Psychoanalytic Play Therapy

thinking, language, cognition, the capacities for self-observation and self-evaluation, and the ability to project present conditions into the future. The child’s active participation in the process is perforce more sporadic and less reliable than that of the adult. (1978, p. 297) Finally, it is vital to stress that in addition to offering interpretations in the idiom of the play, the analyst must choose carefully the time and setting when interpretations are offered directly because the child is so intolerant of them. ‘‘If confronted with too much interpretation in reality when defensively still resistant, the child can be prone to become anxious, uncomfortable, and uncomprehending in response to a direct interpretation, and to break off the communication by fantasy play’’ (Ritvo, 1978, p. 301). CASE STUDY 1: JASON L. CASE FORMULATION: TEMPERAMENT AND ITS CLASHES WITH THE SOCIAL ENVIRONMENT The case of Jason L. illustrates in bold relief many of the distortions and arrests Anna Freud stressed, which arise when the three factors of normal development go awry. While the course of normal development does not always proceed smoothly, the interaction of endowment, environment, and rate of structuralization and maturation within the individual are absolute prerequisites for normal development. I shall thus attempt to view this case through the lens of these three factors, first considering together Jason’s constitutional endowment and rate of structuralization and maturity. I will also propose that he be viewed as having many indications consistent with a diagnosis of Attention Deficit Hyperactive Disorder. Third, I will consider familial dynamics that have interacted with his particular set of constitutional and ego deficits, specifically the familial history and present symptoms manifested by his mother. Lastly, I shall 46 PSYCHOANALYTIC PLAY THERAPY E1C01_1 02/11/2009 47 attempt to describe the ecosystem pressures with which this family struggles daily, now so commonplace in these modern times. From the prenatal period on, Jason manifested symptoms in physical factors that raise the possibility of later constitutional vulnerability and temperament disturbances (Chess, Thomas, Birch, & Hertzig 1960). This is strongly suggested by the mother’s prenatal complications requiring bedrest from the 26th week on, his low birth weight despite full gestation, and mother’s denial of substance abuse. His constant irritability and poor sleeping suggest temperament disturbance, and his hypensensitivity to clothing, having his hair washed or nails cut, or changes in his life also suggest a need for stability and sameness of routine. These circumstances are likely to raise the question of constitutional variables operating to disturb the psychic equilibrium of the infant in the earliest months, creating in the infant a psychic sense of the body being out of control. As his mother already felt guilty about the difficult pregnancy, she worried about his survival, holding him constantly. A baby held constantly would also likely suffer some reaction once this period has passed, an inevitable fact of life once the mother resumes her life and the demands of the infant are crowded out by competing factors (e.g., the birth of siblings, mother’s return to other responsibilities, etc.). Jason walked and acquired toilet training within normal limits, suggesting adequate motoric and neurologic development. Psychologically, however, he was reportedly an irritable, difficult toddler who complied poorly with her demands and threw violent tantrums when frustrated in his aims. These can be interpreted as Jason’s experiencing autonomy strivings, which abraded the needs of his mother. This also led to autonomy and control issues, which course throughout his life. Her inconsistent limit-setting and spanking hardly set the stage for a consistent, positive mother–infant bond, as well as his defiance of authority, creating also a feeling of permission for violation of personal space through the physical punishment delivered. This is later carried out to the extreme in her hitting and bruising him. Her remark that he took several hours before he would warm up to her after attending preschool also suggest the ambivalent attachment pattern found by Mary Ainsworth (1978), now setting the template for their future interactions. Furthermore, this writer would suggest that his history of impulsivity, overactivity, and risk-taking, as reported by parents and teachers, as well as his results on the WISC IV, specifically a Working Memory Index of 100 and compromised Processing Speed of 110, lend support for the possibility of ADHD in this bright but grandiose and unreflective child who could describe barely his own characteristic attributes, positive or negative. His Case Study 1: Jason L. 47 E1C01_1 02/11/2009 48 immaturity and poor peer relations, as reported in the Behavior scale of the DTORF-R, also suggest difficulty in keeping still for movement or group activities where he must inhibit his normally active and determined self. For the most part, his behavior is destructive, defiant, and singular, hardly recognizing of mutual engagement with others his age. On the Achenbach scales, Jason’s parents differed markedly on their view of his difficulties, with his mother endorsing many symptoms while his father seeming more lenient and generous in his assessment of Jason’s negative behaviors. While mothers generally report a child’s behaviors with greater accuracy, perhaps because of the length of time they usually spend with children when they are young, Emilio seems particularly unreflective in his acknowledgment of Jason’s core difficulties. The parents’ report of his complaints of boredom, restlessness, agitation, and difficulty focusing, even on things he enjoys, further suggest the presence of ADHD. In addition to his temperamental difficulties from birth leading to the question of ADHD, Jason’s moodiness and full-blown rage attacks suggest also the issue of a bipolar disorder, as exemplified by his unpredictable and explosive rage attacks when frustrated. (‘‘The slightest thing sets him off.’’) As is frequently the case, bipolar disorder and ADHD are often comorbid conditions. His throwing down his books after school seems mild compared to his deliberate throwing of the lotion bottle against the wall when performing the MIM task with his mother. Here, his anger and frustration are immediately expressed in a destructive act that would likely threaten his mother with his defiance. For her part, his mother appears to act with annoyance and removes the lotion. Sensing her beginning to withdraw, he throws the bottle against the wall, perhaps to keep her engaged even if she is angry. In turn, she withdraws her attention completely. This demonstrates in vivo the cycle of rejection that both feel toward the other, another example of the rejecting pattern of attachment discussed by Ainsworth et al. (1976). It also demonstrates how quickly Jason dilates with rage when he feels his mother’s intolerance of his moods. Jason’s already tenuous impulse control and frustration tolerance seem to decompensate quickly in the face of emotional distress, resulting in the maladaptive, acting-out behavior that comprised his behavior disorder. Several of these provocative episodes also eventuated in physical abuse by his mother. More significantly, however, Jason shows significant attachment and separation-individuation disturbance vis-á-vis his mothering, a likely result of maternal withdrawal and depression during the latter part 48 PSYCHOANALYTIC PLAY THERAPY E1C01_1 02/11/2009 49 of the second year of his life. These, indeed, occurred during what would normally be the rapprochement subphase of the process toward achievement of individuation as described by Mahler (1980). This phase is usually a period characterized by the baby’s moves away from the mother only to return to her for ‘‘emotional refueling.’’ Unfortunately, in this case, Jason’s mother was unavailable for him to return to home base, as it were, as she was undergoing yet another difficult pregnancy with his sister Carla, and he was relegated to the care of the grandmothers. Matters could not have fared worse for him as his mother experienced a much easier time raising his sister, causing her to treat his sister with more outright affection. To add to this, hewas ousted from his favored position still further when sent to preschool at age four, perhaps causing him to wonder about how mother and daughter were bonding without him. This might have been experienced as further rejection of him, as evidenced by his protest upon leaving and his distancing upon reunion with his mother. Indeed, the resistance toward school continued to present day. One notes, for instance, that his worst behavior is usually the hour after school, whereupon he arrives furious and raging, requiring some time to cool down before he can reconnoiter with his mother. His more tractable and compliant behavior with his mother during the weekends further raises the question of his anger and protest about separating from her during the weekday. When there is more time for both parent and children to relax from the pressures of school and work, the entire family system appears more tranquil. Jason’s unresolved dependency, autonomy, and oedipal needs in relation to his mother all appear to coexist and are characterized by his anger and hostility, rendering Jason rebellious and defiant where his mother is concerned.While he longs for a more loving relationship with her, as noted in the observations made during MIM tasks, his disappointment over her perceived betrayal by favoring his sister may signify the need to maintain distance from her, even at the expense of unmet dependency needs. His oedipal longings are tingedwith envy, and he appears to have turned away from his mother toward his father for emotional supplies. Symptomatically, Jason’s disruptive behavior can be parsimoniously viewed as an acting out of frustration and rage felt toward his mother for her perceived coldness and controlling behavior toward him. While his warmer and more nurturant relationship with his father compensates to some extent for the contentiousness and rebelliousness of his relationship with his mother, it hardly approximates his disappointment over the ambivalence of this primary relationship. Moreover, my basic premise is that disturbances of attachment and bonding existed early on between Case Study 1: Jason L. 49 E1C01_1 02/11/2009 50 Jason and his mother, setting the pattern of relating for this dyad that has since been exacerbated by maternal depression, postpartum and longterm, along with his mother’s seeming preference for his younger sister. Structurally speaking, Jason had to grapple with developing his own identity at a time when the primary caretaker of his life, his mother, was in the grips of her own ongoing depression, which rendered her psychologically unavailable to her toddler son. His maturation could have developed more normally if these factors had not intervened to cause his fixations in the phase of anal-sadism. Thus, his marked rebelliousness and hostility bespeak the enormous disappointment and rage he feels toward having supplies withheld from him. This is actualized later in development by his destructive, antisocial behavior. Jason has evidenced a selective capacity for more integrated object relations, as for instance in the relationship with his father. Here, he allows his dependency needs to emerge, and his father appears to be a willing partner to provide the nurturance he seeks. This stands in marked contrast to his behavior with females. His anger toward female authority figures is persistent and causes him to relate with almost equal ambivalence and rage toward other females in displacement. An example of this is the differential reaction to his female teachers versus his male student aide. Males are felt to be less dangerous and ominous, whereas females irritate him because they seek to control him excessively. Toward the latter, he evidences in bold relief his lability, variable impulse control, immature judgment, and lack of even ageand phase-specific insight. Thus, he evidences part-object relationships, split off by the presence of intolerable anger. Females who have disappointed him in the past are tainted, whereasmales are perceived as more loving and approachable. Jason continues to mourn the psychic abandonment by his mother through depressive withdrawal. Although his tie with his father seems relatively unambivalently loving, it rests on a foundation of hostile dependency toward his mother, thereby setting the stage for poor object ties with subsequent object relationships, especially with female figures. Further complicating the picture are each parent’s distinct ways of parenting each child in the family, due as much to their ethnic and socioeconomic differences as to their individual personality characteristics. For example, Mary came from a middle-class Caucasian background, whereas her husband came from a lower-socioeconomic Mexican one. She also had a father and grandfatherwith volatile behavior and prolongedmood swings, as well as a father with alcoholism. While Mary’s parents were divorced and she was alienated from her mother and sister, Emilio hailed from a 50 PSYCHOANALYTIC PLAY THERAPY E1C01_1 02/11/2009 51 close-knit, first-generation Mexican family, which seemed fairly functional despite the alcoholism of his father and brother. Thus, Jasonappears tobe the thirdgeneration in this family suffering from mood disorders. His parents differ enormously on their own achievement strivings. Employed as a secretary in a law firm, Mary harbors greater ambitions to further her education, even as she is aware of the impediments toward this goal, reflecting her middle-class origins. On the other hand, Emilio is contentwithhisposition as a supervisor inablue-collar job.Neither parent has more than secondary education and the possibilities it portends. The diagnostic protocol is revealing of several important basic components of Jason’s ego structure, defenses, and resources. An intelligent child, he nevertheless seems more immature than his measured intelligence would suggest. His poor attachment history and possible ADHD and bipolar disorder (Papolos & Papolos, 1999) lend support for the ego disturbances that he experiences consistently. He relates, also, in unpredictably immature ways, which appear motivated by a regressive need to be a younger child, perhaps reflecting his envy of his younger sister, and as a way of satisfying age-appropriate but thwarted dependency needs. Such can be seen at one end in his clingy behavior toward his father and, at the other extreme, his strident defense against showing vulnerability and neediness to his mother. Indeed, he lacks a well-developed observing ego and cannot comprehend the effect of his behavior on others. While this is certainly age-appropriate, given the egocentrism of this age, Jason appears unable to have any insight into his difficulties. Superego weakness is also seen in his reaction to being caught setting a fire with a friend. He avidly seeks to avoid all mention or discussion of his conduct disorder, as noted in his initial silence during the opening interview and during confrontation after setting the trash can on fire. Nor does he assume much responsibility for his own behavior, even when confronted with the contrary. His sobbing and crying when finally admitting his culpability is more suggestive of the shame and fear of punishment he felt rather than any well-organized remorse or sense of guilt for having destroyed property. Indeed, superego deficits are roundly suspected from this vignette, raising the specter of more antisocial acts in the future if his hostility ascends. While they can be seen as isolated acts of rage, they are fundamentally acts of defiance and attempts to humiliate in displacement, almost always at internalized authority figures who are experienced negatively. At this juncture of his psychic life (i.e., in the beginning of the latency phase), Jason could be expected to be maturing out of the narcissistic Case Study 1: Jason L. 51 E1C01_1 02/11/2009 52 egocentrism of this phase to a more advanced level of conscience development. His oedipal conflicts are negative, however, and show fixations with the unavailable, hostile maternal introject, thereby slowing the progress of this crucial phase. Defensively, Jason’s chief ways of coping against overwhelming affect appear to be habitual avoidance and externalization, although this can appear to regress toward outright denial and projection in the face of extreme threat. Such renders him, thereby, a child who resists fiercely admission of culpability of his pervasive acting-out behavior. He also utilizes splitting and projective identification as major coping mechanisms against his anger. Thus, he ismore capable of investing lovewith one object and hating the other, showing thereby a great difficulty in integrating the two polar opposite affects within one singular identity. In this same vein, Schore (2002) discusses the infant’s psychobiological response to trauma as being comprised of two separate response patterns, hyperarousal and dissociation. He notes that in the initial stage of threat, an alarm reaction is initiated, setting off the sympathetic nervous system of response of increased heart rate, pressure and respiration. . . . But a second, later forming longer-lasting traumatic reaction sets in with dissociation, in which the child disengages from stimuli in the external world and attends to an ‘‘inner world,’’ involving numbing, avoidance, compliance and restricted affect. (Schore, 2002, p. 451) Jason generally remains reality-bound, however. Despite the pervasiveness of his anger and his capacity to dissociate aspects of his thinking when rageful, at no time does he lapse into psychosis or delusional thought disorder, despite the abundance of anger he experiences. More possible, however, is his vulnerability toward psychopathy if his anger and sense of helpless rage go unaddressed. While diffuse and labile in affect, Jason evidenced generally appropriate moodwhen observed with both parents in theMIM. Apparently, his mood alternates with the presence of the particular adult whom he has well differentiated. Thus, his object relatedness appears intact even if taxed to the extreme by his resentment of his mother’s distance and coldness. Such prolonged oedipal fixation for his mother rests on a template of frustrated preoedipal wishes to have an exclusive, dyadic relationshipwith her. With his sister present, possibilities for this relationship are virtually nonexistent. Hartmann’s (1950) concept of an ‘‘average expectable environment’’ for each child appears poorly realized for Jason, despite each parent’s obvious intent on providing it for both children. In the case of Jason’s mother, her 52 PSYCHOANALYTIC PLAY THERAPY E1C01_1 02/11/2009 53 psychopathology based on early deprivations appears impressive. Her own depression appears to stem from an early history of familial disturbance and losses. For this reason, she reacted with anxiety to possibly losing Jason immediately after his birth. This anxiety, normal for first-time mothers, has dynamic roots in her anger toward her father and men in general. She may have distanced herself defensively from Jason in order to stave off feelings of loss if he were truly ill. Certainly, it is safe to characterize her childhood as deprived and burdened, permeated with a sense of loneliness and isolation. This is evident in her dysphoric description of her relationships with her mother and sisters. It also motivates her to avoid her mother, as she is prone toward offering depressing reminders of their family’s past, as well as the mother’s perceived lack of empathy for her marital and family difficulties. Mary appears to have little contact with her sisters, perhaps seeking to avoid any envy she might feel over their supposed success in marrying upwardly mobile men. Was she disappointed that she married someone who was not equally accomplishing? Throughout, Mary has minimized and denied the extent of her own depression and neediness, despite the occurrence of several fairly serious depressive episodes in her life. The question is raised, here, of the neglect she may have suffered from her own family as she endured these episodes. The cycles and vicissitudes of depression certainly suggest a long-standing need for intervention early in her life, neither of which seemed noticed or offered. As an adult, Mary appears quite narcissistically concerned with her own conflicts, and hence seems unreflective about the extent to which she was presently inflicting psychic and physical harm on Jason. Her lack of sensitive attunement to his needs attest to her level of narcissistic involvement and depletion of nurturance. Her own impulse control seems poor in that she hit him several times, sufficient to cause bruises. While there is no reported history of her being physically abused as a child, the question is raised as to the type of discipline she received during childhood, especially with her history of a father who was alcoholic and violent. Her lack of urgency when reporting her abuse of Jason is worrisome in that she may feel justified in delivering such punishment in response to his misbehavior. To be sure, avoidance and denial appear a favored defense against anxiety in this family. As both parents seem to minimize the seriousness and implication of Jason’s conduct disorder, they also turn the same lens toward their own personal issues. Mary’s blunted affect about her parents’ divorce and father’s subsequent death during her adolescence seems impressive. She has apparently repressed whatever unresolved oedipal longings remained for her father Case Study 1: Jason L. 53 E1C01_1 02/11/2009 54 by the time of his untimely death. Experiencing her mother as depressive, she may have longed for some comfort from this parent, but this need remained unrequited. Mary’s difficulty relating to males repeats itself now with her own son: Jason’s need to identify himself as a male is something that she can poorly relate to, having been raised in an allfemale household. It is safe to surmise that she held anger toward her father for his drinking and violent behavior, causing the family to break up and sink into more dire circumstances, of which her mother reminds her regularly. As for Emilio, he appears to be amanwho did not have the psychological awareness or emotional strength to confront Mary’s depression in order to help her or the family. To his credit, however, he appears to be a warmer, less remote parent thanMary, able to engage their children’s compliance in a more pleasurable and gentle way. He seems entirely more patient and concerned in engaging their interest in the tasks of daily living, as in meal preparation, and he appears generous with praise and affection. His own report of relations with his family seem unilaterally favorable, despite the question of the extent of his father’s alcoholism on his own development. His view of his mother as being nurturant but almost invisible hardly bodes well, however, for his understanding of the female gender. Thus he seems to bemore emotionally available to devote psychic energy to playing with his children andmanifests more of the sensitivity and attunement that Mary cannot give Jason. The results of the dyadic and family assessment illustrate clearly the different parent–child interactions. Mary, for example, lets Jason struggle with his house drawing and intervened only after a while. Lacking much support, Jason produced little and sought to quit the field as soon as he could. With his father, however, he felt a greater sense of parental interest and involvement. His father also helped him with less criticism and judgment. Thus, Jason’s interest in the task was captivated, and he created a drawing that was longer and more elaborate. With this encouragement, his production highlighted more clearly his above-average intellectual potential. Definitely, there is more evidence of playfulness and humor on the part of Jason’s father than in his mother. The latter shows little empathic understanding for what he felt, indulged little in his need for face-saving measures, mindless of the shame he felt when confronted with possible failure. His father showed far greater sensitivity to this fact in his play with both children, cajoling them to do tasks even as they were protesting. Eventually he elicited far greater cooperation from them. They even viewed the task as fun and pleasurable, when hitherto it had been irksome when supervised by their mother. 54 PSYCHOANALYTIC PLAY THERAPY E1C01_1 02/11/2009 55 Such an episode highlights clearly Moran’s (1987) view of the role parents have in integrating play into their interactions with their children: We believe that loving parents who are in tune with their children playfully react to the child’s anxieties with highly specific, well-timed interventions. Such responses are empathic, but the link between parents’ behavior and the child’s anxiety remains precocious for both parties. Such parental responses aim to ease the child’s dilemma by introducing a modicum of enjoyment and thereby increasing the child’s options for mediating or solving conflict.