DIFFERENTIAL USES O F PLAY IN T R E A T M E N T O F YOUNG CHII,DREN*

FANNY AMSTER Jewish Board d Guardians, Brookhn, N . Y.

play activity of a child, his natural medium for self-expression, has

i n which play can be used in treatment of children. We are all aware of the many psychoanalytic contributions on play technique and of how we case workers, in our usual adoptive manner, take over psychoanalytic contributions. We must keep in mind that the differences in the psychoanalyst’s and the case worker’s use of play are inherent in the differences in training, orientation, understanding, experience, and skill. I n other words, the case worker’s use of play in treatment is basically an adaptation.

In my experience as a case worker, I have attempted to develop some under- standing of what play means to a child. I have tried to integrate such understand- ing with my casework training, the agency’s function, the child as a person, and the problems he presents. Through the composite of this awareness and integra- tion, I haveattempted to evolveapplicableusesofplay in the treatmentofchildren.

As others have discovered, I have found play to have many meanings and values to a child. Essentially, play is an activity a child comprehends and in which he is comfortable, an integral part of his world, his method of communica- tion, his medium of exchange, and his means of testing, partly incorporating and mastering external realities.

A child, to whom a formal interview situation can be an uncomfortable ex- perience, can feel more a t ease when he finds play materials which are known entities to him. Provision of play materials means the provision of a medium, a natural means of communication, through which the child’s problems may be expressed more readily and the treatment more likely to succeed.

In treatment of children, play is always a medium of exchange and it is com- parable to words, the adult’s medium of exchange. I t is not a therapy i n itself any more than words can be: All therapies require a therapeutic relationship and a medium of exchange. The purpose of the play activity determines its role and importance in treatment. Therefore, play as a medium differsfrom play as a tech- nique even as words differfrom any purposive use of them. Play is a technique when it is used in treatment for dejnite diagnostic and therapeutic purposes.

I have found various adaptations of play activity to be useful in the treatment of children. These adaptations have differential purposes and values and varying roles for the therapist. In what follows, I shall at tempt to define, illustrate, and examine six uses of play through excerpts of case material. Although I recognize that the use of excerpts isolates a technique from its total context in a case and necessitates the omission of pertinent data, I believe that only by the method of using excerpts of case material can these uses of play be defined clearly within limited space.

THE stimulated much thought, experimentation, and conclusions as to the ways

* Presented a t the 1942 Meeting.

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As these uses of play a re delineated, each excerpt of case mater ia l will be examined for t h e diagnostic a n d therapeut ic aspects. None of these uses is mu- tually exclusive. &lore than one use of play is usually necessary in t h e total treatment of a child a n d all uses have both diagnostic a n d therapeut ic values. The conscious direction of t h e play act ivi ty gives i t purpose, meaning, a n d value in treatment.

Play can be used f o r diagnostic understanding of the child, supplementing t h e historical material. W e can observe t h e child’s capaci ty to relate himself to others, his distractibility, his rigidity, his areas of preoccupation, his areas of inhibition, the direction of his aggression, his perception of people, his wishes, a n d his per- ception of himself. I n t h e play, his behavior, ideas, feelings a n d expressions help our understanding of his problem a n d how he sees it.

Mortha, g, is referred because she wrote an impassioned love note to a boy in school. She is a stout, meticulously dressed girl who walks with her arms far away from her body. In play, she tries to keep clean, avoids using her hands, and refers to paints as “dirty.” She squirms as I begin modelling in clay; vehemently insists that I model fully-dressed figures; prudishly says she dislikes people without clothes, and furtively peers a t some undressed dolls in the room.

In this play activity, Martha reveals her aversion to dirt, discomfort about her sex curiosity, a strong desire to peep, efforts to cloak her interest in nudity, and the possibility of masturbation.

ENen, g , is an unusually polite, compliant child who speaks like an old woman resigned to her many burdens. To help her feel like a child, I suggest we play and she selects draw- ing, but uncomfortably asks for suggestions. When I comment that her ideas are important and that she draw what she wants, Ellen sits with pencil poised in mid-air while she frowns and radiates mental struggle. After several minutes she draws an unimaginative, precise picture, a copy of one she recently made in school.

In this play activity, Ellen reveals inhibitions of play and thought and inability to act like a child.

Lawrence, 6 , elder of two children, is referred for spitting on people. For several inter- views, he draws large figures of women with exaggerated breasts and then scribbles over, and spits on them. As he annihilates these figures, he boasts of his strength and, with mis- chievous glances a t me, carefully accumulates a quantity of spit. He alternates the draw- ings of women with drawings of trees laden with fruit. He makes many dcmands, snatches what he wants, and insists that I should not see other boys. I limit the amount of materials he can use and give him toys when he does not demand them.

In his play activity Lawrence shows capacity for relationship and reveals that to him women have large sources of satisfaction; that his spitting provides gratification and re- taliation; that fruit probably symbolizes substitutive gratification; that destructiveness makes him feel weak; and that he seeks support and strength through boasting, snatching, and through demands for material gratification and for the only place in the affections of a mother substitute.

These children, cited as illustrations of t h e use o fp lay for diagnostic understund- ing, derived some therapeut ic values in their individual p lay activity. M a r t h a achieved some release through a shar ing act ivi ty wi th a n adul t who tolerated her interests a n d accepted her feelings. Ellen could feel more like a child; learned she was expected to be a child with ideas a n d imagination; and shared a n ac- tivity with a n adul t to whom her ideas a n d wishes were important . Lawrence

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secured release of his feelings and shared an experience with an adult whose atti- tude and handling were different.

PIay can be used to establish a working relationship. This use of play is helpful with the young child who lacks the adult’s facility for verbal self-expression and with the older child who shows resistance or inability to articulate.

Bertha, 10, is referred by her mother who asks for “lectures” and complains of the girl’s temper tantrums. In the interview, Bertha, with stolid expression, seems overtly compliant but guarded in her limited responses. She is startled and nonplussed when I inquire about her interests and blurts out that she likes to draw. I provide the materials and she draws what she labels as an “ideal girl.” We discuss the “ideal girl” whom Bertha vests with an appearance which is the antithesis of her own. When I comment about Bertha’s aptitude for drawing, she tearfully blurts out that her family thinks her drawings are babyish. She is surprised by my recognition of her feelings.

In this situation, the therapist provides materials in which Bertha is interested; meets her passive aggression by doing the unexpected; encourages her interests; and identifies with her feelings about her family. Bertha sees she is accepted as a person; releases feeling about her family; has a sharing experience with an adult different from others she knows; and establishes a working relationship with the therapist. Two focal areas of treatment are presented: Bertha’s percep- tion of herself as contrasted with the “ideal girl”; and Bertha’s feelings about her family’s att i tude toward her and her interests.

Jeannette, g, is referred for her hostile behavior toward her younger siblings and for refusal to permit her mother out of her sight. History material reveals she has suffered alternate over-indulgence and cruel punishment from her father, rejection by her mother, and many traumatic hospitalizations. At the first interview, with a fearful expression in her eyes and rigidity in her body, Jeannette eyes me apprehensively but slowly enters the room when she sees the play material. For several interviews she models animals in clay or draws stilted landscapes, keeps her head lowered, and speaks to herself in whispers. Gradually, she permits me to assist her and I confine my comments to the play activity and to her real abilities. When Jeannette achieves the first therapeutic objective of thaw- ing out, she confides that now she is sure I will not send her away as her mother threatened.

In this situation, the therapist provides play material from which the child can select and through which she can safely express herself; remains passive until invited to share; confines comments to play activity and to the child’s abilities; helps the child thaw out ; and prepares the child for a relationship. Jeannette slowly releases some tension through her activity; slowly permits the activity to become a sharing one; feels encouraged to again extend herself as a person and to expect warmth from an adult; learns tha t all adults a re not punitive like her mother; feels the therapist is her ally; and establishes a working relationship with the therapist.

Arthur, 5 , is referred for extreme stubbornness and refusal to speak. In the interview he stands as far from me as possible and only shakes his head in response to my overtures. I seat myself, begin to model clay figures, and whisper to myself. Arthur edges toward me, peers over my shoulder and, exasperated, shouts: “What you say?” He grabs some clay and chatters in a husky, flat voice.

In this situation, the therapist ignores the boy’s method of avoiding participa-

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tion; initiates play activity which piques the boy’s curiosity and stimulates his desire to participate; whispers to further pique his curiosity and to secure his interest. Arthur begins to speak; surrenders some negativism as he learns to share activity with another person; recognizes that his refusal to speak can block him from pleasure; and establishes a working relationship with the therapist.

These children provided through their individual play activity, some additional diagnostic understanding. Bertha revealed her stolidity and limited responses to be defenses against “lectures” and punishment and that she was unaccustomed to any acceptance or interest in her and her feelings. Jeannette’s apprehensiveness, inability to share, and whispering to herself, revealed her fear of attack and her ways of protecting herself. Arthur showed that his stubbornness and refusal to speak helped him secure attention.

Play can be used to break through a child‘s way of playing i n his d a i b life and his defenses against anxiety. This use is helpful as an additional way of treating dis- tortions in a child’s way of playing.

Momiqage7, feels inadequate and his mother reports that in his games with other chil- dren, he emphasizes winning. In one interview he brings a game of tickets and insists I play with him. When he thinks he is losing the game, he immediately changes the rules. I comment about his way of playing and we discuss his concern about his strength. Several interviews later his mother reports that in his street games, Morris enjoys a game even when he does not win.

Jeannette, Lawrence, and Ellen were also helped through this use of play. Jeannette’s protectiveness made it necessary for her to emphasize rules, clean- liness, and tiny, precise production in her play activity. During treatment I encourage her, through my attitude and participation, to change rules, to smear with paints, and to draw large figures. As the motivations for her protective- ness are worked out, the play activity concurrently helps her learn that she can play in a different way. Lawrence, who snatched everything, learns through the play activity that he must accept limitations, and that when he does not demand, he secures gratification. Ellen shows inhibition of play and thought. In treatment I encourage her to express, develop, and strengthen her own ideas. I stimulate her interest in drawing and in making up stories. Through this play activity she tests out and learns that self-assertion results in recognition and approbation instead of danger as she feared.

With these children, who had distorted ways of playing, the therapist provides material, opportunities and encouragement which break through the child’s distorted way of playing and his defenses against anxiety. Each child, through the play activity, receives help in developing different ways of handling himself which are valuable to him as a child and which will help him as an adult.

Play can be used to help a child verbalize certain conscious material and the associated feelings. This use is helpful when a child blocks in discussing certain material and an impasse in treatment is created.

StunZey, 10, doggedly refuses to discuss his encopresis and his mother’s attitude toward him. As he is interested in building with blocks, I suggest he build a house. He builds one

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but omits the bathroom. We discuss what such omission might mean to the imaginary family who lives in the house. Stanley then builds an ornate bathroom but places it outside the house. We discuss this in terms of the inconvenience to the family. The boy comments that he dislikes the simple bathroom in his home. Later, he relates that he soils himself; that his mother punishes him by whipping and by rubbing his faeces on his face; that he gets even because she has to wash his trousers. We discuss the pleasurable aspects of his soiling and whether through his “getting even” he can achieve the escape he wants from his mother’s domination.

I n this situation, the therapist uses material in which the boy is interested a t this point in treatment; initiates a general play situation and permits the boy to fill in the details, discusses his omission of a reality, makes interpretative remarks geared to the content of the play and, later, when the boy makes his own associa- tions, the therapist makes interpretations which point u p the symptomatic nature of his soiling and which fits this into his general problem. T h e boy is helped to verbalize material which represents failure, punishment and retaliation; secures release of his feelings, surrenders some of his negativism, gradually accepts the reality of bathrooms, verbalizes his role in his relationship to his mother, and is helped to doubt the effectiveness of his method. Some of his discomfort is alleviated and an impasse in treatment is worked out.

Leon, 7, who was referred for refusal to attend school, denies any concern as to what his mother and I discuss, yet he always stands outside my door when I am interviewing his mother. I n an interview with him I initiate a play situation with three dolls which are designated as a boy, his mother, and myself. Leon quickly uses chains of paper clips to outline the floor plan of my office and the small outside foyer, and uses strips of paper for the office furniture. As he moves the dolls around, he talks freely: “I am standing outside. I can’t hear. I smack you down ’cause I can’t hear what you tell my mother. I can’t smack her down-she’s my mother.” He acts out and verbalizes what happens from the time he and his mother arrive for their appointments: “We come in. We ask for you. You tell me ‘come in.’ You ask questions. Then you say ‘time is up. I want to see your mother.’ I say ‘Oh, yeh?’ I knock you down. I go home with my mother. Now it is next week. We come here. . . . ” Leon demonstrates and verbalizes this scene three times and the intensity of his feelings diminishes. He then starts the same scene but shows that he permits the mother to come into my office and he accompanies her. He shows that I tell him to go out- side and says: “I go out. I try to open the door but you won’t let me. I listen. I can’t hear.” He quickly draws two figures, designates them as he and I, and says I am shooting and killing him. I recognize his fearfulness, his concern about what will happen to him, and his feeling that I am mean because I limit his desire to control. Leon now draws me a val- entine, then decides it is too good for me and he will keep it.

I n this situation, the therapist initiates a general play situation and permits the boy to fill in the details, allows him to continue the play activity until the intensity of his feelings diminishes and, after the boy has expressed his hostility and fearfulness, the therapist verbalizes his feelings and his wishes. Leon secures release of his feelings of exclusion and fearfulness, feels omnipotent and retalia- tory in his play, reduces the intensity of his feelings through the repetitive play, recognizes the unreality of the power he desires, verbalizes guardedly his hostility toward his mother while he uses the therapist as a substitutive foil for her, and expresses mixed feelings for the therapist. Some of his discomfort in the thera- peutic relationship has been alleviated and the barrier in treatment has been removed.

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These children provided in their play activity some additional diagnostic un- derstanding. Stanley revealed his desire to maintain infantile behavior and ability to carry his negativism to the point of denying the existence of bathrooms. Leon revealed his desire to maintain infantile omnipotence, his resentment at limitations which were set on his efforts to control a n d which heightened his feeling of helplessness, and his expectation of annihilation for his behavior.

Play can be used to help a child act out unconscious material and to relieve the accompanying tension. This cathartic use of play deals with symbolic material which has dangerous significance to the child. T h e therapist must be aware of how much release in play the particular child can tolerate without panic and must be aware of the kind of participation and interpretation in which to engage.

Morton, 7, is referred for a sudden onset of sleeplessness. He anxiously relates that Max is the name of the neighborhood bully who beat him severely. He slowly writes out: “Max is a triple based (bastard),” and walks restlessly about the room as he shows me how well he can bounce a ball. He quickly accepts my suggestion that we make up a story about a little boy and a big boy. I draw the stick figures while Morton tells the story. He relates that the little boy meets the big boy who beats the little boy until the little boy loses his nose and legs. The little boy manages to escape by running home on his hands. The little boy is disappointed because his mother does not kiss him. A doctor makes the little boy well. The second scene shows the little boy challenging the big boy to fight. This time Mor- ton and I decide the little boy has grown and has muscles. In the fight the little boy knocks off the bully’s nose, legs and arms. The last scene shows the big boy, covered with band- ages, confined to his bed and weeping. A doctor is preparing painful remedies and the little boy who is standing outside the bedroom window is laughing heartily.

In subsequent interviews, Morton acts out through stories and jokes, various dangers which overtake small boys and how these boys emerge victorious. After this play activity Morton spontaneously relates that he and Max are friends and share activities. His mother reports that Morton is now able to sleep.

In this situation, the therapist initiates a general play situation in which the boy can act ou t his fear and relieve his tension, permits the boy to fill in the details of the play activity, participates in a manner which helps the boy work out his feelings, and interprets only through activity geared to the content of the play. Morton acts ou t his fear of injury by stronger males, his feeling of weak- ness, and his desire for strength and retaliation. H e becomes less anxious and develops strength through the repetitive play. In his daily life he forms a friend- ship on equal terms with a stronger male whom he formerly feared and avoided. He regains his ability to sleep.

This boy contributed through play activity additional diagnostic understand- ing. H e revealed his feeling of weakness, desire for consolation from his mother, concern about injury, and his need to feel strong.

Play can be used to develop a child’s play interests which he can carry over into his daily life and which will strengthen him f o r his future life. This use of play has particular importance because of the correlation between the play and work ca- pacities of an individual.

Maurice, 9, who has many phobias, is unable to participate in any activity with other children. When, during treatment, he becomes less phobic, he expresses an interest in baseball but feels inadequate because he cannot throw a ball. I plan several interviews in which Maurice can spend some of the time in the use of a ring toss game which develops

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his skill in throwing. Subsequently, he reports that he is playing ball in the street with other children.

Josephine, 8, was referred for her voracious thumbsucking. In one interview she com- plains that nobody chooses her for games of jumping rope. She feels she would spoil the games because she does not know how “to run in.” As this child needs to compete socially with children her age, I feel it is important for her to learn this activity. I teach her, by revolving a pencil in large circles into which she runs and jumps, how to time the “running in.” In a later interview, she reports how well she can jump rope.

With these children the therapist provides material, opportunities, and en- couragement in order that each child may use the interview situation as a place to test himself out as a person and to mobilize his strength for his current and future life. Each child develops sources for current gratification and capacity for future accomplishments.

The examination of these uses of play reveals that in each use, irrespective of the specific purpose, both diagnostic and therapeutic values are present. As we can learn more about any child through his play activity, all uses of play add to our diagnostic understanding. As all play helps a child to share himself and, in varying degree, to re-enact, re-live and release, all play has some therapeutic value. The therapist’s role, which includes the tolerant attitude permissive with- in realistic limitations, depends on the purpose of the play and the child’s use of the relationship. The therapist may be part of a room, part of a symbolic repre- sentation, or a person. The therapist’s role and significance can change many times during the play activitity. One generalization of applicable importance is: in all uses of play, diagnostic understanding of the dynamics of a child’s person- ality determines the kind of material selected for the particular child, and the kind and degree of the therapist’s verbal and motor activity.

As stated above, the limited space led to the plan of using excerpts of case material to illustrate these adaptations of play. The use of excerpts not only removed material from its total context in a case, but necessitated the omission of data which would offer a comprehensive understanding of each child and of the interpretations of the specific case material. With these points in mind, this paper might be viewed as a limited outline of ways in which play can be used in casework treatment of a child. In this outline I have attempted to indicate that the case worker’s role, including participation, limitation, and interpretation, is only analogous to that of the psychoanalyst.

In conclusion, several basic points should be emphasized. Play activity, ir- respective of how we want to use it, must be recognized always as a complex, distorted assortment of the child’s conscious and unconscious expressions. The therapeutic relationship is basic whether we use the medium of words or the medium of play activity in treatment. The purposive conscious use of play determines when and how it is interwoven with the therapeutic relationship in our effort to provide a meaningful therapeutic growth experience for our young clients. Treatment of a child includes more than the use of a technique. Total treatment of a child’s difficulties also involves the handling and treatment of all factors in his life situation which have contributed to his problem.