Play for a Change; Therapeutic Action in Contemporary Child Psychotherapy

Introduction

The Play for a Change Conference (Bryn Mawr College, November 2019)*evoked the feeling of play in an enriched collaborative exchange of ideas. This volume gathered the ideas presented in the conference into further conversation with other authors of this volume. This special issue weaves in enrichments from developmental theory, trauma research, neuroscience, cognitive science, and attachment theory to explore the multiple aspects of play, including changes in its quality and manifestations in our culture and its current uses in psychotherapy with children, adolescents, and their families.

While it is beyond the scope of this introduction to offer a comprehensive historical context for the study of play, I intend to share two reflections on play by some of our close observers of children, Piaget and Winnicott. This volume of JICAP intends to build upon their insights.

“Play is the answer to how does anything new come about” (Piaget, 1950).

“It may very well be that we have missed something … I am reaching for a new statement on playing” (p. 39) … “I am making a significant distinction between the meanings of the noun ‘play’ and the verbal noun ‘playing,’” (40) for … “playing is doing” (41) and … “reminded of what we owe Freud but also of what we owe to the natural and universal thing called playing” (41). The “precariousness of play” … has to do with the loss of a “place” or “cultural location” … potentially a failure of “environmental provision” to co-create a “space” for “the child to surprise himself or herself … (51)” “It is not inside, not outside, it occurs in a place built in the overlap.” “In this area of overlap between the playing of the child and the playing of the other person there is a chance to introduce enrichments” (Winnicott, 1971, p. 50).

Both Piaget and Winnicott note the movement in play (doing, emerging) and this volume continues to focus on the action of play for therapeutic change. We wonder similarly to Winnicott, what else are we missing as we introduce to you: Play for a Change. This special issue is itself located in an overlap: from outside, reflecting on the implications of the cultural devaluation of free play and to inside, the internal experience of the child and to the intermediate space built within a therapeutic relationship, which holds in mind the overlapping influences. And generally speaking, the cultural context as an influence in a psychodynamic treatment process is affirmed as we situate the study of play in the overlap. The articles in this volume traverse these spaces for a contemporary consideration of play.

In light of the fact that development is change, how we understand developmental process informs our view of change in psychotherapy. Developmental research has put a more recent spotlight on the procedural, non-verbal, implicit realm as a formative location where change occurs; it is also the place where play exists (The Process of Change Study Group et al., 1998). This deepening elaboration of “play as doing” converges a point of criticality: it is time to reexamine and re-contextualize the therapeutic action in our natural resource – play. The purpose of this volume is to open up new questions: How are we using play? How are new theoretical models, including new conceptions of development, guiding the use of play? And, how do we engage children, adolescents, and their parents entering a play therapy modality unfamiliar with the experience of play? What creative ideas might emerge from play advocates to address the contemporary cultural diminution of free play? And within the field, how do we reinvigorate the space for play in child therapy? These articles seek answers to these questions, incorporating wide-ranging research, and case examples illustrative of the uses of play for healing from trauma. It is both in the content of the articles and the movement between, in the links across the divergent ideas, that much possibility for recovering what we are missing exists.

Emerging “new statements on playing” is consistent with changing models of development and therapeutic action. Several authors (Frankel, 1998; Lyons-Ruth, 2006; Slade, 1994) emphasized as Winnicott did – the doing of play, the process of negotiating the meaning. These views reflected a shift from one model that framed play as an uncovering of symbols that are repressed – hence the content that needs interpretation – to one of discovering through enactment, fragments of self-experience that come to form a coherent narrative of experience. Our original understanding of the therapeutic uses of play from Anna Freud and Melanie Klein continues to be questioned and reconfigured, from a one-person to a two-person model. Slade concluded: “Simply playing is among our most valuable clinical tools … where meaning and symbols are created rather than uncovered, our views of the therapeutic process and of our role as therapists must change” (Slade, 1994, pp. 103–105).

Contextualizing play therapy into a relational paradigm connects with core dimensions of adult relational sensibilities, the interaction conceptualized as both mutual and asymmetrical (Aron, 1996). This flow of movement between positions is captured in Tuber (this issue) stating, “The capacity for playfulness implies the ability to be simultaneously in the moment and yet not subsumed by the moment.” The authors in this volume, the therapists, conveyed this complex skill in action recognizing the child’s developing agency and registering the import of affect within the engagement. In resisting cultural attitudes devaluing play, they braved the uncertainties and joined the child’s efforts to make sense of their experience. The children were given space to “surprise themselves” in the experience of discovery of self.

Shifting to a new model can be messy. Incorporating changes into the role of the therapist informed by theoretical changes is woven throughout this volume. Of particular emphasis is Tronick’s (2007) dyadic expansion of consciousness model, based in non-linear dynamic systems theory, as it is well suited to frame a play modality. The theory views change as a result of seeking more “enrichments” (expansion) toward greater complexity and coherence. There is “fittedness” between the multiplicity of simultaneous dimensions characteristic of play and non-linear dynamic systems theory. And as Frankel (1998) noted the essential things in therapeutic action can be seen more readily in play therapy.

In J. Timothy Davis’ (2015) article, Even More Than the “Something More”: Tronick’s Dyadic Expansion of Consciousness Model and the Expansion of Child Psychoanalytic Technique, it is noteworthy that in the circumstance of presenting his clinical work to an invited senior child analyst discussant, a collision of models occurred in the discussion. He described a case presentation thus: “He (the senior child analyst) and several of the audience members were uncomfortable with the treatment described. The discussant felt the child patient was dysregulated by our play and said that it was his preference to do this type of work in the displacement. Others in the audience felt that I had lost control of the analytic situation in letting the play get this ‘violent,’ in letting family members into the session, and in letting the child leave the hour early” (p. 440). As the discussion ensued, the child’s progress in the treatment was also acknowledged. This kind of experience, presenting work to classically trained senior child analysts, was not dissimilar to my own experience. For example, bringing family members into focused work in the session was criticized by senior child analysts as paying too much attention to the external world of the child, and in so doing, the internal world was assumed dismissed. These examples represent a clash over the use of different models and the shift in the understanding of what it is we are playing and why. The role of the child therapist is continuing to change. The change involves an increased appreciation for how children communicate what is on their minds, what they are doing when they play and what they seek from adults so they can grow and change. The culture of childhood, also changing, influences the way we play in the treatment.

The special volume brings into the discussion the following contributions:

Long’s article, Fractured Stories: Self Experiences of Third Culture Kids becomes particularly relevant in this location of study, in the overlap, as it describes the use of play with children living in different cultures (relocated families) to address the challenges in forming a cohesive identity. Culture, in other words, is taken up as an undeniable subject. One comes away from the moving case descriptions with a sense of the texture of a child’s loneliness when this circumstance is not recognized and the benefit to their development to creatively access this dimension of experience in child psychotherapy.

In Leibowitz’s article, Protecting Play: It’s a Matter of Life and Death the recognition of the “emotional impoverishment” evidenced in children in a culture “preoccupied with guaranteeing safety and success.” In defending against vulnerabilities, Leibowitz’s notes, we are impinging on the space for play. The experience of play is introduced into her clinical work in circumstances where children feel disconnected, even deadened. Clinicians increasingly see the impact of the absence of play in life experience in their consulting rooms and Leibowitz is sounding an alarm about this.

In further elaboration on the absence of play in children’s lives, Schlesinger et.al.’s article, Cognitive Behavioral Science Behind the Value of Play: Leveraging Everyday Experiences to Promote Play, Learning, and Positive Interactions demonstrate the multiple ways play enriches childhood. In the spirit of collaborating with multiple disciplines with a shared interest in strengthening childhood play within the consulting rooms and out, in the community and schools, this article documents with research and offers suggestions for this purpose. The public health issue of the absence of play in childhood is too widespread to address from siloed professional spaces.

Barish, also this volume, The Role of Play in Contemporary Child Therapy: A Developmental Perspective offers a broad reach into educational, evolution, and neuroscience research converging a conclusion of the primary necessity for social-emotional development of play. Parent–child joyful play strengthens affective aliveness and attachment benefitting self-regulatory abilities. Barish encourages therapists working with children and parents to (re) introduce play into their lives, as part of the intervention.

Tuber (2020), a keynote presenter to the Play for a Change conference, who has applied Winnicottian views to clinical practice, situated the “capacity to be playful” in the essential relationship, the parent–child relationship in his article, There’s a Place: How Parents Help Their Children Create A Capacity for Playfulness and Can It Be Sustained Across the Lifespan. It is a relationship that shifts in response to bi-directional developmental changes across the lifespan. The adaptations are promoted by an inherent quality of playfulness within the relationship.

Children learn the language of play, as Tuber and Barish elaborate in different ways, within the emotional vibrancy of the parent–child relationship. When the primary focus is on the attachment and relational developmental realities and needs of the child, preserving the structural binary regarding the inner and external world of the child is called into question. With a non-linear dynamic view, the inner and outer worlds are seen as more interwoven rather than either/or. The model recognizes growth and change as more context-dependent.

Within the psychoanalytic context, Cooper referred to a “posttribal period of psychoanalytic theory, practitioners are leaving a period of theoretical splitting between a number of previously dichotomized polarities: old and new experience; developmental reconstruction versus here-and-now focus; appreciation of elements of symmetry, as well as asymmetry, between patient and analyst; intrapsychic versus interpersonal surfaces; and interest in unconscious fantasy versus interpersonal enactment” (Cooper, 2015, p. 344). With an overarching umbrella of play, a non-linear dynamic system holds multiple dimensions of experience with equifinality. These articles reflect efforts to move beyond an either/or linear quality and bring together multiple perspectives on the use of play (and it’s limitations) giving us much to reflect on.

As psychoanalysis has shifted to a relational paradigm, the parents are not “parameters,” their subjectivity can be part of the work and part of the play. To open up the theoretical space including children in the relational paradigm is to adapt Bromberg’s (2001) objective, “standing in the spaces” to playing in the multiple spaces across multiple minds of child relational therapy. Once the model frames adults and children in a relational developmental context, a more expansive scope, what Slade has called a “playspace”, is created. Slade defined it as: “the creation of an environment of reflectiveness; that is, we create a context for symbolization and meaning making on the part of a parent” (Slade, 2008, p. 321). Play is infused in multiple ways across the developmental span of the parent, child, and parent–child relationship. Children enact, play at and about their confusion and feelings of disorganization within primary relationships, as an effort toward seeking security in their attachment, culminating in greater relational freedom. In a transformative process, the relational context around the child experiences changes as well.

Further reflections on the change process through play can be found in the articles:

Balch and Golub’s article, (In) visible Scars: Two Siblings, a Shared Trauma History, and Their Play, elucidates the way a play modality adapts around the pace and sequence of a child’s internal negotiating of trauma within a responsive therapeutic relationship. We learn through the contrasting of sameness and difference the many permutations of process, including the therapist’s negotiating their own affective reactions. An implicit strength of this article is contemplating the value of a “nested mentalized space” (collegial support) for doing this kind of work (reminiscent of the therapists’ teamwork in Fraiberg et al.’s, 1975 Ghosts in the Nursery) to hold the therapist’s mind in mind as they do the challenging work of holding in mind the mind of the traumatized child.

In Mikulka’s Surviving Destruction and Finding Connection: Play Therapy with an 11 Year Old Boy, his patient, David, in an initial consultation conveyed a vital metaphor “a very lonely house that is broken on the inside. There were tools that could fix it but they didn’t want to put in the work.” David’s assessment and his wondering if his new therapist might have tools to “fix it” is a profound beginning to a very challenging emotional journey. Sapountzis’ commentary, Can you help me? Commentary on Mr. Mikulka’s paper expounds on that journey with increasing emotional nuance to appreciate the complex skill involved in the play negotiation to repair self. The tools they co-create work in surprising ways.

In Silber’s Reimagining Humpty Dumpty with Play’s Therapeutic Action the metaphor of fixing brokenness continues. The repair of ruptures is accomplished in part, by calling in the parents, rather than all the King’s horses and all the king’s men, to strengthen the attachment system. Earning attachment security is to live with the cracks. In Bosk’s commentary, Therapeutic Action in the Work of a Playful Clinician: A Reflection on Dr. Silber’s Reimagining of Humpty Dumpty, it is so gratifying to have a colleague to play with! Dr. Bosk took the metaphor central to the paper and ran with it, elaborating on the relational improvisational moves that benefit from unpacking.

All the authors in this volume appreciate the experience of joy as an understated aim of play, which overlaps with an American democratic ideal: “the pursuit of happiness.” Children experience democratic values transmitted in the invitation to play (or not, in the absence of permission). They are invited to seek autonomous creative thought and to be heard (in personal communication with Marjorie Bosk and the Philadelphia Declaration of Play).

When children enter a mental health space, how do they trust an adult to share what is bothering them? How do they convey the kind of pain they are in?

They build a shared space – a transitional space – a dyadic (or triadic) space to sort out and expand meaning. It is this space – “there is a place” – as Tuber – directs our attention that children seek help to construct in play therapy. It is an environmental provision, the space to share minds, not a given. The child therapist approaches the play with an open mind, wondering where the play is going, tolerating the uncertainty of making things up, hence placing trust in a joint project of meaning making. The experience of surprise extends to the therapist, as well. The following is an example from my own experience of surprise in regard to a child’s surprise finding that play can happen and be so gratifying.

I arrived in the waiting room to meet 5-year-old Derrick and suggested we walk down the hall to my playroom for our first meeting. His mother came along with us. She wanted help managing Derrick’s many temper tantrums that mystified and upset her. We walked passed some doorways before we reached my playroom/consulting room. As we entered Derrick looked around and anxiously asked, “Where are the screens?” I said, “My playroom is without screens. How about we take a look around and see what might be fun to play with?” He then continued to problem solve this predicament by suggesting that some of the doors we passed, “Maybe they have a screen?” I redirected him and he chose Lincoln Logs and we proceeded to build a town he labeled “destroyville.” The next time Derrick came to play he brought me one of his toys from home and placed it in my hand. “It is a zombie,” he explained. As Derrick put the zombie down and searched for the Lincoln Logs to return to the building project, I began to reflect that there is a contrast between the zombie and the playing child. Derrick had no idea he could express feelings having to do with adjusting to transitions (including loss) in his family and he had more to say. The collapse of the play space can come from many impingements; Derrick may have felt it had been destroyed, left with a feeling he was a destroyer? There was much we were building as we built our very elaborate city including hope about sharing experience. Derrick was expanding possibilities of communicating feelings and the feelings leading to temper tantrums were being mentalized with his parents to help them build a space. Derrick’s difficulty with affect regulation was a symptom, connected to the absence of play, as described in Barish’s comprehensive treatment of the subject (this volume). And Derrick’s symbol of the zombie connects to the thesis in Leibowitz’s article (this volume) “Protecting Play: It’s a Matter of Life and Death.”

The cultural support of play, as well as the therapeutic action of play, is indeed precarious. As these articles will share, we may wish to protect the child’s developmental need from being “destroyvilled.” The volume does much to enliven the discussion with advances in theory and commentary on culture, research, and therapeutic examples.

The Journal hopes to keep this conversation moving. Consider submitting your commentary to future volumes to advance our understanding and protect a space for play.

*We wish to thank the Play for a Change Organizing Committee: Seth Aronson, Marjorie Bosk, Sara Bressi, Sophie Fink, Ronald Naso, Larry Rosenberg, Ionas Sapountzis, and Laurel Silber. The conference was co-sponsored by JICAP and we wish to thank Dr. Susan Warshaw for all of her guidance throughout this project. Other sponsors that we wish to thank: Dr. Janet Shapiro, dean of Bryn Mawr College’s Graduate School of Social Work and Social Research, Section II of Division 39 of American Psychological Association, Philadelphia Center for Psychoanalytic Education, and Institute for Relational Psychoanalysis of Philadelphia. The event also included collaboration with a nonprofit arts association, Philadelphia’s ArtWell, whose mission is to bring multidisciplinary arts expression into the lives of young people.

Acknowledgments

The author wishes to thank Madelyn Silber, Corinne Masur, Marjorie Bosk, and Barbara Stern for cultivating play advocacy and to her father, Stanley Moldawsky, who knew how to play; a gift that keeps on giving.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Laurel M. Silber

Laurel M. Silber, PsyD, faculty at Institute for Relational Psychoanalysis of Philadelphia, private practice with children and their families in Bryn Mawr, PA.