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Play therapy technique : an examination of a Childrens Aid Society experimental project for disturbed… Finlayson, Helen M. 1951

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/fry ftf I PLAY THERAPY TECHNIQUE: An Examination of a Childrens Aid Society Experimental Project for Disturbed Children, 19^8 to 1951. by Helen M. Finlayson Thesis Submitted in Part ia l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK i n the Department of Social Work 1951 The University of Br i t i sh Columbia A b s t r a c t This study has been made t o evaluate the b e n e f i t s of p l a y therapy i n the treatment of d i s t u r b e d c h i l d r e n , and s p e c i f i c a l l y t o consider the p a r t i c u l a r technique used at the C h i l d r e n s A i d S o c i e t y i n Vancouver. The term "treatment" i s a nebulous one i n t h i s age of m u l t i p l e treatment methods; however, the therapy technique, as i l l u s t r a t e d i n t h i s t h e s i s , lends i t s e l f to comparatively concise e v a l u a t i o n . The play therapy p r o j e c t was i n i t i a t e d a t the C h i l d -rens A i d S o c i e t y i n J u l y of 19*+8, under the auspices of the Junio r League of Vancouver. For the f i r s t few months, only one c h i l d r e c e i v ed treatment, but the p r o j e c t has broadened to i nclude a t o t a l of t h i r t e e n c h i l d r e n who have received treatment and are r e c e i v i n g treatment at the present time. These c h i l d r e n are c a r e f u l l y s e l e c t e d w i t h regard t o the de-gree of t h e i r disturbance rather than whether they are wards or non-wards. Such a s e l e c t i o n of the c h i l d r e n i s necessary because the therapy p r o j e c t i s l i m i t e d and the resources must be used to the greatest advantage. The t h e s i s f i r s t describes the t e c h n i c a l aspects of the p l a y therapy technique i n general. A second chapter then sets f o r t h the p r a c t i c a l issues i n v o l v e d . D e t a i l e d cases are next examined of c h i l d r e n r e c e i v i n g treatment f o r (a) con-duct d i s o r d e r s , (b) h a b i t d i s o r d e r s , and (c) n e u r o t i c t r a i t s . For each of these groupings, three cases were s e l e c t e d to ex-empli f y the c h a r a c t e r i s t i c s commonly as s o c i a t e d w i t h these d i s o r d e r s . The f i r s t of these cases i l l u s t r a t e s the therapy given to a c h i l d who showed a marked conduct d i s o r d e r ; the second case showed a c h i l d w i t h a h a b i t d i s o r d e r ; and the t h i r d case described a c h i l d w i t h n e u r o t i c t r a i t s . With each of these cases, the therapy i s described through a c t u a l t h e r -apy e x c e r p t s , p o i n t i n g out at the same time the meaning of the movement ta k i n g p l a c e . A d d i t i o n a l l y , f o r each of these three chapters, two f u r t h e r cases were used, as an i l l u s t r a -t i o n of instances i n which therapy might be b e n e f i c i a l , and a l s o to b r i n g out r e l a t e d casework concepts i n the en v i r o n -mental s i t u a t i o n . An attempt i s made to group the cases i n such a way that s i m i l a r t r ' a i t s were shown i n those c h i l d r e n r e c e i v i n g treatment and those who are not. I t i s found that the therapy at the Ch i l d r e n s A i d S o c i e t y i s , f o r the most p a r t , conducted on a ' p l a y - i n t e r -viewing' b a s i s , and the co n c l u s i o n from t h i s f a c t i s that there i s a r e a l need f o r s p e c i a l l y t r a i n e d t h e r a p i s t s so that treatment may be given on a more i n t e n s i v e l e v e l . In a d d i t i o n , the case records used i n the study seem to i n d i c a t e a l a c k of adequate casework w i t h parents and f o s t e r parents, as w e l l as a need f o r b e t t e r placement p o l i c i e s w i t h these c h i l d r e n . A c c o r d i n g l y , an attempt i s made i n t h i s study to show both the strengths and weaknesses of a p r o j e c t -which i s the f i r s t of i t s k i n d i n the c i t y . The p o s i t i v e values are very c l e a r where treatment can be given c o n s i s t e n t l y . At the same time i t emphasizes the great need f o r treatment resources towards which such a method can only o f f e r a p a r t i a l c o n t r i b u -t i o n . PLAY THERAPY TECHNIQUE: An Examination of a Childrens Aid Society Experimental Project for Disturbed Children, 19*+8 to 1951. Table of Contents Chapter 1. Theories of Play Therapy Page History of treatment for disturbed children. Definition of play therapy for the purposes of this study. Various approaches to the therapy technique. The unique features of the play therapy situation 1 Chapter 11. Play Therapy Research Aspects Conduct disorder, habit disorder, and neurotic t ra i t s , as commonly accepted groupings. The purpose of the study. The method used in selecting cases; Practical issues involved In play therapy 12 Chapter 111.The Child with a Conduct Disorder The case of the f i r s t chi ld to receive play therapy at the Childrens Aid Society. A case in which therapy has been recently in i t ia ted . A case in which therapy might be beneficial 31 Chapter IV. The Child with a Habit Disorder A therapy case during which i t was found necessary to remove the child from the home. A case which i l lustrates the need for therapy and casework with a parent. The case of a three-year-old chi ld who has a sexual problem...61 Chapter V. The Child with Neurotic Traits The case of a chi ld showing definite paranoic trends. A case i l lus tra t ing the results of good casework with a parent. A case which shows the need for an observation centre to ensure more adequate placement policy 95 Chapter VI. The Play Therapy Project in Review . A consideration of the Results obtained from play therapy treatment, at the Childrens Aid Society. The need for specially trained therapists. Provision of an observation cen-tre. The setting up of a treatment centre. A foster parent training program. Responsib-i l i t i e s of a l l social workers in the f i e ld of child welfare 136 Bibliography 157 Chapter I Theories of Play Therapy During the second decade of the twentieth century c h i l d care was i n a period of t r a n s i t i o n . P s y c h i a t r i s t s suddenly r e a l i z e d that, although there could be no better s t a r t i n g point i n the mental hygiene movement than an un-derstanding of the e a r l i e s t signs of misbehaviour i n the formative years of childhood, very l i t t l e was known of t h i s period. This r e a l i z a t i o n resulted i n the beginning of serious, s c i e n t i f i c e f f o r t s to study, comprehend, and treat personal disorders experienced or presented by young human beings* The t h i r d decade of the twentieth century brought with i t a broadened horizon i n understanding of the c h i l d . The f i r s t c h i l d guidance c l i n i c s opened t h e i r doors i n the United States i n 1921. A "team" composed of p s y c h i a t r i s t , psychologist, and s o c i a l worker formed the nucleus of each c l i n i c to which parents, schools, and child-caring agencies were encouraged to bring "or re f e r children with disturbing or otherwise puzzling behaviour. Behaviour which had been previously regarded as *bad*, unexplained, and incomprehen-s i b l e , came to be recognized as a ch i l d ' s reaction to adult oversolicitude, perfectionism, disapproval, and overt or concealed h o s t i l i t y * The fourth decade of the twentieth century saw - 2 « the development of s p e c i a l ways of working with children. Prior to t h i s time, the children themselves had been gener-a l l y disregarded as f a r as therapeutic procedures were con-cerned. But c h i l d p s y c h i a t r i s t s , searching f o r means of giving children opportunities f o r self-expression, were d i r -ected by Anna Preud toward the u t i l i z a t i o n of play as the most natural and promising instrument. This method gave the observer s i g n i f i c a n t knowledge of a chil d ' s feelings, and at the same time provided curative emotional releases 1 for the c h i l d himself. A v a r i e t y of i n i t i a l concepts have been formed as to the nature of play. The *surplus energy* theory assumed that i n play a c h i l d 'blows off steam'. The • i n -s t i n c t -pra,ctice* theory assumes that man does not play because he i s young, but i s made by Nature to go through a period of childhood i n order that he may play and thus prepare himself for adult a c t i v i t i e s * The 'recreation* theory held that play is the s a t i s f a c t i o n of a physiolog-i c need f o r relaxation. The *recapitulation' theory of play saw the growing c h i l d as passing through a series of stages which recapitulate the 'culture epochs' i n the evol-ution of the race, animal, savage, nomad, a g r i c u l t u r a l , and t r i b a l . The * catharsis* theory considers play as a •safety v a l v e 1 f o r pent-up emotions; the c h i l d plays out his c o n f l i c t s . The *self-expression* theory maintains that children f i n d i n play the medium for the s a t i s f a c t i o n of the great majority of t h e i r motives. But i n any case, 1 Leo Kanner, Child Psychiatry, S p r i n g f i e l d , C. E. Thomas, p. 14. — 3 «* play i s the natural and most readily available outlet for a child ' s needs and fee l i n g s , which cannot, as i n the adult, be worked out verbally, vocationally, or i n other ways not 2 accessible to the c h i l d . "Play" i s , af t e r a l l , the name given to a great deal of ordinary c h i l d behaviour. What is int e r e s t i n g i n a review of the various schools of thought i n the use of the play therapy tech-nique i s that, as one school a f t e r another i s examined, the s i m i l a r i t i e s rather than the differences appear more evident i n each of them. An objective may be reached in many ways. It i s the sureness of the approach that determines the success or f a i l u r e . Throughout the varying uses of the technique, the unverbalized parts of tte process become quite apparent« Results attained were si m i l a r ; approaches to the therapy were d i f f e r e n t . The common unmentioned fac-to r influencing the res u l t s of therapy was the personality of the in d i v i d u a l therapist. Accordingly, one d e f i n i t i o n of the term 'play ther-apy*, adopted for the present study i s as follows: Play therapy i s the use of play as a medium through which the c h i l d , i n the process of playing, may convey to the therapist sym-b o l i c a l l y and i n verbal form his conscious and unconscious feelings about h i s environment, himself, and the relat i o n s h i p he f e e l s to those about him. 2 Ibid., p. 228. Dr. Frederick Allen describes play therapy as a process of helping the child to help himself. He says "the therapeutic process occurs as a unique growth experience created by one person seeking and needing help, from another 3 who accepts the responsibility of offering i t " . The relation-ship set up in the play therapy situation provides a medium for making conscious the unconscious trends and drives, and for recreating the past, in order to release anxiety bound up with these earlier experiences. However, in this connection, although the medium is provided for making conscious these trends and drives, it is important to remember that the ther-apist's real responsibility lies in helping a child to do what he is free or ready to do, without trying to force him into any particular channel of expression. The helping process, as has been pointed out previous-ly, is carried out in various ways according to the school of thought under review. There are, however, basic similar-ities in a l l schools which it appears are the most important items to be considered. The in i t i a l procedure under consideration in the present study consists of studying a l l the pertinent aspects of the child and his situation, formulating a plan for the relief or resolution of the; difficulties, and putting the plan into action. Parents, in this conception of the scheme of things, were originally the receivers of scientifio advice 3 Frederick Allen, Psychotherapy with Children, ¥ . W. Norton and Co. Incw, New York, 1942, p# 31. on the basis of which i t was hoped they would "do something d i r e c t l y for t h e i r offspring and more i n d i r e c t l y work on 4 themselves i n his behalf." This concept eventually develop-ed to a point where the l i v e s of parents and children were seen to be emotionally intertwined. The feelings and a l t i -tudes of parents, which were regarded as the chief determine ants of children's d i f f i c u l t i e s , were i n turn seen to be dep-endent upon the parent's own early emotional experiences.' It seemed to follow that work with parents should be directed toward resolving some of t h e i r own emotional c o n f l i c t s , for otherwise i t was thought they would continue to act towards t h e i r children i n t h e i r accustomed manner, no matter how c l e a r l y they were t o l d they must a l t e r t h e i r behavior. Prom thi s theory, a procedure developed by which s o c i a l workers, under the guidance of p s y c h i a t r i s t s , t r i e d to help parents discover the emotional o r i g i n of t h e i r adverse feelings to-wards t h e i r c h i l d r e n . The above procedure has modified to a point where most c h i l d guidance s o c i a l workers now take as t h e i r task the fostering and enhancing of the strength that a parent display when he decides to do something about an unpleasant s i t u a t i o n They t r y to prepare the c h i l d for psychotherapy by discuss-ing with the parent, i n the intake interview, how he w i l l present to the c h i l d the plan of coming to the c l i n i c . This 4 Helen Witmer, Psychiatric Interviews with Children, Hew York, Commonwealth Fund,. 1946, p. 9» i s the basic f i r s t step towards i n i t i a t i n g the play therapy s i t u a t i o n . The type of c h i l d l i k e l y to f i n d help by the play therapy technique i s c h i e f l y the c h i l d whose d i f f i c u l t i e s are l a r g e l y attributable to maladjustments i n the parent-child r e l a t i o n s h i p and whose parents want assistance with these problems* Thus most cases of feeble-mindedness and neurol-ogical disorder and those which show gross s o c i a l pathology, 5 must be excluded^ It i s commonly found that the children dealt with through play therapy show a great v a r i e t y of symp-toms including: aggressiveness, uncontrolled behaviour, ner-vousness, s e n s i t i v i t y , fears, excessive shyness, other d i f f -i c u l t i e s r e l a t i n g to people, various kinds of school malad-justment, physical disorders without discoverable organic bases, delinquencies of various kinds, marked p e c u l i a r i t i e s of behaviour and personality. An attempt at c l a s s i f y i n g these d i f f -i c u l t , but there seems to be substantial agreement that i n some cases the behaviour i s symptomatic of a neurosis, while in others i t i s a dir e c t reaction to the adverse circumstan-ces under which the c h i l d l i v e s . "The; conscious use of a relationship characterizes dynamic c h i l d psychiatry and distinguishes i t from the work 6 of p s y c h i a t r i s t s who r e l y upon other therapeutic agents*. 5 Ibid., p. 16. 6 Ibid., p. 34. By means of relationships with other human beings the b i o l -ogical drives of individuals are turned to s o c i a l ends. It i s believed that the o r i g i n a l basis f o r an individual's ab-i l i t y to form r e l a t i o n s , s o c i a l or personal, l i e s i n the i n -fant's physiological s e n s i t i v i t y to his mother's moods and d e s i r e s i In the attempt to r e t a i n the sense of harmony and warmth which i s provided i n the normal mother§child r e l a t i o n ship, the infant makes his f i r s t e f f o r t s to conform to h i s mother's desires and thenceforth to society. The l i m i t a -tions set up i n the c u l t u r a l system to which they belong assign, certain roles to various i n d i v i d u a l s . The adjust-ment of the p a r t i c u l a r c h i l d i s proportionate to his a b i l -i t y to relate himself i n prescribed ways to these various individuals and to play his assigned role with them. Events which disturb the c h i l d ' s sense of security i n h i s parents* love and esteem set up an emotional •climate i n which deviations i n adjustment may e a s i l y be generated. The basic attitude prescribed for; the therapist includes genuine f r i e n d l i n e s s and warmth, interest i n the c h i l d and his problems, tolerance f o r his opinions and f e e l i n g s , and a deep s e n s i t i v i t y to his needs and desires. These pre-req u i s i t e s are, of course, the requirements for any form of s o c i a l casework, whether i t deals with the c h i l d or the adult. To t h i s must be added the requirement that the ther-apist be aware and i n control of the impulses, aims, and sentiments i n himself that might hinder the c h i l d i n the f u l l expression of his thoughts and wishes. - 8 » Two separate viewpoints as to the method of opera-tion are found in the remedy proposed by Anna Freud as com-pared with American chi ld psychiatrists . Anna Freud says that an affectionate attachment, with an accompanying fa i th in the therapist, admission of i l lness , and desire for recov-ery, must be secured from the chi ld * So she suggests that the therapist strive for the chi ld ' s love, stress the serious-ness of his d i s ab i l i ty , and then insinuate himself into his 7 confidence. American child psychiatrists put less emphasis on 'winning' the chi ld and more on the chi ld ' s own interest in being helped. An example of this latter tenet is shown in Dr. Frederick Allen*s basic bel ief of helping the ch i ld to help himself. However, regardless of the specific approach made to the problem, the therap i s t s role is especially des-igned to foster the development of feelings of security in the c h i l d . These feelings of security are constructed, as men-tioned previously, in the permeating friendliness and sensit-i v i t y to the ch i ld ' s moods, actions, and words. His doubts and fears may be anticipated; or, more l i k e l y , by implication, the chi ld is given to realize that his ideas w i l l receive f u l l attention. The therapist is very careful to be non-judgmental, neither condemning nor praising, but receiving a l l information in an accepting manner and permitting a free expression of feeling and opinion, even i f accompanying behaviour has to be forbidden. A very important step in the i n i t i a l contact with 7 Anna Freud, Introduction to the Technique of Child Analysis , New York, Nervous and Mental Disease Publishing Company, 1928, pp. 1-14. the c h i l d i s to define f o r him what therapy i s to consist of, and from that point on to allow him freedom of choice, even i f he chooses to be t o t a l l y non-communicative. These devices are technical ones. They would be cold and abortive without the i n d i v i d u a l personality of the therapist himself. Dr. Jessie Taft says: "In my op-i n i o n the basis of therapy f i n a l l y l i e s in the therapist himself, i n his capacity to permit the use of s e l f which the therapeutic r e l a t i o n s h i p implies, as well as his psycholog-i c a l insight and t e c h n i c a l s k i l l . To practice therapeutic 8 casework, one must be^  a therapist. The d e f i n i t i o n of what the therapy i s to consist of varies among the d i f f e r e n t schools. There i s , however, cons-iderable agreement among them about the nature of the ther-apy s i t u a t i o n . "It i s a 'unique s i t u a t i o n * , unique i n the sense that no other s o c i a l relationships are conducted i n "9 accordance with the same conventions. The setting, f o r the c h i l d , i s not merely that of a play period with an unusually tolerant adult. The d i r e c t i n g of an interview along l i n e s p r o f i t a b l e to the c h i l d without obstructing the spontaneity of the c h i l d ' s actions i s a s k i l l which i s p e c u l i a r l y a part of the i n d i v i d u a l therapist's own personality. The therapist must insert enough of h i s own p a r t i c u l a r s e l f into the s i t u a t i o n to provide the medium, and yet r e s t r a i n any element of that s e l f which mi$it induce a judgmental emotional tone. 8 Jessie Taft, "The Time Element i n Therapy", American  Journal of Orthopsychiatry, 3: 75-76,77, January 1923. 9 Helen Witmer, Psychiatric Interviews with Children, New York, The Commonwealth Fund, 1946, p. 43. «. 10 -Secondly, the t h e r a p i s t u t i l i z e s h i s s k i l l t o d i r e c t the type of m a t e r i a l produced, i f he i s t o evolve a b e n e f i c i a l approach to the c h i l d ' s problem. The open ex-p r e s s i o n of a l l f e e l i n g s and d e s i r e s , i n f a c t a l l subject matter, i s the purpose of the s i t u a t i o n , w i t h the s t i p u l a " * t i o n t h a t i t bears on the c h i l d ' s problem.. The p r o h i b i -t i o n s i n the play therapy s i t u a t i o n occur i n the realm of a c t i o n . The play room s i t u a t i o n i s one i n which the worker s t r e s s e s the f a c t t o the c h i l d that here, w i t h i n the realm of reason, h o s t i l e emotions may be r e l e a s e d i n a reasonably d e s t r u c t i v e f a s h i o n as long as there is; no p h y s i c a l i m p a i r -ment of the i n d i v i d u a l s concerned. The second l i m i t a t i o n l i e s i n the time element. The f e e l i n g s and emotions i n the p a r t i c u l a r span of time encompassed by the i n t e r v i e w hour are f e e l i n g s and emotions which belong s p e c i f i c a l l y t o t h a t hour. By way of i l l u s t r a t i o n , the c h i l d i s seldom allowed t o keep any of the objects he plays w i t h during the hour* Those objects are h i s w i t h i n the area of that hour, and s i m i l a r l y the f r e e expression of h i s f e e l i n g s i s an oppor-t u n i t y which i s a part of that hour. Once the r e l a t i o n s h i p i s e s t a b l i s h e d , the second step may be i n i t i a t e d . This step c o n s i s t s i n h e l p i n g the c h i l d to develop i n s i g h t i n t o the reasons f o r h i s d i f f i c u l -t i e s , which may mean a i d i n g him t o c l e a r up the misconcep-t i o n s that confuse him. The s o c i a l worker i n the r o l e of t h e r a p i s t does not d e a l w i t h the emotional tones that l i e b u r i e d i n the subconscious, but r a t h e r w i t h the repressed m a t e r i a l that comes i n t o consciousness as a r e s u l t of the - 11 -permissive atmosphere of the therapy s i t u a t i o n . This l a t t e r statement is r e l a t i v e and must be considered i n the context of the p a r t i c u l a r c h i l d concerned, h i s p a r t i c u l a r problem, and the degree of his disturbance. A quotation from Helen Witmer best sums up the unique features of the play therapy s i t u a t i o n : "Here (the child) may be a f r a i d without having e f f o r t s made imm-ediately to remove his fearso Here he has met with a per-son who understands and accepts both his need and his r i g h t to be a f r a i d without melting before i t . He finds that he can be aggressive and h o s t i l e , and, at the same time, finds a person who can both accept the f e e l i n g and give l i m i t s to i t s expression. He finds a person who i s interested i n what he says, i n what he i s , and i s not tr y i n g to squeeze him into a preconceived mould. He can have his own power, without having i t overwhelmed by the greater power of an-other. He comes expecting to be changed and finds a person interested and related to what he i s now. Truly, t h i s i s a unique experience which i s started with (the ch i l d ) i n the 10 centre of i t " . 10 Ibid., p. 44. - 12 -Chapter II Play Therapy Research Aspects Conduct disturbances form a part of the large group of primary behaviour disorders. The name, primary, i s given because these disorders are not secondary to any other pathological condition. They develop i n reaction to environmental influences i n the form of p e r s i s t i n g behav-11 iour patterns. It i s customary to speak of a conduct d i s -order whenever there i s a deviation from the accepted code of morals. Thus l y i n g , truanting, s t e a l i n g , disobedience, running away, destructiveness, f i g h t i n g , and sexual a c t i v -i t i e s , along with other s i m i l a r deviations are considered to be disorders of a conduct v a r i e t y . Children with t h i s type of disorder show l i t t l e response to punishment nor indicate any sign of g u i l t , a l -though i t must be remembered that a certain degree of neg-ativism i s a normal reaction around the age of three years. It i s often found, however, that such a disturbance has started at an early age, at three years or even younger. At the point that such a c h i l d makes his f i r s t entry i n the s o c i a l group when he starts school the behaviour may become markedly worse. If he i s taken to an expert at t h i s point the complaints about his behaviour are found to be 11 .J.H.W. Van Ophuijsen, M.D., "Primary Conduct Disturb-ances", i n Nolan D. C. Lewis and others ed., Modern  Trends i n Child Psychiatry, International U n i v e r s i t i e s Press, 1950, p. 35. - 13 .-very r e a l i s t i c . Usually the parents f e e l that they have a c h i l d who i s " s t r i c t l y bad" and t h e i r whole attitude i s one of an accusative nature and a bewildered wondering as to how they could have produced a c h i l d so completely devoid of what they consider normal actions. The constant c o n f l i c t with the environment and the ab-sence of g u i l t which, characterize each case provide a dual nature to the problem. This two-fold abnormality leads to a consideration of the early period i n which a c h i l d adjusts his aggressive i n s t i n c t s both to society and to himself. Outwardly, the c h i l d with a conduct disturbance, when he reaches the rebellious three year old period, shows an i n -ordinate aggressive i n s t i n c t towards society. Inwardly, there i s l i t t l e aggression i n the form of c r i t i c i s m of s e l f . Instead, the examiner finds a n a r c i s s i s t i c self-evaluation as though the c h i l d f e l t himself above the demands of society and immune to the punishments l a i d down to protect society. Again and again he must act out and attempt to prove his i n v u l n e r a b i l i t y . Abnormal aggressiveness, absence or defective develop-ment of g u i l t f e e l i n g , and n a r c i s s i s t i c self-evaluation, form the t r i a d that characterizes the c h i l d with a conduct disturbance. Although there are degrees of in t e n s i t y , vary-ing from the abnormally disobedient c h i l d to the full-blown gangster type, the above mentioned t r i a d i s always recogniz-able . - 14 In a d d i t i o n t o conduct t r a i t s , h a b i t d i s t u r b a n c e s are o f t e n present, or the h i s t o r y r e v e a l s that they have been i n the p a s t . Much l e s s frequent i n case r e c o r d s , i s the combination w i t h n e u r o t i c t r a i t s . As a consequence o f the o v e r l a p p i n g so o f t e n found between the conduct and hab-i t d i s o r d e r s , and a l s o the ha b i t and n e u r o t i c t r a i t s d i s -o r d e r s , i t i s d i f f i c u l t t o p r e d i c a t e a r e a l l y d i s t i n c t sep-a r a t i o n i n the t h r e e groups t o be d i s c u s s e d i n t h i s study. Gases have been chosen which seemed predominently of one p a r t i c u l a r group, but throughout i t i s necessary t o remember that g e n e r a l l y speaking one group does not exclude the o t h e r . The p a r t i c u l a r case of Tommy Snyder, used as an example of a conduct d i s o r d e r c o n t a i n s elements of both a conduct and h a b i t d i s o r d e r . H i s poor adjustment i n a l l s o c i a l r e l a t i o n s h i p s , h y s t e r i c a l screaming tantrums and ex-treme sexual a c t i v i t i e s suggested most s t r o n g l y the t y p i c a l conduct d i s o r d e r . However, h i s e x c e s s i v e masturbation of such long standing i s h i g h l y suggestive of a h a b i t d i s t u r -bance. S i m i l a r l y the case of Dennis Green used i n the same chapter, i l l u s t r a t e d the running away, l y i n g and s t e a l i n g combined w i t h the l a c k of g u i l t so o f t e n found i n the con-duct d i s o r d e r . Ronnie Trenton, a l s o d i s c u s s e d i n the chap-t e r i s e n e u r e t i c and masturbates which suggest a h a b i t d i s -order of long standing as he i s now eleven years o l d . How-ever, predominant i n Ronnie's case were h i s s t e a l i n g , l y -in g and a g g r e s s i v e s e x u a l a c t i v i t i e s accompanied by an a l -most complete l a c k of g u i l t about h i s behaviour. For t h i s - 15 -r e a s o n h i s c a s e w a s f e l t t o p r o p e r l y b e l o n g i n t h e c o n d u c t d i s o r d e r c h a p t e r . H a b i t d i s o r d e r s a r e o f t e n d e s c r i b e d a s b e i n g t h e f i r s t m a n i f e s t a t i o n s o f f a u l t y e g o d e v e l o p m e n t a n d m a y o c c -u r i n e a r l y y e a r s a r o u n d t h e a g e s o f t w o , t h r e e , o r f o u r . C l i n i c a l d a t a p r o v e t h a t o b s t i n a t e a n d s e v e r e p r i m a r y h a b i t d i s o r d e r s a r e d u e t o e a r l y t r a u m a t i z a t i o n a n d s u d d e n d i s -r u p t i o n a t a v e r y e a r l y a g e o f t h e m o s t i m p o r t a n t n o r m a l h a b i t s c o n n e c t e d w i t h t h e f u n c t i o n s o f f o o d i n t a k e , e x c r e -t i o n , e a r l y m o b i l i t y f u n c t i o n s , w h e n c o n c u r r i n g w i t h t h e 1 2 d i s r u p t i o n o f s m o o t h r e l a t i o n s h i p w i t h t h e m o t h e r . P r o l o n g e d t h u m b - s u c k i n g , n a i l - b i t i n g , e n e u r e s i s , m a s t u r b a t i o n , t r i c h o t o l o m a n i a ( t h e h a b i t u a l p u l l i n g o u t o f h a i r ) a n d t h e p s y c h o g e n i c t i c a r e c o m m o n e x a m p l e s o f t h e p r i m a r y h a b i t d i s o r d e r s . T h e s e s y m p t o m s m a y b e r e l a t e d , a s w e l l a s t h e s y m p t o m s s h o w n i n c o n d u c t d i s t u r b a n c e s , t o t h e e c o n o m y o f a g g r e s s i o n , a s a s t u b b o r n d e f e n s e , r a t h e r t h a n a n o f f e n s i v e r e b e l l i o n . I n o r d e r t o u n d e r s t a n d t h e n a t u r e o f t h e h a b i t d i s o r d e r , w h i c h i s t h e e a r l i e s t d e v i a t i o n , i t i s n e c e s s a r y t o e x a m i n e t h e d y n a m i c s o f i n f a n c y . C o n s t i t u t i o n a l f a c t o r s w h i c h m a y h a v e s t a r t e d t h e c h i l d w i t h a s t r o n g o r w e a k s t r u c t u r e , p r e n a t a l i n f l u e n c e s , a n d t h e r e l a t i o n o f b i r t h t o a n x i e t y a r e e , l l m a t t e r s w h i c h m u s t b e t a k e n i n t o c o n s i d -1 3 e r a t i o n w h e n e s t i m a t i n g t h e c a u s e o f a h a b i t d i s t u r b a n c e . 1 2 M a r g a r e t S . M a h l e r , " E g o P s y c h o l o g y " i n N o l a n D . C . L e w i s a n d o t h e r s e d . , M o d e r n T r e n d s i n C h i l d P s y c h i a t r y , I n t e r n a t i o n a l U n i v e r s i t i e s P r e s s , 1 9 5 0 , p . 4 7 . 1 3 G o r d o n H a m i l t o n , P s y c h o t h e r a p y i n C h i l d G u i d a n c e , N e w Y o r k , C o l u m b i a U n i v e r s i t y P r e s s , 1 9 4 7 , p . 2 4 . - 16 -The i n s t i n c t u a l s a t i s f a c t i o n s o f t h e o r a l n u r s i n g p e r i o d , w h i c h make f o r g r o w t h and l a t e r f u l l a d j u s t m e n t , p l a y a l a r g e r o l e i n w h e t h e r t h e c h i l d makes a n a d e q u a t e a d j u s t m e n t o r becomes v i c t i m o f a p r i m a r y b e h a v i o u r d i s o r d e r . The c h i l d d e v e l o p s s e l f - d e p e n d e n c e t h r o u g h i n c r e a s i n g m a s t e r y o f p h y s i c a l a n d s o c i a l e x p e r i e n c e i n a warmly s u p p o r t i v e a t m o s p h e r e . Thus d e v i a t i o n s i n t h e e a r l i e s t s t a g e o f t h e 14 s e l f - h o o d e x p r e s s t h e m s e l v e s a s h a b i t d i s o r d e r s . I f t h e baby does not g e t enough m o t h e r i n g he i s f o r c e d b a c k upon h i m s e l f f o r p l e a s u r e and a t t e n t i o n , a n d o r d i n a r y t h u m b - s u c k i n g , m a s t u r b a t i o n , a l o n g w i t h o t h e r body p l a y may be p r o l o n g e d o r i n t e n s i f i e d . The c h i l d who i s t h u s f o r c e d t o l o v e h i m s e l f a n d p r o l o n g s h i s i n f a n c y , does not outgrow i n f a n t i l e h a b i t s , w h i c h i f not t r e a t e d , become a p a r t of t h e permanent p e r s o n a l i t y s t r u c t u r e . A s h a b i t d i s o r d e r s s t e m f r o m t h e e a r l i e s t y e a r s a s r e a c t i o n s t o i n a d e q u a t e m o t h e r i n g , t h e l e n g t h o f t i m e o v e r w h i c h t h e y have b e e n f o r m e d s e r v e a s a w a r n i n g i n so f a r a s t h e d e g r e e o f o b d u r a c y i n p r o g n o s i s i s c o n c e r n e d . I n a p p r o p r i a t e l y p r o l o n g e d c h i l d i s h h a b i t s o r t h o s e w h i c h a r e u n u s u a l i n q u a n t i t y o r q u a l i t y a r e t h e ones w h i c h , by r e a s o n o f t h e i r i n t e n s i t y a r e c o n s i d e r e d d i s o r d e r s . I t i s commonly a c c e p t e d t h a t t h e c h i l d w i t h a marked h a b i t d i s o r d e r i s u s u a l l y a p a s s i v e c h i l d , p r e o c c u p i e d w i t h s e l f . The c a s e o f J e n n i e M o r t o n , c o n s i d e r e d i n t h i s 14 I b i d . , p . 26. - 17 a study as a c h i l d with a habit disorder i s quite t y p i c a l of t h i s group. The neurotic foster mother who raised her was una/ble to permit Jennie to develop as an i n d i v i d u a l . She over-emphasized the pleasures of dependency by refusing to let Jennie become independent, thus keeping the c h i l d t i e d to her. To be noted i n t h i s case are the early thumbsucking, consistent eneuresis, and extreme p a s s i v i t y which are found i n the c h i l d ' s personality. The tendency to withdrawal, noted i n the p s y c h i a t r i s t ' s diagnosis, indicate an inten-s i f i c a t i o n of the passive trends and suggest one of the t r a i t s common to the habit disorder. There i s a very close r e l a t i o n s h i p between the disorders c a l l e d habit disorders and those which result i n a degree of neurosis. It has often been pointed out that interest i n the body and excretions are normal fo r a l l i n -fants. However, during the early period when through bowel tr a i n i n g and other r e s t r i c t i o n s , the c h i l d makes his. f i r s t adaptation to society there i s a certain channelling of the aggressive impulses. When the c h i l d conforms only because of fear of punishment, neurotic t r a i t s may r e s u l t . The super-ego dev-elopment originates because of parental prohibitions esp-e c i a l l y i n the area of t o i l e t t r a i n i n g . The c h i l d represses his crude impulses following the example set by his parent, and thus gradually i n t e r n a l i z e s parental p r o h i b i t i o n s . Gradually the c h i l d i s helped by h i s parents to make the proper i d e n t i f i c a t i o n , learns to accept as r e a l i t y - 18 the interrelatedness "between hi s parents, and represses his impulses to gain the greater s a t i s f a c t i o n of t h e i r love and approval. In neurosis, however, these problems are not s o l -ved; there i s i n s u f f i c i e n t or incomplete repression for there i s a lack of reason to give up the impulses so that when they are acted out there i s a f e e l i n g of g u i l t accompanying them. With normal super-ego development the child's aggression i s turned against his own censured impulses and acts. In the deviations, the c h i l d who has had an unsatisfactory parental experience does not resolve his problem. He regresses to avoid anxiety and becomes quite dependent or he throws up a' -15 defensive structure of anxiety. In t h i s case he i s able to fkiction as long as the anxiety holds. A d i f f e r e n t i a t i o n i s made in the behaviour disorders described as neurotic t r a i t s , betwen preoedipal and oedipal. The case of Teddy Lawson, described in the chapter under neur-oti c t r a i t s i s t y p i c a l of the preoedipal type of disorder be-cause h i s whole early picture was one of deprivation, and the period of i d e n t i f i c a t i o n with the parent of the same sex i s so obviously incomplete. Teddy showed a great ambivalence between his des-i r e s f o r masculinity and femininity. He had a very poor con-cept of s e l f due to early deprivations, and the whole pattern of h i s development into a normal male c h i l d was hindered by a f i x a t i o n i n the preoedipal l e v e l of development. Teddy's con- « f l i c t i s brought to the surface, and as he begins to i d e n t i f y 15 Ibid., p. 30 - 19 -with the male worker i t is quite evident that he has both a fear of and a desire for feminine attributes. Unless the greater part of Teddy's conflict can be resolved through the therapy and positive l i f e experien-ces i t seems l i k e l y that the strong impulses attendant on the adolescent phase w i l l prove disastrous. Theybby is not i yet sure of himself as a male and the tendency to homosex-ual i ty w i l l be accentuated by the adolescent drives. Gordon Hamilton points out that the child with a neurotic confl ict is the chi ld whose l i f e energies are block-ed and distorted because they are par t ia l ly fixated in i n -fanti le wishes and impulses which the ego rejects. The i n -terview in Chapter Five which describes Teddy's d i f f i cu l t i e s in school around soi l ing his clothes would be an i l lus t ra t ion of this situation. Teddy comes into the playroom during In-terview Sixty-Two smelling very strongly of urine, although he is a boy nine years of age. When asked why he didn't use the l i t t l e pot which had been purposefully placed in a handy place he refused saying, "I'm not a baby anymore". The i n -fanti le desire to so i l was realized in his poor bladder con-t ro l but the chi ld ' s ego rejected the idea that he was being infanti le and should use what he considered a baby's pot. Deeply disguised anxiety, another symptom of the chi ld with a neurosis, is i l lustrated in the expression of Teddy's compulsive fears shown in his horror of ghosts and a hostile world. The deficiency of super-ego in the chi ld with a neurosis leads him to project his own hos t i l i ty onto the outer world and thus he fears continually that other people - 20 -are going to attack him rather than that the attack w i l l come from within himself. The psycho-neurotic ch i ld , on the other hand, suffers from a too severe super-ego and feels that his danger comes from within, that is from his own prim-i t ive desires. The Purpose of the Study Treatment of disturbed children by means of play therapy is a re lat ively new method in Vancouver. The tech-nique of the therapy has been evolved over a considerable period of time, but i t i s comparatively recently that the project now underway at the Childrens Aid Society was:^in-i t ia ted . ... •' Thus, because of the newness of the enterprise, and a keen general interest in the results obtained through the application of this particular treatment, i t was decided that this study should be made. The focus of the study is to evaluate the actual therapy project with a view to determin-ing i t s value. •• i A necessary prerequisite to the evaluation;of* play therapy as a treatment method is an understanding of the re-sources available, both in terms of finances and trained per-sonnel. This project was started in 19h& on a very small scale, one child for several months being used as a test case. Finances were l imited, those available being supplied by the courtesy of the Junior League of Vancouver. Trained thera-pists were completely lacking so that i t was f i r s t necessary - 21 -to in i t ia te a training programme. Such a programme was started by Dr. E l l a Linden-fe ld , psychiatrist , and a specially trained social worker who had learned her s k i l l under child psychiatrists in London, England. For long months several of the staff at the Chi ld-rens Aid Society were given the opportunity of studying the therapy process through the weekly conferences held. How-ever, even with such training i t was natural that only a few of the select group would possess the particular i n -tuit ive s k i l l that characterizes a true chi ld therapist. It is therefore the purpose of this study to eval-uate the actual therapy carried on, and by assessing i ts strengths and weaknesses assess the value of the project. The purpose is also to emphasize the tremendous need for specialized help in dealing with disturbed children. These children represent part of the next gener-ation and their numbers seem to increase with great rapidity. Some answer must be found to the problem, for as each child grows through l i f e carrying with him the burden of an un-happy, disturbed childhood, in the same measure the problems of the modern world are increased. As most of these children in Vancouver are under the care of the Childrens Aid Society, there is a tendency that their problems be dismissed by the general public, the impersonal agency setting providing a blanket effect which shields a more personal approach. It is the contention in this study that the public should be more informed of what - 22 -i s happening to children who are without the normal prot-ection of their own parents. Consequently, i t is believed that a study completed on this particular subject should be a re la t ive ly non-technical description of the actual •work done in the agency project. The objective is to describe each ch i ld f s back-ground, i l lustrate through the therapy how he reveals his reactions to that background, and show how the relationship created in the playroom can in a certain measure compensate for early deprivations. Every chi ld has a right to two parents who love and care for him, but many children have neither parents who build their strengths nor help them with their weakness-es. Such a building and helping are the aims of therapy. The case records presented w i l l provide at least a part of the answer in regard to real ization of these aims. On the other hand, as wel l , the whole process of treatment w i l l be seen as a part of the total environmental s ituation. No child can be treated in a vacuum. Consequent-l y , a further purpose of the study w i l l be to i l lustrate the importance of s k i l l in selecting the proper homes for these children, and of good casework with their parents and foster parents, so that the therapy may be accompanied by an ade-quate environmental medium. The Method used in selecting cases The study is divided into three main groups, - 23 -namely, the chapters describing children who show a large proportion of the conduct disorders, habit disorders, and those having neurotic t ra i t s . It seemed desirable to choose cases which were definitely significant, so that movement could be traced from a hazardous beginning to a more adjust-ed termination or level l ing point. For reasons of c l a r i ty and interest, the cases were chosen to i l lustrate the var-ious disorders, and within this divis ion to bring out concepts related to the whole treatment process. The case chosen as an example of a conduct disorder was one in which the treatment was carried on by a ski l led therapist. This was the f i r s t chi ld given therapy under the agency project and, for this reason, plus the fact that i t provides a clear i l lu s t ra t ion of treatment at a high l eve l , the case was selected as study material. The other two cases used in the chapter on conduct disturbances, namely, that of Ronnie Trenton and Dennis Green, were cases discussed in the class given by Dr. Lindenfeld entitled 'Behaviour Problems of Chi ldren' , in the year 1951. The presentation of these cases in this study is based on the interpretation given by Dr. Lindenfeld in the course of class discussion. The i l lus t ra t ion of a chi ld with a habit disorder i s provided by the case history of Jennie Morton. This s i t -uation also supplies an opportunity to emphasize the fact that a chi ld cannot be fu l ly helped when the environment which contributed to the disorder remains stationary. The other two cases used in this chapter are further examples of - 2U, -the part therapy plays in helping children whose disturb-ances stem from early years. The child with neurotic tra i t s is i l lustrated by the case of Teddy Lawson whose d i f f i cu l t i e s started at an early preoedipal l eve l , where most of this type of disturb-ance originates. The case of Carol Peters, whose emotional relationships were' of such a superficial variety, was used to bring out the interrelationship between therapy and good casework with parents. Although the therapy in this case was of a short term variety, i t was possible, through the excellent casework carried on with Mrs. Peters, to effect a much happier existence for Carol. The neurotic ties which bound her to a rejecting mother were gradually loosened as the mother was given a strong supportive relationship. The third case described in this chapter was an-other case which was discussed in Dr. Lindenfeld's class at the University. This case was chosen as an i l lus t ra t ion of inadequate placements, made without sufficient understanding of the chi ld ' s needs, the result being that her personality may be irrevocably damaged. In addition, this case repres-ents a tremendous challenge to therapy and also shows the long time and labour involved in working with such a chi ld in the play therapy medium. Summarizing, the method of choosing material in this study is one which permitted f l e x i b i l i t y in selecting cases so that varying degrees in treatment might be i l l u s t -rated, while at the same time the necessary complements of - 25 -good casework and placement s k i l l could be exemplified. Practical Issues involved in Play Therapy The opening chapter in this study was concerned with the actual techniques used in play therapy which i n -cluded a description of the personal qualities of the ther-apist , and an explanation of the reasons that the medium of play was particularly suitable to the young ch i ld . The conclusion was that in this specialized setting, which pro-vides for the child his natural means of expression, the framework was ini t iated for expression of innermost fee l-ings. If the chi ld is to express himself by play, there i s , however, a very practical issue involved; namely, that adequate play materials be provided to offer the outlet. Therefore, in the play room a great variety of toys are essential . Such toys as guns, hammers, and pounding boards, are provided in the Childrens Aid Society playroom to pro-vide the aggressive child with a means for expressing his hostile feelings. Oh the other hand, the repressed child may be gently urged towards unleashing some of his res t r ic t -ed feelings through the use of this type of toy. Finger paints are provided so that children who have d i f f i cu l t i e s which are residues of urethral and anal phases, may gradually express their desire to so i l and in addition, bring out anxieties which may be symbolized by - 26 -the choice of particular colors. To be noted in the sym-bolism of colors i s the fact that the significance of such choices must be considered in relat ion to the individual c h i l d , his mood at the moment, as well as his whole back-ground of personality. A variety of plasticine and clay are placed in the playroom so that the children may model or carve such objects as they want. At the same time, these materials have value in work with children showing anal tendencies, as the consis-tency of the materials w i l l , in a l l probability, revive ear-l i e r memories. Dolls of a l l shapes and sizes are part of the equip-ment. These dolls are often used to act out family relat ion-ships, confusions in the sexual area, and through playing with the baby dolls the children many times express their own unsatisfied infantile needs. The do l l that wets when water is placed in i t s mouth provides the chi ld with the opport-unity to act out his earl ier emotions in the oral and anal-phases of development. Games of many kinds are a part of the playroom equipment. Competitive games allow the chi ld to learn the meaning of a relationship where people have the same goal. The therapist can guage the strengths and weaknesses of a ch i ld ' s reactions in a competitive situation. Constructive toys such as building materials, saws and mechano sets, allow- for the building of ego when other toys such as the pounding board have been used destructively. The measurement of the chi ld ' s personality can be fac i l i ta ted - 27 -by his manner of using this type of toy. Additionally, a chi ld who is unsure of his own sex, may be encouraged tow-ards masculine pursuits. Similarly, the playroom is equipped with cosmet-ics and cooking materials so that the g i r l chi ld may be assisted in identif icat ion with her own sex and, through the use of toys conventionally feminine, become accepting of her own role . The conventionally feminine as well as masculine toys are used interchangeably so that children of both sexes may play out feelings of ambivalence in re-gard to their male or female ro le . Crayons and colouring books are provided for the re t i r ing ch i ld , as well as a l l the children who desire them, so that these materials may be used when the relationship is too threatening to the defences, or when they wish to express themselves in this manner. The Childrens Aid Society playroom is equipped to handle nearly every play requirement that a chi ld may have. However, play materials are expensive, and when an estimation of therapy equipment is to be made, the practical issue of toys, which may be continually broken and replaced, must be considered. The playroom setting must be of a sturdy nature. Furniture gets broken, and walls become defaced, during the course of working with disturbed children. The room must be of a type which allows for a certain amount of destruc-tion and hard wear. - 28 -Another practical consideration in regard to play therapy is the treatment time involved in working with a ch i ld . Ordinarily each case requires one hour weekly. In addition to the hour spent in the play interview, the therapist usually has to count on a half hour after the session, during which time she makes notes on the proceed-ings. It is found that the taking of notes during an inter-view tends to inhibit the chi ld ' s ac t iv i t i e s , for a large part of the process i s dependent on the therapist's part-icipation in the proceedings. Following the time spent in notetaking, the thera-pist must record the interview, the time involved in this recording probably amounting to half an hour. Thus, the total time adds up to approximately two hours for each weekly session, plus the three hour consultation period held once a week with the supervising psychiatrist . It may be noted, however, that such an investment of time is not generally the case where therapists are especially sk i l l ed . Such extremely detailed recording is not used, nor is so much consultation time spent with the psychiat-r i s t . Adequate s k i l l in this type of treatment is acquired through additional training after the normal six year education in social work. Therefore, as a specialized person, the therapist should receive a higher remuneration commensurate with the time involved in training, for few social workers are prepared to invest the time and extra - 29 -study connected with perfecting this specialization. Un-fortunately, due to the newness of the project, and the lack of public awareness in regard to the benefits to be accrued from i t , very few agencies are prepared to engage real spec-i a l i s t s . On the other hand, i t must be pointed out that the lack of adequate f a c i l i t i e s in Canada for training play therapists, makes the whole situation more d i f f i c u l t . The practical issue then, l i e s in the training and hir ing of specialists and in being prepared to pay sufficient salaries for the therapists hired. As an additional means of i l lus t ra t ing the detailed nature of the whole treatment process, the matter of record-ing should be described. Play therapy recording is process recording in the most minute sense of the word, unt i l such time as the therapist is sure of his s k i l l . Then, at this point a briefer form of recording should be possible. The case of Teddy Lawson, the chi ld with deep-seated neurotic t ra i t s , provides an excellent example. The length of each interview is about four typewritten pages, single-spaced. ^There are, to date, some seventy interviews or a total case record of two hundred and eighty pages. In order to evaluate the therapy, i t was necessary to read the two hundred and eighty pages previously mentioned, the chi ld ' s personal f i l e involving a lengthy summary record, and the family f i l e made up of a further ten to twenty pages. There-fore, the reading on a lengthy case may involve over three hundred pages. For the purpose of this study, by way of - 30 -i l l u s t r a t ion , i t was necessary to read several cases of around three hundred pages as well as additional records pertaining to the personal and family f i l e of the chi ld selected. The practical issues in carrying on a play ther-apy project are numerous. In explaining some of the most significant ones, the object is to provide an understand-ing of the problems involved in the process as a whole. - 31 -Chapter III The Child with a Conduct Disorder The case of Tommy Snyder was opened in March, 19*+2, when the child was a year and a half old. A com-plaint had been l a id that Tommy and his four-months-old brother v/ere being neglected by their mother. It was her custom to go out and leave the children for long hours by themselves. Although an investigation was made, no def-inite neglect was established. Three months later , the mother and two children moved to Vancouver Island to be with the father, a sergeant in the army, and the case was closed. It was opened again in December, 19>+5> when i t was revealed that an il legitimate chi ld had been born to the mother, and the parents were now separated. The two boys remained with the father for the next two years, and during this period only a spasmodic contact was maintained with the agency. The records do not indicate what kind of care the children received during this interval . However, although the mother and father l ived together periodical ly, each interval terminated with the mother's decision that she could no longer l ive with her husband. There were also a series of other men in the picture during the two year period. In the f i r s t part of 19^7» both parents had dec-ided that placement for adoption was the only solution for - 32 -the children. But two months later the parents had changed their minds about thi s . They planned on a divorce and Mrs. Snyder intended to ask for custody of the children. Three months la ter , letters of complaint were received, indicating that Mrs. Snyder was neglecting the children. It appeared that she thought the Society would apprehend them i f she neglected them, and for this reason was deliberately try-ing to force the issue. Further information pertaining to this mother indicated that she had been twice named as a con-tact for venereal disease, while a Child Guidance evaluation stated that Mrs. Snyder had a schizoid personality, with definite trends toward becoming a marked schizophrenic. V i s i t s with the family during this time indicated that Tommy seemed more aware of his lack of security than the younger ch i ld . However, the only specific comment made in the records at this time was that he appeared to be starved for affection. No other symptoms were particularly mentioned. Shortly after the children were apprehended in Dec-ember, 19^7? the father demanded their return. At this point i t was suggested that i f the parents could make a home to-gether and show evidence of s tab i l i ty and permanence, the children could be returned to them. Despite this sugges-t ion, i t was during the next two months that Mrs. Snyder made, another unsuccessful attempt to l ive with her husband. At a court hearing, Mr. Snyder's request for a six months adjournment of custody proceedings was granted. Later - 33 -on, in January, 19^8, however, a committal order was made. In February, Mrs. Snyder, who had rejoined her husband again, desired to re-apply for the children. She le f t him again in July, 19*+8, unt i l January, 19^9 > when she returned once more. However, by June, 1950, Mrs. Snyder was l iv ing with another man and said she would sign consent for adoption of the children i f her husband would sign i t f i r s t . The family background has been described so that i t w i l l be possible to understand the d i f f i cu l t i e s Tommy had to contend with in his early background. He was six and a half years old at the time he was taken into the care of the agency, in December, 191+7. Along with his brother, he spent a few weeks in the Receiving Home, unt i l they were both placed in February, 19*+8, in a boarding home. A month later the foster mother complained that Tommy was engaged in sexual ac t iv i t ie s with other children in the neighborhood. A conversation with Tommy disclosed the fact that he had been in the habit of playing with his younger sister and with another older g i r l in the neighbor-hood. It was found that he masturbated continually, and also played with f i r e . When Tommy was examined at the Child Guidance C l i n i c , i t was estimated that he had average intelligence with an I. Q. of 107. He was found to have strong feelings of in fer ior i ty and h o s t i l i t y . His adjustment was poor at home, at school, and in a l l social relationships. The C l in ic personnel recommended that he was urgently in need of - 3h -psychiatric treatment. In the foster home Tommy's behaviour became worse. He screamed when reprimanded, u n t i l he was hysterical ; and masturbated regularly every night. He was ostracized in the neighborhood for his sexual ac t iv i t i e s , and was unable to concentrate at school. During May, 1 9 ^ 8 ? Tommy was moved to the Receiving Home again. At f i r s t he seemed to adjust quite wel l , but he was jealous of a l l the other children in the home and was constantly seeking affection from the adults. It is obvious from the information provided that this chi ld was seriously disturbed. Although the records do not provide detailed indications, the unsettled state of his early l i f e suggests a very emotionally deprived ch i ld . Tommy had had a very d i f f i cu l t start in l i f e and, in order to help him with his problems i t was decided to give him play therapy treatment. Play Therapy Treatment The play interviews with Tommy started on July 3> 19*+8. There were forty-three sessions in a l l , the last one being held on May 7 , 19^9. A restatement of Tommy's symptoms of disturbance w i l l indicate reasons for the direction of treatment i n i t -iated in the play therapy. (1) Strong feelings of infer ior-i ty and h o s t i l i t y . (2) Poor adjustment in a l l social re la-tionships - at home, at school, and outside. (3) Hyster-i c a l screaming tantrums, (h) Extreme sexual ac t iv i t i e s , - 35 -including sex play with other children and excessive mast-urbation on a compulsive l eve l . The basic causes of these symptoms, as diagnosed by the psychiatrist in charge, were: (1) A great disturb-ance in family relationships accompanied by distorted fant-asies. This primary disturbance was i l lustrated by: (a) Hate for the mother figure, and fear of men, as they seemed always, from his experience, to be the ones who got hurt, (b) Due to this fear of men's vulnerabil i ty, a fear of his own male ro le . Women were dangerous and powerful; to survive he had to destroy them. This led to (c) Aggressive sexual exhibitionism, which presented i t s e l f to Tommy as the only way he could 'overcome' women. The f i r s t few play therapy interviews with Tommy were met with great resistance on his part towards the thera-pi s t . At every turn he attempted to control'-the situation. The therapist was completely permissive and rather seductive, but at the same time imposed very slight l imits in the matter of terminating the play room sessions in reasonable time. Tommy's hos t i l i ty was indicated openly in the fourth inter-view: He went to the cupboard and fetched the gun. He f i r s t had me hold out my hand for him to shoot, then went to the far end of the room, ordered me to hold my hands up and shot energetically at my hands and face. I said quite often people fe l t l ike shoot-ing, and wondered i f he could think of any-one else he would l ike to shoot i f he had the chance. - 36 -The therapist's remark when she said that she "wondered i f he could think of anyone else he would i ike to shoot i f he had a chance" offered Tommy a chance to go further in expressing his hos t i l i ty , but did not urge him to do so. Tommy expressed direct curiosity as to why he was coming to the play room. The therapist responded: I began to talk of the fact that children sometimes had a lot of d i f f i cu l t i e s which the grownups did not always understand. For instance, people often had feelings about wanting to shoot people and be mad at them, and to do different things which were called bad. Children might have feelings l ike this , but grownups would always be t e l l ing them that they were bad feelings and want them to be good a l l the time, and this might be very d i f f i cu l t for children. Later on, in the same interview: I then wondered i f he ever thought what he would l ike to do when he grew up to be a man? He announced, "then I wouldn't have to come here, would I? Nobody would have to bring me, would they? I should be able to find my own way". I said I thought he would, and that he would certainly grow up to be a man - a l l boys did - just the same as a l l g i r l s grew up to be women. Here, in this excerpt, are the f i r s t decisive steps of the therapist's part in promoting Tommy's male role . The f i f t h interview showed an instance where Tommy was made aware of himself in relation to other people. Close to him was a very tied up and knotted chain belonging presumably to an unused swing. He suddenly remarked "Its a l l tied up". I agreed that i t was, and said i t - 37 -would probably be d i f f i cu l t to undo, possibly i t would take two people to do i t - there were some things that need-ed two people. I then remarked that sometimes people get tied up inside too. They might feel tangled up just l ike that chain, and perhaps they would need someone else to help them get untied again. Tommy's aggression towards women and his concomitant fear of them had begun imperceptibly to lessen through the ther-apist 's continual acceptance of his hos t i l i ty , without re-ta l ia t ion of any sort. An instance of this is observable in an excerpt from Interview Six. He decided to f i l l the gun with red paint and shot at me. As the damage to my clothes threatened to be considerable, I said I knew he would l ike to shoot me a l l over but that he was only to shoot at my arms or other parts I could easi ly wash. He seemed not at a l l abashed, and no longer appeared to feel afraid of my reactions to his aggression. In the same interview Tommy is again helped to accept the differentiation in the sexes, and encouraged to assume his own male ro le . He used mainly purple, asking " i sn ' t i t a pretty colour", and painted various parts of the d o l l . Then he decided he would take off- i t s diaper. He needed some help with the second pin and then when he had i t off asked me "which the do l l was". I wondered in turn, and he said definite-l y , " I t ' s a g i r l " . I said i t certainly seemed more l ike a g i r l than a boy since i t did not have a boy's l i t t l e penis. Tommy said nothing, but did not seem esp-ec ia l ly disturbed now, and carried on, thickly painting the do l l ' s legs, saying he would paint i t a l l over. Tommy's lack of confidence in himself as a male, and his hos t i l i ty to women is shown clearly in Interview Eight. - 38 -Before he had come upon the money in my purse, Tommy had found my l i p s t i c k , had put a l i t t l e on his l i p s , then hurried-l y wiped i t off and asked suddenly i f I had any scissors. Asked what he wanted them for, he said he would cut my hair . I wond-ered what sort of a cut he would give me, just a l i t t l e b i t , or was he going to cut i t very short? He said emphatically "Very short!" I said " l ike a boy?", and he nodded and said "yes". I wondered i f he l iked boys better than ladies and he again nodded and looked down. I said that perhaps some-times children didn't l ike ladies so much i f they didn't always do the things they wanted. Children, for instance, quite often fe l t angry with their mothers when they did not give them the things they asked for , and perhaps they might feel that ladies weren't so nice. With repeated experiences of this kind, Tommy began to accept the therapist. Through acceptance of her, moreover, he began to move towards l ik ing mother people, as Interview Nine showed. For example, He said goodbye quite normally, and a l i t t l e later got the worker who was look-ing after him to bring him back into the room where I was clearing up. He pretended to be a sack of coal and wanted the worker to ask me i f I wanted a sack of coal. I smiled, and wondered out loud i f the sack of coal wanted to be delivered here. We a l l smiled, and the worker said he thought i t was time for them to go. In this instance, the therapist both accepts Tommy's asking i f she wants him, and is permissive and non-aggressive in saying she wants 'the sack of coa l ' , i f i t wants to come. Tommy's urgent need to be the dominant male s t i l l remained, and i t is aptly demonstrated in Interview Ten. The therapist's calm acceptance of his demonstration is to be not ed. - 39 -At the foot of the stairs he said, "Where1s the bathroom? I know where i t i s . Take these, and wait for me there" -pointing towards the top of the stairs . I assured him I would wait. As he came out of the door I heard him say "It ' s heavy, i sn ' t i t ? " , and when he came into view saw that he was showing me his penis with a half triumphant, half shy smile. I smiled in a friendly way and said "Yes, i t ' s a nice big one". He put i t back with a l i t t l e laugh and then rushed up the stairs in a domineering sort of way, ordering me to give him the lacrosse st ick and to come outside, adding "You have to do what I say". I wondered i f he fe l t that I must do what he told me because he had a big strong penis, and he said "yes". I said a moment later that I thought people could be strong in other ways, too - they could be strong in their arms or legs or other parts of them. Tommy's desire to be a baby and also his desire to possess the mother person, which represent respectively the wish to regress to the infant state and the start of oedipal development, are shown clearly in Interview Eleven. He then said he wanted to play, that he was my baby and wanted to come and s i t on my lap and see my breasts. I said I would l ike to play that he was my baby, but I was afraid I could not show my breasts so we would just pretend that I was doing , so. However, he looked very put out and would not come round from the other side-of the table. He became very loud and domineering, ordering me to take every-thing out of the cupboard and bring i t to him. A moment la ter , when I had told him I could not show him my breasts because my husband would not l ike me to do this , ; Tommy announced that he was my husband -he was going to marry me. Part of the therapy with Tommy related to his i n -tense desire for money, which to him symbolized both power and love. Small amounts of money were given to him from time 5 - i+o -to time in the play room, but each time an effort was made towards having him take less than was available. It was pointed out on each occasion that though the therapist might not be able to give him a l l the money he wanted, i t was not because she did not love him. His resistance to this idea was demonstrated in Interview Thirteen, after the therapist had refused to give him the money he wanted. After playing with the water a few moments and p i l ing pots inside the big jar unt i l i t over-flowed, Tommy poured as much water as he could into the card-board box which holds the paint pot. He drew in breaths of joy as the water splashed messily around, and then said that he was flooding my house. I ex-pressed interest, and wondered what would happen to me in that case? He replied that I would be k i l l e d . I smiled and said we often did feel for a time that we would l ike to k i l l someone off when they did not give us what we were want-ing, but usually, after a while, we found a lot of things that were nice about them and we fe l t dif ferently. In the next interview an excerpt is given which i l lustrates both an interest in the excretory functions, and a start towards being able to part with money and share with others. I brought him the wetting do l l and he received i t with pleasure, saying this was something he always l iked - the dol l which drank and then wetted (demonstrating the acts with gestures upon the d o l l ) . He wanted me to fetch the feeding bottle, and then became interested in my handbag. There were just four cents in i t this time and he took them out, almost immed-iately handing me two of the cents, saying "Here are two for you and I have two". I thanked him and said I thought this was nice that we were sharing equally. - hi -A conversation in this same interview, about babies, enabled the therapist to express understanding of early unsatisfied needs in Tommy. I suggested that babies would feel "very awful inside" i f their mothers did not give them the things that they were wanting, and that some mothers were not very good at th i s . I said I knew some children when they were l i t t l e had mothers who did not know how to give them what they were needing, and that often they went on feeling badly when they were older. They fe l t there were a lot of things they wanted and that people would not give them to them. The therapist has an opportunity, while Tommy is modelling a male figure out of plasticine to bring out some of his sexual fantasies connected with scenes he actually witnessed in his parental home. He rol led quite an enormous sausage of plast icine, which he f i t ted onto the plasticine male figure he had made. I wondered i f this would be very comfort-able for the man since i t would be d i f f -i cu l t for him to wear clothes and would probably get in his way a l o t . Tommy assured me that the man would be quite a l l right as he would keep i t bent up. (He demonstrated with the figure). He then put the figure on the floor to stand up and said there was a lady coming, and she would say "Whee-eel" (Talking as i f she were thr i l l ed and amazed). I wondered i f ladies l iked men to have very big penises, and he said they did. They would say "Hubba-hubba ding-ding-because their husbands had one, "and my mother said that when she saw i t , when he was going to the bathroom in his mouth". The therapist followed up this conversation with a simple description of how babies were conceived and born, and how God had made men and women this way so that they could have children in the sexual way. After this discussion - h2 -she followed up by saying that men seemed to be able to make babies just as well with small penises, as with big ones. The play therapy process is v iv id ly i l lustrated as the above excerpt is examined. F i r s t of a l l there was the drawing out of Tommy's fantasy around the plasticine penis, and the part i t played in his imagination. When the fantasy was brought to verbal form, the therapist was able to offer rea l i s t i c interpretation as to the nature of the sexual act, and the fact that male power was not dependent on the size of the penis. This interview represented a turning point in getting closer to the real conflicts behind Tommy's prob-lems. The talk and play about babies and the discussion of sex were used to dispel the fantasies. Tommy's talk about the penis, as though i t were less an instrument of aggression, and more a means of obtaining applause and f lattery (e. g. "hubba-hubba" e tc . ) , marked a small step forward in his development - the beginning of a concept of love and pos-i t ive selfhood. Interview Nineteen contains shows further evidence of Tommy's need to dominate; however, the therapist permits him to order her around, but at the same time makes him con-t inual ly aware of what he is doing and why. While he was being 'boss', I made him aware of i t continuously, and press-ed inquiries about 'bosses'. I wondered i f people sometimes f e l t that i t would be safer to be a big strong boss, because then you would not have to do what others - ^3 -told you or be afraid of them. You would be in command. I said I thought children might feel l ike that i f they met rather a lot of people who were un-kind to them. They might feel that they must become big and strong to be safe. I said I knew there were some bad people about, though not very many, and some who were unkind to children. Some children did meet these people and perhaps they might feel they wanted to be big strong bosses because of this . Tommy's need to be the only ch i ld , and his fee l -ing about s ibl ings, was i l lustrated in Interview Twenty-One. I wondered again why he was break-ing so many things today, and said perhaps he did not want there to be things for others to play with. He immediately nodded his head and said "That's r ight " . I said I thought he did not l ike me having other children besides him. He again said "That's r ight " . He did not look un-happy or anxious, but remarkably aware of himself. I said I knew how hard this was for him and I thought a lot of people f e l t that way. They would l ike to be the only one to be loved, but rea l ly no one was able to have thi s . In most families there were more than one child and mother did love other people too. However, we could find people could l ike us a l o t , even though they did things for others also. I added that I l iked him very much indeed. Tommy's preoccupation with sexual matters is i l l -ustrated in Interview Twenty-Two, during a conversation which ensued when he was playing with the wetting d o l l . The therapist's rea l i s t i c interpretations and warm understanding of his feelings helped him to express his curiosity about sex. Her remark that her husband would not wish other people to see her body was directed towards helping Tommy give up his drive towards sexual possession of the mother person. - hh -I fe l t moved to remark that I knew some children, who, when they saw how ladies and g ir l s were made down below, and found that they did not have a penis, thought perhaps they had had an accident. (I f e l t that I had h i t the right spot with this remark). I went on to say that of course this was not so, that a l l g i r l s and ladies were made this way and that men had the pen-is to put in the women's holes. Tommy nodded and said "I know". Then he said, " I ' l l t e l l you what, we ' l l go to the to i l e t - when you want to go, that is - and I ' l l come and look down there" (pointing to his own gen-i t a l s ) . I said he meant he would l ike to look at how I was made there, and he nodded. I said that this was l ike the time he had wanted to look at my breasts. I knew how he fe l t about i t actually, but supposing I drew a very big picture just l ike I would look? I also put in the remark about my hus-band not wishing other people to see my body, just as I had in that earl ier interview. In the next interview, Tommy's need to dominate is shown as lessening. He is beginning to comprehend a situation where one does not need to be 'boss' a l l the time. He called me 'Servants' and told me to fetch him a small box. He ex-plained spontaneously that 'Servants' meant I had to do everything he told me. I noted this in the usual way, and then wondered i f I would c a l l him 'Master* in this case? He understood this at once and said "Yes", but a few moments later said sometimes he would c a l l me 'Master' too. I said that we would take turns being the one who ordered, and that i t was l ike being boss. He agreed and. I f e l t i t was quite plain to him. The fact that Tommy s t i l l retains many of the feelings common to children during the to i le t training period, - >+5 -i s i l lustrated in Interview Twenty-Five, when he and the therapist are in the bathroom. At this point Tommy ex-pressed an urgent desire to defecate on the floor rather than in the t o i l e t . He then suddenly said could he do i t 'on the floor? Just this once? He seemed most anxious for me to agree and pleaded again. I thought for a moment and said "What about getting i t off the floor again?" He said he could do that eas i ly , so I agreed. He thereupon pro-ceeded to move his bowels on the floor with quite a lot of concentration and an appearance of great satisfaction. The confidence which Tommy now feels in the ther-apist as a mother person, as well as his unconscious desire to be a baby, is shown in Interview Twenty-Six. The ther-apist made him aware of his feelings, while at the same time accepting them. Right at the beginning of the i n -terview, while he was s t i l l wandering around.examining the changes in the room, Tommy went to the half-open drawer into which he climbed, asking me to help him. I agreed, and he had me shut i t up with him curled up inside, and then immediately opened again, himself l i f t e d out at the same time. He seemed to take pleasure in having me l i f t him. I made him aware and commented that he was hav-ing himself tucked away in the drawer, shut up inside, and I wondered i f he fe l t that was fun to do? He did not reply. Interview Thirty contains further i l lustrat ions of Tommy's need to be a baby. Early in the interview, when he was preparing a drink for me, he asked i f I would l ike some warm milk. I said that milk was something that babies needed a l o t , and as I said this , Tommy began - U n -making a funny l i t t l e wailing noise, and said in an aside "What is i t , baby?" He did not answer my query when I asked him about this , so I said babies needed milk very much when they were t iny, and sometimes i f their mothers did not give them enough they would feel hungry and unhappy a l l the time. Sometimes when this happened a lot to a t iny baby, they got into the way of feeling as i f they were hungry for something a l l the time, even when they grew bigger. They might rea l ly have plenty to eat, but somehow right inside they would feel as though there were something they wanted a l l the time. Really what they fe l t came because they remembered, way down inside, the hungry feeling they had when they were t iny. A t iny baby could not get what i t needed for i t s e l f ; i t could only cry and wait for i t s mother. As we grew older, however, we were able to get things for ourselves and to ask people for what we needed. At this point in the therapy, i t was decided that Tommy had improved suff iciently to warrant being moved to a new foster home. He was fearful and did not want to talk about the move. The therapist, in reassuring Tommy, again made use of media chosen by the ch i ld . I said I wondered what he fe l t about going to a new home, and what i t might be l i k e . He looked agitated and told me not to talk - we should play something. He thrust the harp into my hands, and said "You play - play something you know, not what I know, something you used to play when you were a l i t t l e baby". He curled up close beside me on the table where I was s i t t ing . He had an air of great need, and I found myself searching f rant ica l ly for the right inspiration. I strummed the harp gently for a moment or two, and then I started quietly -"Once upon a time - that's the way a l l stories begin, i sn ' t i t? Once upon a time there was a l i t t l e boy he was not a l -ways very happy, in fact he was often very - h7 -unhappy and then by and by he came to a place where he was happy, and he found friends who were nice to him and then the time came when he had to go somewhere new again, and he was very frightened because he thought i f he went anywhere different i t would be l ike i t was before and he would be very unhappy but this was not so because he would be happy in new places too there were other people who would be friends and he would s t i l l see some of the friends he knew now and where-ever he went i t would never be as i t was before and he himself was older and understood more things and would know better how to be happy he would never again be as unhappy as when he was l i t t l e . " I strummed as I said th i s , giving as closely as possible the feeling of a song narrative, so that my hesitation as I went along f i t ted quite wel l , I think, into the general atmosphere. As I searched for-further words, Tommy took the instru-ment from me and said "Very good - that was very good." The therapist constantly emphasizes Tommy's fee l -ings about people, separating his angry reactions from his affectional reactions, while accepting both. Towards the end of the session, I patted Tommy on the shoulder in a friendly way. He said "Don't do that I" I said he didn't want me to touch him and wond-ered why - did he think i t was ' s issy' or something? He said "Yes" - he did think i t was ' s i s sy ' . I said i t was a thing grownups did to each other when they were friends, however, and that I would do i t to a grownup whom I l iked . Tommy said "I know that, but I don't l ike i t " . I thought a moment, and then said perhaps i t might give him a funny feeling? He said "That's r ight , i t makes me feel funny inside - I don't l ike i t " . I said quietly that I thought being friends with people could give you - 1+8 -a funny feel ing, just as being angry with people could also do - but they v/ere different sorts of funny feel ing. Throughout the therapy, Tommy plays out l i t t l e stories of his own improvisation. In Interview Thirty-Four, for example, Tommy te l l s a story about a group of horses in a f i e l d , and the therapist uses this to help him understand the process of growing up. One l i t t l e horse (a foal) ranaround whinnying for someone to carry him on their back as he could not swim in the deep water alone. After trying several of the horses for a good size, Tommy eventually got the l i t t l e one fixed on-to the back of a s l ight ly large horse, arid he was le f t there during the game. I commented that the l i t t l e one fe l t i t needed help, because i t was too small to swim by i t s e l f , and that the bigger horse was carrying i t . So l i t t l e ones did get helped in different ways by stronger ones, and later they would be able to manage for themselves. The therapist, in Interview Thirty-Six commences a deeper interpretation to Tommy. By now, through the ther-apy, he has accepted the therapist as a loving mother figure. A great deal of his hos t i l i ty has disappeared. The mother is no longer a hostile person, but rather, a giving person. It is necessary now to 'wean' Tommy, so that he is able to differentiate between the amount of love a chi ld needs v/hen i t is so helpless, and the compensating strengths that a person acquires through growth. The therapist is paving the way for the fact that, from now on, she w i l l not be giving Tommy as many l i t t l e gifts of money, as had been her custom. Sometimes when people had been un-happy when they were l i t t l e , they had a - h9 -feeling inside that a real Mum would be someone who gave them a l l they wanted and would never say no, and they thought perhaps somewhere they could meet one l ike that. I said real ly nobody was l ike that - even the nicest Mums could not give a l l the time - that was the way people were. And I said everyone I had ever known got mad at their Mums sometimes because they did not give them just what they wanted, or wanted them to do things they didn't l i k e . This was quite natural, and;~people got along together just the same. As Tommy pocketted his twenty cents, I remarked that i t was a lot and I was giving i t to him today, but that I should not always be giving him some-thing from now on. I,said we were friends and I did not give my friends presents every time we met. - I repeated that I had been glad to give things to him because I l iked him very much and he seemed to need them. Now, however, he was growing older and he would be able to understand why he was wanting something a l l the time. Tommy's need to express himself in an aggressive fashion is interpreted by the therapist quite direct ly now. I started to speak about his feeling that he wanted to be very strong when he was feeling unhappy inside about something. He said "I'm strong too", and proceeded to demonstrate i t by climbing up the shelves. I said I thought he was quite strong - just as strong'as any boy of his age - but that I didn't think i t mattered so much either way. I said I did not think people l iked others chiefly because they were big or strong, but for other things - their fr iendliness , and the way they l iked to be together, and do and share things. I said "I l ike you very much, Tommy, and I should not l ike you more i f you were a lo t stronger or bigger".: A l i t t l e later when he was walking on topi of the cupboard, I wondered i f he had been thinking when • he 'peed' in the do l l ' s mouth, of the way in which men put their penises in women's holes to make babies? I said of course - 5o -i t was the do l l ' s mouth he had used but they were both holes, and I wond-ered i f he had been thinking inside that he wanted to be a big man. Tommy did not say anything and I went on with further remarks about i t being a l l right to be his own age and that I did not think he needed to be so much bigger. The therapist has been preparing Tommy for the fact that she is leaving. In Interview Forty-Two, she tr ies to express the idea that, although she Is leaving, she does not want him to feel rejected. Then he went back to the drawers and I had a chance to remark that I wanted him to know that I did not want to go away from him at a l l - that I l iked him very much and enjoyed coming to play with him, but that as he knew, I had a husband, and he had got a job in a distant place -so we had to move there. Tommy nodded, and then when I said again that I was sorry not to be able to see him anymore, he looked up, and said in a very friendly way "And I'm sorry not to be seeing you anymore." His tone was very sincere and mature. In the last interview, that is Interview Forty-Three, Tommy seizes his f ina l opportunity to be a baby. Once established in the shade, Tommy settled down to a comfortable baby play. He adopted a very babyish voice with baby words and began by cal l ing "Mummy, - d i t ty , d i t ty " . He' gestured to the water and then asked in an ordinary tone i f I knew what he meant? I said I thought he was the baby asking for the ' t i t t y ' for the feeding bottle . He said that was r ight , so I prep-ared at once to fetch the l i t t l e bottles from indoors. He was very pleased that I had everything f i l l e d and ready. I said I had them a l l f i l l e d for the baby - mummy would want to have a feed for the baby when he was hungry. Tommy began sucking hung-r i l y and turned out to be a voracious baby, quickly getting through one bottle and wanting more and more. I commented on how - 51 -hungry the baby was and how the mother was seeing that i t got as much as i t wanted to eat. At different places I threw in remarks about how almost a l l mothers were kind and loving l ike this and gave their babies what they needed. Sometimes they might be a b i t cross or stop the babies doing something, but mostly they wanted to do a lot for them and make them happy and comfortable. Tommy played with some of the other toys while he lay in a blanket, smiling happ-i l y and talking in baby language. After this phase of expressing himself as a baby was over, Tommy made a last effort to act out his sexual fantasies. . I asked i f he would t e l l me about this thing he wanted to do, so that I would know whether i t was something we could do outside here? Tommy accepted this suggestion and proceeded to play out an intercourse scene with the two dol l s . He repeated the scene several times - the man do l l was placed on top once, but mostly i t was the woman d o l l . I made just a few factual observations at f i r s t , and then by and by I said I thought this was something grown-up men and women did together - i t was something Tommy had seen fathers and mothers do. He said "yes11 outright to this , and then began to look a l i t t l e self-conscious. I said in a very matter of fact and friendly way that people who were married and l ived together did play games of this sort quite often -.they did act just as he had shown me with the dol l s . This had to do with their making babies and also because they loved each other. In this last interview, the therapist makes a last interpretation to Tommy. I said that we had done many things together over a long time and that I knew sometimes he got frightened, and fe l t that people were being mean to him or did not understand, and i t was when he got frightened - 52 -t h a t he acted i n ways which people outside d i d not approve of. I s a i d that i t would be b e t t e r i f he could t e l l some of h i s f r i e n d s when he f e l t unhappy, and ask them to help him i n some way, and that i f he could do that. I was sure he would f i n d they d i d some-t h i n g f o r him. Tommy was f i n a l l y moved, August, 19^9» to a f o s t e r home which provided an understanding mother and a p a r t i c u l -a r l y sympathetic f a t h e r , who spent considerable time w i t h him. Here, Tommy's sex play has ceased, and he seems happy and secure i n the home. The f o s t e r parents are anxious to adopt Tommy, but to t h i s date have not been able to contact h i s f a t h e r , whose consent i s necessary. Had t h i s problem been worked through e a r l i e r w i t h the parents, Tommy's fu t u r e would be more secure. However, Tommy i s now a f a i r l y w e l l adjusted eleven-year-old boy, doing w e l l i n s c h o o l , and making c o n s i d -erable s t r i d e s forward i n h i s adjustment w i t h other c h i l d r e n . A Review of the Treatment Process i n t h i s Case I t i s p o s s i b l e t o observe i n t h i s therapy s i t u a t i o n , both the general technique, which i s used w i t h a l l c h i l d r e n , and the p a r t i c u l a r technique used to help Tommy w i t h h i s spec-i f i c problems. The t h e r a p i s t , during the whole treatment per-i o d , b u i l d s up h i s strengths and seeks to guide him towards an acceptance of him s e l f and outside r e l a t i o n s h i p s . The f i r s t few in t e r v i e w s were concerned w i t h d e v e l -oping the r e l a t i o n s h i p . Through being permissive to the c h i l d , yet s e t t i n g such l i m i t s as were necessary to keep the p l a y w i t h i n bounds, Tommy was e v e n t u a l l y able t o accept the t h e r a p i s t - 53 -as a mother person. Remembering that one of Tommy's basic d i f f i cu l t i e s was hate for mother figures, i t is possible r to see that once the relationship has been established, the therapist has set the stage for future healthy devel-opment. Tommy's second disturbance being in the realm of his sexual fantasies, the ameliorating treatment is shown quite c lear ly . Again and again, Tommy plays out his i n -tense preoccupations with sex. On each occasion, the ther-apist makes him aware of what he is feeling and explains to him in simple terms the exact nature of his sexual fantasies. Through continual acceptance of his display of his penis, she diminishes i t s importance, constantly stressing the fact that he can gain recognition in other ways. Play therapy rules include the general tenet that a chi ld is not allowed to keep any of the objects he plays with in the play room. It must be remembered, however, that the method is not an inflexible one, and may be varied with the particular chi ld concerned. Tommy's problems were deep ones, and in order to develop a mother relationship i t was necessary to vary the rule in his case, and allow him to take some toys from the play room to provide him with a carry-over to outside relationships. With another c h i l d , not so emotion-a l l y deprived, the rule of not retaining play room art ic les would have been appropriate. In Tommy's case, however, the early relationships had been so unsatisfactory that a certain amount of seduction, through gif ts , was necessary. In his case, too, he was permitted to regress to an early level of development - to a phase where he was - 9+ -completely the baby, in an effort to satisfy the i n i t i a l , deeplyrfelt insecurity feelings. The therapist, however, made him completely aware of what he was doing and, while giving him satisfaction on that l eve l , emphasized his growth and lessening need for such pleasures. At the present time, Tommy is by no means a comp-le te ly normal ch i ld . He s t i l l has d i f f i cu l t i e s in mixing and playing with other children. On the other hand, his sexual preoccupation has decreased in intensity. The sex play and masturbation has discontinued. Tommy is now enter-ing into puberty and into a phase when the sexual instincts are heightened. He has been given a base of understanding of sex which w i l l prove invaluable to him. At the same time, he has been given an awareness of his own feelings, and of his relationship to the world about him, which w i l l act as s tabi l iz ing agents in the awakened turmoil of puberty. The whole treatment process with Tommy approximates Dr. Frederick Al len ' s method of helping the child to help him-self . The relationship, as used in this case, provided the medium for making conscious, Tommy's unconscious trends and drives, for recreating the past, and generally releasing the anxiety bound up with his earl ier experiences. Such a chi ld required highly sk i l led treatment. The therapist who conducted the treatment given to Tommy was a. woman who had studied the process intensively in England. The process as shown in this case is of very high calibre -at a level towards which subsequent therapy has been aimed, and for this reason i t has been described in considerable de ta i l . - 55 -Two Cases which may benefit by Play Therapy Many children are deprived in their early r e l -ationships, just as Tommy was deprived. What happens to them? Ronnie Trenton is another l i t t l e boy who needs help very badly, but for whom therapy has only just been in i t i a ted . His example is i l lus t ra t ive because i t shows the great amount of work i t w i l l take to help him. Ronnie was completely neglected during his early years. He was lef t alone for long hours, and both his father and mother were very s t r ic t in his early training. Now twelve years of age, he is eneuretic, masturbates, and engages in sex play.with his brother and s ister , as well as other children in the neighborhood. In addition, he l i e s , steals, and is cruel to those smaller or weaker than himself. Physically, Ronnie is an attractive boy, with an a b i l i t y to 'win' people; but once he has secured what he wants, he has no particular feeling for them. There is no doubt that Ronnie is a chi ld whose personality is damaged. Having had no early experience of warmth and love, now as he grows up, he does not rea l ly know the meaning of affec-t ion. The child who has not been "given to" has no stand-ard of what love means. How can he be expected to give, when he has never received? Perhaps the therapy relationship may be able to reverse the trend his development is taking, but i t is quite possible that i t is too late . The super-ego structure i s almost completely absent. Without treatment, this boy - 56 -w i l l probably join the ranks of the psychopathic criminals, to be a burden on society for the rest of his l i f e . With treatment, there is a poss ib i l i ty that he w i l l improve. It is because, in Ronnie's case, the consultant psychiatrist thinks there is a ' f i f t y - f i f t y ' chance, that treatment is being in i t i a ted . There are, however, many children with personality deficiencies similar to Ronnie's, who are not receiving treatment. The f a c i l i t i e s for treatment are insufficient, and the expense and time involved render extensive therapy an impossibil ity. An observation centre would be helpful in these cases so that a reasonably accurate diagnosis might be made. Secondly, the need is great for a treatment centre for these children so that they may be given the opportunity to become useful c i t izens , rather than deprived creatures who are prey to every whim of uncontrollable impulse. Dennis Green, who came into the care of the Chi ld-rens Aid Society three years ago, is another example. Now ten years old, Dennis has been running away since he was a very small boy. He l i e s consistently about his running away, and begs from strangers. Mrs. Green, Dennis' mother, does not care about him. She married his father because Dennis way on the way, and has always resented the boy's place in her l i f e . Mrs. Green is a person who was very closely tied to her mother. She has considerable unconscious feelings about being a woman and also about the fact that, through motherhood, she was forced into a female role . She has a l -ways preferred to work and finds that Dennis hampers her in - 57 -earning her l i v i n g . When Dennis does run home to her, Mrs. Green is quite indifferent as to his welfare, and w i l l not make the slightest effort to look after him. The ch i ld , however, has not given up his mother. She represents his f i r s t and only-strong, i f negative, relationship, and he goes back to her time and again, seeking what he has never real ly had. The records indicate that Mrs. Green was extreme-l y vague about Dennis1 early development. It appears that her mother cared for Dennis at times during his f i r s t three years, and after her death he attended a foster-day-care home irregular ly . For the past two years, he has been in a foster home which has not provided him with the emotional warmth he needs. It was January, 1951 > when the foster family demand-ed his removal. The stated reasons were that the Childrens Aid Society had fai led to do anything for him - and \^ere, in effect, neglecting him. Dennis was moved back to the Receiving Home. He asked to go to a home where he had previously spent a short time. During his stay in this home, Dennis had trouble with a new school principal, who was determined to reform him in a few weeks. Shortly after this d i f f i cu l ty , the chi ld re-fused to return to school and ran away downtown instead, riding the elevators in the stores by the hour. When Dennis was returned to the Receiving Home again, he showed overt anger. He struck back at other children and the Receiving Home staff, as well as his worker. He said no one l iked him, and he l iked only his mother. - 58 -Dennis1 mother, however, thinks differently. As far as she is concerned, he is the cause of much of her un-happiness. She desires freedom as she thinks a man has freedom. Her anger is transmitted to her male ch i ld , who is a representative of the sex she believes is more privileged. Dennis1 father, a re lat ively stable person, could help in this case. Although he is l i v ing in a common-law relationship at present, he w i l l marry as soon as his wife w i l l give him a divorce. The danger i s , however, that Dennis might try to find both a father and mother person in Mr. Green. He could move into homosexuality, i f the father regarded him as a chi ld too long, and i t is probable, as wel l , that he would reject his stepmother unless he was given a great deal of help in this connection. Dennis has an intense, emotional involvement with his mother, and wants a satisfying mother person who meets his every need. Thus, i t is believed that his development is arrested in the oral phase. Although he represses his hos t i l i ty to his mother, feeling safer thereby, he displaces his hostile feelings onto his worker and other people. His needs are acted out impulsively; and he is not able to "take" a frustrating situation. Instinctively knowing that he meant very l i t t l e to his mother, he feels very infer ior , re-jected, and poxtferless. People, in his l i f e have meaning only in regard to his feelings for his mother, so that he has l i t t l e real relationship with anyone. Prognosis, even on treatment, would be guarded, for such a youngster would l i k e l y use people, be ant i-socia l , and - 59 -continue to operate on the pleasure principle . Treatment, in his case, would probably have to last two or three years, and in addition, there is the problem of his care during this period unless a treatment centre were available. Dennis has been in the care of the Society for nearly three years. Had i t been possible to institute ther-apy for him at an earl ier date, much of the i n i t i a l work might have been now complete. The play therapy project, however, was barely ini t ia ted in 19^ +8, and scarcity of fac-i l i t i e s for carrying out the work are rea l i s t i c l imits in the situation. Three years could have made a great di f fer-ence in Dennis* future, had there been an observation centre to provide the means for a diagnosis in his case at the time he was taken into care. A more careful selection of foster homes suited to his particular needs could have been made, and casework help, though less intensive than therapy, given to him on a 'play-interviewing' basis. Perhaps Dennis w i l l now receive treatment, but there may not be room for him. The project is a limited one, and sk i l led therapists are scarce. Expert casework is required also, so that Dennis' mother may be helped to understand his needs. Actually, such an understanding may be impossible for Mrs. Green. Emotionally, she is a chi ld herself. xhe record provides ample evidence of her particular d i f f i cu l t i e s . A ski l led caseworker, with sufficient time at her disposal, might have contributed greatly towards her development, e i th-er in assuming her maternal role , or in helping to cut the neurotic ties with which she binds Dennis to her. The rec-ords do not indicate that a sufficient attempt has been made. - 60 -P l a y therapy i s not c a r r i e d on i n a vacuum. Work w i t h parents i s the supportive medium. Before play therapy, however, i s used as a treatment p l a n , i t i s necessary to r e -member the in v a l u a b l e nature of good casework w i t h c h i l d r e n and parents. The d i f f i c u l t y w i t h problem c h i l d r e n , i t i s s a i d , o f t e n 'originates i n pa r e n t a l disturbances. Treatment may not be necessary where adequate casework i s done. Thus, where treatment f a c i l i t i e s are l i m i t e d , as i n the p r o j e c t being s t u d i e d , the importance of casework cannot be too s t r o n g l y emphasized. Although casework w i t h parents, f o s t e r parents, and adoptive parents, may include work around personal prob-lems when r e q u i r e d , the major d i f f e r e n c e i n de a l i n g w i t h these three groups l i e s i n the p a r e n t s ' f e e l i n g s of g u i l t . The r e a l f a t h e r and mother may f e e l that they are the cause of the c h i l d ' s problem. However, t h i s p o i n t i s only one example of things that must be considered i n a casework r e -l a t i o n s h i p . There are many other concepts, an understanding of which i s included i n the p a r t i c u l a r s k i l l s so necessary f o r workers d e a l i n g w i t h c h i l d placement and p a r e n t a l d i f f -i c u l t i e s . For in s t a n c e , placement of a c h i l d w i t h Dennis Green's problems, could not p o s s i b l y be s u c c e s s f u l unless the worker formed a strong p o s i t i v e "bridge" r e l a t i o n s h i p w i t h him, and prepared a c a r e f u l l y s e l e c t e d f o s t e r f a m i l y t o accept h i s r e g r e s s i o n , while at the same time g i v i n g him s u s t a i n i n g a f f e c t i o n without expecting a r e t u r n f o r some time. Such a pre p a r a t i o n i s an e s s e n t i a l i n a l l good case-work r e l a t e d t o the p a r t i c u l a r f i e l d of c h i l d placement. - 61 -Chapter IV The Child with a Habit Disorder Jennie Morton was born December 15, 1938, and admitted to the care of the Childrens Aid Society on non-ward basis December, 1939. On the surface this l i t t l e g i r l seemed to have received a l l of the care requisite for norm-a l development, yet symptoms formed which are commonly associated with a habit disorder, ^he background of this ch i ld , including that of her mother and foster mother, w i l l be examined so that an estimate may be made of the factors leading up to her problem. Dorothy Morton, Jennie's mother, was f i r s t inter-viewed by a worker of the Childrens Aid Society on the occasion that she was brought to the United Church Home by her father, for medical care and confinement. The story she told was that she had always l ived with her parents who ran a rooming house in a small c i ty near Vancouver. When the worker asked her for information, she named a putative father; but she f i n a l l y admitted that she had been having intercourse with her own father and brother over a period of years. Although i t was impossible to corroborate the evidence, there seemed l i t t l e doubt that Jennie was the result of an incestuous contact between her mother and grandfather. Four weeks after her b i r th , Jennie's mother dropped out of the picture, and was not heard of unt i l twelve years - 62 -l a ter , when an attempt was made to contact her so that permanent plans might be made for Jennie in the form of wardship by the Childrens Aid Society. It was found that in the intervening years, the mother had married, made a new l i f e for herself and what seemed to be an adequate ad-justment. Through a long and d i f f i cu l t contact with the mother, Jennie was eventually made a ward. The reason for this action was that she appeared to be a very disturbed g i r l who had developed a most with-drawn personality. The years between the time that Jennie was f i r s t placed in the care of her foster mother, when she was four weeks old, w i l l provide a part of the answer to the total disturbance picture. The records do not provide sufficient details regarding the chi ld ' s early development, but sugg-est that during the f i r s t few months in the home the child seemed to adjust quite normally with no particular feeding d i f f i c u l t i e s . She was fu l ly to i le t trained in the daytime at f ifteen months, for the foster mother was a rather, r i g id person in regard to to i l e t training. Although the comment was made at this time that she did not play with other ch i ld -ren and seemed quite lost when they came to her house, such behaviour would be re la t ive ly normal at this age. Insofar as her sleeping habits were concerned, i t v/as stated that she was inclined to be 'fussy*. Considered altogether, the comments that were made regarding Jennie's early habits, suggested a quite normal ch i ld . The concern that the foster mother showed in regard to normal development of the child might well have been the focus of the problem at this point. - 6 3 -When she was just over two years old, her tonsils and adenoids were removed, as she had been subject to sev-eral colds and a very sore throat. Three months later Jennie was troubled with a very sore eye, but when she was brought to the c l i n i c nothing was prescribed as the eye seemed to" be in normal condition. At two and a half years of age the child ran a persistently high temperature and coughed a great deal. The foster mother commented at this time on the trouble she was having in overcoming Jennie's desire to suck her thumb. The worker accentuated this d i f f i cu l ty when she suggested that the foster mother should st iffen the elbow joint so that Jennie could not get her hand to her mouth. A few months later when she was brought to the c l i n i c , Jennie was found to be in good condition. She had stopped sucking her finger and foster mother said this had been accomplished by keeping gloves on her hands. An examination, when she was nearly four years old, indicated that development seemed normal. In fact, progress seemed satisfactory unt i l Jennie was nearly five when the foster mother, for the f i r s t time, indicated a concern over the chi ld ' s frequent eneuresis and wondered i f there were anything wrong with her. Jennie had become very self-cons-cious about her eneuresis, for she wet her panties when at school and had to come home at noon for a clean pair. The foster mother stated that she did not punish Jennie for her fai lure to control herself. - 6h -A medical examination stated that the eneuresis was "organic" and a prescription was provided. There seemed to be some improvement in the situation organically; however, at school her rating in Grade II showed behaviour as 'good' but retarded her to this grade because of immat-ur i ty . At the time when J-ennie was nearly nine years old the f i r s t real contact was made with the foster mother. It seems obvious that although contact was maintained over the years, the degree of the problem was not brought out. The records dated October 22 , 19^7 > state that "worker took the time on this occasion to s i t down and rea l ly l i s ten to the foster mother. She is a young woman inclined to be a worrier and excitable, worker thought she talks very fast and jumps from subject to subject, and worker f e l t that in her conversation she gave the impression of fav-oring the other foster chi ld in the home who she said seemed to "act more normally than Jennie". As an instance of this she mentioned that she could have candy in the cup-board for months on end and Jennie would never mention i t or ask for any, whereas Johnnie, the other ch i ld , would pester the l i f e out of her unt i l the last bit of candy was gone". A Child Guidance Cl in ic examination was discussed with the mother at this time and she brought out the idea that children who went there must be either dul l or queer. The worker fe l t that the foster mother was inclined to identify herself with the children, as she talked at some length about"the poor l i t t l e things, and she knew how they ( - 65 -must feel as she had been out of her own home when eight years old. Jennie's lack of adjustment at school was acc-elerated when the child became quite anxious over an inc id-ent that occurred a month later . She came home to her mother and stated that the teacher had told her in front of the class that she was using the to i le t as an excuse to leave the room, that she was no 'good 1, and would never be any good. A v i s i t to the school did not substantiate the acc-uracy of these remarks, but the teacher was quite defensive on the subject of Jennie's adjustment and mentioned the fact that the chi ld seemed to expect special privileges. "The teacher remarked that she could not see why there was so much fuss being made over one ch i ld , and worker had to ex-plain considerably so that she might understand the agency's desire to help both Jennie and the school". The teacher be-came more affable towards the end of the conversation and ex-pressed a desire to cooperate. Jennie's case was reviewed by the consultant psy-chiatr i s t in January, 19^8, and the significant phases of her development were considered, in an effort to understand the present lack of adjustment. F i r s t l y , i t was believed that undue stress had been l a id on her thumb-sueking. Sec-ondly, the matter of to i le t training was evaluated and i t was decided that too much importance had been placed on proper functioning, so that the chi ld might unconsciously be blaming the person who trained her, or i t might be a - 6 6 -t u r n i n g i n of the blame on h e r s e l f . T h i r d l y , i n regard t o the s c h o o l problem, " i t was f e l t t h a t t h i s c h i l d s t i l l had some unsolved problem between h e r s e l f and her f o s t e r mother, so t h a t the sch o o l s i t u a t i o n added t o i t . The h i s t o r y would i n d i c a t e t h a t she i s not happy or independent. She i s only independent i n a negative way. She r e a l l y wants to be wit h other c h i l d r e n but cannot h o l d her own. She needs lo v e and gets management. In her f o s t e r home there appears t o be e f f i c i e n c y combined w i t h a tenseness of atmosphere. Because the f o s t e r mother i s worried and anxious the c h i l d f e e l s she cannot depend on her". The comment was made that t h i s c h i l d was not being helped t o grow up and ge n e r a l d i s c u s s i o n around t h i s p o i n t was to the e f f e c t t h a t such c h i l d r e n o f t e n grow up h a t i n g the parent who puts them i n the p o s i t i o n of not being able t o stand on t h e i r own, and t h a t they had a need t o remain a baby because on l y as such do they r e c e i v e the a t t e n t i o n they v/ant. I t v/as mentioned i n a d d i t i o n t h a t the f o s t e r mother's own problems were s t i l l unsolved and th a t she was u s i n g t h i s c h i l d t o t r y t o solve them. There was c o n s i d e r a b l e d i s c u s s i o n about how to work w i t h t h i s f o s t e r mother, and i t was f e l t t h a t c o n s i d e r -able use c o u l d be made of her intense i n t e r e s t i n h e a l t h , to the extent t h a t suggestions c o u l d be made to encourage her t o be conscious of mental h e a l t h . r The f o u r t h area of d i f f i c u l t y hinged on Jennie's s l e e p i n g d i f f i c u l t i e s , and i t was suggested t h a t t h i s c h i l d shov/ed f e a r of the world i n t h i s symptom, and should be -- 67 -helped to realize that i t was not such a threatening world. Jennie's behavior showed a new development at this period. Although the bed-wetting almost ceased she insisted that she must have her panties very t ight- f i t t ing so that they were moulded into a l l the creases of her body. She was most unhappy i f they were not tight and would stand up and fidget around. At this time "worker told mother that there was a danger in concentrating too much on this habit and tried to help her relax, be less tense, and not constant-l y on the lookout for such behaviour". In June,'19^-8, the foster mother became very con-cerned again, regarding Jennie's eneuresis, as i t had grown steadily worse, both diurnal and nocturnal. During the interview in which the eneuresis was discussed, f u l l atten-tion was given to the foster mother's own problems. Appar-ently she had considerable anxiety because of the fact that her mother was committed to a mental inst i tut ion with the diagnosis of schizophrenia. I'he worker was able to offer some reassurance in this matter, and the foster mother app-eared to gain security through the discussion. The interview as a whole, however, proved unsatis-factory. The worker's comment on November 2 6 , 19^-8, indicat-ed that "worker had a very unsatisfied feeling about the in -terview. Whenever worker suggested something to foster moth-er, foster mother had always tr ied i t , or was trying i t , and the fundamental question of the relationship between the mother and Jennie was untouched". - 68 -D u r i n g a f u r t h e r i n t e r v i e w on F e b r u a r y 2 3 , 19*+9s Worker s a i d once more t h a t J e n n i e seemed t o be a r e s t l e s s c h i l d , the s o r t t h a t one must never be i m p a t i e n t w i t h . The f o s t e r mother s a i d r a t h e r r u d e l y , t h a t she was n o t always as p a t i e n t as she might be and t h e n J e n n i e got c o n f u s e d and l o s t her head, so t o speak. Worker s a i d t h a t i t was v e r y d i f f i c u l t t o be p a t i e n t a t a l l t i m e s and she c o u l d und-e r s t a n d how f o s t e r mother f e l t . A t the same t i m e , she f e l t t h a t i f f o s t e r mother was i m p a t i e n t w i t h J e n n i e , she was i n danger of j u s t making the whole '• s i t u a t i o n worse. F o s t e r mother s t a t e d t h a t J e n n i e ' s absent-mindedness has a l s o c o n t i n u e d . F o r i n s t a n c e , f o s t e r mother s a i d , she i s asked t o wash her hands b e f o r e she s e t s the t a b l e and she always f o r g e t s t o do t h i s , w h i c h i r r i t a t e s f o s t e r mother. Worker wondered i f perhaps f o s t e r mother was t e l l i n g h er t o do t h i n g s t o o o f t e n , and t h a t . t h e r e f o r e , J e n n i e was t u r n i n g f r om d o i n g them a t a l l . F o s t e r mother s a i d t h i s c o u l d be, and c e r t a i n l y seemed t o have a c o n s c i o u s -n e s s of her own r a t h e r nervous p e r s o n -a l i t y . F o s t e r mother a d m i t t e d she found day-dreaming e x t r e m e l y i r r i t a t i n g and h a r d t o u n d e r s t a n d , s a y i n g t h a t she had n e ver been t h i s s o r t o f p e r s o n h e r s e l f . She and worker lau g h e d over t h i s , b o t h o f them a g r e e i n g t h a t i t was no good t r y i n g t o t u r n J e n n i e i n t o a n o t h e r k i n d o f c h i l d . F o s t e r mother s a i d she d i d n o t t h i n k t h a t J e n n i e would 'get v e r y f a r *. F o s t e r mother seemed t o be s e e i n g the c h i l d r e n as t h e y would be i n the f u t u r e i n s t e a d o f as t h e y are now and g e t t i n g e n j o y -ment out of them now F o s t e r mother a l s o spoke of how h a r d i t was t o get J e n n i e i n t e r e s t e d i n a n y t h i n g . She i s n o t n e a r l y as i n t e r e s t e d i n d a n c i n g as she was a t f i r s t The i n t e r v i e w ended on the same f r i e n d l y b a s i s . Worker a g a i n had the f e e l i n g t h a t the problem had been s k i r t e d and n o t t o u c h e d . I n December of the same year the f o s t e r mother became i n t e n s e l y i n t e r e s t e d i n the r e l i g i o u s group known - 69 -as Jehovah Witnesses. She said "that Jehovah Witnesses gave so much meaning to l i f e " , indicating that she had at last found the answer to a lot of things. But, despite this newly-found concept, the adjustment between the foster mother and Jennie became more precarious and, November 2*+, 19*+9» she telephoned the agency and informed the worker that Jennie had been home from school several days, and had been suffering from crying spells . Jennie refused to go to school, saying that she did not want to leave her foster mother. These crying spells continued, and when the nurse vis i ted the home, i t was noted that the foster mother kept saying how upset Jennie was, but a l l of her comments were made in the presence of the ch i ld . Apparently foster mother had given Jennie the idea that she could accompany her to school, and Jennie had asked her i f she would go right into the school room and stay in the class with her. Foster mother telephoned the principal to see i f this was possible, and of course the principal re-fused. Very minor description is given in the records of the foster father. Any mention made of him, merely indicat-ed that he played a rather ''neutral1 role in the whole s i t -uation. December 9» 19^9, when Jennie was almost eleven years old, a Child Guidance Cl in ic was held to confer on her case. The Cl in ic took a very serious view of Jennie and said of her: "She appeared so very disturbed emotionally that i t - 70 -was strongly recommended she should have private intensive psychiatric treatment". Jennie displayed a fear of growing up, a shallow superficial reaction to people lacking s in-cer i ty , and a marked decrease in her outside interests. Jennie's case has been described in considerable detai l for two particular reasons. F i r s t l y , this ch i ld , in her early problems of thumb-sucking and eneuresis dis-played the typical habit disturbance symptoms. ' Secondly, as habit disturbances are intertwined with an early dis-location of the proper mother-child relationship, a des-cript ion of the early background was essential so that formation of the disorder might be followed to some extent. Details of the f u l l development of this pattern are, how-ever, lacking in the records. This case, then, i l lustrates how habit formation may be accelerated by inadequate environment and parental relationships, to a point where neurotic tra i t s emerge. The symptoms having developed over the period of eleven years, i t i s possible to understand how treatment of such a child would be slow and exacting. Play Therapy Treatment The treatment commenced January 26 , 1950, and has continued u n t i l the present, a total of thirty-four inter-views. Previous description of the case has indicated that Jennie was a child who was particularly r i g id in the area of to i le t training and so i l ing . F i r s t definite indications of her d i f f i cu l t i e s in this area are i l lustrated in Interview - 71 -Three when she i s engaged i n f i n g e r p a i n t i n g . She t h e n p a i n t e d p i n k i n t o the r o o f , c a r e f u l l y t r y i n g a t f i r s t t o f i l l e a c h square and s a y i n g t h a t she d i d n o t seem t o be a b l e t o do t h i s w e l l . I r e m a r k e d , as I had b e f o r e , t h a t she seemed t o want t o make i t e x a c t , perhaps i t was q u i t e i m p o r t a n t t o h e r ? She i m m e d i a t e l y p a i n t -ed over s e v e r a l l i n e s a t o n c e . She gave me a b r u s h and s t i c k and a s k e d me t o c l e a n t h e s e . When I t u r n e d from the s i n k she was l o o k i n g a t me i n r a t h e r an e x c i t e d way, and had p a i n t e d a b i g sun i n y e l l o w w i t h about f o u r r a y s from i t . I s a i d t h a t she had done t h a t q u i c k l y and she b u r s t i n t o e x c i t e d l a u g h t e r and s a i d i t was a mess, and began a d d i n g more r a y s t o i t w i t h a r a t h e r u n s t e a d y h a n d . I s a i d i t was a b i g sun and was i n -t e r e s t e d because i t made i t l o o k l i k e a h o t d a y . She seemed t o c a l m down a t t h i s and added one or two more r a y s i n a calmer manner. She remarked a t t h i s p o i n t about the s u n , s a y i n g she d i d n o t know why she d i d t h a t . She t h e n t o o k b l u e and began p a i n t i n g i n the sky w i t h sweeping g e s t u r e s . When some p a i n t r a n over the r e d r o o f she made as i f t o wipe i t o f f and t h e n d e c i d e d t o l e t i t go. She l e f t the sky f o r a b i t and s a i d she was g o i n g t o f i n i s h the h o u s e , and put h e r b r u s h w i t h b l u e p a i n t i n t o the brown and b e -gan t o p a i n t s q u a r e s on the w a l l s , mak-i n g an a t t e m p t t o keep the p a i n t i n the s q u a r e s , but p a i n t i n g so q u i c k l y t h a t she went over the edges and m i s s e d a l o t . She remarked t h a t t h i s w a s n ' t a house anymore. I s a i d t h a t was i n t e r e s t i n g . She s a i d she was making a mess o f i t . I r e p e a t e d t h a t she was making a mess o f i t so i t was no l o n g e r a h o u s e . The §.bove e x c e r p t i s i n t e r e s t i n g from the p o i n t o f v i e w t h a t i t i l l u s t r a t e s b o t h J e n n i e ' s d e e p l y r e p r e s s e d f e e l i n g s a r o u n d m e s s i n g , and the t h e r a p i s t ' s u n d e r s t a n d i n g o f what the f i n g e r p a i n t i n g means t o the c h i l d . The t h e r a p i s t ' s comment "she was making a mess o f i t so i t was no l o n g e r - 72 -a house" would tend to reinforce Jennie's early t r a i n i n g insofar as 'messing' was concerned. Perhaps i t would have been wiser for the therapist to have said " so you think i t i s no longer a house", and i n t h i s way an attempt would have been made to draw out her feelings about the house. The therapist's comments on t h i s interview suggest-ed that Jennie was a c t u a l l y testing the s i t u a t i o n a b i t ; that for her, painting a messy picture and mixing the colours was the equivalent of a much more active testing on the part of another c h i l d . She seemed unable to do any exploring, and the therapist d e l i b e r a t e l y gave her a l o t of help, i n some cases a n t i c i p a t i n g her needs so as to give her a f e e l i n g of warmth and i n t e r e s t . The f i r s t seven interviews showed l i t t l e advance i n the r e l a t i o n s h i p with the therapist. Jennie was very conforming and quite agreeable to any play that happened to be suggested i n the sessions. Between the seventh and.eighth interviews there was a lapse of three weeks. On the occasion qf the eighth interview the therapist i n i t i a t e s a discussion of why Jennie i s coming into the play room. Such a discussion would have been more appropriate at an e a r l i e r date, as i s customary i n play therapy treatment, but i n t h i s case i t may have been f e l t that Jennie was too insecure to permit an e a r l i e r focus on her problems. * I sat on the edge of the table where I could watch, and then said to her that t h i s was now the eighth time she had come here to see me and I f e l t that she might not be altogether clear on the • .•• ! purpose of these v i s i t s so I would l i k e to discuss t h i s with her. She put down - 73 -her spoon, smiled brightly, and said that would be f ine. I went on to say that we a l l had d i f f i cu l t i e s one way or another, and there are always times when everybody fe l t badly or confused or angry, without understanding why they fe l t this way, and sometimes they could feel unhappy. I understood that Jennie too, might have some of these feelings and I wanted to help her by being her fr iend. Here, we could do as we l iked , or say anything we l iked , and sometimes i f we had feelings inside us that we did not know how to handle, we could come here and use the room to try to under-stand what these feelings were, and in that way could sometimes get r i d of them. Jennie said, "Oh, is that a l l I Can I have a cocoanut in this too? (She was playing at making a cake, while this conversation was taking place) I said she could have as much cocoanut as she needed and could either use i t in or on the cake. She said "I can do anything I want here?" I said "yes, pract ical ly anything within reasonable l imi t s . Often there may be things we can't rea l ly do somewhere else, but this room is different from school or anywhere else, where we have to follow a lot more rules. However, in coming here and doing almost any-. thing, we can maybe understand our-selves a bi t better, and i f we are un-happy, find out a l i t t l e about what is making us unhappy and whether we can do anything to make ourselves stop feeling that way". Jennie said "I wasn't happy last f a l l " , and then quickly turned to mixing the cake. . I f e l t that she had been very venture-some in saying this and i t would be wiser simply to smile at her and let the matter go for the present. This excerpt represents an excellent piece of i n terpretation in explaining to a chi ld the reason for play therapy interviews. The therapist showed understanding of the situation when she wisely refrained from commenting on - 7h -Jennie's, outburst about not having been happy last f a l l . 'The chi ld ' s comment, in this instance, was the f i r s t verbal indication of the d i f f i cu l t i e s that lay underneath her out-wardly conforming personality. The security that Jennie is beginning to feel with the therapist, as the relationship deepens, is i l lustrated in the Ninth Interview. Jennie is again playing at cooking, and the therapist makes additional comments about why she is coming to the playroom. The chi ld does not pick up these comments immediately, but after a time has passed, She offered a comment about babies, saying she loved babies and the only thing that was wrong was that she wanted to grow up very fast, so she could have babies herself. I said "You want to grow up right away do you?" She said "yes", i f she only could, she loved babies. In a moment she amended this by saying she did not l ike boy babies, just g i r l s . I . repeated this and she agreed, and went on to say that she had a lot of trouble with her brother. Her manner was a bit tense and she was smiling rather anxious-l y at me throughout the conversation, and I thought she was a l i t t l e afraid of my judging her in anyway. I said that often boys and g i r l s don't get along too well , and I wondered what particular d i f f i cu l t i e s she had with her brother? She said "Oh, you know, he's bossy and he wants everything". I said I could understand she would find i t d i f f i cu l t i f he was l ike that; i t would make i t very hard for her. This seemed as far as she was able to go at the time, and there was no further discussion in this interview about her personal problems. Jennie became a l i t t l e more aggressive in the Eleventh Interview, and indicated her inab i l i ty to compete and her need to excel . • The therapist makes no comments at this point, on her obvious desire to favour herself, as i t - 75 -was fe l t the relationship was not secure enough to venture any remarks that might be considered cr i t ic i sm by the ch i ld . She was very pleased each time she caught a ba l l and was ready with excuses about i t being too far from her when she missed i t . The play was quite active, and after a short while she decided she wanted to play ba l l and took the bat, having me act as pitcher. She wanted me to throw the ba l l right at the t ip of the bat, and for a time had me standing rather far back, so that in order to get the ba l l high I had to throw rather hard. After quite a long period of my pitching to her, but with no counter strikes, she said i t was now my turn. I said "You feel I should have a turn at that? She said "yes, of course". I said that would be f ine, but i f she preferred to be batter, I would enjoy that too, and she was to do as she wanted. However, I had a turn and hi t two or three bal l s , but missed a number. She seemed very pleased to have me miss the ba l l s , and a l i t t l e accusing once or twice when,I hi t i t f a i r l y hard. She then said i t was her turn again, but after a few minutes of that decided she would play baseball She then had a long turn at bat, and the rules she l a id down proved to be very e las t ic . If I got to home base with the b a l l when she was s t i l l at the step, then she could return home to start batting, but i f I could tag her while she was between bases she would be out. She contrived to put the blame on me when she ran up to five strikes - this v/as obviously because I did not throw the ba l l wel l . During interviews twelve, thirteen, and fourteen, Jennie played out a school situation in which she was the prim, fussy teacher, who insisted on exercises being just r ight . The psychiatrist f e l t at this point that in her play Jennie tended to inhibit everything inside herself. Figura-t ive ly speaking, she made " a magic c i r c l e , and sat in i t doing nothing but being good - in spite of her mother". - 7 6 -The stronger her need to develop became, the harder she h e l d i t down i n s i d e , so t h a t t h e . g r e a t e r the t e n s i o n , the more the v i c i o u s c i r c l e expanded i n a d i r e c t i o n which c o u l d mean mental i l l n e s s . There was an i n t e r v a l from June 3? 1950, t o J u l y l U , 1950, d u r i n g which p e r i o d the t h e r a p i s t l e f t on h o l i d a y s . Jennie expressed some a n x i e t y i n t h i s c o n n ection, but apart from the f a c t t h a t the t h e r a p i s t prepared her two weeks i n advance, there was no a l t e r n a t i v e to the temporary h a l t of the therapy. Some new toys had been added to the p l a y room eq-uipment when Jennie a r r i v e d back some f i v e weeks l a t e r . One of these toys was a b l a c k , p l a s t i c camera which s q u i r t e d wat-e r . Jennie played w i t h the camera f o r a few moments and then the f o l l o w i n g comments were made i n Interview F i f t e e n . She then s a i d she would take some p i c t u r e s . She s a i d a t f i r s t she would take a p i c t u r e of me and then exclaimed, "Oh, no, I c o u l d n ' t , because then you would be s q u i r t e d w i t h water" . I remarked t h a t I had the smock on and p o s s i b l y a b i t of s q u i r t i n g wouldn't h u r t v e r y much, so i f she wanted to take a p i c t u r e of me i t would be a l r i g h t . (The p s y c h i a t r i s t suggested t h a t a t t h i s p o i n t the therap-i s t might have s a i d "You f e e l i f you s q u i r t me you w i l l be bad", thus b r i n g -i n g out Jennie's r e a l d e s i r e s ) She r e -j e c t e d the i d e a , however, and s q u i r t e d a t some of the p i p e s , commenting each time t h a t she wasn't v e r y good at aiming. She v e r y c a r e f u l l y h e l d i t up to her eye t o l o o k through the hole and v e r y solemn-l y s q u i r t e d v a r i o u s p a r t s of the room, b i t by b i t , g e t t i n g c l o s e r t o me, f i n a l l y s q u i r t i n g a b i t of water on my shoulder. T h i s e v i d e n t l y made her nervous, and I remarked t h a t I had gotten i n t o a corner of one of the p i c t u r e s and then t o l d her - 77 -not to worry, that I realized she won-dered i f i t was alright to squirt at me. This play i l lustrated the deep inhibitions operat-ing in Jennie's unconscious, and i t was fe l t that her method-ica l attempt to squirt the water was so restrained, as to indicate extremely unhealthy restr ict ion of impulse. After this interview, school was out for the summer, and the foster mother resisted the idea of bringing her in during the holidays. The result was that there were no inter-views from July l 1 * , 1950, un t i l November 3 0 , 1950. Jennie expressed interest in coming to the play room again, during Interview Sixteen. There was, however, considerable doubt as to whether the interviews would be continued. Two weeks later during Interview Seventeen, Jennie entered into play with the Wettums d o l l . Her repressions in the area of to i le t training are expressed quite c learly . The therapist points out the fact that she associates being dir ty with badness. In addition, the psychiatrist suggested that the therapist might have reassured Jennie that soi l ing wasn't a permanent thing and might be corrected by cleansing in the same way that people were not bad a l l the way through, and might be helped by releasing some of the feelings they thought were bad. She then noticed the dol l clothing (a dainty white voile dress, a l ight blue s i lk s l i p , and panties;" on the table, and we examined them. She held them up against her d o l l , which was too small, and then, at her request, we rummaged in the basket, f ina l ly finding a Wettums do l l about the right size. - 78 -She thought this was too dirty and she'd wash i t . She began scrubbing i t vigor-ously and said something about i t being bad. I said "Bad, because i t ' s dirty?" She said "yes" with some vigor and rubbed i t s bottom especially hard, giggled and glanced at me and rubbed some more. I remarked she was washing i t s bottom extra hard and she agreed that was d i r t i e s t , giggling. Some of Jennie's feelings around mother people began to emerge in the same interview. The therapist accepts her reaction to the rubber cow with no comment. For Jennie, such an action is unusual and quite s ignificant. She again roamed about without at once focussing on any one thing. She noted the table tennis balls and bounced one, intrigued at the sound i t made, and then bounced i t repeatedly She abandoned the ba l l br ie f ly when she saw the rubber cow. Instead of seeing i t as a charming toy, she handled i t roughly, saying c r i t -i c a l l y that i t was a soft rubber thing and wouldn't stand up. (I took this to mean, i t wouldn't last well) . She punched i t , I think ofi the udders, certainly on the stomach, with some emphasis, then slammed i t back on the shelf. I made no comment on her ac t iv i ty here. The therapist could have made a comment to the effect that " we a l l feel l ike punching people sometimes" in a general sort of way, so that Jennie would feel no guilt about her action. During the course of Interview Twenty, the therapist refers again to the reason for Jennie coming to the play room. I took this opportunity to go on to say that we hadn't talked so much late ly about why she was coming, and I thought perhaps she understood in part, that i t was because often people were unhappy about things - but often their unhappin-ess was sort of inside them and they needed a good friend to whom they could talk and with - 79 -whom they could relax in order to help them see their way out of their d i f f i cu l t i e s . I spoke in very simple terms and Jennie l i s t -ened quietly. When I had finished, she said "Do I have to keep coming?" I asked her just what she meant by this and she said, wel l , her mother and dad didn't feel that she ought to be s t i l l coming, and they wond-ered i f she had to keep on coming? I asked her how she fe l t about i t , and she said that she wanted very badly to come. I told her that I fe l t she should keep on coming and I did hope that she would. The parental pressures that are operating in Jennie's case, are quite obvious from this excerpt. Jennie's foster mother is threatened by the play room sessions, and unless the conflict between the two situations could be res-olved, the treatment was being given at an extreme disadvant-age. It is suggested that further efforts to overcome the foster mother's resistance to the therapy, should have been made at an earl ier date. Further instances, in the Twenty-First interview, indicate the neurotic relationship which the foster mother has with the ch i ld . Jennie shows a real ization of the t ies , and tr ies to express her feelings in this regard, at the point where she is experimenting with some finger n a i l polish. She said her mother didn't l ike any one to use n a i l polish. However, she could put on the pink, since i t was-n ' t so dark and she would be able to wear that at home, as her mother had come to realize that people do wear na i l polish and she may as well accept i t . She did-n ' t quite use these words but that was the import of what she said. I made a quiet remark to the effect that her mother was making some necessary adjust-ments to Jennie growing up and Jennie said "Well , some", and then added very quickly, "sometimes I think she doesn't - 8 0 -l ike to" , and then quickly went on to point out what the na i l polish was looking l i k e . I hesitated to pick this up, as I f e l t i t had been rather hard for Jennie to say. I smiled sympath-e t i ca l ly at her and said "yes, that was so" in a general sort of way, hoping that she would know I was agreeing with what she had said. Jennie's early deprivations, in terms of emotional response from her foster mother are brought out later in the same interview. It becomes quite clear that the child has been insuff iciently loved in a warm responsive way. She didn't say anything for a few minutes, and then said something about her mother which I didn't quite catch. She went on more clearly, saying that her mommy didn't l ike her hugging her. "She hates to have anyone handle her. Some-times she pushes me away, when I put my arms around her", Jennie said. She amend-ed this by saying "She always does this . Once, recently I put my arm around her, and she said "go away!" I said this must be quite d i f f i cu l t for Jennie. Had her mother alxrays done this? She said "oh, yes. When I was smaller, she'd slap me, but now that I'm bigger, she just pushes me. She doesn't l ike anybody to touch her", Jennie repeated. I said that I supposed some people were l ike that, but I didn't think most people were. Jennie said "I l ike to hug people". I said that was a natural way to f ee l . It might make a chi ld rather unhappy not to have someone who meant as much as mother does, not wanting to be hugged. Jennie didn't respond direct ly to this but repeated "I do l ike to hug someone". In this situation, when the chi ld was expressing a direct desire to show affectionate feelings, the therapist might have given her permission in a general sort of way by saying something to the effect that "wel l , Jennie, here in the play room is the place where we can show a l l sorts of - 81 -feelings. There are always times when people want to show how much they l ike another person". As the above excerpt is examined, i t becomes quite evident that the greater part of Jennie's problem is based on the neurotic and rejecting response of her foster mother. The Christmas holidays, 1950? intervened before the child was expected for the next interview. The therapist presents a gift to Jennie in the last part of the interview. I had brought her a small gift wrapped in Christmas wrappings, and she said she was going to keep this and place i t under the tree. It was s t i l l in the wrappings when she l e f t . She carried i t quite carefully, and when I was bidding goodbye to her, and saying that probably I wouldn't see her unt i l after New Year's, I added that I would miss her in the meantime, and would be thinking of her, she held out the gift and said, "Well , I ' l l have something to remember you by in the meantime". Jennie carried a part of the play room relationship with her, as a symbol of the warmth so denied her in her own home. This was the last interview with the chi ld before the holidays.. After the holidays, during Interview Twenty-Three, Jennie is discussing her foster brother, a chi ld s l ight ly younger than herself, who is proving a problem child in the home. She dis l ikes the brother very much, as he makes many demands on her. As she talks about her brother, she describes the way in which she often makes up stories to amuse and pac-i fy him. While she was talking about t e l l ing the stories, she became quite agitated. She s l id quite far down in her chair, f i n a l l y ending up almost out of i t , with - 82 -one arm wrapped around the back of the chair, and the other moving around rather aimlessly. She said that she wanted to t e l l me a story that she'd thought about f a i r l y recently It had to do with three cars. There had been three thieves who took the three cars. (Jennie was apparently with them in some capacity.) The thieves had taken two of the cars right away and had taken the brake off the third car. It was this third car that Jennie was l e f t with The car was equipped with some sort of button whereby, i f you pressed the button up, the car would take to the a i r ; i f you pressed i t down the car would land, and this car could drive through anything. She had been in i t , and had been driving along and had gone right through a barn, in the process acquiring a horse on the roof, which remained on the roof of the car throughout the rest of the adventure. They drove or broke into an ice cream-factory, and ended up with cases of ice cream stuck a l l over the car and they were eating thi s . The police chased them, and they came to a river and Jennie pressed the button so that the car flew over the r iver , and the police were very surprised and completely helpless. She went on talking about i t a b i t and while she was doing so, she wiggled around in her seat. I wondered where the car was going. Jennie looked a l i t t l e surprised at this and said "Away, just away", and when I said "Oh, i t wasn't going anywhere, just away", she said "Oh, yes" and became a l i t t l e ag-itated at this point again. She said she just loved having these mental ad-ventures, and she'd l ike to t e l l me about some more of them next time. Prior to the point where Jennie told this story, there had been a considerable amount of play with dol l s . The psychiatrist fe l t that the manner in which the therapist had played with the dolls, so that the d o l l children were permitted to be naughty and dir ty had released Jennie suff iciently to t e l l her fantasy. - 83 -/ An interpretation of Jennie's fantasy provided by the psychiatrist , indicated that when she "flew away in the car without brakes", leaving the police helpless on the river bank, she was, in fantasy, removing her restraints with no way of helping herself (no brakes). However, i t was noticed that in the fantasy she was not rea l ly respons-ib le , for 'a thief 1 had fixed the car so that the brakes were missing. Once the brake was gone, she had a kind of magic control, which might symbolize the idea that i f she could escape her mother's control, her own control would make anything possible. However, the next few interviews showed l i t t l e movement. Comments included in the introduction to Inter-view Twenty-Eight were as follows: Jennie's general case was reviewed at the consultation period on A p r i l 6. It was fe l t that things must come to a head very shortly; that either we leave Jennie where she i s , and abandon the play therapy, because she cannot progress on i t as long as she is in the foster home, or else we decide to move her. V i s i t s over a period of three weeks were made to the foster home to evaluate the situation and discuss the matter with the parents. The v i s i t ing worker found that the foster mother and father were resisting the play therapy, feeling that there was no problem. It was decided that the foster mother, would never accept the idea that Jennie was disturbed and that therefore, she would have to be informed that such was the case, and that Jennie would carry a serious problem into adulthood. The foster mother listened but would not accept this . - &+ -Since this time there have been six additional interviews, a total of Thirty-Four to the present time. These have been purposefully carried on at a superficial level so that too much material would not be produced at this c r i t i c a l point in the therapy. It has been decided to move Jennie to the Receiving Home for a t r i a l period of six months, during which the therapy w i l l continue. The case w i l l be reviewed at the end of that time, and plans for the future made. This is a case, which i l lustrates the interrelation-ship between the home situation and therapy. The therapeutic process cannot be adequately carried on, where the environ-ment which created the d i f f i cu l ty remains stationary. A considerable amount of casework was done with Jennie's foster mother, although on a rather intermittent basis, but i t was found in the f ina l analysis, that any change in her attitude to the child was highly improbable. The encourage-ment given in the play room, in contrast to the restrictions at home tended to increase the confl ict Jennie already had in her adjustment to society. This situation is an excellent example of the ass-istance provided by legal guardianship, in permitting removal of a chi ld from an unpromising rea l i ty situation. The right of the chi ld to an emotionally secure future is being prot-ected by the-Society in the action taken. The therapy given in Jennie's case, where the en-vironmental handicaps were so great, indicates the way in which a supportive relationship can be used. It is necessary-- 85 -\ • also, to point out the importance of moving a child as early as possible from an environment of this kind. This child was exceedingly inhibited; yet through the warm, un-derstanding bond established in the play room she grew to the point where she could make use of the situation to ex-press her inner-most feelings. Jennie had suffered from early emotional depriv-ations, so that a disorder including eneuresis and a tend-ency to neurotic withdrawal formed. L i t t l e mention is made of these symptoms during the latter part of the case, but i t is unlikely they would disappear, except over a long period of time. The habit disorders are formed at a very early age, and in Jennie's case, the situation which created them remained unchanged. As a new environment is provided which makes fewer demands on the ch i ld , the therapy may be a means of relaxing the overly s t r ic t super-ego, rather than as i t is in the situation at present, acting as a conflicting influence. If a treatment centre were available, in which Jennie might be placed during the therapy, the help given by the trained personnel in such a centre, would be invaluable. The a b i l i t y of the therapist, in being able to form a relationship with this inhibited and insecure ch i ld , whose contacts with society were formerly of such a superficial variety, is i l lustrated throughout the interviews. The art of making the proper response to a chi ld in a therapy session, is a ski l led one. The intangible quality of good therapy, however, l i e s in the intuitiveness of the therapist, in her manner, and in her expression as she talks to the ch i ld . - 86 -These qualities cannot be recorded, but in this case the results obtained in breaking through the shell of Jennie's inhibit ions , are ample evidence of the therapist's a b i l i t y . Two Cases which may benefit by Play Therapy F i r s t information on the case of Janis Cooper, was provided in a social history outline prepared for the Child Guidance Cl in ic by the Family Welfare Bureau of Vancouver. The opening date was February, Ijhl, at which time Janis' mother wished to place her two-months-old child for adoption. The mother had decided that neither she nor the chi ld would have a fa i r chance unless Janis was adopted. This plan was abandoned, however, and from March, l ^ l j un t i l five years later Janis was placed in the home of family friends. At the age of f ive , the child returned to l ive with her mother, who had in the meantime married. The tentative plan was to adopt her. Two years later , in 19*+9» the case was opened at the Childrens Aid Society. Janis had become quite disturbed, was ly ing , stealing, and running away from home, as well as becoming a problem in the schoolroom. At this point the symptoms seemed to be of a conduct disorder. Attendance at school was discontinued and, as the record states, Janis was told she was being kept home as a punishment for her behaviour. Early history of the ch i ld , during the five years she l ived with the family friends, is lacking. The assumption i s , however, that early traumatic experiences, in a l l prob-a b i l i t y provided the basis for the increase in disturbance. - 87 -Six months la ter , further information was prepared for the C l i n i c . Janis 1 running away had increased; she was found to have a number of se l f - inf l i c ted sores on her face, which she picked with her finger nai ls or jabbed with any ava i l -able sharp object; and considerable d i f f i cu l ty was had with regard to elimination. Janis did not s o i l herself, but moved her bowels in her bedroom and then tr ied to hide the evidence. There was also some history of masturbation, but the chi ld did not appear to have this habit at the present time. No action was taken unt i l May, 1951. At this time, a further report was prepared for the Child Guidance Cl in ic which described a whole new set of disturbances, to which Janis had become subject. It appeared that, following the Cl in ic consultation held in September, 19*+8, the mother had again sent Janis to the home where she spent the f i r s t five years of her l i f e . A year later the mother requested the agency's help in f ac i l i t a t ing Janis' return. A; .medical examination, given in the foster home, provided no explan-ation for the fact that the chi ld had disjointed thumbs, a l -though a later statement from Janis indicated that "her mummy kicked her in the basement and pulled her thumbs". The foster mother maintained that i t was because of state-ments of this nature that she had kept Janis, rather than returning her to her. mother. However, Janis was returned to her own home in - 8 8 -July,--1950, much against her w i l l . At this point, her mother stated Janis did not seem to " f i t into the family", and she had only brought her back because she " fe l t guilty" at having sent her away. Her mother stated that she wanted to give Janis more affection, as she had not given her enough be-fore, but she now realized i t was of no use. She stated that she had lost her love for Janis. In the Child Guidance history prepared on May 25? 1951: The mother said that she had be-come aware of the patient's masturb-ation only since moving to their present home about October, 1950. Patient had told mother of her experiences with a fourteen-year- old boy at her foster home. Patient told of sleeping with this boy and of having sexual relations with him. Patient, who used to state that she did not know why she ran away, now told mother that she ran away be-cause she wanted to sleep with the boy. Patient stated that she l iked having sexual relations with him because ' i t f e l t so n i c e ' . Janis is now eleven years old. The school nurse reported that she did good work in school, although she is behind, due to so many absences. She does neat work, and although she tends to be a 'dreamer' there is no evidence of masturbation, or other disturbances in school. However, the mother found i t necessary to keep Janis at home. The above report continued with the statement that "mother has kept patient, who is in Grade I I , out of school for the last month as she has run away after school quite often recently. She does not eat while she is away, and stays in empty houses and in garages. Patient te l l s her mother that she goes away to - 89 -masturbate, as mother w i l l not let her do i t at home". "In regard to the masturbation, the mother report-ed that she cannot allow patient to have pencils, rulers , or any similar objects, as she uses them in the act of mast-urbation. Patient's mother has been encouraging her to keep up with her school work, but cannot continue, as she cannot allow her to have penci l s . " Janis is confined to bed, which is an upper bunk, for i f she is around the house she w i l l pick up various ob-jects for sexual use. She tends to withhold elimination, and requests to go to the bathroom about every half hour. She has a large scratch on her nose, which she continually picks, and also is continuing to bite her na i l s . Very l i t t l e detai l is provided of the stepfather and three brothers. It would seem that the stepfather, though not completely negative in his Janis, provides l i t t l e help in the situation. The mother's plan, i f there is no alternative sugg-estion made, is to either send Janis back to the previous foster home, or to arrange with a couple of doctors to have the chi ld committed to a mental home, although she prefers the latter plan, as she feels Janis' trouble started in the foster home. This case is d i f f i c u l t to evaluate. Nearly every symptom of the three groups of behaviour disorders are ind-icated. Lying, stealing, running away, extreme sexual act-i v i t i e s , masturbation, na i l -b i t ing , skin scratching, and day-dreaming are the symptoms l i s t ed . It would be d i f f i cu l t - 90 -to find a more disturbed ch i ld . The answer to the formation of these problems would, in a l l l ikel ihood, be found in the f i r s t five years of Janis* l i f e during which time she l ived in the foster home. In addition to this , i t would probably be found that the time spent with her own mother has aggravated the dist-urbance. This case has been described, as an i l lus t ra t ion of a chi ld who is disturbed in almost every possible way. The most prominent symptoms, at the present time, are mast-urbation, na i l -b i t ing and skin scratching, which may be re-garded as indicative of a typical habit disorder. However, in addition, both conduct and neurotic tra i t s are in f u l l evidence, suggesting a mult ip l ic i ty of causes. When Janis was eight years old, a conduct dis t-urbance was indicated in the history presented. No steps were taken to help in the situation. Three years later , Janis had become such a disturbed ch i ld , that in a l l prob-a b i l i t y very l i t t l e can be done to help her. It is possible that play therapy may be recommended; but at this late date a favourable prognosis is dubious. The probable sequel to Janis 1 problem w i l l be in a mental inst i tut ion or complete sexual delinquency, most l i k e l y of a psychopathic nature. This case i l lustrates the past, the present, and the future need for a treatment centre to deal with children of her kind, so that complete destruc-tion of personality is prevented. The second child to be described in this chapter, as one who might benefit from play therapy treatment, is - 91 -Roy Chadden, born March, I9U-8. He was made a ward of the Childrens Aid Society in August, 19hQ. The history indicates that he was the third i l legitimate chi ld of a working mother. At birth Roy was small, underweight, and had a very poor colour, fie seemed to adjust f a i r l y well in the foster home, in which he was placed, although there was some evidence of excessive screaming. June, 19^9? when Roy was a year old, he was placed in a new foster home, due to the ins tab i l i ty of the f i r s t foster parents. It seems that the foster mother in the f i r s t home decided to leave her husband, and made an abrupt departure. Four months later Roy was admitted to the hospital , with a diagnosis of phimosis, and was circumcised. Following this , there is no significant information in the records unt i l March, 1 9 5 0 , when the foster father said "Roy was l ike an adult sexually". Apparently the child was masturbating with his wool blankets; he did not use his hands at a l l . Sometimes, several days in a row, he would have an erection. The foster mother f e l t Roy's genitals were as developed as a thirteen year old, and that "he seemed to know more than was naturalI" It was noted that on each occasion Roy was taken in for an examination, the masturbation ceased for several days. He was admitted to the Childrens' Hospital July, 1950 when he was two years old. Work with the parents brought out the fact that there was a considerable amount of marital tension in the home. It appeared that foster father blamed the mother for not being able to have a child of their own, and she blamed him. A more thorough foster home investigation should have revealed a - 92 -great many of these d e t a i l s , and the importance of i n v e s t -i g a t i n g the question of s t e r i l i t y i n s u b s t i t u t e homes, i s suggested. In connection w i t h Boy's behaviour, the f o s t e r mother s a i d "he seemed unnatural i n h i s d e s i r e f o r g r a t i f -i c a t i o n and s a t i s f a c t i o n when he played w i t h her breasts any time he was put i n bed w i t h her". Such a statement from a f o s t e r mother i n d i c a t e d the need f o r an i n t e r p r e t a t i o n to her regarding the normalcy of such a c t i o n s i n a c h i l d . During the period i n the h o s p i t a l , Roy d i d not masturbate to any v i s i b l e extent. A month l a t e r , he was placed i n a t h i r d f o s t e r home. A c e r t a i n amount of mastur-b a t i o n took place i n the new home, but to a l i m i t e d degree. However, at t h i s time Roy began to m i s t r e a t animals, and had temper tantrums over minor t h i n g s , as w e l l as b i t i n g neigh-borhood c h i l d r e n . H is a t t e n t i o n span was sho r t , although the f o s t e r parents attempted to encourage h i s i n t e r e s t i n other people. The records i n d i c a t e that the f o s t e r mother gave Roy a great d e a l of a t t e n t i o n , and r e a l l y attempted t o help him w i t h h i s problems. E a r l y i n 1951 > Roy developed a severe case of i n -f l u e n z a . D u r i n g t h i s p e r i o d , he was very s i c k and re c e i v e d every a t t e n t i o n from the f o s t e r mother. However, i t was f e l t t h at h i s d i f f i c u l t i e s l a y i n a p a r t i c u l a r l y strong need f o r mothering. Although p h y s i c a l l y a th r e e - y e a r - o l d , he was em-o t i o n a l l y only nine to eleven months. For t h i s reason, i t was b e l i e v e d he should be indulged w i t h a great deal of nurs-ing care, even to the extent of p e r m i t t i n g him to go back to - 93 -the bottle. • However, during the course of the next three months, Roy's behaviour seemed to become too much for the foster mother. Although, on the occasion of each complaint made about the ch i ld , an attempt was made to reassure the foster mother, there does not seem to have been sufficient interpretation given to her so that she might reach a real understanding of Roy's problems. . It was May, 195l» that the foster parents decided that they would never be able to trust Roy. His strong sexual impulses were more than they could contend with adequately. The foster mother verbalized her wish for a replacement and requested that a six-year-old child of whom she had previous knowledge, be considered for their home, in Roy *s place. A replacement for Roy, w i l l represent his fourth foster home. He is now three years old and the record ind-icates that he is well on his way to a disorder which w i l l mould his personality to an undetermined extent in the f o l l -owing years. What w i l l be done about this child? The pattern for future d i f f i cu l t i e s is well set. A great deal of ser-ious attention is required to avert a habit disorder which w i l l probably develop into a definite neurosis, i f not a psycho-neurosis. The answer w i l l l i e in the ava i l ab i l i ty of an ad-equate home for him, with foster parents who understand his needs for love and have the patience to cope with his uninhib-ited impulses. Play therapy with such a young child is quite - 9^ -tenable, and should prove interesting from the point of view that he is so young. Roy can be helped now. Later on perhaps that help cannot be used. Resources for his treatment are essential. A des-irable foster home and treatment by a ski l led therapist are the two main requisites. The case of this chi ld is a real challenge. A three-year-old has travelled a comparatively short journey in l i f e . The next few years are very important. He is entering the phase in his development when the attach-ment to a mother person w i l l become intensif ied. Thus, great care must be taken in the choice of a foster father, as well as a warm mother. Otherwise this chi ld may, because of his unsatisfied oral needs, identify with the mother and retain his sexual play on a fixated narciss i s t ic l eve l . Right now is the time that Roy needs help. The tendency may be to think that a three-year-old w i l l 'grow out o f behaviour d i f f i c u l t i e s . Such is not l i k e l y to be the case. His present d i f f i cu l t i e s c learly i l lustrate the need for immediate assistance, ;and the u t i l i za t ion of every available resource in terms of casework s k i l l and a high level of therapy treatment. - 95 -Chapter V The Child with Neurotic Traits The cases considered in this chapter are mainly those in which the behaviour disorder is predominantly of a neurotic variety. The c lass i f icat ion of 'neurotic' has been discussed in Chapter II, and i t has been pointed out that this category does not exclude symptoms which appear also in other groupings, particularly in the habit grouping. However, to fac i l i ta te this study, i t has been found desir-able to concentrate on the characteristics which seem to confine the various cases to the three specific groups. The f i r s t case, in the group of children showing neurotic t ra i t s , is that of Teddy Lawson, who received pro-longed play therapy treatment. It is not surprising that he should have developed into a child having a disorder of this nature. Teddy's mother had no particular desire to have a baby, so when he was born l i t t l e preparation had been made to provide him with the kind of attention he needed for normal development. Probably his mother could not have given him the right kind'of attention, in any case, for she was young, and needed a great deal of help herself. When Viola White (Teddy's mother) was eighteen years old, she asked for police protection, and was placed in the Childrens Aid Society subsidized boarding home. She told the worker who interviewed her that there had been i n -cestuous relationships between herself and her father and - 96 -brother,- before she le f t home four years previously to join her mother in Vancouver. Since coming to the c i ty , she had been forced into immoral relationships with more than one man on her mother's instigation. Viola remained in the boarding home for about three months and then i t was decided that she should return to her father and stepmother in another province. Consider-ing the g i r l ' s statement regarding her former home situation, i t is d i f f i c u l t to understand why such arrangements were made. However, the feeling seemed to be that the home with her father offered more in the way of security than anything else available. When the case was re-opened several years later , Viola had three children, the eldest being Teddy, at that time nearly five years of age. It appeared that Viola had been l iv ing with a Mr. Lawson for the past few years and had maintained a common-law relationship with him since shortly after her return to her father's home. Within a brief period after Teddy was made a ward of the Childrens Aid Society, in the year 19^8, his mother le f t Mr. Lawson and entered into another relationship with a different man. Teddy was six years old at this time. He v/as made a ward of the Childrens Aid Society because i t was believed that he had been completely rejected by both his mother and putative father. No one had ever cared very much about Teddy, and, at the time he was f i r s t placed temporarily in the Fifty-Ninth Avenue Receiving home, he was a very confused l i t t l e boy. - 97 -During this placement, i t was found that Teddy-did not play well with other children, as he was inclined to be "bossy1. He was quite a 'show-off with everyone, although he seemed to adjust more adequately with adults than with children. Within his own age group he proved to be a l i t t l e 'imp', stirring up trouble whenever he could. After a month, Teddy was placed in a foster home. His mother left a short note for him at the place where his new foster parents went to pick up his clothes. In the note his mother had said "Teddy, be a good boy. I might see you again when you grow up". With this rather abrupt and disinterested dismiss-a l , Teddy took up his new abode, but not for long. Unfort-unately the new foster parents with whom he was placed, had l i t t l e understanding of his needs, and casework help was not given to build this understanding. Teddy's behaviour did not help to improve the situation. While he was in this home he regressed quite def-initely, for he talked like a small child and seemed unable to follow the simplest instructions. He seemed to be asking for the motherly attention he had never received. The foster parents had not been prepared for regression, and one month later asked that he be removed. The following day he was re-turned to the Receiving Home, and although he expressed con-siderable reluctance at having to give up his new home, he had no choice in the matter. T n e worker pointed out to him that he had had a nice v i s i t , and the foster mother suggested that perhaps he could return again. It is to be questioned - 98 -whether such an attitude would be particularly satisfying to a small child who was undergoing his second major rejection by an adult world. On his return to the Receiving Home, i t was found that he was s t i l l a disturbing influence, constantly mischiev-ous and disobedient. The records indicate that the matron at the Home found Teddy a d i f f i cu l t chi ld to work with, but i t was recognized that she had l i t t l e understanding of his needs. Although she gradually accepted the fact that corp-oral punishment should not be used with this ch i ld , she found i t very d i f f i c u l t to discipline him in any other fashion. His background was discussed with her, but the special s k i l l necessary to deal with such a child was lacking. Three months later the worker fe l t that Teddy should be moved, as the Receiving Home was not meeting his needs. It had been brought to the worker's attention that the matron was s t i l l using corporal punishment to a great de-gree in disc ipl ining the boy, and there seemed to be an ov-vious discrimination against him in the Home. At this time he was moved to a new foster home, in which the foster mother was a very patient person who seemed to realize that one of the boy's greatest needs was for a mother person. Teddy's way of expressing his deep feel-ing was to cry a great deal and demand a lot of attention. The foster father did not l ike having a boy who cried so much. Teddy's continued tearfulness grated on the foster father, a staunch Englishment of the type that believed in keeping "a s t i f f upper l i p " . As was to be expected, the - 99 -equilibrium of the second home was maintained for a brief time only. It was two months later that the strain became too great and Teddy was sent to the Alma Road Receiving Home. This move constituted the third rejection in Teddy's attempts to adjust to the world about him. Although this was a different Receiving Home than the former, Teddy's d i f f i cu l t i e s were of a similar nature. The matron found that looking after this six-year-old chi ld involved a great deal of responsibi l i ty. She was constantly having to send people to look for him, and always had to arrange to have someone walk home with him. He wandered along the streets, stopping whenever he met other children, becoming absorbed in their play or whatever attracted his attention momentarily. At school, his teacher found that whatever she was doing, part of her attention had to be given to Teddy alone,, in order to control him and keep him from upsetting the whole class. He talked out continually and wiggled around in his seat, annoying the other children, and trying to get as much attention from them as he could. For these reasons he was not adjusting well at school. The principal was at a point where he was using cor-poral punishment with the boy, and he fe l t Teddy was getting more and more delinquent. It was not possible to convince the principal that this chi ld needed another kind of treat-ment, rather than physical punishment, for he fe l t that i t was more desirable to sacrifice one child for the sake of the group, rather than jeopardize the whole class. In addition - 1 0 0 -to these d i f f i cu l t i e s , several times during this period Teddy was found playing with matches, and l ighting f ires in the basement of the Receiving Home. As these actions, combined with the complete misadjustment throughout the rest of his l i f e became increasingly apparent, treatment was in i t i a ted , and October lh, 19^9} when Teddy was seven years old, he had his f i r s t play therapy interview. Play Therapy Treatment This child was very disturbed in a l l areas, and for this reason no immediate attempt was made to focus the treatment in any particular area. Eventually, however, the pattern which emerged was found to be of an exceedingly deep nature. Very strong paranoidal trends were shown; these trends / being indicated in Teddy's fear that there were unknown forces which were going to hurt him, and that people were going to do something to hurt him, i f they knew he was strong. The psychiatrist f e l t that Teddy seemed to see the world in terms of superior and inferior people and, being so consumed by fear, was unable to recognize the f a l s i ty of this concept. In order to get him to accept the fact that i t was safe,to l ive in a world where people are equal, i t was necessary for him to understand his overwhelming fear and examine the rea-sons behind i t . A secondary feature of Teddy's problem was related to his fearfulness around sex. It was f e l t that there was a great need for interpretation in the area of sex, and a general dimunition of his castration anxieties. - 101 -The diagnosis described him as a child who had suffered in every area through early deprivations. Spec-i f i c symptoms, apart from temper tantrums did not stand out, the main apparent misadjustment showing in his inab i l i ty to l ive with people. This chi ld was not 'at home* in the world, and there was no one able to meet his needs sufficiently to f i l l the vast gaps created by his early loss of love and the pain received from powerful adults. The i n i t i a l depriv-ations had created in Teddy a t e r r i f i c need to dominate, which served as a defence against his repressed guilt and fear of punishment. A chi ld with this particular pattern presents a very great challenge to a therapist. There is no part icul-ar area in which the therapist can concentrate, for the neur-otic tra i t s are formed through deep repression, which extends into a l l phases of the personality. In Teddy's case there were exceedingly great frustrations. He had no understand-ing of what a mother was, and in view of this total lack of a mother concept, i t was f e l t that a different sort of a picture should be created. Rather than making an attempt to give Teddy an experience of mother love that had been comp-lete ly missing, and perhaps encourage what could be a comp-lete regression, the process was directed towards providing an adult ' fr iendship 1 . This choice of friendship, rather than a mother-child relationship in working with the boy, represented an effort to build his ego strength from the point where he - 102 -was, rather than taking a chance in developing a trans-ference which might cause too d i f f i cu l t regression. The hos-t i l e elements in Teddy's personality were close to the sur-face, and i t was necessary for the therapist to be constant-i l y on guard to foresta l l any untoward move on her part which might be interpreted by the child as rejection. In the i n i t i a l interviews, Teddy exhibited great passion. He picked up knives and stabbed about the room with them, ignoring the therapist for the greater part of the time, and was quite unable to include her in his play or his problems. Because of his need to be superior, he could not admit that he needed any help. He fe l t that the room was surrounded with ghosts, and that the world was a hostile place, f u l l of vague and undefined horrors. Every-time the therapist approached him, he was i r r i ta ted and angry. Interview Three provides an early indication of Teddy's feelings about the people around him. Projection of his own suspiciousness are shown quite c learly . The therapist's response consisted of a gentle drawing out of Teddy's fee l -ings, with a simple interpretation of his dependency needs in suggesting that maybe he would want to be liked by the other children. A discussion of the Receiving Home had been init iated by the therapist, about which Teddy made the follow-ing comments. He said "The kids in the Receiving Home are jealous of me". I wondered why this was so. Teddy explained that they didn't have as many toys as he did, and that they were jealous of him be-cause he had lots of toys. I wondered - 103 -which kids he meant, and he indicated that i t was a l l the children in the Receiving Home who were jealous. I asked how he fe l t about their being jealous and he said he didn't l ike i t . I said that I guessed he wanted to be liked by the other kids in the Home, but Teddy did not reply to this . The same interview contains evidence of Teddy's sadistic feelings. By means of a toy soldier, the boy shows his hostile feelings, and also his enjoyment of the aggression. He then went on to the figure of the man with his arms in the a ir and said he was going to hit off one of the man's arms. However, he hit off the man's head instead and said to me "the man's head came off instead!" I asked what had happened to the man, and Teddy said that he died. I asked i f he was k i l l e d or had he died and Teddy replied "He died, but he begged for mercy". The therapist's inquiry, when she asked Teddy i f the man had been k i l l e d or i f he had died may have been too threatening to the boy. In asking this question, she was actually coming very close to his destructive impulses. It might have been wiser to have accepted the fact that Teddy had ' k i l l e d ' the man and to say "Yes, i t is true that we feel quite angry at people sometimes". By asking the question instead, the therapist was asking the chi ld whether he fe l t l ike k i l l i n g , rather than accepting the fact that he did. Teddy's desire to be the master of a l l things, which is a part of the paranoic pattern, is exemplified in an excerpt from Interview Three. The therapist accepts his need for expression of an all-conquering self . - lOh -He then picked up his jar of water and poised i t over a page of the book he was reading. He looked up at me, obviously wondering what my reaction to this would be, and I said, "You do that i f you want Teddy, with which he began pouring water onto the pages of the book. He said, "This is going to be the way I want i t " , stressing the word, " I " . I said that was f ine . He could do what he wished with the book, and that often outside the room we could not do what we fe l t l ike doing and let our feelings out, and sometimes we wanted to do things. This was a room, however, where we could do what we fe l t l ike doing and le t our feelings out and some-times we fe l t better afterwards. Teddy became more courageous and began dumping a lot of water on various pages of the book. After the f i r s t few interviews, Teddy begins to throw off his superficial politeness and good nature. He was no longer pretending a compliance with the rules. Instead, he began to show his feelings about leaving the toys in the room, and about other children being in the room, or in the more general sense, his feelings about the world and the people in i t . He also began to display a great deal of hos-t i l i t y to the therapist, as a representative of what was to him a punitive world. Interview Six showed Teddy's towering rage towards an environment he could not control. The play, at this point, consisted of working with finger paints. Teddy then moved away from the table and suddenly his anger seemed to seize hold of him, and he again began to smash things. He picked up l i t t l e glass jars and hurled them with great force against the wall , so that they freq-uently bounced back. After throwing a red jar, his hand was covered with red. - 1 0 5 -I asked had he cut himself? "No", he said, "This i s red paint". Then he picked up another jar to throw and put his index finger into i t . "Different coloured blood", he said, and pro-ceeded to dip his fingers into the jars before throwing them. He got down and looked at the paint on the wal l , and said "I t ' s a bleeding wall , i sn ' t i t ? " I agreed that i t certainly-looked l ike that, and he went to the sink and washed his hands. Teddy's aggression and destructive impulses were extreme. In dealing with such passion in a ch i ld , one of the best techniques is to deflect the hos t i l i ty which the chi ld desires to expend on the therapist, towards a likeness which represents her. As an example of this technique, a few interviews later Teddy is expressing his rage towards the therapist by pelting her with snow. She suggests that while he cannot continue to wreak his anger at her in such fashion, he may df-aw a picture of her, and direct his feelings towards the paper image. I had my hand on his shoulders as I said this to him, and I fe l t that he was relieved that I had stopped the snowballing. Under his direction, I drew a face on the drawing board and gave i t some hair , eyes, a nose, and a mouth. Teddy now came up and squished snow on i t . "Oh" I said, "you got me on the nose". Then he got the idea of getting some red paint, and mixing i t with some snow so that i t looked as i f I had a bleeding nose. He continued to hammer at my poor nose, and then at my head and announced that I had a bleeding nose and a bleeding head. Then he indicated that I was finished with. "What happens to me now", I asked, and Tedd said "You go home to your mother. You have to go to bed for two hundred years. I'm going to smash this drawing - 106 -frame". So, with some force and anger he grabbed the frame, and began banging out the board, u n t i l just the frame was l e f t . He dragged i t to the window. He said "I'm going to throw this out the window, and then you w i l l freeze when you go out to get i t . Teddy's deeper fears begin to emerge in Interview Eleven. His expressions of hos t i l i ty have become quite in -tense, but the relationship with the therapist becomes more tangible, as he invites her to share in his fantasies. He said, "Did you hear that noise outside the playroom? It was a ghost". He went to the door and opened i t and looked around. He had the waterguns. "Here", he said, "you take the other water gun and we ' l l look for the ghost". I took the water gun and said "I'm searching with you today. "Today you are let t ing me fight the ghosts with you", We went around to the various rooms looking for the ghost. There was a certain compulsive nature to this as Teddy had to look into every nook and cranny. The next interview i l lustrated the chi ld ' s desire for a closer relationship with the therapist, and the budding of a confidence in her, as a mother person. The therapist had tried to participate in the play, but in the role of an affectionate friend, rather than encouraging Teddy to think of her as a mother person. It w i l l be remembered that an important phase of Teddy's treatment plan hinged on building his relationship to adults without encouraging too much of a regression to an oral dependency l eve l . "Now", said Teddy, after he had crawled into the drawer, "you put the drawers in again". I said "You want me to push the drawer i n , while you are s t i l l inside?" He said "yes", so I - 107 -began to do th i s . He said "don't push i t too far" , and I said "no", that I certainly wouldn't. I began to push the drawer i n , and of course i t meant that Teddy was in a very confined space. However, when I stopped shoving the drawer, he climbed out and repeated the experience with the next drawer. I expressed interest in this and said that each of the drawers had been a sort of a house. He arranged his house as he wanted i t to be. Then he wanted to go to the bathroom. Teddy's anxiety is apparent in the desire to go to the bathroom, for the experimenting with houses was prob-'ably symbolic of mother figures, and represented his f i r s t real acceptance of the therapist as a sympathetic, rather than a hostile adult. He put himself in her power, becoming wholly dependent. The therapist met his need to have his regression accepted, when she allowed him, to use her as a mother person. At this point in the therapy, an evaluation was made of Teddy's aggressive actions, and i t was fe l t that he associated being angry with power. As the play therapy ex-perience represented his f i r s t feelings of real power, the decision was made that he needed a chance to feel success and power, before an attempt was made to show him that such po\^ er had to be l imited, and that i t was not necessary to feel tota l ly powerful in order to be accepted by other people. Interview Fifteen contains an expression of the violent pent-up feelings, typical of Teddy's personality. When he had finished this act iv i ty , one of his hostile" spells overcame him - 1 0 8 -again, and he threw a l l the cartons across the room so that they hi t the wall and splashed. He then threw his coffee mixture which he had wanted to keep, onto the f loor . He said "Oh, vomit!", and i t certainly looked rather l ike that. He also threw the l i t t l e to i le t pot on the floor and then became very hostile and began smashing i t to b i t s . I asked him what the pot had done but he did not make any answer. He just continued, and said "I'm going to get i t ! I'm going to get i t ! " , and kicking i t away from him, "It w i l l have to leave the room now". Then he said " I ' l l have to wash this bloody coffee pot too", and he slammed the pot ac-ross the sink. Then his violent fee l-ings seemed to die down, as quickly as they had come, and he began to wash the art icles in a soothing way. Teddy was a d i f f i cu l t child to work with through the play therapy process. Progress was infinitesimal , and as the next fifteen interviews proceeded, a certain pattern of behaviour became apparent. Each time he came in to see the therapist, he demanded that the room be prepared in ad-vance. Preparation would consist of putting the baby bask-et up on the table and f i l l i n g i t with blankets and cushions, with a board placed across i t , on which were a l l his favour-ite toys. It was necessary to have a baby bottle ready to be f i l l e d with cocoa, brown sugar, and water, which he would suck while he played with the toys and made baby noises. He became more and more open in his desire for these activ-i t i e s , although often displaying an ambivalence about them. As he became more able to acknowledge his funda-mental desires, he began to feel that his trouble must be due to himself, and that the things that happened came from within himself, rather than from the outside world. This - 109 -indicated a very gradual decrease of the paranoidal trends, in that the paranoid person is unable to realize that the hos t i l i ty he feels in the world about him is a reflection of his own hos t i l i ty . The whole emotional mechanism in this being actually in reverse of the normal, the treatment in this case is of a less spectacular, but more laboursome nature than with Tommy Snyder, as was described in the third chapter. The climax, as far as the relationship with the therapist was concerned, came in Interview Thirty. During this interview he seemed able to accept the fact that the therapist was his fr iend. At f i r s t he was very anxious to do everything for himself. The therapist spoke about fee l-ings of dependence and independence, and then at the end of the interview Teddy said, in reference to the boat that he had constructed out of wood, "We both made i t " . This move is an indication of the normal phase for, after dep-endency, comes the Going-together' in the parent-child r e l -ationship, ii In connection with Teddy's problems there was the secondary symptom previously mentioned - that of his prob-lems in the sexual area. Unsure of himself as a male child he had great trouble in relating to males, and the antagon-ism he fe l t towards the whole world was intensified in his i approach to men. During interviews thirty to th ir ty- f ive , he became much happier during the therapy period, more con-fident, and showed a desire to express himself as a male. He took great pleasure in the saw, the hammer and the nai ls - 110 -and constructed various things of wood which he was allowed to take home. The taking home of ar t ic les , which was also per-mitted in Tommy Snyder's case, represented another special deviation from the general rule that art icles should not be removed from the playroom. It was fe l t in Teddy's treat-ment, that the taking home of art icles created in a conven-t ional ly male occupation, that of carpentering, would be symbolic to Teddy of carrying his newly-found masculinity with him, to the outside world. Through a continuing i n -terest, during the play room sessions in darts, guns, and other art ic les having a male significance, which he had i n i t i a l l y rejected, he indicated a lessening fear of, and a desire for , masculinity.. However, Teddy's paranoidal trend was s t i l l very evident. He feared that there were unknown forces going to hurt him, and that people were going to do something to hurt him i f they knew that he was strong. Although he trusted the therapist, he had to be in control of the inter-view. The therapist had prepared the room as usual for his a r r i v a l , in play session number forty-four. Teddy super-vised the making of the cocoa, and in the play that followed, showed both his need to satisfy himself on an oral l eve l , and his need to control the situation. He said, " I ' l l show you how I want i t mixed so y o u ' l l know for next time. I said that would be just f ine . I did want to do i t the way that would make him happy. He made the cocoa quite l i q u i d , and then f i l l e d the baby bottle. - I l l -He sucked on the baby bottle. He had tried very hard to put the nipple on the bottle, and I suggested that I help him. He did not seem to wish'me to help him at f i r s t , but I said "Some-times there are things that other people can do, and sometimes we l ike to do things ourselves, and perhaps this is a job that we can share. This seemed to appeal to him, and he le t me put the nipple on the bottle. Instead of sucking from the bottle as most of the children do, Teddy chewed very hard on the nipple. He chewed and chewed, and as he had no front teeth, he got the nipple twisted around to his back teeth. F ina l ly he bi t a good big hole in i t . The therapist who had worked with Teddy for the f i r s t forty interviews had to leave the agency, and i t was necessary to try to reassure the child about her departure, and also to accustom him to a new treatment person. The fort ieth interview occurred August 2, 1950, and four weeks from this time represented the time of her departure. It is unfortunate that Teddy was not prepared further in advance. The relationship had been bui l t up with such d i f f i cu l ty , that a longer preparation would have been preferable to avoid any chance of jeopardizing the treatment situation. During the interview in which Teddy is to be intro-duced to the new therapist, he reverts to an earl ier pattern of fantasy. A discussion of his parents arouses his hostile inst incts , and he imagines their death in a car accident. It would seem that the therapist's imminent departure roused his intense feelings of rejection by an adult world, and he is un-able to see her leaving the agency as other than a blow at himself. At the same moment that he expresses death wishes - 112 -for his parents, Teddy suddenly said "Oh look! A ghost!", and turned to his fantasy of early interviews. He went to the window, and showed me a ref lect ion. He looked outside to the door. I said "V/as there a ghost there, did you think? and he said, "Oh, did you see that one?" I said "Maybe you are feeling a l i t t l e worried just now?", but he denied this suggestion. Teddy was transferred to another female worker. He made the transition from one worker to another' surpris-ingly wel l , the fact that•. he was able to do so, being a great credit to the departing therapist, for i t is often found that a change of workers in the treatment of a chi ld as disturbed as Teddy, creates a set-back in the relat ion-ship. A few weeks later , i t was decided that he should have a male therapist. Because of the improvement that had been made in the boy's emotional development, towards accepting his male role,<'a further identif ication with mas-culine feelings was deemed important. Through identif ication with a non-threatening male, i t was anticipated that he might move s t i l l further in the direction of masculinity. At this point in the therapy, psychiatric comm-ents indicated that many paranoidal trends were s t i l l shown in Teddy's behaviour. He seemed to be at a stage where he wanted to 'grow up' , but there was considerable blocking. His development towards masculinity appeared to be hindered, because of his interest in women. It was fe l t that he should be assured that "mother wants to see boys grow up and none were going to stand in his way". The suggestion was made - 113 -that more cooperative play should be introduced, in which Teddy would learn to participate in act iv i t ie s on an equal footing with an adult person. The therapy was continued with a male worker, and i t was shortly after the new therapist commenced working with Teddy that he made his next move in foster home place-ment. The largest number of Teddy's placements had been made before the therapy commenced, but i t is possible to un-derstand how detrimental so many placements were in the em-otional adjustment of a chi ld who had had a minimum of sec-ur i ty during the eight years of his l i f e . Had he received treatment from the point he f i r s t came into care, these abortive replacements could have been avoided; and i f the foster parents had participated through being given help in understanding his problems, fewer moves might have been necessary. During the treatment process, he should have remained in the Receiving Home. Ideally, the Receiving Home should have been staffed with a personnel trained to understand the behaviour problems of a disturbed ch i ld . Each replacement representing a further blow to the inner security of the boy, placement should not have been made u n t i l such time as the ego was strong enough, and the home in which he was to be placed suitable to meet his emotional needs. Continuing with the therapy, Interview Fifty-Three i l lustrates clearly the conflict that is going on between Teddy's masculine and feminine desires. The therapist en-courages Teddy's male interests by suggesting play that is -111+ _ c o n s t r u c t i v e , and of a c o n v e n t i o n a l l y masculine type, such as working w i t h a saw and some wood. As they enter the p l a y room i n t h i s i n t e r v i e w , the t h e r a p i s t and Teddy f i n d some face powder and n a i l p o l i s h l y i n g on the t a b l e . The d i s c u s s i o n that f o l l o w s i s quite i n d i c a t i v e of Teddy's am-b i v a l e n t f e e l i n g s towards masculine and feminine p u r s u i t s . We then went i n t o the p l a y room and Teddy s a i d , "Oh, t h i s s t u f f " ( r e f e r r i n g to the face powder and n a i l p o l i s h l y i n g on the t a b l e ) . The worker wondered whether they should put i t away and get something to b u i l d ? "No", s a i d Teddy, "I'm going to throw i t out". He then took the n a i l p o l i s h r e -mover and went over t o the s i n k and poured i t a l l out. He came back to the t a b l e and took the red n a i l p o l i s h which he emptied i n the same manner. "Looks l i k e blood", he commented. "But i t ' s only n a i l p o l i s h " , the worker s a i d , and added "Now the g i r l s who come down here w i l l not be able to use the s e t " . Teddy made no comment. The n a i l p o l i s h had made a red b l o t c h on the top of the s i n k . Teddy then dumped the face powder i n t o the s i n k and comm-ented "This i s g i r l i s h s t u f f . I t shouldn't be here". The t h e r a p i s t ' s response i n the matter of the n a i l p o l i s h , and Teddy's r e a c t i o n to the feminine a r t i c l e s , might have been handled d i f f e r e n t l y . At the p o i n t where Teddy dumped out the n a i l p o l i s h , the t h e r a p i s t might have comment-ed that "sometimes boys didn't l i k e g i r l s at a l l , but other times there was something about the thi n g s they used that was a l o t of fun. That was a l r i g h t , and sometimes boys and g i r l s enjoyed games that involved both g i r l s and boys toys". The t h e r a p i s t ' s suggestion t h a t Teddy was destroying a r t i c l e s which belonged t o the opposite sex might have been l e s s - 115 -threatening, had he added that i t was alright for Teddy to destroy the polish, and i t would be possible to replace i t . Such a remark would have accepted the boy's hos t i l i ty and fear of the opposite sex, without making him overly cons-cious of his action to the point where he might become an-xious. There was a month's interval in the therapy over the Christmas holidays, and when Teddy returned to the ag-ency, another male therapist took over the treatment. This change of workers represented the third transfer in a space of five months. The fact that l i t t l e progress was made during this period, would be part ia l ly due to the shifting of therapists. The handicap in the whole situation was that there was l i t t l e consistent treatment and a shortage of trained therapists. While the experience of adjusting to new. people, and probable feelings of being deserted by friends', may have been a hazard in the treatment situation, i t is possible that the addition of positive relationships with several adults would be valuable, in terms of rea l i ty experience. If Teddy had had the security of being accepted in a treatment centre or specialized foster home with the same people, his feeling of complete loss would have been less . The new therapist had d i f f i cu l ty in establishing a relationship, Teddy is not sure of his acceptance by the therapist, and his insecurity is shown at the end of the Fifty-Sixth interview. It was now near the end of our hour, - 116 -and I suggested that we put the toys away and have them to play with next time. Teddy kept on working at the spurs, and seemed to be in no way ready to leave. He avoided me several times when I suggested that there was another boy waiting. F ina l ly I suggest-ed that the other boy was rea l ly anxious to get i n , and we had better put the things away. Teddy continued to resist the idea of leaving. The boy wanted to take some of the materials with him. The therapist refused to permit this , and Teddy f i n -a l l y said "no, leave them a l l here for the other boy to play with" , as he rushed out of the room. This excerpt is an example of poor play therapy technique in dealing with a ch i ld . Teddy undoubedly fe l t quite insecure in the whole situation. The therapist was new, and the boy was very unsure of whether he was accepted. The therapist might have said, when Teddy showed anxiety and did not want to leave, " I know how much you are enjoying the play, Teddy. I am enjoying being here with you, for I l ike you very much but our time is up and we ' l l have to continue next time. There is another child coming i n , and i t is his turn now, but that does not mean that we won't have lots of fun next time in the hour that is especially yours". As Teddy showed such a strong desire to take some of the toys with him, on this particular occasion when the boy's need for acceptance and a show of warmth from the therapist was so great, some relaxation of the rule might have been made. Permission to take some small ar t ic le from the play room at this particular point, where so much anxiety was - 117 -shown, might w e l l have been g r a n t e d . I n s t e a d , Teddy's r e a l g r i e f and f e e l i n g t h a t he i s b e i n g r e j e c t e d i s i n d i c a t e d by h i s comment "No, l e a v e them a l l here f o r the o t h e r boy t o p l a y w i t h " . The p s y c h i a t r i c comments on t h i s i n t e r v i e w i n d i c a t -ed t h a t e v e r y e f f o r t s h o u l d be made t o have Teddy f e e l t h a t he was the o n l y boy i n the scene, and t h a t any r e f e r e n c e t o o t h e r c h i l d r e n s h o u l d be m i n i m i z e d . The t h e r a p i s t makes an e f f o r t t o w i n Teddy's a p p r o v a l t h r o u g h a s m a l l g i f t o f candy and the c h i l d r e a c t e d t o t h i s by a c c e p t i n g the g i f t r a t h e r g r e e d i l y , showing h i s need f o r a g e s t u r e of warmth and l o v e f r om the wo r k e r . I n I n t e r v i e w F i f t y - E i g h t , .Teddy b r i n g s out a d d i t i o n -a l f e e l i n g s about the l i t t l e g i r l s who come t o the playroom. T h i s e x p r e s s i o n f o l l o w s an i n t e r v i e w i n which he becomes more secure w i t h the t h e r a p i s t . He put the bag o f candy i n h i s p o c k e t , and walked over t o the s h e l f where he s u d d e n l y d i s c o v e r e d some of the c o s m e t i c s t h a t were used by the g i r l s . " I don't want the g i r l s t o have t h e s e " , he s a i d i n q u i t e an i n d i g n a n t v o i c e , and i m m e d i a t e l y proceeded t o dump them o u t . The t h e r a p i s t e n q u i r e d why he d i d not want the g i r l s t o have them. Teddy r e p l i e d , "Oh, I don't want them around. They t r y t o make themselves l o o k p r e t t y . They are u g l y . I don't want them t o be a b l e t o do t h a t 1 . He t h e r e u p o n t o o k a b i t of l i p s t i c k and threw i t on the f l o o r , g r i n d i n g i t i n t o the cement q u i t e v i c i o u s l y . He d i s c o v e r e d a b o t t l e o f t o i l e t water and proceeded t o pour i t o u t . "Don't you t h i n k some of the g i r l s would l i k e t o have t h a t ? I t b e l o n g s t o them". " I don't c a r e " , he s a i d , " t h e y ' r e u g l y and - 118 -they're not going to have a chance to f ix themselves up". He brought the to i le t water over to me, and also a l i t t l e jar. He poured some of i t in there and said "You smell i t " . I did and said "My, i t smells quite nice" . He said "Smell i t again", and then he took the l i t t l e jar and put i t down saying, "I'm going to give this to them. They can have some of th i s " . The inter-play of feeling in this passage was quite' s ignificant. As the therapist expressed approval of Teddy through the gift of candy, the boy was able to direct his hos t i l i ty towards the opposite sex in the matter of the cos-metics. An acceptance of.the hos t i l i ty and the suggestion that perhaps the perfume real ly was quite nice, permitted Teddy to relax his hostile feelings, and be more permissive of the feminine ar t ic le s . It was reported at this point, that Teddy had been having some severe disturbances at school around the question of bowel movements and to i le t training. The psychiatrist f e l t that these were indicative of his protest against mas-cul in i ty and.also his struggle to prove himself. The ther-apist arranged to have a small chamber in the play room when he arrived, and also a baby's stool with an opening in the seat. When Teddy arrived, he rushed right into the play room and seemed to be in very good sp i r i t s . It was noticed that he smelled very strongly of urine, and soon the room was quite over-powered with i t . It did not seem to worry him. He put the gun belt on, and then sudden-l y said, "I've got to go to the to i l e t . Come with me". As we walked down the h a l l I said "Why didn't you use the l i t t l e pot?" "Oh, that's for babies", - 119 -he said, "and I'm not a baby any more. It 's too small". Teddy's hesitancy in identifying with the mas-culine sex, as well as his desire to make a relationship with boys, is i l lustrated in Interview Sixty-Three. The therapist has complimented Teddy on the nice hair-cut he has just had. "It ' s a pretty good haircut, Teddy, and you certainly look pretty nice today. You look pretty happy too". "Oh," he said, " i t ' s a lr ight , but we s t i l l don't play together. I play by myself and I won't play with those other boys". Teddy continues, however, to show a great interest in baseball, and is able to express many of his frustrated feelings, as his interest in boys' games is encouraged. "Let 's play b a l l " , he said and proceeded to hunt around unt i l he had found a baseball. "Strike One!" he cr ied. Then he went to Strike Two and Strike Three. "Novr i t ' s your turn", he said, and we changed. We played quite an active l i t t l e game back and forth, and then f i n a l l y he said "I'm going to eat my chocolate Easter rabbit" , and went back into the play room. As he was eating his rabbit, he discovered the wooden mallet of the croquet set, and then dug out the iron drums. He had a grand time beating i t very fer-ociously unt i l the head of the wooden mallet flew off. He was greatly pleased at this , and laughed heart i ly , saying "I didn't think I could break th i s " . He then proceeded to f in i sh up his chocolate egg. The psychiatrist fe l t that Teddy was making a great effort to show himself as a male and was therefore trying to control the play room situation. He was ordering the therap-i s t around a great deal, so that he might feel himself to be a big boy. It vas believed that as these games were played, - 120 -'Teddy should be encouraged to express his feelings about them. At the same time that the therapist encouraged Teddy towards masculine pursuits, the transference becomes deeper, and the boy shows signs of an awakening identi f ica-tion with the therapist. This is indicated in Interview Sixty-Five when Teddy says, in the course of the play, "You're my daddy. You've come to v i s i t me. Do you l ike cocoa? Anyway, our play time is nearly up. Now I'm going to v i s i t my Mum". The therapy with Teddy is s t i l l underway. The male therapist is gradually establishing a relationship with the ch i ld , and he is becoming more confident in his approach to the male sex. Teddy is s t i l l l i v ing in the Receiving Home, and there are no immediate plans for placement. He i s , however, adjusting to a much better degree in his r e l -ationships at the Home, and is showing improvement in his a b i l i t y to play more comfortably with the other boys. It is quite possible that Teddy w i l l never make a normal ad-justment to society, but he' has received a sufficient amount of security through the therapy relationship to carry him over an average amount of l i f e frustrations. The prognosis in this case is a doubtful one, for the child was in a near-psychotic state when treatment was undertaken. The therapy w i l l be continued for an indefinite period, probably at least unt i l such point where i t is poss-ible to place him in an adequate foster home. The d i f f i cu l ty with this boy, insofar as the therapy was concerned, lay in - 121 -a proper evaluation of his progress. The degree of im-provement shown in the child from the time he commenced therapy, produced an overly optimistic attitude in regard to placement. Quite possibly, also, the type of foster homes were not given enough consideration. The result of the optimism was that Teddy was placed in foster homes too hast i ly , and in each instance, the resultant failure in placement had a negative effect on the gains effected through the therapeutic process. The records do not provide sufficient information regarding the foster homes, but i t is quite possible that the process of 'masculine ident i f icat ion' could have been carried on with greater success in an 'accepting' foster home with understanding parents. The conclusion from this particular situation seems to be quite obvious. As a chi ld with strong paran-oidal trends, Teddy required the most careful selection of foster parents capable of meeting his needs. Furthermore, although the records are not too concise in this regard, there was an unexplored background of homosexual seduction in Teddy's early history. Such a combination of deep pro-jected h o s t i l i t y , and experiences of a homosexual nature would require both an exceptionally warm mother person, and a particularly kind and understanding father. The inst i tut ional setting is quite inadequate for Teddy, and the main support he receives is through the ther-apy relationship. Few, i f any, foster parents would have the s k i l l to deal with a chi ld who has suffered such early - 122 -deprivations, as Teddy had received by the time he was f i r s t accepted into care. Therefore, the answer, for i n i t i a l care, l ies , in another area, that of an inst i tut ional setting, staffed v/ith trained people capable of providing the support-ive medium so essential to such a chi ld ' s progress. In addition, there is a great need for consistency in the treatment of a disturbed ch i ld . The therapy records indicate a far too 'hit-and-miss' selection of therapists. Teddy's treatment was carried on from October 1*+, 19^9? to the date of writing, which represents a period of approxim-ately a year and a half . During this period, he has had four therapists. It is questionable, when the second and third therapists were introduced, whether the boy was ready to enlarge his number of relationships. Each change, when a new therapist was introduced, would constitute to Teddy a further rejection by an adult world, of v/hich he already had a deep suspicion. The reasons for the large turnover in therapists were undoubtedly r e a l i s t i c , from the point of view of ava i l -a b i l i t y of trained people. However, as no project can go beyond the s k i l l s of the personnel operating i t , there is an obvious conclusion to be made; that i s , when a disturbed child is to be given treatment through a special technique, that technique to be effective, must be consistent in method and administration. The cr i t ic i sm involved in this last statement does not l i e in the fact that Teddy was transferred from a female to a male worker, for this was deemed essential in the phase of his development, where male identif ication - 123 -was so necessary. It l i e s rather in the choice of the third therapist who was selected to work with Teddy. This therapist was an experienced person in the f i e l d , but com-pletely lacking in therapy training. The r i sk taken in this selection was too great, and direct ly opposed to the principle that a therapy specialist should be thoroughly trained, and particularly ski l led in direct treatment work with children. In undertaking therapy as a specialty, too, workers assume a responsibil ity for continuing practice and proper timing of treatment so that no treatment process is abruptly cut off. After the change of therapists this child seemed to have regressed to an earl ier stage of development. Thus, the constant change of therapists in this case is an i l l u s t -ration of poor therapy practice. Because of the shortage of trained personnel, play therapy in the agency is carried on in a too intermittent fashion, a fact of which the staff is f u l l y aware. This awareness of necessary limitations in the technique, is a positive factor in the whole situation. However, .within these limitations there is scope for improve ment. When a particular s k i l l such as therapy must be l im-ited, and administered on a supportive rather than truly therapeutic l eve l , special attention must be given to u t i l -ization of other principles . Although the operation of treatment may be held to a supportive l eve l , such treatment should be consistent insofar as choice and sk i l l s of therapists is concerned. Therefore, the whole of this discussion centers on f i r s t l y , - 12U- -the need for extensive training of therapists to improve the treatment process, and secondly, where the level of treatment cannot be raised, due to the rea l i s t i c shortage of personnel, within this l imitat ion, s t r ic t attention should be given to provide the most consistent s k i l l ava i l -able. The child in this case, should not have been trans-ferred from one therapist who showed considerable understand-ing of his needs to a therapist who had no training in ther-apy, particularly at a point where the factor of relat ion-ship was so important. Very positive results were shown in Teddy's case. From a point at the beginning of treatment, when he was a confused l i t t l e boy, f u l l of bitterness and hate towards what he conceived to be a hostile world, he moved, through the supportive relationship provided in the therapy, towards a far more normal adjustment. The movement in this case was slow, but this was to be expected. The important thing in this instance was the method used. There was actually a minimum of interpretation on a play therapy leve l , but con-siderable re l iv ing of early feelings in this more accepting environment. Rather, the method encompassed what is consid-ered to be more of a 'play-interviewing' s k i l l . The child was able to make such tremendous advances through this more superficial method of therapy that the conclusion is obvious. That i s , when- such advance can be made on the supportive level of 'play-interviewing', the advance could be greatly fac i l i ta ted were other resources more fu l ly u t i l i z e d . These resources would include the use of potential casework s k i l l - 125 -in the agency to make adequate environmental arrangements. It is believed that i f the casework staff of the agency were in closer contact with the therapy project, and had a deeper understanding of the interaction of casework and therapy, more positive results could be attained. Potential case-work sk i l l in the agency is undeniable, but until there is an attempt made to coordinate good therapy with efficient home-finding, and continuous help given to foster and own parents so that they may understand and accept the therapy step by step, play therapy is being carried on ' in a vac-uum' . A Case illustrating the Results of Casework with a Parent An outstanding example of the proper interplay between therapy and casework practice is illustrated in a case which first came to the agency in June, 19 -^8. Such a combination of play therapy and excellent casework with the parents of the child, is highly desirable and points up the important role played by each. Mrs. Peters f irst requested placement of her daugh-ter, Carol, aged six years, on the above date. Emergency financial help was given through referral to another agency, and the case was closed until January, 19*+9> when Mrs. Peters again asked help in planning for Carol, who she stated, was a behaviour problem beyond her ability to handle. A description of the reasons for admission of the child to agency care stated that Carol was an illegitimate child whose mother was .severely neurotic. She had lived with - 126 -her mother for only four months during the last seven years. She had been placed in numerous private boarding homes where the people refused to keep her more than a couple of months, because of her behaviour. It was believed that Carol was completely rejected by her mother whose guilt would not allow her to give up the chi ld completely. Carol was placed in non-ward care, March, 19^9• The worker, in a series of interviews with Mrs. Peters, the boarding home mother, and the school teacher, gathered det-ailed information regarding the situation. It was found that Carol's relationships with people were of a superficial nature. From her history and her mann-er, i t was gathered that she was a child who had always been made to conform to rules, and had at the same time in a subtle way, been rejected by her mother, and indifferently treated in the various private boarding homes in which she had been placed. As a result , she had come to view the ad-ult world as being composed of adults who, for reasons of their own, imposed rules to which children must conform, not out of wish but out of necessity. She shov/ed an exaggerated interest in her health, but a neurotic need to do things which endangered i t . Altogether, she alternated between dis-obeying and feeling great guilt for her disobedience. The psychiatrist diagnosed Carol as suffering from what is known as a compulsive adjustment. The mother identified with Carol on a d i s t inct ly neurotic l eve l . Mrs. Peters' history indicated a f ixation on a severe, harsh father, which was intensified in her marriage - 127 -to a drug-addict, some twelve years older than herself. The marriage collapsed after a short time, and i t was dur-ing the next four years that Carol was conceived as the result of a common-law relationship. The caseworker maintained contact with both the mother and chi ld , during the two years which followed and to the date of writing. The mother has been able, through the casework relationship established with the worker, to verbalize many of her problems. She has been able to exp-ress her deep hatred of a l l men, and also her ambivalent feelings towards Carol. The worker's acceptance of her deep-rooted hos t i l i t i e s has provided a supportive base, through which she has taken some i n i t i a l steps towards an acceptance of her feminine role , and her responsibil i t ies as a mother. The casework process has emphasized Mrs. Peters1 own needs, and the approach has been to concentrate on bui ld-ing her ego to a point where she can give up Carol, by stress-ing the real courage i t would take to do thi s . Throughout the therapy with Carol, the method has been one of counteracting Carol's deep sense of inadequacy, and helping her discover her own worthwhileness as an ind-iv idual . It was realized that Mrs. Peters would never be able to provide Carol with a sense of her own worth, and that the child must obtain the acceptance so essential to her personal development from other sources. As long, how-ever, as the neurotic tie with the mother remains, any - 128 -p l a n n i n g i s d i f f i c u l t . Through the s u p p o r t i n g r e l a t i o n s h i p p r o v i d e d , M r s , P e t e r s has moved t o a p o i n t where t h e r e was a l a p s e o f some seven months i n her d e s i r e t o s e e . C a r o l . The c h i l d , s i m i l -a r l y , e x p r e s s e d no d e s i r e t o v i s i t the m o t h e r , and has been l i v i n g i n a good f o s t e r home where the p a r e n t s w i s h t o a d -opt h e r . The casework p r o c e s s i s s t i l l underway, b u t i t i s hoped e v e n t u a l l y t o b r i n g M r s . P e t e r s t o a p o i n t o f s i g n -i n g the c o n s e n t t o a d o p t i o n . The t h e r a p y w i t h C a r o l l a s t e d from September, 19U9? t o J u n e , 1950, d u r i n g w h i c h time she grew c o n s i d e r a b l y i n c a p a c i t y f o r r e l a t i o n s h i p s , and i n h e r c o n f i d e n c e i n the a d u l t w o r l d . Had C a r o l remained w i t h h e r m o t h e r , d e s -p i t e a l l b e n e f i t s t h a t t h e r a p y might have o f f e r e d h e r , such an improvement \tfould have been d o u b t f u l . T h u s , i t i s p o s s -i b l e t o see t h r o u g h t h i s example, how c l o s e l y i n t e r w o v e n a r e the p a r t s p l a y e d by the t h e r a p y i n d e v e l o p i n g and h e l p -i n g a c h i l d , and the casework p r o c e s s i n p r o v i d i n g the e n -v i r o n m e n t i n which r e s u l t s produced by the t h e r a p y may b e s t be m a i n t a i n e d . The need f o r casework i n a l l i n s t a n c e s i s e q u a l l y e s s e n t i a l t o the e f f e c t i v e movement o f the p l a y t h e r a p y t e c h -n i q u e , whether i t be a case w h i c h i n v o l v e s i n s t i t u t i o n a l c a r e or f o s t e r p a r e n t s , one o f the most i m p o r t a n t f a c t o r s l i e s i n the casework a p p r o a c h t o the t o t a l s i t u a t i o n . I n the case o f i n s t i t u t i o n s , the s t a f f o f the i n s t i t u t i o n s h o u l d be c h o s e n f o r t h e i r a c c e p t a n c e o f c h i l d r e n , and t h e i r a b i l i t y t o be warm as w e l l as f i r m . They s h o u l d be t r a i n e d t o the T 129 " f u l l extent of their capacity to assimilate such t r a i n i n g , so that they provide the proper background for treatment. S i m i l a r l y , i n the instance where a c h i l d i s being placed i n a home, i t i s absolutely es s e n t i a l that e f f i c i e n t casework be done so that the needs of the c h i l d are made clear to the parents, and at the same time an accurate evaluation i s made of the par t i c u l a r strengths and weaknesses of the par-ents to ascertain the suitableness of the placement for both. A Case i l l u s t r a t i n g the Results of Inadequate Casework An example of i n s u f f i c i e n t casework planning for a c h i l d i s found i n the case of Joan Brown. This g i r l was made a ward of the Childrens Aid Society August 18, 19*+7> when she was six years old. Very l i t t l e i s known of the b i r t h and early dev-elopment of Joan, except that she was the i l l e g i t i m a t e c h i l d of a thirty-four-year-old woman who was badly crippled with a r t h r i t i s . For the f i r s t four and a half years of her l i f e , Joan and her mother l i v e d with her maternal grandparents, who were both i n the i r middle seventies. The c h i l d seemed to have had a very close relationship with her mother during th i s period. The following year, Joan's mother married a seventy-five-year-old man who was described as being rather eccentric. Later information regarding t h i s man, revealed that there had been some incidents i n which he was accused of molesting children. Although the records i n thi s connection are i n -d e f i n i t e , there was some doubt as to what extent Joan might - 130 -have been affected. The pattern of rejection commences, insofar as the records are concerned, from the point of Joan's mother's marriage, for the stepfather had no interest in the child and completely ignored her after her mother's death August, 19^-7. Following her mother's death, Joan was placed for varying periods in three different foster homes, and then in the present home where she is s t i l l l i v i n g , during the month of March, I 9 U 9 . During placement in the f i r s t three homes, Joan's reaction pattern proved to be the same. I n i t i a l l y , in each home she seemed to settle down quite wel l . Once, however, she fe l t herself to be accepted in the home, the same beh-aviour, namely, crying spells , commenced. The foster par-ents in a l l the homes, found Joan to be a very sensitive child who cried for no apparent reason. In the case of each placement, the foster parents are described in the records as being warm, accepting people, interested in having Joan and anxious to help her towards becoming more outgoing. It would seem, however, that they were not prepared for a, per-iod of regression, a phase during which Joan ' tr ied them out' , after an i n i t i a l period of 'good behaviour'. These f i r s t three placements showed situations in which Joan was subject to many colds, and required a great deal of attention. There would seem to have been insufficient preparation of the prospective foster parents for the fact that here was a child who would, for a considerable period of time, represent a great strain on their ab i l i ty to give. - 131 -Of these three placements, two were situations in which there was another child in the home several years older than Joan, and in both of these homes, the comparison bet-ween the two children placed Joan at a disadvantage. The parents seemed unable to understand that Joan was a younger ch i ld , tied emotionally to her own mother, v/ith a great need for a strong mother relationship. The inadequacy of casework with the foster parents le f t them unprepared for Joan's reactions. Thus?*:, three times the chi ld was moved from one home to another, show-ing less outward feeling v/ith each move, and becoming more conforming at f i r s t , in each situation. Her one outlet was her crying spells , which became more and more intensive during the repeated placements unt i l the fourth move was anticipated. The last move placed Joan in the home of a kindly, middle-age couple. By this time, Joan was a very subdued ch i ld , eight years of age. The foster mother approved of this type of ch i ld , for she said she did not l ike a 'bold' ch i ld . This danger signal should have been evident as this placement was contemplated. Shortly after Joan was placed in the home the worker made a v i s i t . During this v i s i t , foster mother told the worker that there had been d i f f i cu l t i e s at f i r s t with Joan's crying, but now everything was f ine. Foster mother said she had asked Joan i f she had a mommy and daddy, and when she replied "no", they had told her they v/ere her mommy and daddy now, and that since she had nov/here else to go she might as well learn to 'obey' their - 132 -wishes, one of which was that she did not cry without a reason. Foster mother stated that this had seemed to solve the problem. The foster mother was quite satisfied with the re-sult of her ultimatum, but i t is hard to estimate the eff-ect of the added strain on Joan's personality when she was deprived of her only remaining outlet for feelings, by the threat of being wholly cast out. The psychiatrist has considered Joan's case from a l l points of view. The interpretation given, describes Joan as a very disturbed child with an obsessive-compulsive pattern, and a deep, neurotic f ixation on her dead mother. As the various placements were considered, a psychiatric explanation was offered for Joan's behaviour. The normal drive to be loved and accepted showed in her f lexible be-haviour at the beginning of each successive placement. Once she fe l t she was accepted, her neurotic tie to her mother began to operate, and she fe l t unable to accept the warmth and love that were hers for the taking. She reacted by crying and an exhibition of deep dependency, which did not show i t s e l f in affectionate responses to the foster parents, but as an unhappy clinging f r i g i d i t y . The parents reacted to the lack of response in the child by feeling themselves burdened by a personality that did not show feelings, but Instead seemed l ike a clinging milestone around their necks. With each replacement then, Joan suffered a punishment for her own desire to relate, and became more deeply fixated on her own mother who had also deserted her through dying. - 133 -U n f o r t u n a t e l y , there was l i t t l e i n i t i a l attempt to draw Joan out a t the time her mother d i e d , and w i t h each r e p e t i t i o u s experience of r e j e c t i o n by a mother person, the f i r s t g u i l t r e a c t i o n became more deeply imbedded. Through casework treatment, Joan might have been helped to give up her n e u r o t i c t i e t o her mother and accept the a f f -e c t i o n of f o s t e r parents who had been helped through case-work, to understand her need to ' c l i n g ' , to r e g r e s s , and to t r y out t h e i r l o v e before a c c e p t i n g i t . Joan w i l l , i n a l l p r o b a b i l i t y , grow up t o be an i n h i b i t e d woman, unsure of the boundaries of her own per-s o n a l i t y , and unable to form a normal r e l a t i o n s h i p w i t h other people. Completely l a c k i n g i n her background, i s an adequate f a t h e r r e l a t i o n s h i p . An i n t e r e s t i n g i n c i d e n t t h a t took place d u r i n g the present placement, concerns Joan's r e a c t i o n t o an ear i n f e c t i o n s u f f e r e d by her f o s t e r f a t h e r . The f a t h e r r e c e i v e d a great d e a l of a t t e n t i o n d u r i n g t h i s i l l n e s s , and s h o r t l y afterwards Joan complained of a sim-i l a r d i s a b i l i t y and i n s i s t e d on being g i v e n s i m i l a r a t t e n -t i o n , d e s p i t e the f a c t t h a t there was no organic b a s i s . Joan complies completely w i t h her f o s t e r mother's d i c t a t e s and r a r e l y shows the s l i g h t e s t i n t e r e s t i n an agg-r e s s i v e impulse. During puberty, when the sexual c o n f l i c t s are r e a c t i v a t e d , i t i s probable t h a t t h i s c h i l d w i l l r e a c t by an even deeper r e p r e s s i o n of her a g g r e s s i v e i n s t i n c t s . There would have been a good chance f o r Joan's adjustment, had her p e r s o n a l i t y been r e a l l y examined a f t e r her mother's death. At t h i s time, and even d u r i n g the f i r s t - I3h -and second placement, her personality rating was found to be within the normal range when examined at the Child Guid-ance C l i n i c . Now, however, grave damage has been done, and the psychiatrist 's analysis of the case indicates a very poor prognosis. Joan could be treated through play therapy. It would, however, be a long slow process, and one for which she would have to be moved from the present r i g i d , uncom-promising home. Where is a home for a chi ld such as she is now, to be found? Possibly i t does not exist . She is being well-cared-for physically in the home where she now l ive s , but her emotional reactions are becoming more l im-ited as the months go by. An inst i tut ional setting, where the staff were trained to understand Joan's need to comply, could provide the medium for play therapy treatment. The therapy would be long and t i r i n g , but through a process of complete acc-eptance from a mother person, the deep repressions which so long have existed in the chi ld ' s inflexible l i t t l e psyche, might be gradually released. This case indicates how greatly treatment is needed. Unfortunately, however, the responsibil ity for Joan's pre-sent disturbance could have been avoided to a considerable degree. If there had been a diagnostic centre, where Joan's problems could have been evaluated at the time of her moth-er's death, an attempt would have been made to understand her needs, and to plan to meet them. Even without such a - 135 -centre, thorough diagnostic study and specific diagnosis and planning can, and should be done, when a child i s ad-mitted to care. It is unfortunate that many placements of children are made on an emergency basis, by personnel hamper-ed both by heavy caseloads and lack of specialized diagnos-t i c s k i l l . In this chapter, Teddy's case, where play therapy was used, i l lustrated the great progress that can be made with a disturbed ch i ld , while Carol's case was an example of the results to be obtained from excellent casework with a parent, so that the proper medium for treatment may be provided. Joan's case, however, is somewhat different. The damage has been done to a great extent, and there are inad-equate resources to counteract i t . The play therapy project is necessarily l imited, for there are few funds available, and fewer sk i l led therapists to carry out the intensive supportive relationship needed to help her. What w i l l happen to Joan? How can the resources be obtained to provide environmental treatment for her, dur-ing the long and time-consuming period that play therapy w i l l be necessary? It is so important that she be offered a rea l i ty of constant, warm relationship, with adults pre-pared to meet her needs, when therapy has helped her become able and ready to accept i t . Chapter VI The Play Therapy Project in Review Play therapy has been defined earl ier in this study as beginning with the use of play as a medium, through which the chi ld in the process of playing, may convey to the therapist symbolically and in verbal form, his conscious and unconscious feelings about his environment, himself, and the relationship he feels to those about him. The relationship set up by this process provides a medium for making cons-cious the unconscious trends and drives, and for recreating the past, in order to release anxiety bound up with these earl ier experiences. However, to be always remembered is that the therapist's real responsibil i ty l i e s in helping a chi ld to do what he is free or ready to do, without trying to force him into any particular channel of expression. The therapy project at the Childrens Aid Society represents a pioneer attempt to in i t ia te this type of treat-ment in Vancouver. Therefore, a brief discussion of the ther-apy cases used in this study w i l l be made from a theoretical aspect, in order to determine the measure in which this pro-cess coincides with the basic concepts of the technique. The case of Tommy Snyder, chosen as an i l lus t ra t ion of a chi ld with an extreme conduct disorder presents a s ig-nificant example of excellent technique. In Chapter I, a quotation from Jessie Taft indicated that "to practice thera-peutic casework, one must be a therapist". The therapist who worked with Tommy exhibited the utmost s k i l l in her cap-acity to permit the use of herself, as well as the use of psychological insight and technical s k i l l . I n i t i a l l y , this chi ld showed extreme sexual act iv i t ies and generally a poor adjustment to his environment. Through the relationship ex-tablished in the therapy medium, Tommy became secure enough to express his innermost feelings about sexual matters. As these unconscious trends and drives were acted out in the playroom setting the therapist was able, through her in tu i t -iveness and technical s k i l l , to correct many of the miscon-ceptions which were the basis of Tommy's d i f f i cu l t i e s . This technique is i l lustrated over and over again throughout the therapy and, as the chi ld i s encouraged to express his agg-ressive sexual feelings in a relationship which is permiss-ive and warm, he becomes less threatened by anxiety in this area. The therapist was able to direct the play interviews along l ines profitable to Tommy without obstructing his spontaneity. Although at a l l times the therapist indicated an awareness of unconscious material, she dealt only with the repressed material that came into consciousness as a result of the permissive atmosphere of the therapy situation. The past, with Tommy, was recreated to the extent that his early oral deprivations were dealt with on a rea l-i s t i c , satisfying basis. He was permitted to regress to a level in which he received oral satisfactions through act-ual ly being fed with a bottle l ike a small baby. The pur-pose of this ac t iv i ty was to endeavour to give him pleasures -138 -which had quite evidently been insufficient in earl ier years. As he satisfied himself at this l eve l , he was more emotionally free to move on towards a maturer phase. Tommy was allowed to feel powerful in the play room setting. He was permitted to express his destructive impulses, the only l imi t being situations which might rep-resent bodily harm to himself and the therapist. As he found that he was not being overwhelmed in the relationship, he was more able to conceive of a world in which he did not have to be all-powerful to survive. The l imits that were set were ones which gave the chi ld the security to be. agg-ressive and host i le , and yet maintained enough equilibrium so that he need not be fearful of his own destructive-urges. As there was no controlled environment for Tommy outside of the playroom, in this case the chi ld was permitt-ed to carry gifts and toys out of the room so that he would be given an extension of the relationship to carry him through day-to-day experience. Ordinarily such a procedure is not considered to be good therapy technique, for an att-empt i s made to confine the act iv i t ies connected with the playroom to the interview hour. Summarizing the techniques used in this case, i t i s found that the therapist used her own particular person-a l i t y to the ful lest extent, directed the type of material produced in a beneficial manner, set up only such prohibi-tions as were necessary, and most important of a l l , helped Tommy to develop insight into the reasons for his d i f f i c u l t i e s , -139 -thus aiding him to clear up the misconceptions that con-fused him. Noteworthy, too, was the therapist's freedom from fear of accepting Tommy's primitive impulses. The type of techniques used by this therapist have been described i n i t i a l l y in this study as requisite to good play therapy practice. It is evident then, that this case f u l f i l l s in large measure the tenets that are extremely de-sirable in a treatment process designed to help disturbed children. This case, i t w i l l be remembered, was handled by a thoroughly trained therapist and the other therapy cases are evaluated from the point of view that subsequent workers had less opportunity to acquire the same degree of s k i l l . In this connection, the case of Jennie Morton was carried on by a worker who learned the technique after the project had started. For this reason, the movement is less forceful , as working with disturbed children. is a precarious matter, and the less technical training possessed by the therapist, the more caution must be employed. Quite r ight fu l ly , the treatment was very closely supervised by the consultant psychiatrist , and unt i l the point in therapy training is reached that permits a greater f lex-i b i l i t y , i t is necessary for the process to be closer to 'play interviewing*. Logical ly, as therapy s k i l l in the ag-ency is more developed, the therapy would be directed to a level nearer to actual 'play therapy'. However, as the case of Jennie Morton was unfolded during the thirty-four interviews which have taken place to -1**0 -the present time, i t became quite evident, through the therapist's a b i l i t y to make a relationship with this with-drawn c h i l d , that basical ly the therapist possessed those intangible qualities of intuit ion and sensi t ivi ty . Without these qualit ies , no therapist can f u l f i l l the deepest thera-peutic function. Thus, as repressed l i t t l e Jennie Morton was able to express her real ization that her foster mother did not rea l ly care for her, she was releasing at least a part of the anxiety that had hemmed her in for so long. The overly r ig id training which the child had rec-eived could not be handled within the play room. Conseq-uently, the agency's action in f i r s t l y obtaining guardian-ship, and secondly preparing to remove her from the home, represented a most economical move, in terms of eff icient use of therapy resources. This action points out the nec-essari ly close working relationship between therapy and casework with parents. The tendency in this age of concen-trated treatment, is to neglect adjacent areas from, which resources may be drawn. The family situation represents such an area, and where the conflict within a home is des-tructive to the therapeutic process, there is a wastage of resources. Hence, a decision must be made as to the most log ica l method of procedure. Jennie Morton received a great deal of supportive help through the therapy. As the psychiatric comments ind-icated from time to time during the interviews, a deeper eon centration on her problems is advisable. Such an intensif-ication of treatment w i l l be possible as she is given the less personally threatening background of the Receiving Home. The process, in future, should be designed to bring out more of her fantasies, and gradually to interpret the meaning of her fears in such a way that she becomes more aware of her own feelings and of what other people rea l ly feel for her. The relationship which the therapist now has with Jennie, should permit the chi ld an emotional freedom in which she can slowly focus on the present situation and free herself from the frustrations of the past. The therapy process, with Jennie, is just underway. Through the play room medium, the unconscious trends and drives are coming closer to the surface. The chi ld ' s ex-pression of feeling in regard to her foster mother's cold, unaffectionate response, represents the start of recreating the past. However, the second phase of therapy, in which, through real l i f e experience, some of the early deprivations are sat isf ied, is yet to come. This can be accomplished through the warm emotional experience Jennie receives in her play therapy treatment which should enable her to accept real l i f e emotional exchange in a carefully chosen foster home. The d i f f i cu l t i e s involved in dealing with a child of this type have been described earlier, as ones which go back to a very early level and which have to a great extent, affected the whole pattern of her early development. The main point to be brought out is the fact that a definite start has been made in helping a chi ld vrhose experiences have not been of a s tr ikingly traumatic nature, but rather of the - Ih2 -variety that warps through consistent and monotonous day to day l i v i n g . The therapy which was carried on with Teddy Lawson represented an equally slow moving type, but the development of this chi ld had taken a more spectacular nature due partly to the persistency with which the adult world seemed to have rejected him. Teddy was a chi ld who showed d i s t inct ly paranoidal trends. As a part of this pattern, he was deeply suspicious of a l l adults and anticipated harm from outside forces. His h o s t i l i t y towards people was of such a deep nature that he was unable to face the destructive urges within himself, and hence had to project his unhappiness on other people as the cause of his trouble. The diagnosis, as stated in the chapter describing Teddy as a child possessing deeply neurotic t ra i t s , stated that in order to get him to accept the fact that i t was safe to l ive in a world where people were equal, i t was necessary for him to understand his overwhelming fear;and ex-amine the reasons behind i t . This was a large order, ca l l ing for a great deal of s k i l f u l therapy. The therapist worked very carefully with Teddy. His hostile impulses knew few bounds, and time and again he became exceedingly disturbed as the therapy progressed.. His fury expressed i t s e l f in the continual smashing and destruc-tion of play room equipment. As these forces were unleashed, and he found the therapist able to accept them and yet retain sufficient control so that the situation did not overwhelm -him, some of the fury within him subsided. It is possible to trace this process throughout the therapy records described. This procedure required considerable s k i l l , in man-ipulating the situation to permit sufficient draining of im-pulses to be beneficial , while at the same time estimating the degree to which the action would be harmful to the ch i ld . As the pressure within him subsided, and the relationship deepened, Teddy became secure enough to bring out some of his fantasies about the unknown forces which he believed were threatening him. Symbolically, these fears were expressed in the interviews during which he imagined there were ghosts hovering around the playroom. Significant in these interviews was the fact that Teddy was able to include the therapist in the search for the ghosts, an action which he would not have taken had he not had confidence in her as a warm and accepting person. The next stage in his development came during the time in which the f i r s t therapist was scheduled to leave the agency. At this point Teddy showed considerable insecurity in his role as a male ch i ld . As has been stated in the chap-ter describing the therapy with Teddy, i t was unfortunate that a worker with no training in therapy should have contin-ued the treatment. Furthermore, the comment was made that such a transfer of workers to the extent of four people dur-ing a treatment situation, i s ordinarily considered to be poor therapy practice. Through the sound base of therapy set up by the f i r s t therapist, however, the change of workers was made more smoothly than ordinari ly would be expected. In this case, as in the case of Jennie Morton, many of the deeper implications were le f t untouched insofar as the actual ther-apy was concerned. The therapists in both cases, were acc-epting of the fantasies and actions of the children, without becoming involved in responses which would have placed the therapy on a deeper l eve l . The treatment process was closely supervised by the psychiatrist in charge, and the therapists were urged to make responses only as they fe l t able to make them natur-a l l y , for without the spontaneity in therapy which comes through training and practice, the procedure can be harmful to the children concerned. The cases describing Jennie Morton who had a habit disorder, and Teddy Lawson, the neur-otic ch i ld , were actually carried on with a maximum of psy-chiatr ic control . The process would, in a l l probability, have been speeded up to a considerable extent, had i t been possible to carry on the interviews at a deeper l eve l . Des-pite this fact, however, the cases described show in general, a high level of play-interviewing technique, which in many instances, depending on the s k i l l of the particular thera-pis t , entered into the realm of play therapy. These instances, during which the therapists quite obviously caught the f u l l emotions of the children, and res-ponded to them on an intuit ive and sk i l fu l l eve l , represent the type of therapy carried on by a fu l ly trained specialist in this f i e l d . It is to be expected, as the training of -Ih5 -therapists is carried on, that the cases w i l l show a cont-inually increasing level of the technical s k i l l involved in the technique. It w i l l be important that those chosen for training remain in this work so that their sk i l l s may inc-rease . To this point, the evaluation of the therapy has been given solely on the basis of technical s k i l l displayed. Such s k i l l , however, is a matter of training and natural capacity for development in the specialization of therapy. The most important aspect in the matter is the actual res-ults produced through the treatment, regardless of the actual depth of the work. The Results obtained from Play Therapy treatment The records indicate, in the case of Tommy Snyder, that this chi ld had been subjected to a particularly unsettled existence during the f i r s t eight years of his l i f e . His moth-er and father were immature adults incapable of adjusting to any form of responsible l i v i n g . The child was shunted back and forth between the parents and exposed to every form of unstable l i f e , emotional and material. It is not surprising that Tommy should have acquired a disorder connected with sexual aggression, for his family background, through the promniscuity of his mother, provided him with a suggestive example. When Tommy commenced therapy in July 19^8, he had already experienced failure in one foster home. His progress in treatment seemed to be good, but when he was again placed - m -in a foster home during February of 19^9 j after a year in the Receiving Home, i t was found that the move had been made too soon. However, by August of the same year, sufficient advance had been made so that he could be placed in the home where he s t i l l i s . Through the therapy, Tommy advanced to a point where he was able to adjust to a pair of foster par-ents carefully selected to meet his needs. The d i f f i cu l t i e s involved in estimating a chi ld ' s progress in treatment are i l lustrated by the second place-ment. Nevertheless, the fact that a few months later i t was possible to place him sat is factori ly suggests the narrow line between a chi ld making a social adjustment and f a i l ing to measure up to normal requirements. This l ine was quite evidently bridged by the treatment carried on during the few months that intervened between the second and third place-ment. The records do not indicate that any great amount of casework was carried on with either the second or third set of foster parents. A point to be emphasized then, is that had sufficient preparatory casework been instituted with the second foster parents, i t is quite possible that the third placement might not have been necessary. Tommy has made a satisfactory adjustment to l i f e in his third and last home. By this fact, as evidence of the benefits he received through the treatment, i t may be pointed out that the play therapy process was successful. It i s , however, necessary to emphasize again that therapy time in the project is valuable, and must be used economically by u t i l i z i n g casework s k i l l in choosing and helping foster - lU-7 -parents, where their understanding is sufficient to bridge the gap between the needs of the comparatively normal and the disturbed ch i ld . Again, in the case of Jennie Morton, there is an ex-ample of the importance of good casework with parents as well as therapy treatment for the ch i ld . Although the case had been in the hands of the agency from the time of Jennie's b i r th , i t was not u n t i l she was nearly nine years old that, as the records state, the f i r s t real contact was made with the foster mother. Rejection of the home as a foster home, or recognition of beginning problems with either resultant casework help to the foster parent, or removal of the child to a more favourable environment, might have saved the great expense of this later treatment. The records show that a second chi ld was also exposed to the warping influences of this foster home. By the time she was nine years old, Jennie had become a chi ld with a strongly marked habit disorder. It was s t i l l later, when she was twelve years old, that play ther-apy was instituted. The conclusion to be drawn from these facts is two-fo ld . F i r s t l y , through the detai l provided in the records, pertaining to the information supplied by the foster mother, i t was obvious that the chi ld was making a poor adjustment, and question as to the use of this home as a foster home at a l l , is pertinent. However, as the therapy project was not started, in the agency unt i l July of I 9 U 8 , i t would not have been possible to have given play therapy treatment before that date. Casework with the foster mother should have been carried on at a more intensive level long before the time Jennie was nine years old, and i t is possible that removal to a more suitable foster home would have been indicated. Secondly, the problem with Jennie becoming increasingly obvious, three years should not have elapsed before an effort was made to correct i t . This lapse of time, though indeed re-grettable as i t involved a greater degree of disturbance, was unavoidable, for a very rea l i s t i c fact was that there were no trained therapists available to carry the number of cases requiring treatment. These facts are pointed out with the idea that children l ike Jennie have needed treat-ment for a long time before the project started, and even after i t started could not be given therapy, because of lack of resources. What therapy treatment can do for these children has been described in this study. The next step, then, is to provide the means to treat them. A chi ld l ike Jennie can be helped. The relationship created in the play room i l lustrated that the tensions in this g i r l were many; but she showed signs of being able to express her feelings in an atmosphere that was conducive to expression. Similarly, the case of Teddy Lawson showed the tremendous benefit that could be given to a child in bui ld-ing up his confidence in himself and other people. The c i r c -umstances of Teddy's birth started him off with i n i t i a l hand-icaps - the most basic of which was the fact that at the time he was six years old his mother had so l i t t l e feeling for him that she could say on parting, "be a good boy and you may see me again when you grow up". The following two foster homes in which he was placed had l i t t l e to offer in the way of compensation for this early rejection. It may be that no foster parents could be capable of f i l l i n g the insatiable needs of this ch i ld . However, the importance of casework with potential foster parents to help them under-stand and accept this boy's needs and probajble' behaviour, so that he suffer no further rejections, is obvious. It takes particular sk i l l s to determine the qual-i t i e s that substitute parents should have in order to meet the needs of disturbed children. A considerable amount of experience and understanding of personality is required, in order to determine whether certain parents possess these qual i t ies . On the other hand, foster home resources may be l imited. Thus, i t is f e l t that some sort of balance needs to be attained between selection of adequate parents and the maintenance of foster home resources. In the case of an i agency l ike the Childrens Aid Society, where great numbers of children require foster parents, an active search, made by trained personnel, is necessary to have available enough high quality homes. However, although a l l children have the right to parents capable of giving them the basic needs of childhood, some children in particular, through greater than average deprivations, have more urgent demands for special understanding and care. The d i f f i cu l ty in this area comes in guaging which - 1 5 0 -children need more specialized attention. There should be some means of determining, before or shortly after a chi ld i s taken into care, precisely what contributions or l i m i t -ations his early background has provided towards the devel-opment of personality. In this way, through a careful ex-amination of a l l the factors which have affected the ch i ld , there is a better chance of supplying an environment that w i l l strengthen him and provide a guide into adult maturity. Where i t is obvious that a chi ld has been seriously rejected in the pre-school years, problems of behaviour can be expect-ed. The conclusion to be drawn in this study is that there should be an observation centre in connection with the placement of children, staffed by a trained personnel poss-essing special qualifications to understand and diagnose childhood problems. Although no such method would be i n -f a l l i b l e , the elements would be provided to eliminate a great deal of the personality deterioration that takes place, through inept placement of children in unsuitable homes. Often by the time a chi ld comes to the attention of the spec-i a l i s t s , the damage has already been done. Several instances of this type of damage were i l lustrated earl ier in the study. The case of Ronnie Trenton, who w i l l require long and expen-sive treatment, which may s t i l l prove valueless at this late date, and the case of Joan Brown, subjected to one inadequate placement after the other, are both striking examples of children for whom treatment w i l l be provided with d i f f i cu l ty -151 -because of shortage of resources, and in addition may-prove useless due to the length of time their problems have been present. Such children are probably not the exception at the Childrens Aid Society, since the need for foster care usually implies a lack of previous f u l l parental care. An observation centre is a great help in an agency that carries the responsibil ity for so many young l ive s . Short of such a centre, a specific diagnostic study, culminating in a plan, should be an invariable f i r s t step before permanent placement, and can be carried on while the child is in a temporary receiving home. Some-where the resources must be found to help carry out the basic principle under which the Society was organized, which was enunciated in their motto "We protect the l i t t l e ones". Some children are going to require therapy des-pite a l l that may be provided for them in the way of i n -i t i a l observation, diagnosis, and other treatment. For this group a treatment centre is required. The play ther-apy project carried on at the Childrens Aid Society since 19^8, represents a pioneer attempt to meet this need. Hand-icapped by inadequate numbers of trained staff and f inancial resources, both of which are essential to the development of such an undertaking, the project has maintained i t s e l f and produced results which augur well for the future of the attempt. The fact that a treatment process which is pushed - 152 -forward through the persistency and determination of a few people, can assist a small group of children towards a much better adjustment to society, points out the great benefits to be obtained from an enlargement of the project. A treatment centre maintained by a group of professional people ski l led in play therapy techniques could provide for the emotional development of children who otherwise may spend their l ives crippled by personality d i f f i cu l t i e s . A further observation in this study concerns the development of foster, home resources. Placement with lov-ing and mature foster parents, for the child who is less emotionally disturbed, can prevent the need for therapy, since severe disturbances can be caused by placement with poorly assessed foster parents. Despite a l l treatment which i s available to children, and even though a treatment centre were accessible in which they might be placed during treat-ment, there w i l l also always be a need for foster parents. Especial ly, there w i l l always be a c a l l for foster parents who are ready to accept the affectional and other inter-change which is the basis of emotional health and growth for children. However, no treatment method offers complete coverage. There must always be the accompaniment of an en-vironmental situation which supplements and strengthens i t , for any therapeutic practice can be rendered nul l and void i f conflicting influences surround the child treated. Thus, - 153 -in addition to strengthening foster homes by competent case-work practices, in this area a way is open for a further step. Ear l ier i t has been said that some children require particular care. This care must be given:,', even in foster homes, by parents especially qualified to give i t . Just as therapists in the play therapy situation must possess the qualities of natural intuitiveness and sensit ivity, so must foster parents dealing with disturbed children, have within them the same potential a b i l i t i e s . In the f i r s t place, great care has to be taken in the selection of such a group. Their particular s k i l l and a b i l i t y would require careful evaluation. This eval-uation could be accomplished, however, by a competent psy-chiatric social worker, with the help of psychiatric con-sultation. It is proposed that a special training prog-ram be init iated for this select group. The suggestion is that a seminar discussion group be carried on for a two hour period weekly, as a maximum, during a six month t r i a l . This seminar would most log ica l ly be given and supervised by the consultant psychiatrist to the Childrens Aid Society. Her professional reputation would carry a great weight in a project of this kind. She would be able to present material concerning the emotional development and needs of various types of children showing behaviour disorders, in such a way that potentially ski l led foster parents would derive large benefits. There would have to be, as wel l , work by individual caseworkers in helping - 19+ -foster parents around specific cases. Such a group of foster parents would provide a reservoir of homes in which children with behaviour prob-lems could be maintained and helped. Provision of homes through a project of this kind, would lighten the respon-s i b i l i t y carried by the agency in planning for children who do not have access to the normal advantages possessed by those who have their own parents. A training program, as described in these paragraphs, would represent a force-fu l advance in the right direction. Other suggestions include: (1) Giving training to a select group of workers in the f i e ld of specialized foster placement for disturbed children, and (2) Group discussion of these special place-ments so that there would be a close integration of know-ledge with a l l of the staff. The conclusions to be drawn as a result of the evaluation in this study are f i v e * i n a l l . They are associat-ed with a development of the project with which this study is primarily concerned and also a development of related f i e ld s . Specif ical ly the f ina l conclusions are: (1) An enlargement of the present therapy pro-ject at the Childrens Aid Society, to the point where spec-i a l l y trained therapists are u t i l i zed so that the treatment may be carried on at a maximum level of intensity. (2) The provision of an observation centre, or specific plan for early diagnosis, so that the problems of children may be evaluated with maximum efficiency, at an early date, thus avoiding the danger that treatment may be - 155 -attempted too late. (3) The setting up of a treatment centre in which children may be maintained during treatment, in a situation which provides a background of ski l led personn-e l capable of understanding and working with disturbed children while they are receiving help. (h) A foster parent, f inding, selecting, and training program, which would provide a group of homes where special children might receive the kind of acceptance and help indispensable to their reorientation to l i f e . Such a program should use and integrate casework and psychiatric s k i l l s . It would also develop the special sk i l l s essential in the placement-treatment program, for i t would be nec-essary for caseworkers to be in very close contact with the project. (5) Integration of the total agency program, so that a l l the staff are brought closer to the causes and nat-ure of psychiatric disturbances in childhood, and how they can be helped. These conclusions represent the ideal treatment situation. They are considered to be a standard towards which i t is the responsibil ity of any agency dealing with children to direct i t s e l f . Additional funds are required to ini t ia te any part of such a program, but funds can us-ual ly be found when the needs are great enough. This study attempts to portray the help that has been given, and also emphasizes the work s t i l l to be done. The contribution made - 1 % -by the play therapy project at the Childrens Aid Society is unquestionable. However, i t is just a start in the benefits that can be provided for a l l children. Play therapy treatment applies only in special cases, whereas an emphasis on developing related sk i l l s in casework and interpretation to the staff generally, would give impetus to the whole agency program. It is the responsibil i ty of every professional social worker to make a contribution in any area which deals with the problems of children. Not every one can contribute in terms of s k i l l , but a l l social workers can maintain a constant interest in the f i e l d of child welfare so that no opportunity i s lost to publicize and interpret the work to be done. Each chi ld that i s helped to grow up towards adult maturity, represents a step in solving the problems of the present c i v i l i z a t i o n . The child welfare agencies of Canada have too many children whose hope for maturity i s a l l too s l ight , unless they benefit from pro-fessional help. - 157 -BIBLIOGRAPHY Aichorri, Frederick, Wayward Youth, New York, Viking Press, 19^5. Al len , Frederick H . , Psychotherapy with Children. New York, W. W . Norton and Co. , Inc. , 1942. Axline, Virginia Mae, Play Therapy. Houghton Mi f f l in Co. , New York, 19^ 7. Family Service Association of America, "Child Therapy - A Casework Symposium", Edited by Eleanor Cl i f ton and Florence H o l l i s . Freud, Anna and Burlingham, Dorothy, War and Children. New York, Medical War Books, 19^ 3. Freud Anna, and others .ed., The Psychoanalytic Study of the Chi ld , New York, International Universities Press, 19^ 5, 2 vols . Hamilton, Gordon, Psychotherapy in Child Guidance. New York, Columbia University Press, 19*+8. Kanner, Leo, Child Psychiatry. Charles C. Thomas, Publisher, Springfield, I l l i n o i s , U. S. A . , 19^8. Lewis, Nolan D. C , ed . , Modern Trends in Child Psychiatry. New York, International Universities Press, 19^ 5. Taft, Jessie, The Dynamics of Therapy in a Controlled  Relationship, New York, Macmillan Co. , 1933. Witmer, Helen Leland, Psychiatric Interviews with Children. New York, The Commonwealth Fund, 1946. 


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