Playing with Reality or Playing outside Reality: Transitional and Defensive Pretend Mode in Therapy with Children

ABSTRACT

The theory of mentalization is about development of thinking about self, others, feelings, thoughts, and intentions, and how this thinking develops in the context of attachment relationship. The model describes how mentalization develops during childhood in stages from concrete undifferentiated thinking (teleological mode and psychic equivalence mode) to phantasy, creative thinking in pretend mode before integrating into mature affective mentalization. A long linage of clinicians has worked on the premise that through children’s play a more mature way of thinking and functioning can develop. In this article, we suggest, as many others have, that the stage of pretend mode is of special interest for psychotherapists, yet it has also been presented in MBT as a defensive mode. However, as child therapists we have experienced that pretend functioning through play has the potential for development and change. We argue that a differentiation of pretend mode into a transitional pretend mode, influenced by Winnicott’s term transitional space, and a defensive pretend mode could be clinically meaningful. We think this is a differentiation that could technically aid therapists. We propose that the quality of the relationship between therapist and patient provides information to discern the sort of pretend-state the child is in during therapeutic work. A way of grasping the quality of the relationship is through focusing on if there is a joint attention, how regulated the affect in the child and therapist is, and finally the symbolic meaningfulness the play holds, and if it has the potential to be mentalized.

L:

Here you go! Take this.

T:

Oh, you wanted to fence with me.

She begins to fence in a playful way. The therapist joins.

T:

Perhaps something just happened now that made us be in a fight. The therapist said, perhaps a bit prematurely.

The girl did not respond, but seemed to move even faster. Fencing wildly with the sword, hitting the therapist’s hand.

The therapist tried to comment on the swift shift but his response seemed to make the girl even more driven. The girl suddenly started to dance and jump up and down and the therapist tried to join with her movement but could not keep up with the speed, and he even felt concerned that the dancing would pull him more into a whirlwind of interaction. Instead of joining her, he sat down a bit, trying to get his head around how to come in contact with the girl and how to regulate and think with his patient. He also wondered about whether there was some way to symbolically understand the meaning of the fencing and the dancing.

Introduction

There are many ways to understand this short interaction within this child psychotherapy session. What we want to address is play within the psychotherapy relationship, and specifically from the viewpoint of mentalization. The theory of mentalization has been applied in developing a format of psychotherapy that is embedded in the heterogenic family of psychodynamic thinking and psychotherapy. In this article, we will explore theoretically the importance of the developmental phase of pretend play, labeled as pretend mode (Fonagy & Target, 1996a). Specifically, we will conceptually explore ways of clarifying and distinguishing creative space in play that implies work being done concerning feelings, ideas, self and relationships, and when play serves the purpose of warding off reality and creating relational distance. We also want to address that therapists sometimes perhaps can overvalue the idea of play, especially if the quality in the relationship and feelings that underlies the child’s and therapists play is not assessed. The issue has been discussed in different ways since the start of child psychotherapy and onwards (Fonagy & Target, 1996a; Klein, 1927; Winnicott, 1982; & Johansen & Cappelen, 2020). Recently, it has been discussed thoroughly within the tradition of mentalizing by Muller and Midgley (2020) and also within a psychoanalytic discourse by Colombi (2021- paper/podcast). However, we still think there is an impending differentiation that may aid the therapist through the concept of transitional pretend mode and defensive pretend mode.

Ethics

Patient material presented in the text is part of a qualitative research-project which has been approved by the privacy ombudsman at Lovisenberg Diaconal Hospital in Oslo and the Regional Committees for Medical and Health Research Ethics of South East Norway. Parents of children has given written consent to the use of material from the therapies in research and published articles. The Material presented has also been made difficult to recognize and stripped of personal information other than age, gender and some information about why they were referred for treatment.

Background

The development of the capacity to mentalize

In four articles, Fonagy and Target (1996a, 1996b, 2000, 2007) began the exploration of how we as humans develop our capacity to think about and understand others and ourselves as feeling, thinking and intentional beings, naming this specific thinking mentalization. The work is integrative and draws on different schools of thought and research. Within the psychoanalytic theoretical history, they draw on Freud, Anna Freud, Winnicott and Bions work, among others. They integrate psychoanalytic theoretical models with research on children’s cognitive development, and research on Theory of Mind. Finally, they integrate research on attachment and intersubjective theory from the likes of Bowlby, Trewarten, Tronick, Stern and others. Throughout the four articles, the authors argue that the child’s capacity to mentalize develops in stages and steps within a good-enough environment through reciprocal interaction and mirroring of the infant/child by the external significant others. The authors also put play in a pivotal position in this development; the Playing with Reality. They argue that this capacity is not gained once and for all, but rather holds a potential for understanding one self and others which fluctuate and is sensitive to external pressure and stresses, and that further it is sensitive during stages of development, where loss, trauma, and parent crisis can impact and derail the development.

The pre-mentalizing modes

The theory of mentalization is a developmental model which specifies stages in the child’s capacity to reflect about themselves and others. The model specifies several pre-mentalizing modes of reflection. The first one is teleological thinking which is understood as “something only exist if I see it.” In teleological mode, intentions, thoughts, and feelings are only valid when they are backed by action and is experienced concretely. When the infant’s mind develops further, he/she develops a capacity for psychic equivalent thinking that comes to expression in his/her struggle to discern representations from the factual reality. For example, a representation of a monster in the mind of the child tends to be thought of as real and thus may be too scary to explore and play with.

The model claims that older children, adolescents, and even adults can regress to this kind of certain, undifferentiated, and concrete thinking from time to time, especially when under stress and intense affects. Children that function mostly in teleological or psychic equivalent modes of thinking have great difficulty playing, reflecting and interacting. In these states of mind there is usually little room for exploration and thought. Things just are, and are acted upon without reflection.

Pretend mode

In this paper we want to focus especially on the stage of Pretend mode. This mode of thinking is especially relevant for therapist working with children because it is a way of thinking inherent in the child’s play. When the child enters its second year, the child in normal development gets a more marked capacity to play with ideas and explore different realities, which becomes manifest in the context of play. The child also starts to understand when other people are playing as a playful mode. For the child between two and four years of age, the possibilities in their play can be endless; the chair can be a space ship and the table a cabin. The pretend mode, which consists of actively fantasizing, allows the child to put themselves inside other’s mind and make stories and adventures: a simple stick can be a knight’s sword and dolls provide the possibility to work through experiences with relations to parents. Fonagy and Target (1996a) address one important feature within this stage of development, typically the child in this stage separates reality and fantasy in a distinct way. For example, a boy aged three was dressed in his favorite costume; the evil hedgehog Peter. After a while his grandmother made him a very realistic hedgehog costume. The boy put it on and looked himself in the mirror but to everybody’s disappointment, he started to cry and ran to his room. It took a whole week before he was able to use the costume, and the parents understood that the suit was too real, in his mind he actually became the scary hedgehog Peter. At best in this stage children gain a capacity to work on an advanced level different affects and relational themes, however, realities must often be kept apart from the play in order for it to continue.

The capacity to mentalize

In the Child’s fifth and sixth year the child in normal development gets more able to integrate the psychic equivalent mode and pretend mode into a capacity to mentalize. This new integrated capacity makes it possible for the child to experience something as both real and unreal, and be able to represent something on a symbolic level and understand representation as mental representatives of reality and not reality itself. In psychoanalytically terms, the child has the potential to distinguish between psychic reality and factual reality in a more flexible way. This gives the child a potential for understanding one’s own and others minds as minds, and with it the potential of reflecting on the mind. This capacity develops in more nuanced ways all through life.

Psychodynamic child psychotherapy and mentalization

Within the tradition of psychodynamic child psychotherapy, it has been stated, based on clinical experience and theory development, that children’s play has the potential of facilitating development, cure psychopathology, and foster creativity (Klein; A Freud; Winnicott; Ferro; Johansen & Cappelen). The theory of mentalizing is also drawn from this experience and tradition. With research on mentalization, there has been a debate on how to best work with children being in Pretend mode, as described above. In one recent paper Muller and Midgley (2020) propose that being in pretend mode in child therapy might be fruitful but also invites challenges. They show many different examples but point to “that its (pretend mode) use in the context needs some clarification.” As we argue, and will illustrate with clinical example, there is a possible clarification of the concept. Specifically, we will demonstrate with the clinical material a way of being in pretend mode which foster development and possibility to work on difficult feelings and ideas.

Another side of pretend mode that Muller and Midgley (2020) address, is when pretend is used as a fleeing from reality, more with a defensive purpose to disconnect from reality, one self, others, feelings or ideas. Work with adult patients with personality disorder has shown that pretend mode of thinking can be uses as means of escape. The pretend in these patients has been understood as synonymous with, as if functioning, or being fake or a lure. For example, speech in this mode has been understood as psycho-babble, as empty speech without meaning and not being anchored in lived experience and the body. Also, pretend like functioning at its most extreme has been understood as dissociation (Kèri & Wiwe, 2017). Thus, there has been argued that pretend mode implies detached and defensive kinds of thinking, at the same time seen as essential in children’s development toward full capacity to mentalize.

Different kinds of pretend mode

We want to make three hypotheses about the phenomena of pretend mode which leads us to propose theoretical integration differentiating two types of pretend mode functioning that might have significant implications for working with patients.

1. We will argue, illustrated by a clinical example, that play that unfolds in a transitional space (Winnicott, 1982) can be understood as a specific kind of pretend mode functioning which foster development. Metaphors, play or other creative representations that are emotionally and relationally connected, co-created in pretend mode, holds the potential to transform and develop, rather than disconnect, stiffen or stop therapeutic change. This pretend mode can be labeled, inspired by Winnicott (1982), transitional pretend mode.

2. The transitional pretend mode is again different from the pretend mode described above that dissociates meaning, feelings, relationships and self. This sort of pretend mode we suggest to be labeled as defensive pretend mode.

3. In the clinical situation, what distinguishes the two pretend modes seems to foremost be manifest in the relational quality between patient and therapist. In mentalization-based treatment for children (MBT-C) this relational quality is structured in three building blocks; joint attention, affect regulation and mentalization (Midgley et al., 2017). As experienced in child therapy play becomes meaningless, empty and defensive when there is no joint attention between patient and therapist, like in the case with Laura described earlier. When there is joint attention, play can be saturated with meaning, and pretend mode, not yet mentalized, holds potential for development, there is a beginning of transitional pretend mode.

Also important is the level and quality of affect, the degree of affect regulation, for the patient to make use of play. Anna Freud called a child’s sudden stop in play, play interruption (Freud, 1992). The level of affect seems to be of especial importance in “interruptions in play.” Thus, helping the patient to regulate, and scaffolding the child’s arousal, is significant to help the child get back to a creative exploration.

The third part which seems important for transitional play is the potential it has for mentalization. This manifest itself through the symbolic play narrative. Kernberg et al. (1998) have empirically studied children’s play in psychodynamic psychotherapy, specifically that the level of representation and symbolization in play reflects maturity and development in the child. Distorted meaning and chaotic narratives can on the other hand show derailed development or post-traumatic play. One could say that if the play holds a potential for representation and mentalization the play might also hold a therapeutic potential.

Research in play in child psychotherapy

Play in child psychotherapy has been studied to some degree. As mentioned above, Paulina Kernberg and Saralea Chazan developed the Childrens Play Therapy Instrument (CPTI) to analyze children’s play in a psychotherapy setting in a comprehensive way (Kernberg et al., 1998) leading to many studies (Chazan, 2009; Cohen et al., 2010; Chazan et al., 2016; Tessier et al., 2016).

Further studies drawing on the CPTI has examined the connection between symbolic play and outcome in child psychotherapy. Halfon and Bulut (2017) studied the process of psychodynamic psychotherapy given to 48 children with conduct difficulties with good outcomes. All therapies where working in accordance with mentaization-based treatment principles. By a Q-set analysis the level of symbolic play and affect regulation of the children were studied. They found that therapies adherent to the MBT principles showed a positive outcome with both a high level of symbolic play and better affect regulation by the children. In 2019, Halfon, Yilmaz and Cavdar (2019) further analyzed 40 therapies through the variables symbolic play, expressions of dysphoric affect and quality of relationship and that these three variables predicted symptomatic improvement in the children. These research findings might support the idea that relational, emotional factors together with child playing and symbolic themes is linked together in fruitful therapy processes.

Transitional pretend mode in B’s play

Five-year-old B was a charming little boy whose parents at the same time described as enjoying mischief. He could at times be angry, giving in to tantrums and sometimes biting other children when upset. He was also in quite a lot of conflicts with teachers and sometimes the parents and did not like it that grown-ups sometimes were authorities. In the first session of MBT-C the therapist observed little play. B used the session for constructing train rails, but it was difficult, even though the therapist tried hard to discern any meaning other than construction. The play gave the therapist the impression that B was lonely, since there were little signs of joint attention. The therapist tried to think about the symbolic meaning in the train building, tried to join in, but there was little contact.

The therapist began to insist on contact and showed curiosity about new play-scenes during the second session which seemed to spark some interest in the child about the therapist. The therapist fantasized openly and suggested different ideas for play. The boy seemed to pick this up and there was a longer sequence where the therapist and child played jointly together, constructing a story about B`s house and intruders coming from the outside.

The family and therapist agreed to start therapy together. During the first session, the quality in play developed further. The child showed a tendency to test limits, like when to end the session which urged the therapist to set firm limits. He sometimes could seem playful but also had a nervous and tense way, which the therapist also could pick up. The sessions switched between the patient testing limits, especially around the therapist’s desk, and when playing the patient introduced games of being mischievous and the fear of persecutory authorities, like policemen.

In one session, the child wanted himself and the therapist to be graffiti-taggers together. He carefully taped a piece of paper on the wall, and together they started writing on it. The boy was very mindful of not drawing outside of the paper. Suddenly, the boy said that the police was coming:

B:

The police is coming!

T:

Oh no! What should we do?

B:

Fast, hide the pencils here (they put them in a drawer).

The boy looked at the therapist with a surprised look that the therapist made back to him.

T:

Here they come.

B:

Hi police, We do not know anything about that tagging (with an innocent look).

T:

No, nothing.

B:

I think they ran out of that door!

T:

Yes, they ran that way!

The boy smiled again and looked excited.

B:

Now they are gone, we can tag again!

T:

I can see that you really enjoyed that tagging and tricking the policeman.

He nodded mischievously.

The scene repeated itself one more time, the humor of it all really got the therapist smiling, even though he got a bit anxious about what he was teaching the boy and what the parents might think about their game. After this B suddenly told the therapist that he must not tell the parents about the play. B then told his therapist about how it was to be a small child and how unfair it felt that grown-ups are in charge. He also told the therapist he missed having a brother so that he also could have someone to be with and play with and feel less lonely. The therapist responded that this can make him feel sad and unjust. “Yes” the boy answered with sadness in his eyes, but at the same time having no problems finishing his session and tidying afterward. The child’s play after this session changed and so did the testing of limits. A more vulnerable side emerged in the play and the therapist felt less tested. The play, contact, and mentalizing in and around the play also became more apparent.

Discussion

We try to put emphasis on different ways of working with and being in this mode of therapy and development, described earlier. We suggest that there exists one more developmentally prone way of playing and being in pretend mode and we also suggest that one of the modes is more defensive and a way of arresting development and move away from reality. The clinical material of B described here might illustrate a process of working in a potential pretend mode through play. In the vignette, we try to illustrate in the therapy-sequence that when the play and pretend mode is more relational, with initiatives and interaction between the therapist and patient, there seems to be a quality between them that can be deemed intersubjective, emotionally regulated, and there is also a potential to mentalize what is going on in the game. From the beginning of the assessment the therapist had difficulty joining in the play. B seemed to have difficulty focusing together with the therapist in his play, he was playing alone. At the same time for the therapist, it was difficult to discern meaning and themes in his playing. One could start to place some symbolic thought to it, but at the same time we suggest that this play, without contact, fluctuated feelings and relationship with another might be more defensive than developmentally prone.

In the graffiti scene there is another quality in the interaction between B and therapist, there is a strong sense of joint attention, the feelings seem regulated and they share the play in a mentalized way. Maybe because of the level of mentalization in it, the boy and the therapist could connect several personal themes together after the play scene. The boy was able to mentalize in a more mature way about unfairness of grown-ups in charge, feeling small, loneliness, and the wish for a brother to play and be with. This play and way of being in pretend mode we therefore would call transitional pretend mode were development in mentalizing is reached and gained through the work within the session.

If the therapist is not keeping a close eye on the contact with the child – the joint attention, relationship, contact, affect, thinking, transference and countertransference and gets lost in the child`s play it might result in a quasi-process were the child and therapist might get stuck in a more defensive pretend mode of playing. It might also be important to find out in what area the child struggles, for example, Ed Tronick has shown that many children might have had little help with early mutual co-regulation and joint attention (Tronick, 2005). Other children have had good enough help by co-regulating, but for different reasons, for example, trauma in the child`s history or parent history, the child has difficulty identifying and regulating emotions. This might focus on different relational aspects while working to create a transitional pretend state were play can develop.

Conclusion

Play has showed to be a powerful and meaningful way of working with children. The theory of mentalizing integrates clinical psychodynamic theory, developmental theory and theories about brain and theory of mind. The theory suggests that the ability to mentalize develops over time, from more concrete undifferentiated thinking (teleological and psychic equivalent thinking) to fantasy and dreamlike thinking where everything is possible (pretend mode) to a representational mentalizing capacity were fantasy and thought represents psychic reality. In therapy going back to a pretend mode can hold a developmental potential, like being in Winnicott’s potential space, but without a focus on the quality of play and quality of the relationship between child and therapist one can get stuck in a defensive use of play were themes, affects and mentalizing is not catalyzed but rather avoided. With a close look at the relational quality between therapist and child, through the lens of developmental building blocks the authors has tried to show different types of pretend-play, a defensive one and a more transitional one that helps contact, affect regulation and mentalizing for the child. The therapist should also be careful to put too much into the child’s play without viewing relational and contextual aspects. An active, curious and stimulating therapeutic way of meeting the child seems also important. We wonder if this differentiation might also be meaningful when working with adolescents, families, and adults. This should be further examined.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Southern and Eastern Norway Regional Health Authority under Grant [440].

Notes on contributors

F. Cappelen

F. Cappelen, Clinical Psychologist specialist Clinical work with children and adolescents. IPA psychoanalyst. Half time lecturer University of Oslo and half time clinical at Lovisenberg Diaconal Hospital.

E. Stänicke

E. Stänicke, PhD, Associate Professor at University of Oslo. He is a clinical psychologist and a training psychoanalyst.