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If you would like additional information on this topic,
Peer-Reviewed Journal Article References:
- Butler, Sue, Jeffrey Guterman, & James Rudes; Using Puppets with Children in Narrative Therapy to Externalize Problem; Journal of Mental Health Counseling; July 2009; Vol. 31; Issue 3; p 225-234.
- Dattilio, Frank; Crisis Intervention Techniques for Panic Disorder; American Journal of Psychotherapy; 2001; Vol. 55, p.388-394
- Hill, Andrew; Factors Influencing the Degree and Pattern of Parental Involvement in Play Therapy for Sexually Abused Children; Journal of Child Sexual Abuse; Aug 2009; Vol. 18; Issue 4; p 455-475
- Iketani, T.; Link between Agoraphobia and Panic Attacks; Acta Psychiatrica Scandinavica; Sept. 2002; Vol. 106, p 171-178.
- Menassa, Bret M.; Theoretical Orientation and Play Therapy: Examining Therapist Role, Session Structure, and Therapeutic Objectives; Journal of Professional Counseling: Practice, Theory, & Research; April 2009; Vol. 37; Issue 1; p 13- 27
- Ollendick, Thomas; Panic Disorder in Children and Adolescents; Journal of Clinical Child Psychology; 1998, Vol. 27, 234-245.
hat place where we live: the discovery of self through the creative play experience. (eng; includes abstract) By Galligan AC, Journal Of Child And Adolescent Psychiatric Nursing: Official Publication Of The Association Of Child And Adolescent Psychiatric Nurses, Inc [J Child Adolesc Psychiatr Nurs], ISSN: 1073-6077, 2000 Oct-Dec; Vol. 13 (4), pp. 169-76; PMID: 11883405
By renewing his confidence in Wendy and believing in Tinkerbell and the magic of her fairy dust, Peter Pan, now a middle-aged, successful attorney, returns to Neverland to recapture his kidnapped children from the infamous Captain Hook. In the adventures that follow, Peter is not only successful in rescuing his children, but manages also to reexperience and reclaim portions of his own childhood through friendship, imagination, magical thinking, and play. For Peter, Neverland proves to be a rewarding cultural experience that enhances his capacity for creative living, self-discovery, and self-healing.
It is not surprising that Peter becomes upset and disillusioned after returning from Neverland when he realizes Tinkerbell will no longer be with him. Disheartened, he cries out to her:
PETER: "Tink . . . Tink . . . ?"
TINKERBELL: "Say it Peter. Say it and mean it."
PETER: "I believe in fairies."
TINKERBELL: "You know that place between sleep and awake? . . . That place where you still remember dreaming? That's where I'll always love you, Peter Pan. That's where I'll be waiting "
(Kennedy et al., 1991)
In a very surreal moment, Tinkerbell is able to soothe Peter with the promise that she will always be with him. Subsequently, she guides him to an illusory place, between sleep and wakefulness, between reality and fantasy, where they can continue their experience.
The illusory place that Tinkerbell has described is similar, perhaps identical, to Winnicott's (1971) conceptualization of the intermediate area of experience, where the infant's self and nonself are only partially differentiated or where the boundaries between reality and fantasy are not fully established (Grolnick, 1990). This intermediate area--also referred to as the third area, the potential space, a resting place, and the location of cultural experience--is a hypothetical dimension of human living, which is neither inside the individual (i.e., personal or psychic reality) nor in the outside world of shared reality (i.e., actual world). Characteristically, it remains relatively constant and is highly variable and unique among individuals, since its foundation is based on the infant's experiences of trust and confidence in the mother during the separation-individuation stage of development (i.e., that she will not fail to be there if she is needed) (Winnicott, 1971, 1986).
The intermediate area (Neverland) is necessary for the initiation of a relationship between the child (Peter Pan) and the world. This relationship is made possible with "good-enough" mothering (e.g., Wendy, not necessarily the infant's biological mother) during the critical stage of separation-individuation and transitional object/transitional phenomena formation (Winnicott, 1971). With good-enough mothering, the infant is able to develop a basic sense of trust, which is fostered by the mother's consistent reliability in relieving stress and promoting a sense of well-being. In essence, the good-enough mother fulfills the role of ego supporter by affecting a fine balance between a constant holding environment (i.e, daily routine of physical and psychological care, accommodating to the unique needs of the infant) and frustration, resulting in gradual disillusionment (i.e., weaning the infant from maternal provision of the holding environment) in the infant. With disillusionment, the infant engages in creative play and creates the transitional object/phenomenon (e.g., Tinkerbell) so that the state of being alone is more tolerable (Grolnick, 1990).
Transitional objects (e.g., blankets, stuffed animals, soft diapers) and transitional phenomena (e.g., music/tunes, a space on the ceiling, crib) are created by the infant to build an illusion (i.e., the object is not mother, but it assists the infant to build the illusion that it is mother) and to represent what will always be important to the infant. While the object itself is not transitional, it signifies the infant's transition from a state of being merged with the mother to a state of being something outside, separate, and in relation to the mother.
The appearance of the transitional object is the first indicator that the infant is able to distinguish between fantasy and reality, between inner objects and external objects, and between primary creativity and perceptions. It is used by the infant as an aid to assist in the journey from an absolute dependence on the mother's adaptive holding environment to relative dependence, where the mother is seen as someone who is separate (Abram, 1996). The infant creates this first "not-me" possession as a symbol of the desired union with the mother. In contrast to the good-enough mother, who cannot and will not avoid involuntary separations, the external object has the advantage of being manipulated by the infant at will. As such, the object represents the ideal caregiver, who is omnipresent and always accessible (Winnicott, 1971).
Just as disillusionment occurred during the earlier stages of development when the infant was frustrated by the mother, so, too, is the child's illusion of magical omnipotence and control over the transitional object gradually replaced with increasing amounts of disillusionment and optimal frustration. As the transitional object loses its meaning, the child begins to accommodate to reality, even though acceptance of that reality is never fully accomplished. The transitional object is not forgotten, but is relegated to limbo, becoming diffused and spread over the entire intermediate area.
The intermediate area or cultural experience (e.g., culture, science, religious feeling, dreaming, art), which has its origin with creative living and is manifested through play and transitional object formation, is a normal extension of the transitional process (Winnicott, 1986). Winnicott believed that the individual's lifelong tension and struggle to relate inner to outer reality could be relieved only within the intermediate/illusory area of experience (i.e., that place between sleep and awake where Tinkerbell waits for Peter). This intermediate area of experience remains unchallenged even into adulthood, especially when it is expressed in the arts, religion, or philosophy (Winnicott, 1971).
When the intermediate area is intact and the inner and outer realities are interrelating with one another, the individual is provided with special ways of knowing (Schwartz, 1992). The transitional process provides a psychological space that is between the subjective internal world and the objective external world. This psychological space is a place where the individual can use objects from the outer world to enhance growth in the inner world (Jones, 1992). In essence, an individual's capacity to play in this intermediate/cultural area demonstrates a capacity for blending illusion and reality and is representative of ultimate human development and health, because it signifies the ability to live creatively and to feel real (Abram, 1996; Meissner, 1992).
The use of the transitional object is symbolic of the union between the baby and the mother at a point in space and time when they are initiating their state of separateness. Subsequently, without a "good-enough" environment, referred to as "primary maternal preoccupation" (i.e., losing oneself in another), balanced with an environment that is mixed with frustration, the infant is not likely to make use of the transitional object/transitional phenomena because of lack of confidence and trust (Winnicott, 1971). Thus, the individual's intermediate area or cultural experience can be jeopardized in two ways: (1) excessive absence of the mother, and later on by other holding environments; and (2) excessive presence or impingement from without, characterized by too rigid or frequent demands to comply with previous constructions of reality (Schwartz, 1992; Winnicott).
Winnicottian therapy encourages the therapist to stay in connection with the client and to take the client's experience seriously. For Winnicott, play was therapy in itself, and psychotherapy occurred in the overlap of the two areas of playing--that of the client and that of the therapist. Psychotherapy involved two people playing together who were able to make use of the potential space. Subsequently, the play-space is believed to be more important than the interpretation of the play, precisely because it allows for the child's creativity, rather than the demonstration of cleverness by the therapist in making an interpretation (Abram, 1996).
Winnicott's clinical approach is consistent with Parse's (1992) theoretical approach to nursing practice, which focuses on the lived experience of health and is based on the premise that events and people mutually shape one another. According to Parse, "the nurse in true presence stays with the person or family while the person or family describes . . . day-to-day living in the now moment. The nurse does not try to calm uneven rhythms but rather goes with the rhythms set by the person or family" (p. 39). While it is beyond the scope of this paper to elaborate on Parse's Theory of Human Becoming, it is evident that both Winnicott and Parse transcend the normative approach of most other theorists. Like Winnicott, Parse values the individual's unique perspective on the quality of life and sees the goal of nursing as a supportive one, rather than as authoritative or interpretive. Parse, like Winnicott, places emphasis on the therapeutic relationship.
The human knowing or becoming that results from the interaction in the relational space between the self and world, the self and object is a transitional process (Jones, 1992). Accordingly, the transitional process moves beyond the dichotomy between inner and outer in two ways: "(1) it involves the use of objects from the outer world in service of projects originating in the inner world; and (2) creates an interpersonal psychological space that is in between the inner and outer worlds" (Jones, p. 225). The longing for an integration between the inner and outer worlds extends throughout the life span.
In instances when the conditions (i.e., good-enough mothering and holding environment) facilitating creative play and finding an object are not provided, the infant is left with no play area or cultural experience (Winnicott, 1971). Subsequently, with the potential space being left empty, the infant is not only deprived and restless due to the inability to play, but also extremely vulnerable, owing to what might be put into the empty space by someone else (Winnicott). This fact reaffirms why Winnicott believed that the play area (i.e., where the individual experiences creative living) was so sacred and more important than the therapist's interpretation. Interpretations can lead to the client's development of a false self, therefore, Winnicott encourages the therapist "to afford the client an opportunity for formless experience, creative impulses, motor and sensory, which are the stuff of playing" (p. 64).
Trauma of any kind (physical or mental, sexual abuse, divorce, or death) jeopardizes children's opportunities for meaningful play experiences. Subsequently, children's energy is consumed in trying to protect the self physically and/or emotionally or resolve the trauma, rather than experiencing the type of play that enhances their current developmental stage (Norton & Norton, 1997). Without therapeutic intervention, the child's emotional memories remain riveted at the developmental stage in which the traumatic event occurred. Further development is impeded, since it is associated with the traumatic event and the child feels insecure and unprotected, having lost trust and confidence (Norton & Norton, 1997).
Nondirective or experiential play therapy, developed by Virginia Axline (1969), offers the child an opportunity to experience growth under the most favorable conditions. It starts where the child is and allows the child to go as far as he/she is able to go. Accordingly, the child is accepted by the therapist without evaluation or pressure to change. Axline described the play therapy room as a good growing ground with many healing qualities. She further explained that it is a room where children can be in control of both the situation and themselves and where no one can criticize, nag, dictate, pry into their private world, or tell them what to do. In the safety of this room, children are accepted completely so that they are able to unfold their wings, test their ideas fully, and be free from the forces of adult authority and rivalry from their contemporaries (Axline).
It is important to note that while the experiential approach is founded on the principle that children have the capacity for solving their own problems within the context of a caring therapeutic environment, there are certain exceptions. Children with selected disorders having an organic or biological base (e.g., mental retardation, pervasive developmental disorder, and attention deficit hyperactivity disorder) are not likely to respond to the experiential approach in it purest form and will need other types of therapy (Norton & Norton, 1997).
Play therapy starts where the child is and allows for change to occur during the therapeutic process. "Play therapy is a relationship between the child and therapist in the setting of the playroom, where the child is encouraged to express him/herself freely, to release pent-up emotions and repressed feelings, and to work through his/her fear and anger so that he/she comes to be himself and functions in terms of his/her real potential and abilities" (Moustakis, 1992, p. 172). The relationship between the therapist and child is an honoring process that allows the child to find meaning in the experience (Moustakis). Therefore, it is the therapist's role to follow the child's lead in play at all times so that the child will receive the needed results from the selected experience.
During the past 5 years, this author has been involved in a comprehensive, community-based elementary school mental health program, which provides quality care and intervention to children and their families who might not otherwise receive the intervention they need. Building on the author's previous work (Galligan, 1994) relative to the transitional process and based on the assumption that children are unique and capable of expressing their emotional conflicts through play, careful attention has been given to support the diverse needs of clients experiencing a variety of crisis situations so that they can ultimately find meaning through self expression.
In the two cases that follow, it is evident how the children themselves were able to deal successfully with their internal stress by experimenting with play in their respective intermediate/potential space. Through the creation and utilization of transitional objects/phenomena, while in the containment of a holding environment, they facilitated their own psychic healing and enriched their creative and cultural experience. The primary task for this author/therapist was to "hold the client," to enable the child to form a sense of continuity, or going-on-being (Grolnick, 1993).
Lena, a timid, quietly spoken, sad 9-year-old, was referred for therapy by her teacher when her symptomatic behaviors of lying, stealing, opposing authority, and destroying others' property escalated to a level that was no longer manageable in the classroom. A history revealed that Lena had had a negative attachment experience, being abandoned during infancy by her biological mother. She underwent further emotional insult at the age of 3, when her maternal grandmother and caretaker, with whom she had developed a very strong attachment, died from heart failure. With no one to care for her, she was sent out-of-state to live with a maternal aunt and her adolescent son, resulting in her estrangement from her 18-year-old biological sister.
The maternal aunt reported that many of Lena's behavioral symptoms (taking food, stealing pencils, wetting the bed) appeared shortly after she came to live with her, but she stated that she gave little attention to them, since she considered Lena's behavior to be a consequence of both her age and history of early neglect.
During the initial stages of therapy, Lena typically demonstrated a yearning for closeness and attachment in her relationships with children and adults, while simultaneously provoking rejection from them. She lacked an ability to engage in play and had difficulty focusing on activities. While she presented with many behavioral symptoms that were somewhat suspect and indicative of abuse, Lena neither disclosed an abusive situation nor did she present with any physical signs of abuse or neglect to this therapist.
It was not until Lena was able to develop enough trust in her therapist (good-enough mother), while in the containment of the playroom situation (holding environment), that she revealed that abuse and neglect were ongoing. Fostered by a consistent, nondirective, experiential approach to therapy, Lena began to unfold through play the details of her emotionally impoverished existence (being locked in her room during evenings and on weekends, deprived of food and clothing, beaten with an electrical cord). She further reported that her aunt had been abusing alcohol and cocaine and had threated to "give her up to foster care" if she disclosed any incriminating information about her home situation.
Prior to her disclosure, Lena's unsafe home situation precluded any opportunities or attempts for her to play, since her energies were focused on survival. Subsequently, Lena began to internalize the negativity she was experiencing from her outside world. While she did not exclude herself from social interactions, her tendency toward oppositional behavior, together with her unkempt appearance, tended to alienate peers and adults alike. Over time, her intermediate area of experience began to mirror the negativity in her inner and outer reality, leaving her with feelings of emptiness, loneliness, and sadness, and the perception that she was "ugly," "bad," and "worthless."
Following her disclosure of abuse, she was removed from her aunt's home and placed in a very nurturing foster home. Within weeks, Lena began to show improvement in her behavior and emotional state. More significant, she was able to use increasingly more complex play activities, such as imagery, metaphor and storytelling, as a means of communicating her newly found perspective. These stories were dictated by Lena and transcribed verbatim by this therapist for inclusion in a book she was preparing, entitled Lena's Book of Stories. Lena took great pride and pleasure in seeing her stories in print and having them read back to her repeatedly.
In preparation for termination, Lena became very attached to one of the playroom puppets, an eagle she named Veronica. Over the course of the remaining sessions, she became increasingly more involved in exploring her play experience with Veronica, while verbally soothing herself with positive self-talk. Lena's play experience culminated with the dictation of her final story about her relationship with Veronica, which this therapist transcribed and included as the final entry in her book.
Veronica and Lena
This is Veronica, my pet. She is a beautiful pet and my name is Lena. Me and Veronica play together almost every day and we have fun.
Veronica is who I like to talk to and we have fun a lot. She hugs me and we dance together and she soars in the sky like a beautiful eagle flies. Here she is flying. Veronica is the best, best eagle I ever had and she soars in the air like a beautiful eagle does.
When she is hurt, I fix her. When she is all clean and ready, she pecks me on the head and says, "Thank you."
Then she whispers stuff in my ear that's funny and I like to laugh.
Veronica soars over my head and watches over me. If someone bothers me, she takes care of me and says leave her alone. Every day we have great fun together. Me and her jump together and play things very fairly and we pretend we're something else, but me and Veronica are just the same.
Through story, Lena demonstrated her ability for creativity by claiming portions of her childhood through friendship, imagination, magical thinking, and play, just as Peter Pan had done when he returned to Neverland. With the development of trust, she was able to engage in the transitional process and use a transitional object (i.e., puppet) followed by selected transitional phenomena (i.e., storytelling) for self-soothing purposes. In so doing, she demonstrated a capacity for self-healing and the likelihood that she will continue to use avenues for creative living and health.
Carlo, a 7-year-old second grader, was the second youngest of five children, ages 18 years to 8 months, living with their biological mother. He was referred for therapy by his teacher for inattentive, impulsive, and disruptive classroom behavior. An initial interview with Carlo's mother revealed that she also had observed these behaviors in the home with increasingly more frequency, but she had attributed his behavior as a response to the birth of her youngest child.
It has been this author's experience that children tend to communicate exactly what is bothering them in the very first session. Knowing this, it is important that the therapist accept whatever is being presented by the child, since the behavior serves to protect and secure his/her sense of safety (Norton & Norton, 1997). It took Carlo little time during the first session for him to scan the playroom for content before he was able to focus his attention on a toy red phone, a selection of therapeutic books, and an assortment of stuffed animal puppets. It was evident that these selected toys had meaning for Carlo and that he would use them in play to resolve his pain. Ultimately, he did just that.
By observing, joining, and honoring him in the experiential play process, together with teacher consultation and family therapy sessions, I soon learned there were multiple stressors in Carlo's home that were negatively impacting his behavior. As play therapy progressed, he assumed the responsibility for director and rule maker, telling this therapist what to play and how to play it. Gradually, he symbolically played out all the issues that were traumatizing him.
In time, he selected a turtle puppet from the playroom and used it for self-soothing purposes and as a conduit for communicating his feelings. The turtle, which he later named Ann, became a regular third member in all play situations. He also ended each session by asking to be read a story, which appeared to be selected at random.
During one session, Carlo gave very explicit directions to the therapist to: (1) join him under the table with his turtle, (2) bring the red telephone and the storybook I Wish Daddy Didn't Drink So Much (Vigna, 1988) and (3) assist him to secure a protective wall around the table. When the area was secured to his specifications, he instructed the therapist to read the book. He informed the therapist that while she was reading he would hold the turtle (to keep self safe) and use the phone to call for help if it was needed.
It was clear that the therapist had been invited into Carlo's intermediate space, where he felt safe. Through play, the symbolic use of story and the use of transitional objects/phenomena, Carlo was able to express his needs through play and to disclose his very traumatic home situation (his older sister and mother were verbally and physically abusive to one another, his mother's alcoholism and abandonment of him). Through play therapy he was able to deal with his traumatizing life events and regain his sense of well-being.
Both Lena and Carlo found their unique Neverland, a place in their imaginations, where everything was the way they wanted it to be. They were able to recapitulate and assimilate their struggles at home through play, gaining mastery and empowerment over their experiences, and recovering their self-exteem.
In accordance with the basic tenets of Winnicottian therapy and the three abiding themes of Parse's Theory of Human Becoming, the nurse therapist supports and guides individuals and families as they create their own health. That is, by providing good-enough mothering to enhance the development of a creative play experience, the nurse permits the child to find meaning through self-expression, to synchronize rhythmical patterns by living moment to moment, and to mobilize transcendence by moving beyond the moment to forge a unique personal path toward health (Parse, 1992).
The Masterson Approach with Play Therapy: A Parallel Process between Mother and Child. By: Mulherin, Marie A.. American Journal of Psychotherapy, Spring2001, Vol. 55 Issue 2, p251, 22p, 5bw; (AN 4765489)
This paper discusses a case in which the Masterson Approach ( 1) was used with play therapy to treat a child with a developing disorder of the self. It also describes the parallel progression of the child and mother in adjunct therapy throughout a six-year period.
The Masterson Approach, when used with the dynamic process of play therapy, provides the therapist with a framework and tool to diagnose and treat a child with a developing disorder of the self. The Masterson Approach is a psychodynamic developmental self and object relations approach. Masterson states:
The advantages of adding self to the developmental, object relations approach are as follows: it provides an architecture of the patient's inner emotions, affective state, and the self- and object-representations linked with that affective state, while also defining the defense mechanisms and ego functions associated with that state. It tells you what emotion is on center stage and how to intervene in the defense against that emotion, and gives you a tool with which to evaluate that intervention. The organizing concept of this psychodynamic diagnostic scheme is the way in which the self-representation relates to the object representation. ( 1,p.59)
Its central theme is the disorders of the self-triad that rests on a simple principle: the activation of real self-capacities evokes abandonment depression and separation anxiety, which are avoided by employing the primitive defense mechanisms of the self ( 1). Abandonment depression is an umbrella term which includes depression, panic, rage, guilt, helplessness, hopelessness, emptiness, void ( 2).
Play is also an active, dynamic process. As the natural medium of the child for self-expression, play allows the child to express conscious thoughts and feelings as well as to reveal unconscious wishes and conflicts. By playing out stresses and traumas, the child may gradually achieve mastery over them. For play to become therapeutic, however, it must have a theoretical orientation and use play techniques that will engage the child. Therapeutic play must include the following components: first, provide opportunities for diagnostic assessment; second, develop a working relationship with the therapist; third, assist in breaking down defenses; fourth, facilitate verbalization; fifth, provide a cathartic release; and sixth, prepare children for future life events ( 3 ).
By combining the Masterson Approach and play therapy, the child's ego strength is built, and real self-capacities, such as self-expression and the maintenance of self-esteem, are supported. The ability to relate to others in a healthy manner is also encouraged. This work, which fosters the development of the child's real self-capacities and whole object relations, prepares the child to experience future life events successfully.
Bobby W., age six, was the designated patient in this case study. The mother, Mrs. W., entered conjoint therapy with the expressed desire to help her son.
Bobby's teacher reported that he was absent 60% of the time. She also reported that he displayed regressive behaviors, such as persistent crying, noncompliance with limits, resistance to teacher guidance, inability to complete tasks, distractibility, anger, and obsessive-compulsive behaviors. Bobby's parents reported his hyperactivity, severe difficulty adjusting to their marital separation, and regressive behaviors, such as temper tantrums, passive resistance, clinging, nagging, baby talk, lisping, and walking on tiptoes. In the initial school interview, Bobby crawled on my lap, rolled into a fetal position, and sobbed.
Mrs. W. presented with severe panic disorder, agoraphobia, and depression. In her initial interview, she stated her primary goal for treatment was to support Bobby. However, she also wished to relieve her own generalized anxiety, panic, tachycardia, allergies, and asthma. She explained: "I think I'm going into depression. I am feeling a closet of fear."
Bobby lived with Mrs. W. and his sixteen-year-old brother. His parents had separated twice: first, two years before Bobby was born, and again seven years later when he was five years old. Fighting, violence, panic, and anxiety characterized the marriage. Both parents reported Bobby was fearful of being alone. In his mother's house, Mrs. W. would sleep in Bobby's room. In his father's house, Bobby slept with Mr. W.
First grade was Bobby's first school experience. He did not attend preschool because Mrs. W. was either too ill to bring him, or feared Bobby would become ill. She reported Bobby had upper-respiratory problems, asthma, and allergic reactions to medications. Mrs. W. resisted giving Bobby medication because she was terrified he would suffer anaphylactic shock. If Bobby developed a single hive after taking any medication, Mrs. W. would rush him to the emergency room and wait until she was certain the risk had passed. When Bobby contracted a cold, Mrs. W. tried to cure him with homeopathic remedies, and kept him home from school for as long as ten days.
Mrs. W. reported she was also severely allergic to "everything," including most foods and medication. However, since her husband had moved out of the house, she was able to swallow and eat a few things. Reportedly, she had gained some weight, but she still weighed less than 100 pounds. At times, when she had tachycardia, her fear of death became so acute that she would go to a hospital and wait outside the emergency room until she. felt better.
THERAPEUTIC STANCE AND FRAME
The treatment for Bobby and Mrs. W. lasted six years, with declining frequency in the sixth year. In addition to individual treatment during these six years, Bobby attended weekly group-therapy sessions. I consulted with Bobby's teachers twice each month in order to contain Bobby's transference acting out at school. The father's conjoint sessions were infrequent throughout the six-year period.
My initial treatment goals were to establish a safe environment, as well as to convey a predictable, stable, and nonintrusive therapeutic stance that would support my neutrality ( 4). Therefore, I resisted giving advice or solving problems. I did, however, discuss with the parents the need for limit setting, impulse control, and boundaries.
The following set of conditions and responsibilities were established for Bobby's parents: responsibility for scheduling issues, timely payments, consistent discipline procedures, and a regular visitation schedule. Finally, we discussed the need for Bobby to sleep separately from his mother or father.
To involve Bobby in this process, I required Bobby to schedule his appointment time, to determine the frequency of visits, and to keep his own appointment card. He complied with these tasks throughout his treatment. During each session, Bobby was required to decide on the type of play, to clean up, and to finish on time. By establishing this therapeutic framework, Bobby and his mother were able to manage their initial anxieties and fears of intrusion ( 4).
The treatment approach I used for Mrs. W. was the traditional Masterson Approach. For Bobby, the Masterson Approach was combined with play therapy. Sand Tray World Play ( 5) was the primary play medium Bobby chose. The locus of play is a tray of sand on a waist-high work area. The sand may be dry, damp, or flooded with water. Many different miniatures are available representing numerous categories and feeling states. Sand tray therapy is a symbolic activity that reveals intrapsychic reality. It is independent of spoken language. The unconscious contents of the psyche are revealed through the miniatures selected, the way the sand is molded, the overall cohesiveness of the picture, and whether or not water is used. The use of water suggests the individual is exploring deeper levels of the unconscious. It is the function of the therapist to validate and support the intrapsychic reality, its evolution and development, and its connection to the conscious processes of the client ( 5-7).
The sand tray provided a free space with boundaries in which Bobby felt safe and was able to play out his conflicts. Because Bobby elected to remain mute for roughly the first five months, the sand-tray method used with the Masterson Approach provided me with a glimpse into Bobby's intrapsychic world. The disorders of the self-triad permitted me to identify Bobby's defenses and to interpret Bobby's reactions and progress in therapy without his needing to talk until he was ready to do so. By observing responses to the therapeutic framework; self-activation behaviors; affective responses to interventions; attachment-style reactions; reactions to separation; and countertransference reactions, I was able to evaluate his affective responses to the interventions and determine their effectiveness ( 4). I knew that to build a therapeutic alliance I needed an intervention that helped me to connect with Bobby in a way that afforded him safety and security and helped him make sense of his internal feelings and perceptions and the reality of the outer world. ( 4).
The differential diagnosis between borderline and schizoid disorders of the self ( 1) for Bobby and Mrs. W. proved difficult. The descriptive symptoms exhibited by both Bobby and Mrs. W. could have been attributed to either of these disorders. There was significant enmeshment among all family members. Mrs. W. presented with severe panic disorder, anxiety accompanied by agoraphobia, and transference acting out, including rage reactions. Bobby presented with severe separation anxiety, loneliness, depersonalization, transference acting out, and selective mutism. On the one hand, these could have been symptoms characteristic of borderline personality disorders by allowing the individual to feel closer to the object. On the other, these very same symptoms, when employed by an individual with a schizoid personality disorder, could have served the function of remaining connected, but distant ( 6).
My initial diagnosis for mother and son was distancing borderline disorder ( 8-10). I theorized that Mrs. W. and Bobby alternated projecting and identifying with part-object or part-self representations of either the rewarding or withdrawing part unit of the borderline disorder. And, in order to establish trust, rapport, create a safe and protected space to serve as a secure base to build a therapeutic alliance, I needed to use the technique of confrontation ( 8).
During the time I used confrontation as an intervention, Bobby was regressed and acted out. In session, he was selectively mute and had difficulty complying with limits, such as putting his toys away and ending on time. He continued to be absent from school three out of five days per week. At home with his mother, Bobby argued, threw tantrums, refused to follow directions or comply with limits. Bobby's mother reacted with anger, screaming, and yelling. Eventually, she would lock herself in her bedroom. Bobby reacted to her withdrawal by pounding on the door, screaming, crying hysterically, and begging for forgiveness. Following these incidents, Mrs. W. experienced panic attacks and feared death. Bobby became ill and regressed. This destructive cycle of reward and withdrawal continued. By engaging in these interactions, mother and child conspired to see reality as dangerous and unhealthy.
After a significant length of time observing Bobby and Mrs. W.'s affective responses to my confrontations, I concluded my diagnosis of borderline disorder was incorrect. Confrontation increased instead of decreasing their anxieties. Bobby was more insecure and fearful. Mrs. W. had major panic attacks when entering my office. After she calmed down, she filled the remainder of the hour with complaints. They experienced confrontation as invasive, coercive, and controlling. Instead of building trust and an alliance with me through the use of confrontation, Bobby and Mrs. W. withdrew. This was evident in Bobby's sand trays. He appears ready to fly away. (Fig. 1)
I surmised my use of confrontation had unwittingly activated Mrs. W.'s projective identification of either the part-self representation of slave within the attachment unit, or the self-in-exile within the nonattachment unit of the schizoid disorder of the self. The part-self representation of slave evoked in Mrs. W. dreaded anxiety and the accompanying fear of feeling enslaved, manipulated, coerced, and appropriated. The part-self representation of self-in-exile evoked the feelings of loneliness, alienation, and isolation without hope of being able to get close to anyone; all the feelings she was terrified of experiencing.
Bobby's reaction to confrontation could also be explained by the intrapsychic structure of a schizoid disorder of the self. Confrontation had activated Bobby's projective identification with the part-self representation of self in exile which he experienced as a feeling of alienation and isolation, yet self-reliance. Initially, when he was identifying with the part-self in exile representations, he would play with objects in the tray completely detached and unaware of his surroundings or my presence.
Consequently, I changed my diagnosis from borderline disorder of the self to schizoid disorder of the self ( 4). Pursuant to this new diagnosis, I began interpreting their schizoid dilemma. By observing their reactions and recognizing that their fear was either the dread of appropriation or the dread of total isolation, I began to interpret their schizoid dilemma. During my use of confrontation, my countertransference experience of their projections of feeling enslaved, or feeling in exile, provided me with insight into the pain of their anxiety and depression which assisted me in making interpretations of their dilemma ( 4).
When I changed my therapeutic technique to interpretation of the schizoid dilemma, Bobby's behavior changed. Initially, I made simple observations about his sand-tray world. I did not directly attribute feelings to Bobby. I also did not want to interpret his feelings without his input. I knew the objects in the tray had symbolic meaning to the individual and may represent something other than what they appeared. However, I also knew I first had to build a connection with Bobby for him to feel safe enough to be willing to take a risk and identify his feelings. Therefore, I compromised and decided I would name one or two items in the tray and ascribe feelings to them in an inquiring manner. For example, I would say, "I wonder if that gorilla is mad? I wonder if it scares the other animals? Are they trying to find a safe place?" Slowly, Bobby started to respond with a head nod or a single word. I was now visible. I no longer felt in exile. Bobby did not withdraw. By describing the tray in an inquiring manner, I was attempting to connect at a safe distance and not trigger his fear of appropriation. If he permitted, I would take a picture of his tray, which he enjoyed.
Mrs. W. also responded positively to my interpretations. Initially, I proceeded cautiously. When she would experience a panic attack, I would simply say, "I am here" and become silent. Her panic attacks lessened, as did her complaints. I was able to interpret my understanding of her feelings of alienation and isolation by saying things like, "It seems to me coming in here and talking about yourself can be anxiety producing because it brings you closer to me than you are prepared to be at this time." Or, "It is sometimes difficult to find a safe distance." She internalized the interpretations. In her account of incidents, I would hear her use the words "safe distance" as well as "feeling anxious about getting too dose. "
I no longer felt distant and detached, but instead experienced the beginnings of a therapeutic alliance with both mother and son. The interpretations of the schizoid dilemma did not cause them to feel manipulated, coerced, or victimized. By using the interpretations, I could reduce the risk of Bobby and Mrs. W. experiencing me as intrusive or invasive, although it was a risk of which I remained aware throughout treatment. This confirmed to me the accuracy of the diagnosis of schizoid disorder of the self with both mother and son ( 4, 9).
Throughout the course of treatment, the parallel progression of Bobby and Mrs. W. in their attachment styles, reactions, and defenses was striking. In the initial stages of treatment, the enmeshment was most pronounced. Frequently, Bobby would mirror in his sand trays the very conflicts his mother was struggling with in her own life.
Five months after I had begun using interpretations of the schizoid dilemma, Bobby attempted to relate to me directly. In the late spring, several months after Valentine's day, he handed me a piece of cardboard and said, "It is a valentine for you. I forgot to bring it in before." Bobby had drawn a heart that had a maze within it on a piece of cardboard and had written: "Here's a maze for you to do. I hope it's fun for you! Help Mr. Heart get out of the angry forest and into his happy home without getting stuck into angry, sad, mad, lazy, and unhappy pits." He was taking a risk and testing the safety of our relationship.
Once Bobby began building a relationship with me, he talked and took more risks with self-disclosure of his feeling states. A pattern developed in the way Bobby approached building his sand trays. Sensing he was ready to explore feelings at a deeper level, he would ask to build a cooperative tray with his mother or father, and later on with me. A cooperative sand tray is when two people work within the same sand tray ( 11). It illustrates how the people relate to one another. In doing a cooperative tray, Bobby would establish a secure base for himself which enabled him to explore and tolerate more painful feelings at a deeper level ( 12).
Bobby's cooperative sand-tray worlds illustrated striking contrasts in the way he related to each parent. The disorder of the self-triad was evident. In his first cooperative sand tray with his father, Bobby activated the nonattachment unit. During this session, Bobby displayed regressive behaviors, elective mutism, and fear. He refused to allow his father to participate as he built a tray that illustrated fighting, rage, and destruction. His father, forced to remain distant and isolated, looked confused, but sat on the couch and watched from a distance saying nothing. Bobby was attempting to transfer to his father the feelings of isolation, confusion, and fear he experienced when witnessing rage and violence being acted out by his parents.
In the cooperative sand-tray session with his mother, Bobby activated the attachment unit. During this session he was regressed, but used some language. He wanted his mother to participate, but he exerted control over what she put in the tray. Mrs. W. appeared hesitant but cooperated with Bobby's orders and asked permission to put certain objects in the tray. He was attempting to transfer to Mrs. W. his feelings of enslavement. Also, he wanted to experience the feeling of being in control. In contrast to the world of violence he built in his session with his father, the world he built with his mother was one of relative happiness, peace, and harmony.
Bobby and his parents' behaviors and actions in building the sand-tray worlds illustrated the schizoid family dynamics. For example, when Bobby initiated building a cooperative tray with each parent, the linking affect was either the feelings of being imprisoned (anxiety), or rage and isolation (depression). He defended by projecting onto his mother the part-self representation of slave and identified with the part-object representation of master. This reduced his anxiety. With his father, he defended by projecting the part-self-in-exile representation onto his father and identified with the sadistic part-object representation. This made him feel safe and reduced his anxiety. These contrasting sand-tray worlds also illustrated Bobby's splitting defense: if he is in an attachment with one parent, he then has to be detached from the other parent.
When Bobby related to his parents, he experienced the schizoid dilemma. In subsequent sessions, I started to interpret Bobby's dilemma by interpreting his splitting defense. For example, I would focus on the tray and make comments such as: "It is hard to find a safe place in this world with those monsters fighting; it looks like a scary place;" or, "This world looks more peaceful; it looks safe--no one is fighting." "What a dilemma: peace or war. I wonder what the compromise can be?"
Mrs. W. also presented with a splitting defense. Her schizoid dilemma was either enslavement or exile. She fantasized and wanted to attach to someone with whom she could feel safe and protected. Her compromise was to engage in a reconciliation fantasy to defend against loneliness and depression. While in the attachment unit, Mrs. W. projected onto her husband part-object representation of master and identified with part-self representation of slave. Her anxiety increased and she became hypervigilant. As she allowed herself to feel closer to him, she broke out in hives, experienced severe anxiety, panic attacks, depression, and fear of the potential for loss of self. She described her fear of appropriation and anxiety: "When I let him come in and start taking care of me, he takes me over. I am being controlled and manipulated. I feel like I'm being choked. I have allergic reactions to everything. I'm stressed and freaked out."
In order to avoid feelings of anxiety, she defended by splitting and projecting onto her husband the sadistic part-object representation of the nonattachment unit and identified with the part-self-in-exile representation. While in this defense, she refused to talk or see Mr. W. for weeks, even though he called daily to talk with Bobby. Although Mrs. W. felt safer, the isolation and loneliness associated with exile deepened her depression. She stated: "I feel trapped in the marriage--my only way out is death--but I don't feel my children are better off without me. I can be an example to the children. He did horrible things to my mind and he took things away from me. I felt terror. I felt bad. I lost my health, my self, my mind, my beliefs." Dysphoria, distress, despair, and rage were all present. Her rage was both self-directed and directed at her husband. She engaged in self-blame, self-hatred, and devalued herself for "being so dependent on Mr. W."
While Mrs. W. was experiencing this dilemma of attachment versus nonattachment, Bobby was building sand-tray worlds that were chaotic. He did not stay within the boundaries of the tray. He frequently spent time tying strings to things outside the tray and connecting the string to something in the tray. He experimented with different lengths of string. He kept things in the tray for brief periods of time and then he pulled the objects attached to the string out of the tray. Bobby was playing out the internal and external conflicts of closeness and distance, control and enslavement.
Separation and Individuation Process
After nine months of therapy, Bobby and Mrs. W. started the process of separation and individuation, and began to explore the idea of connecting with others. This was an inherently risky action in their minds because they experienced others as potentially dangerous. Mrs. W. started to attend small group prayer meetings in her religious community. At the same time, Bobby, now in second grade, was making attempts to play with the children at school.
Bobby's regressive behaviors declined. He communicated his feelings instead of acting them out and completed his work by the end of the session. His sand-tray worlds became more organized and contained within the tray boundaries. Mrs. W.'s anxiety had diminished as well. She no longer experienced severe panic attacks, or self-destructive rage. Also, she was letting go of her fantasy of reconciliation with Mr. W.
During this time, Bobby began a series of trays that revealed some depression and rage ( 13). In his first tray of this series, Bobby built a mountain. He said: "It is a volcano with water seeping out of it and covered with rocks." After he built the mountain, he put cars in the tray to run around the mountain in circles. Volcanoes symbolize suppressed feelings, usually anger. Rocks symbolize feelings not yet addressed. The cars symbolize Bobby's anxiety in confronting the feelings inside the mountain. When he completed this tray, Bobby asked to do cooperative trays with each of his parents and with me.
The next sessions with his parents were very different from his prior cooperative sessions. This time Bobby remained in the attachment unit with both of his parents. In the presence of his father, Bobby had acquired more ego strength and was able to be more age appropriate, although still mildly regressed. Bobby and his mother each built their own sand-tray worlds in a self-reliant manner. They negotiated a compromise with each other. Separation and individuation were beginning to emerge in each of them and the enmeshment was beginning to resolve. Bobby was attempting to build a working alliance with me and with his parents. Following the cooperative trays, Bobby built many sand-tray worlds that symbolized fears, traps, and unknown dangers. After building and flooding one of the worlds, he said: "I am glad those bad feelings are gone. They were scary."
After a year in treatment, Mrs. W. initiated divorce proceedings that triggered her anxiety and depression. She defended against these feelings with detachment, splitting, and regression. When I interpreted her defenses, she cried and identified how afraid she was that she may not survive. At this time, divorce was for her equivalent to death. It was total exile.
Simultaneously, Bobby's anxiety was evoked by his attempt to connect with other children. As a way to defend against feelings of anxiety and find a safe distance for himself in relation to others, he tried to control situations and boss his playmates. Bobby was identifying with the part-object representation of master and projecting onto his classmates the part-self representation of slave. His classmates did not cooperate and instead became angry. Bobby became disappointed and afraid. He defended by splitting and emotionally detaching from his classmates. Initially, he identified with the sadistic part-object representation and became aggressive in attempt to protect himself and keep the others away. As the year progressed, Bobby either identified with the projections of part-self representations of slave or self-in-exile, or with the sadistic part-object representation. When he worked with clay, he would make clay monsters and talk about being swallowed up by the monster but not being scared of it (Fig 2). His sand trays during this period showed his struggles with feelings of alienation, isolation, and despair.
In third grade, Bobby continued to alternate projecting and identifying with either the sadistic part-object representation or with the part-self representation of self-in-exile within the nonattachment unit. Bobby generalized his fear to his teacher and experienced her as threatening and coercive. He reacted by withdrawing and being nonresponsive in class. His absences increased. Unfortunately, the teacher resonated with his projections and began acting out her countertransference. Her interventions with him changed frequently from confrontation to threats, punishments, then rewards. Bobby's response to her inconsistent interventions was to withdraw even further, usually by getting sick and staying at home. Eventually, the teacher became angry and was unreceptive to listening to any guidance with regard to interventions.
At the same time, Bobby was emotionally separating from his mother and feeling disconnected from his father. At times separation felt to him as though he was being abandoned ( 13-16) At home and at school Bobby acted out abandonment depression. He had severe tantrums at home and picked fights at school venting overwhelming talionic rage of "doing unto others" so as not to remember or feel ( 17). Abandonment depression for the individual with schizoid disorder of self has components of rage as well as emptiness, alienation, and isolation ( 4).
Bobby, in spite of the massive internal and external turmoil, continued within the relational unit with me. During his individual session, he reenacted his conflicts surrounding relationships. For example, when Bobby played a game with me, he felt he had to accept the master/slave relatedness part-unit as the condition to achieve the actual experience of connection. The only way he felt safe enough to take the risk was to identify with the part-object representation of master. However, when he started to lose the game, the fragile thread of connection broke. The schizoid dilemma of safety within a relationship would surface for him arid he would become angry, sabotage the game, or quit playing it. Then, he would build a sand-tray world of fighting dinosaurs. I would interpret, saying for instance: "It seems to me winning the game feels like being in control and safe and not winning doesn't feel safe and that makes you mad. So, in order to feel safe, you leave the game." He listened to fine interpretation and calmed down. I suggested thinking about a better compromise than getting mad and leaving. He would sometimes make a suggestion, but most often he would quietly think.
During second and third grades, Bobby's feelings of abandonment depression and talionic rage were intense, as reflected in his sand-tray worlds. One tray that illustrated his part-self-representations of enslavement versus exile was divided into two sides separated by a body of water. There were boats for connection. On one side were two castles surrounded by soldiers, an Indian winged messenger, treasure chests, and eagles. This side appeared to symbolize freedom from enslavement, protected and safe, a sanctuary, peace--exile. The other side had two large skulls, black castles, black faceless riders on horses, wizards, an amazon queen with a slave in chains at her feet, faceless figures in shrouds, dragons--enslavement, death. Bobby attacked the side that symbolized enslavement with fearsome dinosaurs and then he flooded the world with water. The castles were the only things that survived the destruction. Following the flooding, he appeared satisfied, calm, and in control.
At the same time, Mrs. W. was also experiencing abandonment depression. Mrs. W. received divorce papers from her lawyer and the reality of divorce evoked intense feelings of depression. She defended by withdrawing and identifying with the part-self-in-exile representation, feeling lost and alienated. It took her three sessions to acknowledge that she was experiencing suicidal ideation, and dissociation. I focused on reducing the rage she was turning against herself and which led her to engage in battles of control with Bobby. Her rage was about living in self-imposed isolation or enslavement. In an attempt to defend against anxiety, depression, and feelings of alienation, Mrs. W. projected onto Bobby feelings of fear, loneliness, helplessness, and anger. Her transference acting out persisted and she continued to sleep in Bobby's room, stating: "He was scared to be alone at night." She had a knife in bed with her in case of an intruder. When Bobby and she argued, she projected onto him sadistic part-object representation, likened him to his father and withdrew and detached, locking herself in her bedroom. Bobby felt abandoned and reacted by crying and frantically pounding on her door pleading for her to open it. Following these interactions, Bobby would become ill and his mother would become very solicitous. This transference acting out continued for several months.
On one occasion in the spring of his third grade, Bobby became enraged when his mother interrupted his session. Mrs. W. explained that she wanted to report that he was out of control at home. Bobby said, "You are taking up my time. If you don't leave, I'll get sick to punish you." I remarked to Bobby after his mother had left: "It seems that getting sick is how you attempt to feel in control." He ignored what I said and concentrated on building his sand tray. It was this tray that confirmed for me that his intrapsychic structure was schizoid.
The tray was divided into two parts separated by a small stream of water, but connected by a bridge. One side of the sand-tray world looked cold and frozen. It contained the amazon queen with a slave kneeling at her feet, an Oriental God of worship, the image of a lady encased in a block of glass, a sarcophagus, King Tut'ankha'men, and cars. By contrast, the other side of the world was filled with green trees, a log cabin, a couple of cars, and the image of a head of a wolf encased in a block of glass. There was a car on the bridge. When interpreting this tray from a schizoid perspective, one side symbolized the master-slave dynamic and the other the sadistic object and self-in-exile. The car on the bridge symbolized a wish for a connection. This tray had a quality of organization and calmness about it. When Bobby completed this world, he did not want to destroy it as he had his preceding ones. He was deafly proud of it and looked at it for a long time, which seemed to calm him. He asked me to take pictures of the tray (Fig. 3).
Gradually, Bobby started to find different compromises for his dilemma rather than acting-out anger. At the end of third grade, he began to play a little with other children and attempted to negotiate temporary alliances. Nevertheless, Bobby was very sensitive and easily injured and frequently he would get angry and withdraw because his feelings were hurt. At one point Bobby said: "I want to go out on a ship in the ocean so no one will bother me."
Mrs. W., six months into working on abandonment depression, was experiencing such severe loneliness and alienation relating to her feeling of being in exile that she negotiated with Mr. W. to live separately, but not divorce. She informed me of their agreement without discussing it beforehand. I interpreted the defense and her compromise. Mrs. W. had not worked through her abandonment depression, but she had developed greater ego strength. She displayed more self-reliance and self-capacity. She no longer isolated herself, and instead started to interact with what she considered to be safe groups of people.
Bobby attempted to keep himself separate from his parents' arguments. He grieved over the loss of his that his parents would reconcile and he continued to work through his abandonment depression. His fourth year of therapy was characterized by experimentation with his emerging real self and his growing awareness that others do not automatically think and feel as he does.
During this time, Bobby started a series of trays that ultimately led to rapprochement. His sand-tray worlds were no longer chaotic. Most of the trays were divided into two sides separated by water. Bobby had resolved his splitting defense and he rarely made trays that symbolized all good or all bad feelings. Sometimes there would be a war on one side with tanks and guns while the other side was peaceful. In others, there were sharks in the water swimming between two peaceful sides. Bobby flooded many of these trays. A small figure of a boy running, he named the "lawyer," was in all of these trays. This figure always survived the flood, just as Bobby survived his very painful feelings that at times overwhelmed him. Bobby re-enacted many of his emotional states of turmoil--anxiety, fear, alienation, isolation, danger, rage, and depression in this series of trays.
At one point Bobby built a sand-tray world divided into two sides connected by a bridge. Each side had an army with tanks and soldiers pointing at the other side. On the bridge he put the "lawyer." This was very symbolic of Bobby's dilemma: his fantasy of trying to negotiate a solution for his warring parents and his attempt to find a safe distance for himself in the midst of conflict both at home and school.
In the final two trays of this series, Bobby confronted his abandonment depression. The first sand-tray world represented the feelings of war and destruction, fear and threats that were a part of his talionic rage. He included in this tray all the objects he used in prior trays to symbolize rage and violence. The second sand-tray world represented feelings of loss, sadness, and fear that were a part of his depression. The objects in this tray were all his prior symbols of death and loss. He placed candles in the tray, lighted them and turned out the lights. He silently viewed the world by candlelight. Then, he flooded it. I was quiet, but stood next to him to view the tray (Fig. 4). He mused, "I don't know who the lawyer is." I wondered aloud if the lawyer might be him. Bobby responded, "I don't know." However, about three months later, he came into session and said: "I was thinking about that tray and I think the 'lawyer' was me."
In a session following his abandonment-depression sand-tray world, it was startling for me to see such an immediate and profound change in Bobby. It was apparent that he had attained considerable self-integration. His manner, actions, and speech had all changed. He no longer lisped, walked on tiptoes, or avoided eye contact. He looked as if he had grown up years in a week. His father accompanied him to the session. He talked to his father directly, making "I" statements about how he was feeling, what he wanted, and what he did not like. He no longer acted out the master/slave dynamics. In the past, Bobby frequently had periods of regressive behaviors; however, after his abandonment-depression trays, his regressive defenses completely disappeared.
Other changes occurred in Bobby's life as well. He started to participate in sports and was excited about learning to roller blade. He reconciled himself to his parents' separation. Bobby's mother had moved out of his bedroom and he was no longer throwing tantrums, but he still did some mild acting out. Bobby and Mrs. W. requested a conflict-resolution session. They stated resentments toward each other and came to some solutions and compromises about their difficulties. Following that session, they appeared to have fewer disagreements.
At school, Bobby, now in fourth grade, developed a working relationship with his teacher. He was healthy and his absence rate reduced to 5%. He continued to participate in the play therapy group at school. He acknowledged responsibility for his actions and no longer invaded boundaries or acted silly to embarrass the other children. When he was disappointed, he was able to talk about it and negotiate a solution. If he hurt someone's feelings, he apologized. He respected limits. At recess, he played group games. In class, he participated in a conflict-resolution session with his classmates and was very happy and excited about the outcome. He said: "I now have a second chance with my friends."
Mrs. W. was also starting to evaluate herself more realistically. She stated: "Unless I do something about myself, I can't expect Bobby to be different." She was depressed and lonely, but was not defending against the feelings as much as she had in the past. Her anxiety declined. She recognized her dependency on her husband and stated, "I have to detach from him." Her manner and attitude were no longer defensive.
By the beginning of her fifth year of treatment, Mrs. W. was making new friends. She set limits with her son, rather than trying to control him. She once again talked about divorce. This time, however, she did not view divorce as exile she would not survive. She simply stated: "It is time I get on with my life." She filed for divorce and began to attend a divorce-recovery group. By the end of the year, the divorce was final. She displayed self-reliance and decided to stop treatment at the end of her fifth year. I told her I was not going anywhere and, if she chose, she could call me at anytime. I did not see Mrs. W. for about nine months. At the end of that time, I received a call from her. She was again experiencing panic attacks and wanted to see me. She returned to treatment and arranged for twice-monthly sessions.
When Mrs. W. was going through the divorce process and feeling a sense of freedom, Bobby chose floor play rather than sand trays to express his feelings. He wanted the space. He carefully placed on the floor many of the objects he had used in prior trays throughout the years. The design was symbolic of a freedom celebration. He used most of the floor of my office and started narrating: "The boats are searching for treasure. They are exploring the unknown. There are masters of the world, God and temptations. There is a guardian angel and dangerous things to watch out for." He continued: "Gods are in the temple protected by guardians and people inside are safe. The treasure is collected in a pile high above the temple. There is a dangerous gorilla behind the gods in a cage. He is kept from the gods." When he completed this play, he appeared very satisfied and wanted to take many pictures (Fig. 5).
In subsequent sessions, Bobby talked spontaneously and started to reflect on past experiences. We played interactive games, like checkers, and he reminisced about the times he would quit mad. At times he returned to puppet plays, and again would engage in a "do you remember when?" During this time, Bobby started playing hide-and-seek with me. He would run ahead to my office and when I arrived I had to find where he had hidden himself. He said, "I like to hide and have you find me." In another session, he initiated a conversation about a disagreement he was having with a friend at school who had played a dirty trick on him. He said: "I've been thinking about what to do about Carl, but I have decided I don't need take revenge on him. God will handle it. I just need to take care of myself."
At school, Bobby was interacting appropriately with friends. He was not regressed and did not engage in transference acting out. He appeared to be calm and he was displaying real self-capacities in all aspects of his life. He regulated the frequency of his sessions and he would call for appointments periodically throughout fifth and sixth grades. Sixth grade was a successful year for him. Treatment for Bobby terminated at the end of sixth grade.
Two years following the end of treatment, Bobby scheduled two additional therapy sessions. He appeared to be checking to see if I was still there, as well as preparing himself for his next stage of separation, which was to graduate from eighth grade and to prepare for high school. During these two sessions, he reminisced about his past therapy experience with me and talked about his future high-school experience.
This case study highlights the dimension of understanding coupled with tools and interventions that the Masterson Approach contributed to the play-therapy process. It supports the theory that a child with a developing disorder of the self (personality disorder, or severe attachment disorder) can develop real self-capacities and whole object relations. It also illustrates the parallel process of mother and son. In spite of internal and external conflicts, Bobby was able to move through the stages of separation and individuation and achieve whole object relations. Although his mother made significant personal gains during her treatment and accomplished significant ego repair, she did not completely work through her abandonment depression. As a result, she did not obtain whole object relations. However, when she feels ready, she can return to treatment and complete the work.
- Coordinating Author/Instructor: Tracy Appleton, LCSW, MEd
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