received elaboration and detailed development in the final 5 sessions.  To these central thematic concepts of Hurt  and Recovery were added the themes of Fear and Death as  or Pain,  (of.  well as Help through Friendship  Figure 6).  Session Middle Phase 91011121314151617181920 12345678 Theme HURT! *  *  *  *  *  *  *  *  *  *  DEATH  *  *  *  FRIENDSHIP  *  *  *  PAIN  *  (*)  RECOVERY  *  *  FEAR  Ficiure 6.  Anna:  Hurt.  Verbal Themes Associated with Doctor Play  Anna as doctor was shocked at Roo’s “hurt tail”  Roo was “hurt, (20).  *  she can’t swim”  (16)  and “sometimes  [he]  (16).  get hurt”  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. little bit I think” “doesn’t hurt” medicine”  (16,  (18).  extended family:  (16), 17,  Injections “hurt a  they “really hurt”  19).  (16),  and it  They also contained “poison  Sometimes “hurt” reached the whale’s imaginary “Your mommy’s hurt,  she can’t swim”  (16).  105 Though few, Anna’s references to fear are  Fear.  as references to fear had dotted other elements of  significant, her play  (Cf.  Anna expressed a  “monsters” during infant play).  sense of her own fears around the whale’s hurt: might get hurt”  (16).  “I’m afraid you  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.  (16).  I’m afraid”  Death. The theme of Death appeared dramatically in her Doctor Play.  (16), Anna  Pretending to read the medical chart  suddenly read Roo the news that he was going to die  and the topic appeared to be  References to Death recurred,  “You gotta die  fraught with fear and often confusion for Anna: ‘cause you might get hurt”; She, when she’s dead. she’ll be sick”  (17).  when she’s dying, she dies” died,”  (20).  (16)  She’s hurt”  “She doesn’t feel when she’s dead.  That’s when you die”  (16);  “When Roo dies,  “Remember something of dying?  and Roo’s hurt,  she dies.  his mommy dead.  (16); and “doctors kill you”  .  “Your mommy She can’t swim.  (17).  “When you die,  help your and you some bandaids to make you better.” appeared to offer some hope to these persistent fears,  told Roo,  I’m gonna Bandaids as did  Involving the small fish figure in this play, Anna  “You gotta die,  friend will help you” remarked,  Roo  Some references to Death were linked to  attempts at solutions to this problem:  Friendship.  .  All about Roo when  She gave him terrifying news:  “poor little whale,  Friendship.  (16).  Roo,  (16).  ‘cause you might get hurt.  Your  When the little fish arrived,  “No more dying, Roo”  (16).  On the other hand,  Anna  the  106 whale’s friend remained vulnerable: friend.  .  .  .  This was evident in Anna’s role.  referred to herself as the healer, (16),  “special treat” or a  (20).  Ilsurprise.H  a  Injections were  (18,  20)  on his “cute  She referred to the recovery process itself.  (20).  (20).  (16),  There was evidence of  as when she kissed her patient  much better now,  She  which were invariably described as a  Anna told Roo “you’re fixed”  “better”  the “doctor whale,”  and “the nurse”  followed by bandaids,  little eye”  (20).  The notion of Recovery was composed of a number  of thematic strands.  affection,  gonna make you a  Now your friend is hurt too”  Recovery.  “good doctor”  “I’m  Roo”  (17),  (16).  She reassured him,  “That’s  and told him she was making him  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, intermingled hope and fear,  she asked him with  “Are you all right?” or “Are you much  better now, Roo?” The Whale:  The Play Themes  Play with the whale At first,  interwove  much of Anna’s play therapy.  its incorporation in her play was brief and subtle, but  in later sessions, whale play surfaced into prominence, linked to both Doctor Play and Infant Play. whale underwent the following metamorphosis:  In general,  strongly the  Introductory Play  Object; Marine Creature; the Doctor’s Patient; the Inf ant’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 3  4  5  6  7  *  *  *  *  *  *  *  *  1  2  Middle Phase 91011121314151617181920 8  Theme HELD OBJECT MARINE CREATURE  *  *  *  *  *  *  *  MEDICAL PATIENT  *  *  *  *  *  *  *  *  *  *  *  *  *  *  INFANT’S TOY  MURAL FOCUS  *  Figure 7.  Play Themes with the Whale  Anna:  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. whale,  These brief contacts with the figure of the  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. this theme.  First,  only in clear water.  in the early sessions In later sessions  added sand to the basin, Second,  There were two variations within  in later sessions  (to 7)  the whale swam  (13 and following) Anna  creating a murky habitat for him. (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, 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).  Sometimes the painting of his tail,  He was  comfort,  subjected to painful treatments as well as care, affection.  fantasy  and  as cited above,  appeared to be part of the recovery process. Inf ant’s toy. the final play phase  Infant Play alternated with Doctor Play in (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.  him playfully between her feet while she drank. variation, Anna treated him as a playmate, with him (18)  she clutched  In one variation,  In another  sharing her bottle  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. concluded Anna’s therapy.  The theme of the whale began and 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 Verbal Themes  The Whale:  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,  Treatment; Relationship; and Nurturance.  and  Embedded Stories and  Songs recurred in all phases of whale play. Whale identity. whale”  (1)  The whale was first identified as a “baby  and at the end of therapy was still  little baby whale.” “Mr. Whale”  (5,  (20)  a “nice  During the Middle Phase, he was occasionally  13).  However, when whale play resurfaced in the  Final Phase, he received a more personal name, persisted in Sessions 16 through 20.  Whale attributes.  it was superimposed  “Roo, you’re the mommy”  In his first appearance  (19).  (1), the whale  was described as “black,” “hungry” and “thirsty.” right” and had to “be good.”  which  Even when Anna in one  instance assigned Roo the role of mother, upon his basic identity of “Roo”:  “Roo,”  He was “all  Anna also called him a “poor  whale,” denoting suffering or misfortune.  This single referent  precursed later references to the whale as “poor”: “poor little whale”  “poor little  stuff”  (14),  (18).  The aspect of smallness embedded in these referents also  saw some repetition: little fellow”  (16).  (16,  19),  “little small whale”  “poor little thing”  (14);  “be a good  110 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  *  *  *  Figure 8.  Anna:  The whale,  Verbal Themes Associated with Whale Play  like Anna,  experienced a sense of conflict  between wanting to express anger and having to be good: don’t think I can get mad because I’m a whale. good whale”  (13).  “Well, I  I always be a  Other descriptors of the whale ran a complete “happy”  gamut of human attributes, with virtually no repetition: (13),  “scared”  (13),  “has big teeth”  “so happy she can swim,” “silly” (18,  19),  “the greatest”  (13),  (16),  “only a whale”  “beautiful”  (17),  (15), “dirty”  (20), and “a dirty little animal”  She also referred to Roo as “a girl”  (16).  (20).  111 Perhaps the most unique verbalized referents concerned the way in which Anna verbally brought the whale to life. 13, Anna picked up the whale and told the therapist: Whale’s gonna say something.” speak,  “Come alive!”  last functioned as a dynamic,  “Mr.  However, he was not quite ready to  as Anna moved on to other play materials.  Anna conunanded him,  In Session  In Session 16,  Later (15), the whale at  interactional character.  handed the whale to the therapist and asked her, her talk, and the whale song is gonna come.”  Anna  “Would you help  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” and his “bathtub”  (16),  (18).  (1,  14), his “swimming pool”  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. hurt, death,  Verbal references to  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” There were consistent references to Roo’s mother: little small whale.  (19).  “Hello,  Do you know where my big mother is?”  I’m a (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. offered him “a big hug”  and a “kiss”  (16)  playfully “tickled” him (17, included tasty food: (19),  19).  “juice”  “cake” and “whale food”  substance,  “poison”  20).  She  Sometimes, her care of him 18),  “dinner”  (18),  “soup”  Roo was also offered a toxic  (20).  (19).  Embedded stories.  A number of Embedded Stories interwove  Anna’s play with the whale, representative.  (17,  (17,  Anna  of which the examples below are  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: And the One day the mother took the little baby somewhere. I’m in here I’m just a little baby. baby said, “WahI This one was next. And Get me out of here!” somewhere. Me too, me too, little whale. Grrr! big bad. A later story highlighted the whale in his struggle between dirtiness and cleanliness (15): He’s going to get some My, he wants. “Yippee!” he said. So he jump inside the mud and he just all mud. Erh erh erh. And he had to get him all clean in some tub of water dirty. to make him all clean. A final example contained themes of hurt and recovery (16): Oh She went out of the swimming pool. Roo was so hurt. She wasn’t hurt any And Roo was so happy. right here. She was way up into the sky, ok. She got a fish. more. There’s Susan. And Roo didn’t come down. 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. first whale song was very brief  (1):  “Up we go.  Her  Up the whale.”  113 Another example reprised her doctor play themes believe the no whales.  (16):  “I won’t  And then then Roo hurts her tail.  gets a bandaid and a shot.  She swims.”  She  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 Nice, so heavy. are home. 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) creatures  (whale and fish)  “Swimming little Roo. swimming swimming, doesn’t. Painting:  distinguished between  which were “hurt” or “not hurt”:  Swimming on her bum.  swim two whale.  Swimming swimming  One has bandaids and one  Swim swim swim.” 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.  revealed  Figure 9)  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, water colors  (1,  legs, 2,  3,  feet, 10,  11,  and sometimes stomach with the 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, its surface.  smearing circles on  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 1  2  3  *  *  *  4  5  6  7  Middle Phase 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, and/or  she occasionally painted the whale’s tail  (17)  a “happy face” for him.  (17,  20)  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. painting (18) floor.  and by colouring with crayons  However,  (19)  She began by on paper on the  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, session  occurring in the final  (20), was the creation of a large mural on the playroom This activity was unique in terms of the size and scope of  wall.  her work with the paints;  large circular swirls filled one  section of the playroom wall.  Anna verbally explained that she Anna  intended this mural to be a representation of marine life. 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. The Verbal Themes  Painting:  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: Mother.  Calls for Attention and References to  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,  “everybody see me”  2,  “mommy will look”  11),  (10),  and  Suggesting ambivalence about receiving  (2).  (10).  attention, Anna also claimed that “Mommy won’t see this” When the theme of Attention later recurred, the whale. purple  it was directed to  after having painted the whale’s tail  Specifically,  (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 bodypainting activity, Anna perceived the paints as enhancing her appearance.  She referred to the paints as her “polish”  made her look “so beautiful”  (11).  However,  (2). They  in one instance (3),  she called her painted hands “gooey” and “mucky,” and she threatened to smear the therapist with them, At the same time  will never get away.”  (3),  telling her,  “You  “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,  that “mommy wash this”  (2,  11).  she remarked  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. saying,  She invited the therapist to join her by  “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,  it’s your turn, mommy.”  Later in her therapy  (19), when she  created the picture which she then tore in pieces, a “picture for my mommy.”  “Now  she called it  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 While painting,  some intense fears.  Anna then threatened to “spank your  “likes spankings.” [therapist’s] therapist,  she commented that the baby  bum” and “paint you” and soon after asked the  “Monsters coming out?  .  .  .  I get scared when they  have claws on them.” Other unique verbal referents clustered around the theme of As Anna painted the playroom  the whale and other marine life.  she first called her creation “a  wall in the final session (20),  But she soon identified the  design” and “a giraffe neck.” circles as “whale!  .  a really big whale.  .  .  makes too much fish.”  and bigger and bigger. .  “Let’s make  The marine theme continued:  one little tiny little fish.  This is a starfish.  It’s so fat that it  .  .  .  .  .  .  .  It’s getting bigger and bigger You see.  because it ate the 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,  aggression, and playing.  Anna also created a play persona for  the therapist, as mother. nursery,  sleeping,  the infant’s home,  The playroom itself became Anna’s complete with crib, bottles,  and  food. In creating infant life, Anna was able to do more than enact She became the infant and as such in her play she  the infant.  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. gave her actual nurturance through cuddling, of drinking.  Drinking from a bottle  (the juice), emotional nurturance  as well as physical pleasure in the sensations  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 She experienced absolute messiness, being covered in  properties.  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, ability to inflict hurt.  In her treatment of the whale,  and the she was  able to depict current real life concerns of repeated trips to the doctor,  receiving medical treatment,  through the mechanism of projection,  and so on.  The whale,  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 “excited” and “upset” baby). capably,  (cf. the  She also functioned verbally very  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, injuries,  and classroom life.  friends, doctors,  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., the fairies.”  “my daddy come and all  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. example, her statement that “baby’s in his mommy’s tummy he’s excited” is representative of this sort.  For  ‘cause  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 In naming him “Roo,”  be considered a positive critical incident.  Anna for the first time bestowed upon him a specific, rather than a generic  (cf.  “Mr. Whale”)  in that the whale,  identity.  This identity was dynamic  following his naming, underwent a number of  adventures, healings, and relationships,  including an  active and interactional relationship with Anna.  The whale’s  trials,  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. impelled by nervous energy.  At times, her play seemed  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. playdoh,  Using sand, water,  and  she set about in an extremely busy and officious manner Here, Anna enacted  to provide “yummy” food for the therapist. the maternal role of caregiver, was to be short—lived.  of nurturer,  a role which for her  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. stirred, mixed,  She  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 house)  (the doll  to the focal point of the playroom (the table) Anna  appeared to be unconsciously,  if microscopically, through a play She barely touched the  symbol,  raising the topic of infant life.  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. controlling caregiver had ended.  The reign of Anna as the  Anna as the infant drank in  physical and emotional nurturance just as she drew physical She epitomized gentleness and  comfort from her bottles. 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. into,  She previewed the world she would be born  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. rehearsal of that event,  Her birth play often seemed to be a  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 Often she emerged  birth than to be thoroughly reexperiencing it.  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. blanket, which had served as the symbolic womb, play in bed,  The flowered accompanied her The  in the crib, and on the therapist’s lap.  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. comfort,  Themes of  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. Middle Phase,  The whale, who had lain dormant during the  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. whale named Roo a peer, companion,  a friend, an infant toy, a child,  and a confidante.  as her medical patient,  Anna created in the a  However, the whale primarily served  such that whale play in this phase was In a sudden shift of roles  substantially fused with doctor play.  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 relationship component,  friendship.  (cf. bandaids)  but also a  Anna created for Roo a  little fish friend who would “save” him and ensure “no more  127 Anna’s journey between the dimensions of hurt and  dying.”  Her doctor play with the whale was  healing was not an easy one. often charged with tension,  especially when references to death  surfaced. Whale play fused with doctor play did not supplant infant play.  They  Scenes of infant life continued in this final phase.  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. vulnerability and neediness; authority. infant life,  In one role,  she personified  in the other, control,  agency, and  She enjoyed regression in the reexperiencing of 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 feeding,  and so on)  (birth,  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. her therapy.  As she painted,  infant; however, even mature,  She filled the wall with whales,  an emblem of  she retained the role of the  she appeared a more capable and self—confident,  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. healing were elaborated.  In doctor play, themes of hurt and  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  THE EMERGENCE OF PLAY AND VERBAL COMMUNICATION  BRAD:  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 Although Brad was normal in appearance,  teachers.  in motor coordination were sometimes evident.  irregularities  His gait was  occasionally unsteady, and his fine motor skills were Brad often looked pale, and he suffered from  inconsistent.  frequent and prolonged colds. Most worrisome to his parents and his teachers was his lack of speech.  However, although quiet, Brad was not mute.  capable of emitting sounds,  He was In  such as crying and screaming.  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, could not play. materials.  apparently,  He appeared unfamiliar with many of the play  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, the teacher.  Brad,  listening to  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 A family doctor had suggested that Brad was mentally  milieu.  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. had been normal,  Brad’s birth  although his mother expressed concern that some  over—the—counter medications that she had taken during pregnancy may have affected his prenatal development. milestones had been delayed.  Brad walked at 14 months and was  toilet trained very late, at age 3, entering preschool.  Developmental  several months before  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 He began  relaxed behavioral limits of the therapeutic playroom. to become involved with play materials and to elaborate activities with them. words,  Gradually, too, phonemes,  syllables,  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, scenario.  and commented on,  a fantasy  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 and the two were virtually inseparable.  Brad,  Toward the end of  the school year, Brad, who by this time had begun to speak discernably, speak.  befriended a moderately autistic boy who did not  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. Sessions 1,  The Beginning Phase,  consisting of  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,  capabilities.  considers the development of Brad’s verbal  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 Absence of Play and Speech  The First Session:  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,  venturing even to touch the materials.  not  The only variations For  during the second session were slight changes in posture.  example, having stood for most of Session 1 with his back to the turning  therapist, he varied his stance slightly in Session 2:  to peek shyly at the therapist and then ever so slowly and subtly At this  rotating his body so that he could face the toy shelf. 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. slight start of his body when the therapist spoke,  By the  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. across the room.  Intently, he watched them float  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 Brad had begun to play, and the therapist, through the  occurred.  Within minutes,  medium of bubbles, had made contact with Brad.  Brad was scampering around the room, waving his arms wildly and stomping on the floor, trying to burst as many bubbles as he His first vocalizations accompanied this first play  could.  Soon after, he  Brad laughed and yelped with delight.  activity.  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 This analysis will focus on the transformations  across sessions.  in play themes and associated verbalizations in Brad’s play with Brad’s unique Sound and Activity Mimics are  these materials. Session 1  2  3  4  5  6  7  Middle Phase 9101112131415 1617 181920 8  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  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 a motorbike,  cars, truck,  a backhoe,  helicopter,  a tow truck, a fire engine,  a plane, a dump  and a set composed of a larger wooden  train, and flatbed truck.  Vehicles was a prominent  Brad’s play with these  (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.  137  Session 1  2  3  4  5  6  7  *  *  *  *  *  8  Middle Phase 910111213 1415 1617 181920  Theme HANDLE Floor Table Water Sand  * *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  PUZZLES w/ HUMAN FIGURES  *  *  *  *  Brad:  *  *  *  *  BRINK  Figure 11.  *  *  * * *  TOSS  *  *  *  * *  *  * *  TRAFFIC Lines Crash Park  *  *  *  *  *  *  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 Brad had  marked an important transformation in his play.  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: Parking,  Collisions,  and Brinkmanship.  Lines of Traffic,  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  The relatively calm and contained activity of  Sessions B and 13.  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. in Session 8,  This variation in vehicle play first appeared  continued through Session 11,  Sessions 13 and 17. intermittent.  and recurred in  Within sessions, Vehicle Throwing was  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, one or two to the floor.  impulsively, and angrily toss  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. Parking activity, Brad had each vehicle, therapist’s edge of the table. side,  in parking lot fashion,  In the  in turn, travel to the  He parked many vehicles side by facing the therapist.  Sensing  Brad’s symbolic approach to her, the therapist gently touched each vehicle as he parked it and commented, backhoe,” or  “Hi, truck.”  “Hi,  jeep,”  “Hi,  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 In this  control and containing new emotional coloration.  Sometimes this  activity, Brad would use only a single vehicle. 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. reverse,  The vehicle then raced forward,  or in  evidently in retreat from this danger, only to crash  into the wall at the opposite edge of the table. occurrences of Brinkmanship in Sessions 13 and 17,  In the sole 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. disliked getting his hands dirty. Vehicles in Sand was sparing.  At the outset of therapy, Brad Not surprisingly, his use of  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) Figure 11).  and spanned his course of therapy (cf.  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, spilled on the floor,  sometimes through the air, and back to the table (12).  into water 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 With few  selection of a seemingly unrelated material——puzzles. 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, on,  and so  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. a woman,  He put a man,  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)  for a ride on the table.  in the large dump truck and took them 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 In one instance,  Brad’s capacity for attention to detail.  Brad  carefully and realistically hooked a small car onto the tow truck In the second, Brad  mechanism and towed it across the table.  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” occurred and it tipped, covered their bodies.  [sic]  spilling the figures into the silt, which 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  He repeated this sequence 5 times with great absorption,  again.  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, silt,  and survived to repeat the experience.  covered with  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 However, this  small human figures rode in various vehicles.  Fantasy Play segment with vehicles reassembled these elements—— interest in the boat and people as passengers——and elaborated No longer simply a fleeting representational activity,  them.  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 While his play depicted and in a sense defined a literal  well.  danger, his words communicated more than the figures’ need for Repeatedly,  “hulp.” gone.  Brad observed with horror,  “Oh, no.  Papa  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 referred to as Vehicle Noises.  (3, and ensuing), hereafter 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. at the table  From Brad’s first play with vehicles  (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, of greater sophistication:  and introducing one  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  pointed out to the therapist a car’s “door, interest.  (7), Brad  on door” with great  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: “hike”  [bike),  “huck” “boh”  [truck],  [boat].  “hwain”  [train],  Interestingly,  “ham”  [plane],  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. example,  “cash”  For  [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, element of surprise.  “Oh no!” which conveyed the  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, hey is houn”  [latter segment indecipherable].  “No go  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) Brad,  as  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: under water [plane]  (16,  19,  “Gone.”  As various vehicles disappeared  and 20), Brad observed,  “Oh no. Gone kane  .“  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). self,  As the child’s emergent ego boundaries clarify the  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. Brad first elaborated his vehicle play  Names of parents.  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, later “Iya papa hung.” “papa,” his own name,  “Mama ha ho mama” and  Throughout his entire therapy,  “mama” and  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, throughout his therapy. worry,  anxiety,  “Oh no,” a phrase which recurred This simple phrase subtly conveyed  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, submerging an airplane in water, offered,  Brad, upon  “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. Go boh. Phhnn. Cash! . No go boh. On boh. Hulp! . . . Whuh mama? . . . Whuh papa? . . . No Papa gone! Gone gone papa. . . . Mama, no mama! papa. 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,  themes of danger and recovery,  it encompassed the  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 At a deeper level, then,  figures.  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. first emerged: noises.  laughter,  A mass of prevocal sounds  shouts, yelps, and,  (3,  4,  5)  later, vehicle  Subsequently, nonspecific syllables and single words  emerged (6),  followed by such two—word strings as “oh no”  simple phrases,  “on boat”  (7).  (6)  and  Virtually unintelligible  sentences began to proliferate in Session 9 and continued throughout his therapy. in Session 19 (20)  Intelligible noun—verb sequences emerged  (“kane gone”)  and proliferated in the final session  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, furniture,  its  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 Brad played with the doll house in some fashion in  play.  Sessions 4 through 13 and 16 through 20. Session 1  2  3  4  5  6  7  Middle Phase 8 9101112 1314151617 181920  Theme HOUSE Touch Climb Deface  * *  *  *  *  *  *  FURNITURE Handle Throw  *  BATHROOM PLAY Athouse Attable  *  *  *  *  *  *  *  *  *  *  *  *  *  OTHER ROOMS Figure 13,  *  Brad:  (1,  *  *  *  *  *  *  Play Themes with the Doll House and Props  Exploratory play. sessions  *  2,  Even during his inactive and silent  and part of 3),  Brad had looked with interest at  the doll house but had not ventured to approach it. play at the doll house  (4)  His first  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),  simply touched some of the furniture,  including the toilet,  Brad an  object which figured prominently in later representative play. Subsequently,  he handled some of the furniture briefly,  as if testing the strength of the structure, the doll house for a few seconds.  and then,  climbed on top of  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: Doll House and the Table.  The miniature bathroom fixtures which  appealed to Brad included a shower stall, mirror,  the  a basin with attached  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  put a small baby figure in the bathtub. figure on the toilet (8,  9).  (7,  8,  9), he  Later, he placed a boy  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, the baby a bath, putting it on the toilet, (12).  giving  and giving it a shower  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. “Huip” and “Mama.” floor.  Brad then tossed these objects angrily to the  In a subsequent transformation of this play (9), the boy  figure climbed all over the fixture, basin.  The boy called out  its toilet, counter,  When the therapist responded,  and  “Now the boy is standing  here,” Brad moved the figure to a new location and asked her, In the final occurrence of Bathroom Play at the  “Ungh now?” 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,  transformation on several levels. materials, Brad,  it is inferred,  is seen as a significant First,  independent of the play  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, Bathroom Play. or,  several sessions after the emergence of  Brad played with these props at the Doll House  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.” the kitchen appliances.  He also handled  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  house furniture down the doll house staircase,  ]J of the doll 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. Session 11,  Brad selected a square piece of doll house furniture  with many open sides, a type of cupboard, table,  In  straight into the air.  and lifted it off the  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. the last session  In  (20), Brad sat quietly at the table near the  therapist playing with the doll house’s standing lamp. quietly and deliberately broke it in two.  He  The therapist wondered  at the significance of this occurrence in the last session. was likely angry at the ending of these sessions,  Brad  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, therapy,  for the first time in his  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,  for the other,  it appeared that one figure was looking  as if they were engaged in a subdued chase.  the boy said “Boyboy”  [bye-bye] to the mother.  figure climbed the doll house chimney twice, times.  Once,  Later, the mother  falling off both  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 the windows), individuals  (looking out  in association (chasing each other), and as  (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, House.  includes a listing for the Doll  The table distinguishes between clearly formed verbal  efforts and those which were unclear,  but reasonably  distinguishable in context through tone and inflection. noises sounds) sounds. se.  (toilet flushing,  Assorted  shower water, defecation, refrigerator  appear to be the only loosely associated grouping of They are only qualifiedly advanced herein as a theme per  The remaining words appearing in the Table essentially  comprise a vocabulary list typical of an impoverished 18-monthold 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. a range of sounds, undecipherable.  Nevertheless, he just as often emitted  syllables,  and words, most of which were  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, from the Doll House figures,  as distinct  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, Caucasian features,  actually had  but his black hair, black moustache,  black clothing lent him a sinister appearance.  and  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.  159  Doctor  Sand  Referent 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  Play Material Hospital Adventure Figures People  Doll House *  Water * *  *  *  *  *  *  *  * *  *  * *  * *  *  *  *  *  *  *  *  *  *  *  *  *  * *  *  * *  *  *  * *  * *  *  * *  *  * *  *  * * * *  *  *  * * * * * * * * *  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: Toileting,  Handling,  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 1  2  3  4  5  6  7  8  Middle Phase 91011121314151617181920  Theme HANDLE  *  TOILET  *  WI VEHICLES  *  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  The figures were the passive victims of a simple  complexity. event:  burying, dumping, or submerging.  active,  such as sitting or riding,  Even when they were  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. session (18),  In the following  an event occurred in play with Adventure People  that was unique on the verbal dimension as well. table, not playing at all but holding a female  Brad sat at the  (presumed mother)  161 figure, who appeared to be the topic of his conversation, follows: Oh no,  “Oh no, unna ho.  oh oh.  as  [Vocalized sounds of running water.]!  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. figure.  He also appeared interested in hurting the  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 The Verbal Themes  Adventure People:  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 This first, and only, verbalized story told  scene in Session 20. 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: the floor,  Handling (on  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. example,  simply walked across Brad’s puzzle (14).  The Nurse,  for  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  Figure 16 lists these themes and cites their  turn, took showers. occurrence. Session 1  2  3  4  5  6  7  8  Middle Phase 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. commented:  As the figures rode in the dump truck (17), Brad “No.  oh no. Gone. Hon [sand?].  go?]. Car cash [crash].”  Whunna go  [Where’d it  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 Later in his therapy (18), Brad ventured to inject the  watch.  therapist’s mouth and to place the thermometer in her mouth.  The  occurrence of these themes is summarized in Figure 17.  Session 1  2  3  4  5  6  7  Middle Phase 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 1  2  3  4  5  6  7  *  *  *  *  *  Middle Phase 8 9 101112 131415 1617 181920  Theme HANDLE OBJECTS  MESS Spill Splash Dump  *  *  *  *  *  *  *  *  *  *  *  *  *  * *  *  *  *  *  *  w/HUMAN FIGURES POUR  *  *  *  *  *  *  *  DRINK Cup Bottle  *  *  *  *  *  * *  Figure 18.  Brad:  Handling.  Play Themes with Water  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, Mess-making. Dumping.  7, 9,  13, and 15 through 19).  Mess-Making involved Spilling,  Brad Spilled water on the doll house  (7),  therapist’s feet (12), and on 2 large baby dolls Splashed water in the basin  (7)  Splashing, and on the  (18).  and on the therapist  He also  (11).  The  most dramatic messes occurred when Brad Dumped the entire basin of water with the small toys onto the playroom floor, wet,  creating a  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 These scenarios, which have been already been  passengers). elaborated,  included the hospital figures going for a ride in the  water  and the hospital figures and adventure people being  (16),  immersed in the water  (17).  In the final instances of  representational play, Brad added sand to the water, silty mixture.  The black man and the nurse figure jumped into  and disappeared in this silt (19). (20)  creating a  The extended boat crash scene  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. The Verbal Themes  Water Play:  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, Vehicle related words  included:  “doors”); names of parents  (vehicle noises,  “my car”  (“mama,” “papa”); referents suggesting  loss or worry (“gone,” “oh oh”).  A preponderance of self—  conscious and even nervous laughter during water play, during Mess-Making activities, was observed. preponderance of Sound Mimics  especially  Similarly,  a  (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:  “splash”;  (b)  “esh,” a rendition of  “won,” “wuh,” “wong,” and “wa—eh,” believed to be  renditions of “water”;  (c)  a repeated expression of “ung ung,”  believed to mean “all gone”; “hink hun”  (a)  (d)  a command to the therapist to  (presumed “drink some”) water from a cup; and  Brad’s reference to the baby bottle as “nine”  (“mine”).  (e)  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,  This Shoveling activity  8 through 14).  underwent a subtle but significant transformation from Solitary In Sessions 15 and 16  to Associative Play with the therapist.  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.  Brad moved the  In the next session (16)  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. may also have been a factor.  Moving closer to the therapist  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 and the transportation of Vehicles (11, complex segments,  12,  (10,  16).  incorporating water as well,  15,  19,  Later more  included:  burying the nurse and the black man (19); and (b)  20);  (a)  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.  Sand Play:  Brad:  *  *  *  *  Play Themes with Sand  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 vehicles.  (“gone”)  and a few references to  Nervous or self—conscious laughter as well as Sound  Mimics occurred sporadically during sand play. comment that “mama” was “okay”  Brad’s clear  (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, syllable,  and so on.  In Sound Mimics,  such as “Dah dah dah!!”  Brad would yell out a  From Brad’s tone,  evident that the therapist was to respond. playfully duplicating (mimicking) changing the volume.  She did so by  the syllable,  sometimes  Brad and the therapist would repeat these Brad  syllables to each other in conversational fashion. sometimes  (5,  11)  it was  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.  same time, they were also vitally relational events,  At the  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, independently.  considered  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. comparison is discerned,  In Brad’s case,  a  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 telephones mama” and spoke,  With the possible exception of play  (not analyzed herein),  in which Brad “caw  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). in the perilous Brinkmanship activity,  The Vehicles,  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.  verbalization was impaired and impoverished.  Brad’s  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. usually carried out in engrossed silence, a range of water and bathroom sounds.  Yet this play was interspersed only with  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. Brad loved the vehicles.  Specifically,  They were familiar to him,  enjoyed playing with them.  and he  These mechanical metal objects  appeared to represent an emotionally safe, perhaps even familiar, uninhabited world. sounds.  Like Brad, they moved and emitted particular  Through his fascination and predilection for these  materials, Brad could also be said to have moved, progressed,  in therapy.  session of his therapy.  that is,  Vehicles accompanied Brad through every 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),  opposite the therapist at the table, commented:  “Nogo heyis houn.”  for example, Brad stood  leaned toward her and  To which the therapist replied,  “It’s not time to go back to your classroom yet. back a little later.”  I will take you  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, doors,  such as the names of his parents, an interest in  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,  tension; excitement and pleasure.  anxiety; aggression and  176 Brad’s verbalizations also provided subtle cues to his cognitive potential. mechanical sounds,  Brad’s adeptness in reproducing a range of  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, plan.  expressing intention and a nascent ability to  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. playroom.  Brad became more confident within the  His presenting impairment with initiative faded as he  selected play materials with increasing interest and interacted with them energetically. right to do so.  He played as if more assured of his  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.  seemed to be an adjunct to making the playroom his own. undoing,  rearranging, and upsetting the playroom,  his own expressive stamp on his surroundings.  This  By  he was putting  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.  activities predominated at the doll house. went for rides in the vehicles. successfully completed them.  Realistic bathroom The adventure people  Brad tried the puzzles and  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. overturned things.  He tossed materials into the container of the  water basin, handled them calmly, toys onto the floor.  Brad played calmly and then  and then dumped the water and  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, speech,  in his play,  in his  and in his emotional and relational capacities.  the unsettled play, with its expressions of aggression, and chaos,  Out of anger,  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.”  “gone” and “oh no!” during play.  He often called out  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. of calm, Brad was no longer paralyzed.  Within those islets  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,  a basin of silt,  jumped into  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. boy,  for example,  said “bye bye” to the mother.  The  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 For that reason,  mentally handicapped.  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 He was  physical health and suffered no physical impairments. 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. the outset of therapy, he was not yet toilet trained.  At  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. these friends and,  Carl had often spent time in the home of 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. his hand,  Accompanied by the therapist, who carried him or held 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, A series of novel play events  (5),  3,  4, and part of 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, fact,  signalled that a new therapeutic phase loomed.  a serious play disruption developed,  through 8).  In  spanning 3 sessions  (6  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, his entire social system.  and pain reverberated throughout  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. sessions were agreed to,  An additional two  and these comprised Carl’s most positive  and productive therapeutic play.  Carl enjoyed calm,  cooperative play with the therapist (16, therapist’s lap near the sandbox,  17).  sustained,  Seated on the  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. active,  His speech was clearer; and he was more present,  and confident in relationships with peers and teachers.  The Phases of Carl’s Therapy Five phases are discerned in Carl’s play therapy. consisted of three principal play phases, disruptions.  These  interrupted by two play  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, his play.  sometimes engaging human figures in  The Second Play Disruption (14,  Carl’s intense despair,  15) was marked by  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. is charted in Figure 20.  Their appearance across sessions  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. occasionally explored other play materials,  Although Carl  such as the paint  brush and the magic wand, his interest in them was fleeting and usually never repeated. with the baby dolls, pivotal session (5).  The exception, a sustained play segment  is discussed within the context of a unique  187 Session Beginning 2 3 4 1  End Middle Phase Disruption 14 15 16 17 10 11 12 13  5  Disruption 6 7 8 9  *  *  *  *  *  *  *  *  *  *  *  Theme *  VEHICLES  *  *  *  DOLL HOUSE FIGURES  Figure 20.  Vehicles:  Carl:  *  *  Overview of Play with Principal Materials  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, using human figures in conjunction with the vehicles.  i.e.,  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. initial Vehicle Play began On the Floor (1,  2).  Carl’s  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.  enjoyed this game,  Carl  and alternately raced the vehicles or brought  them to a sudden stop, thereby indirectly controlling the  188  Session Beginning 3 4 2 1  5  8  7  6  9  Middle Phase 13 11 12 10  14 *  Theme HANDLE Sand  *  *  Floor Water Table  *  * *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  15  End 17 16 *  *  *  *  *  *  *  MANEUVER *  *  *  Dig/dump Bury Stuck Complex  w/HUMAN FIGURES W/ Therapist Figure 21.  *  Carl:  *  *  *  *  *  *  *  Play Themes with Vehicles  therapist’s movements as well. mirrored activity,  Through this little game of  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). the table,  Carl preferred to settle into play with vehicles at  the sandtray. 4;  Running vehicles for a matter of seconds across  Likewise,  Carl’s play with Vehicles in Water (2 to  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. gritty and abrasive,  Carl loved the sandtray.  Sometimes  sometimes smooth and soothing, wet or dry,  flowing through his fingers or resisting the attempts of his  189 vehicles to traverse it, engrossed Carl.  sand was a medium which thoroughly  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.  vehicle play,  His  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, interrelated.  in fact,  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. added.  In subsequent sessions, more complex activities were  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, dis” in another corner of the “sanbok.”  and “dumping  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. sand (11), truck.”  Burying a truck in the  Carl understood what he had done,  observing,  “No  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, got “stuck” in the sand.  17), Carl’s vehicles often  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. cars,  The backhoe,  a truck,  several  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, activity.  in a sense pausing or resting before resuming  “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.” complete  (“move dat log!”).  The vehicles had difficult work to 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, at the table,  seated on the therapist’s lap  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,  “dump” them.  in turn,  Telling the  “I wan Daddy now,” he retrieved from the table the  therapist,  other 3 figures of his extended family grouping and added them to This time he buried the adoptive woman in the sand,  the sand.  With  with her body becoming an obstacle to his vehicle, a train.  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 “Where [she] go?”  commented,  In the final appearance of human figures with vehicles the backhoe, the focal vehicle,  (13),  functioned not only as a piece of  working machinery and as a moving transport, but also as an enclosing container, people.  a kind of moving home,  for the miniature  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 “Look! Carl driving!  the backhoe: down der. [sleep].”  .  .  .  Daddy’s driving it!  Two people! .  .  .  .  .  .  Duh sit  I wuh can seep seep  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. At the end of the Middle  Vehicle play with the therapist. 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.”  out his instructions with the vehicle(s)  As she carried  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: car.  .  .  .  I like that truck.  .  .  .  “I like boo [blue]  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. first directed the therapist in play (12,  When Carl  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. The Verbal Themes  Vehicles:  The following verbal themes emerged during Carl’s play with Vehicle Noises; Names of Vehicles; Vehicle Activities;  vehicles:  Vehicle Qualities; Expression of Wants; Expression of Liking; Absence; Relational Phrases; and Calls for Help. verbalization was minimal,  Figure 22 provides representative  examples of the verbal themes across play phases. Session Beginning 4 1 2 3  5  6  7  8  Because  9  Middle Phase 10 11 12 13  14  15  The following End 16 17  Theme VEHICLE NAMES  fie huck (3) choo choo (4)  QUALITIES clean bQh (3) moh car (3) WORK  didig (1)  OTHER ACTIONS  No go.  Die is lots? (12) Dis car door open? It dump.  (13) No moh wookin.(16)  (12)  What backhoe doing?  (3)  dumptruck (16)  dumptruck (11) mack truck (12) front loader (13)  (12)  Dah fah down?  [consistent across phases]  STUCK ABSENCE / LACK  Car gone.  WANTS  I wan more cars.  HELP  Hup dis.  RELATING  Bye didig.  No car.  (1)  (2) (1)  (3)  (12) I needa work oer der.(17)  I wanna pay in the sandbox. (11) Help pees, mudder. (12) Dit need help. (13) Daddy’s driving it.  (13)  Pay dis one. (17) I like boo car. (17)  LIKES  Figure 22.  (16)  Carl:  Examples of Verbal Themes with Vehicles  discussion focuses on the across-session thematic developments and trends.  196 Carl provided realistic noises for his  Vehicle noises.  such as motor noises, sirens, and back—up signals.  vehicles,  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 “Der boat!” or “Dah truck.”  during his play: progressed,  As his therapy  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. “Moh didig,”  This was amply elaborated in subsequent sessions: “I making tunnuh,”  (2);  “Moh wook,”  dirt up,” “Pick the wock up” wookin’”  (16);  “Dump”  (3);  “Picks the big  (12); “Working finished.  “I move dat rock,” “Dis carry logs”  No moh  (17).  noteworthy that not only did this subtheme of Work persist  It is  197 as even these few examples  throughout his therapy, but also,  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  going”  (4);  “What backhoe doing?”  drive,” “Is going in sand” tip over,”  “Dis stan’ up?”  “No go”  “Stop,”  Description of Vehicle Movements:  “Car come”  (12);  (2);  “There  “Dih go  “Beep beep backing up!”  (13);  “Carl  (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. size (“big backhoe,” “little car”) now?”  “Low down”).  He was aware of  and place or position (“High  He expressed interest in additional or  greater quantities (“Nudduh car”  [[2];  “Dis is lots”  [12];  “Moh  He was aware that one vehicle was “bokin [broken]”  park”  [16]).  (4).  He commented that “Dis car door open”  [allowed] get wet?”  (13)  and “Boat loud  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 Such references proliferated throughout his therapy.  “duhtee.”  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”  Absence or lack.  (17).  Verbalizations of the concept of objects  being hidden, missing, or absent were meager throughout his Carl expressed this concept in most elemental form.  therapy.  the Beginning Play Phase, he commented “Car gone” dih [digging] gone”  (3).  and “Dih  In the Middle Play Phase, he formulated  this concept differently, commenting “No truck!” (12)  (1)  In  when he buried them in the sand.  (11),  “No car!”  This verbal theme did not  recur in the End Play Phase. Expression of wants.  Carl was able to express what he “I,” from the outset of therapy.  wanted using the first person,  This Expression of Wants transformed across play phases and occurred even during play disruptions. Phase,  In the Beginning Play  Carl was able to communicate what he wanted to do and with  which object he wished to play: wuh more cars”  “I wuh ride dat boat”  (1);  (2).  In the Middle Play Phase,  a number of transformations  In addition to designating the object he desired,  occurred.  “I  Carl  more frequently announced what he wanted to play before engaging in play, san”  “I wanna pay in the sandbox”  (12);  “I wuh pay airpane”  (13).  (11); “I wan boat in ner He was able to express his  wants even at the risk of being limited by the therapist: bing dis [backhoe back to the classroom]”  (10).  “  I wan  He also conveyed  199 a wish to attempt an activity: vehicle]”  “1 wuh try [using a particular  (13)  Carl’s most emotionally charged Expression of Wants was his eloquent request for help during play with the vehicles help”  [12,  13]).  (“I wuh  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. well, pleased to see a new dump truck in the room,  As  Carl settled  into contented play at the sandbox, nestled in the therapist’s lap.  “I like boo [blue] car,”  “I like that truck!” and, Although on one level, the  “I like Susan,” he commented.  therapist was certain that Carl did, materials and the therapist,  later,  in fact,  like both the play  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. assumed two forms:  This theme  indirect and direct calls for help.  The Help theme in its indirect form first emerged briefly in Session 2. one.  Carl commented that one vehicle would “hup dis” other  This verbal expression is considered indirect in that the  need for help was projected onto the play material, impersonally in the third person.  and worded  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 In both Sessions 11 and  personal appeal in the second person.  12, as Carl endeavoured to free the “stuck” vehicles, he repeatedly called out,  “Help mommy.  Help pees, Mommy.  Help  Although an element of projection was involved in  pees, Mudder.” this expression,  as Carl clearly intended to be speaking for the  driver of the stalled vehicles, the sincerity of his  (invisible)  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,  However, this verbal thematic category refers to  relational.  those verbalizations which either (a) materials with Carl,  all of Carl’s speech was  (vehicles) (b)  directly addressed the play  as respondents in a personal relationship  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: (11);  “Daddy’s driving car!”  (13).  “Dis pick up Daddy”  202 The third category proliferated in the latter two Play Carl frequently addressed the therapist directly,  Phases.  in  tones that implied both friend and playmate, beginning with a simple call for her attention,  “Look, truck!”  began to verbally direct the therapist to play: backhoe,”  “Try again”  (12); “Pay dis one!”  “Let’s pick mommy daddy.  Session 12,  Later, Carl  (10).  “Pay with  (13).  His comment in  Pick ‘em up,” was a  particularly clear expression of mutual interest and effort (cf. “let’s”). Phase.  Similar directives continued throughout the Final Play  To these directives, Carl verbally added the element of  competition, (“Set go!”)  inviting the therapist’s vehicle to race his own and even compete in parking (“Set park!”).  Human Figures:  The Play Themes  Carl played with the following sets of human figures: Adventure People, the Hospital Grouping, Baby Dolls, House Figures (cf. Appendix C).  the  and the Doll  The Adventure People figured  only cursorily in his play, with Carl placing one of them (unidentified) the “black man” (6).  on the boat in the sand (1), biting the head of (3), and holding an unidentified female figure  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.  table knife, he tried to “cut” the eyes of one doll. the bedding from the large playroom cradle,  Taking a Removing  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, touchingly,  often very  to enact the elements of his primary relationships  that were important from his three—year—old perspective.  204 Session Beginning 1 2 3 4  5  6  7  8  *  *  9  Middle Phase 10 11 12 13  14  15  16  End 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, therapist enacted,  if briefly, whenever the  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, Separation, Related.  Sleeping, Bathroom Activity,  Exploring Body Parts, Tossing,  Burying,  and Vehicle  Carl carried out all play with human figures while  seated on the therapist’s lap near the table. occurred solely within the Middle Play Phase  His play with them (9 through 13).  Carl did not return to play with human figures after the Second Play Disruption. Expression of affection. 9,  As Figure 23 illustrates,  Session  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. kissed the child and the father. the adoptive parents.  The mother  Later, the father kissed one of  The child figure kissed her as well.  activity recurred with diminished frequency  This  (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. Enactments of separation between the child and  Separation.  As  the parents occurred in association with the Sleeping theme.  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,  These  saying “Nie nie, Daddy.”  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, Bathroom activity.  “Bye, A.  Go home, Daddy.”  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. in the tub.  In the next recurrence of this theme  Carl also put A Carl  (11),  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, fixture itself,  intermittent interest in the toilet  adding it to the sand (12,  Exploring bodies. Doll House figures.  16).  Carl was curious about the anatomy of the 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 of f 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)  checking that they were unharmed from the fall  or intently (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, three successive sessions  (11 to 13).  in  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  transformed in that,  (12), this theme subtly  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,  joined by the child. child,  soon  Then a series of human figures, mother,  and B, were each picked up by the backhoe and dumped.  Finally,  the adoptive couple, A and B,  driving the backhoe together.  joined the child in  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, very much “his.”  Therefore,  the vehicles were  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  209 clustered around the following themes:  Expression of Affection,  Sleeping, Bathroom Activity, the Vehicles,  Separation,  Relationships, Exploring Bodies, Activity Descriptions,  With the exception of the Bathroom  Projected Attributes.  all of these themes were expressed solely during the  category,  None of these themes recurred in the End Play  Middle Play Phase. Phase.  and  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. Middle Phase Examples  Theme Bye bye,  SEPARATION  Daddy.  (9)  [kissing sounds;  AFFECTION ATTRIBUTES  He’s frying.  BATHROOM  Daddy pee up there.  OTHER ACTIVITIES  Up high.  SLEEP  Nie nie, mama.  RELATIONAL  Toy mommy.  EXPLORE BODIES  Der bum der.  Carl:  (9)  9,  (9)  Der pee.  (11) (11)  Dis pick up Daddy?  (9)  (10)  (11)  I wuh can seep. I wun daddy now.  (10) (12)  (13)  10)  A dirty.  (9)  A top train.  VEHICLE RELATED  Figure 24.  Dis goobye mommy?  (13) (12)  Mummy has a penis too? Daddy’s driving it.  (13)  (13)  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, Sleep.  Here,  10,  13).  Carl’s vocabulary was very limited.  However,  his tone of voice communicated tenderness as he put the figures  210  into their beds and wished them,  “Nie nie, Mama.  Nie nie, Dada”  He was able to minimally describe the activity of these  (9).  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: Bathroom.  “I wuh [that they] can seep.” Again within the range of a limited vocabulary,  Carl was able to adequately describe bathroom interest, and activities.  fixtures,  This verbal theme initiated in the first session  as Carl identified the contents of the doll house bathroom: wah wah.  Dah basroom?  Pee dah.  Pee!”  “Dis  In the most elaborate  expression of this theme (9), Carl described his figures jumping into the tub and using the toilet: wah wah.  Hot.  Dad ah wet.  “Wah wah jump.  Daddy pee up there!  Dad in duh Smell dat.”  The final occurrence of this theme (11) was very limited (“toilet,” “water,” “der pee”), in the bathroom,  suggesting that Carl’s interest  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, victims of the vehicles.  Representative examples of such  descriptive speech from the two principal sessions these referents occurred include: [s]top train?” Carl up.”  or  (12,  13) where  “Let’s pick mommy daddy.”  “Daddy’s driving it.  He fell off.”  “B  “I wuh pick  “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 (10)  Daddy,”  or asking,  “Wheh mama?”  Where B go?”  Carl’s most  poignant verbalization around the theme of Separation occurred in Session 13. hand,  Holding the child and the mother figure, one in each  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’ and to verbalize “goodbye.”  embrace and kiss) Relationships.  This category includes references to Carl’s  feelings toward and relationships with people, during play with the doll house figures. Session 12. sandbox,  A brief but compelling example arose in  Playing with some of the human figures at the  Carl realized several were missing.  he told the therapist. plastic figures,  “I wan Daddy now,”  While ostensibly referring to the small  Carl was also accurately expressing how he felt  at a deeper level, missing his father. In this same session, the sand, he commented,  as Carl buried adoptive parent B in  “B makin’ happy face?”  the question appears genuine, a simple query.  On the surface, 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 Papa.”  “Dah Mommy.  In a statement which indicates that he comprehended  the figures’ projective function, he then commented, Finally, he partly stated and partly inquired, Dah A mommy?”  “Is A’s duh mommy?  Carl was actively grappling with what was perhaps  the most difficult question in his life: Exploring bodies.  “Is A my mommy?”  Carl initiated this verbal theme while  trying to pull the clothing of f the figures open up?  Der bum der?  Der body!”  (10):  important transformation.  “Dah [clothes]  Several sessions later, when  this theme arose for the second and final time,  figures,  “Toy mommy.”  it underwent an  From an interest in the “bum” of these  Carl was now more interested in determining which  figures had a penis: Dis bum, too. see penis too.  “Dah look [I look at that].  B penis too?  Mommy has a penis too?  Duh penis. No toes?  I  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. in this regard were abundant,  spanning all play phases.  following are representative examples: high,” “Fall,”  (9);  “Dis pick up Daddy?”  Prolected attributes.  His verbalizations  “Hey, walking!”  The (3);  “Up  (11).  Carl comprehended that the miniature  doll house figures could be animated and enlivened through actions which recapitulated and/or reworked the basic activities  213 Verbally, he offered two important elaborations on  of his life.  their activity.  Holding the Carl and the father figure so they  could embrace and kiss  (9),  Carl commented,  “He’s frying  It was not clear from this statement which of the  [crying].”  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” of attributes  (10).  (crying, walking)  (“toy mommy”).  He had moved from the assigning to the designation of identity  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. session of the ensuing 3—session disruption with water,  (6),  In the first  a period of play  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:  because he’s very sad.”  “Bobo, please don’t bother Carl today, 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, summary,  absorbed play with the human figures.  In  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. the figures, then touched them, them in play.  He first watched  and, ultimately began to engage  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. disruption  (14,  In the ensuing second  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. behavioral transformation occurred (15)  A slight  as Carl repeatedly left  the therapist’s lap to stand by the door, as if to emphasize his need to leave the room. therapist’s lap,  However, he returned each time to the  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: done now!”  “No wan payroom.  Open door.  Within this general context, two singular  Ah  216 communications stand out.  The first was a consequential  Communication of Affect, Carl’s admission,  “I’m not happy,”  The second suggested the theme of Feeling Abandoned:  8).  coming now?”  (Miri was Carl’s favorite teacher.)  (7, “Miri  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. verbal refrain.  “Time go back now?” was his almost continual 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, teacher] pick Carl up!” “big hug,” 2.  15),  talk! 3.  “Diane [a  Through racking sobs, he often added  “big big hug,” an expression of his need for love.  Carl began to verbally assert himself in relation to the  therapist. (14,  and needy, he sobbed,  When the therapist verbally interpreted his anguish Carl silenced her with a determined and angry:  “No wan  No talking!” Some verbalizations suggested that Carl was a  personality capable of complex emotional defenses and sophisticated reasoning. separate occasions,  Still sobbing, he insisted on 4  “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.  words seemed to well from deep within him,  Time go home.”  The  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  Carl replied that he wanted to see the adoptive  to see at home?” 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 vehicle activities and elements of human relationships.  meaning:  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,  depicted certain details of relationship, parting.  Carl  such as kissing or  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. however,  some exceptions to this general tendency:  There were,  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. objects,  Carl occasionally introduced verbal referents to events,  either immediate home).  or people outside the playroom. (related to the preschool)  These could be  or remote  (related to  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,  with other settings, events, objects,  connections  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”). reflected capacities for awareness,  Carl’s verbalizations  intelligence,  and imagination  not revealed in the literalness of play activities. Carl used verbal communication to express wishes, wants, likes,  Through  and dislikes with a range of intensity.  verbalization, Carl was able to announce and to plan his play, telling the therapist what he wanted to do next. verbalization,  Through  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, psychologically complex verbal communication.  subtle,  and  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.” value,  Taking the comment at face  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. convey that I no longer need help, place.”  Perhaps if I  I can leave this terrible  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,  stuck (cf. play disruptions)  Carl, too,  sometimes got  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, love and pain.  frightened feelings of  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, stories.  The human figures,  coherent  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, transformation from a focus on vehicles focus on human figures is discerned.  (Middle),  a global play  (Beginning Phase), to a  and a return to vehicles  (End)  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, referents about them arose.  no verbal  This fact reflects the power of the  physical presence of play materials to facilitate therapeutic