Abstract
In Starting Treatment with Children and Adolescents, Steven Tuber and Jane Caflisch bring us into the wild and sometimes chaotic world of play therapy, with all its unexpected delights and mysteries. While the book is geared to the beginning therapist, all clinicians working with children will find themselves challenged and engaged by it. Unlike other introductory works, this volume is unique in that it uses raw material from beginning therapists—material as difficult, forthright, and honest as any that therapists will likely encounter early in their careers, or indeed, throughout their professional lives.
Using a close process technique, the authors, drawing on Tuber’s experience and wisdom and Caflisch’s fresh eye and clinical astuteness, intersperse carefully transcribed process material with supervisory-style reflections on these vignettes. Thus, in an accessible and engaging manner the authors provide us alternating views into the minds of the clinician, the supervisor, and the child patient. Reading this book is like participating in a child therapy seminar of the highest order, one that allows for frank discussion of what has actually transpired in the playroom between child patient and therapist—omitting neither the good nor the bad nor, at times, the ugly. In this vein, they offer an indispensable lesson in child therapy, specifically, that there will always be a second chance, a time to revisit and rework clinical challenges.
The book has at its heart several main themes that are interwoven throughout. The first, embracing all the others, is that therapy is a self-reflective process whereby the therapist invites the child patient to join in and wonder alongside one another. This is an essential concept for the child therapist. By adapting this stance, the therapist encourages the child to become curious about his or her internal experience and to develop the sort of psychological mindedness that permits introspection. Over time, the authors suggest, this stance allows the child to begin to regulate intense emotions, to develop greater problem-solving strategies, and ultimately to experience more positive interactions in the world. “Verbalization,” they write, “. . . allows for the potential transformation of . . . experience” (p. 2).
Second, Tuber and Caflisch suggest that the therapist creates a frame (both temporal and spatial) for the therapy to unfold in such a way that the child’s experience can be thought about, talked about, and wondered about in the course of the sessions. Creation of the frame permits the child to tolerate negative and frightening emotions that might otherwise interfere with the unfolding therapeutic process. Thus, the frame helps keep a “sense of wonder and curiosity at the forefront of the process,” a sense that “can come to be experienced by the child as an antidote to feelings of shame and guilt” (p. 3). Establishing a consistent and predictable therapeutic frame allows the child to safely explore negative emotions and destructive fantasies.
A third theme running throughout the book is the exploration of the technical aspects of interpretation. Interpretations, they suggest, should be constructed with a view to enhancing the child’s capacity for wonder. Tuber and Caflisch show how, by using interpretations that emphasize the notion of curiosity about one’s self, one’s mind, and one’s emotions, the child’s inner world is gradually revealed and internal conflicts are brought to the surface. The child experiences the therapist as a trustworthy, noncritical helpmate in the therapeutic process. This, the authors suggest, is what creates the holding environment, the sense of “putting your arms around the child’s experience” (p. 8).
Similarly, throughout the book, Tuber and Caflisch “put their arms” around the experience of the novice therapist. They recognize that the new therapist must develop the fortitude to tolerate the uncertainty and intensity of the child’s inner world. Through numerous examples, they demonstrate that it takes courage not to know exactly where the play is heading or what the child might need the therapist to do or say. The authors acknowledge the presence of anxiety for the beginning therapist, and suggest that it must be understood and reckoned with from the beginning. Using close process material from sessions with new therapists, they show how the beginning therapist can learn to accept the ambiguity of the process in the service of the emerging treatment alliance.
The authors provide a helpful opening gambit for the therapist as a way to introduce the child to both the therapy and the therapeutic process, a way of conveying to the child the message that “this will be the place where we will come together each week to try to learn all we can about how you think and feel”—in other words, that the work of therapy will be a joint effort to make sense of the child’s complex brew of emotions. They also point out that, in spite of the novelty of the situation, the therapist will gradually encounter the full array of the child’s defenses and resistance. They offer a template for wording interpretive comments to a child in a way that is even-toned, interested, and open-minded: “I wonder what having (e.g., mixed-up, angry, scary) feelings would be like?” While this turn of phrase may become almost formulaic at times, it serves the very useful function of helping new therapists find a language that conveys deep respect for the integrity and complexity of their young patients’ inner experience.
In “Play and Therapeutic Action,” Cohen and Solnit (1993) write that “play—that is, the suspension of reality in the service of experimenting, imagining and working through—in the presence of an understanding, empathic and facilitating person (the therapist) is itself therapeutic, in that it allows for the unfolding or resumption of a developmental process that has been stalled or gone awry” (p. 50).
In this vein, Tuber and Caflisch believe that play therapy works by providing a vehicle for understanding and working through conflict and for promoting development. They also show how the presence of an empathically attuned therapist is transformative for a child. Through the use of close process material, they demonstrate how the alliance between therapist and patient allows symbolic play to unfold. They help us see how fragile and precarious the play space can be, and how quickly powerful and overwhelming affects can subsume the patient’s ability to play. They point out that “play is always at the balancing point between being real and not real and can easily tip into being far too real. When this happens, the child must retreat from the play, and the therapist must help him regain his balance” (p. 63).
Tuber and Caflisch highlight the importance of establishing, managing and expanding the therapeutic frame in child play therapy. They draw on complex clinical material, offering only enough details about the patient to ground the reader without distracting from the analysis of the process. In this way, the reader is given the impression of being engaged in a deep, ongoing conversation with a wise, experienced teacher who truly appreciates the whirlwind world of child play therapy. The authors’ tone is profoundly respectful of new therapists, who must learn to be intrepid and resilient when confronted with challenging moments in the consulting room. The material they draw on never shies away from such moments, and they thus engage the reader in a frank and open discussion of difficult challenges with very regressed or emotionally fragile young patients.
One particularly poignant chapter presents a session with a nine-year-old girl who has experienced significant losses in her life, and who now mourns the loss of a previous therapist. In this session, the child patient garners the full strength of her aggressive impulses. She criticizes the new therapist with gleeful abandon, using a tape recorder to register her complaints with an imagined stern authority, the “professor” who will take the therapist to task for her failures. She shrieks into the recorder, “Professor, I just want to tell you something. She [the new therapist] is ruining my life. I can never sleep, I can never eat. . . . Let me tell you about my old therapist. . . . We would go down to the second floor and get soda. . . . But Ms. T, what she does is to sit around, always looking at me . . . and she got evil eyes, evil eyes. . . . What I said to her is that . . . her earwax is so sticky that she can use them as glue. Now that’s funny . . . and she always wears the same shirt every single day. She said that I have got issues. She said that I am mentally retarded. Now just kidding about that. But she is mean” (pp. 128–129). Here, under persistent psychological assault in the play, the therapist gamely perseveres, working to empathize with her patient’s anger, detoxify her attacks, and tolerate the unfolding of the girl’s destructive and desperate impulses as they play out in the transference. For instance, the therapist comments a short while later, “I could say [to the professor] I made a big discovery. A discovery that I now understand why the soda downstairs is so important” (p. 130).
Tuber and Caflisch comment on the girl’s rant:
Perhaps what is most remarkable is the pleasure E appears to be deriving from her put-downs of her therapist. . . . Can it be possible to get E to reflect on this pleasure, or is it too ego syntonic? I would want at least to test out whether she could reflect on this behavior: “What does it feel like to get a chance to record so many ways that I’ve hurt your feelings?” One could also go down the path of bringing her former therapist into the room: “Ms. X seemed to make you feel very different inside. What were those feelings like?” Anger and ridicule are just so easy for this child, to the point of caricature, and they mask a sadness and deprivation that are profound [p. 129].
Thus the authors demonstrate how the child’s sadistic urges, which include shaming, humiliating, and demeaning the therapist, serve to protect her from her feelings of powerlessness and deprivation. They describe how they might think their way through this onslaught, and suggest that there might be many ways of constructing a useful intervention. Their commentary leaves room for all the “ineffables” of child therapy, and for the therapist’s intuitive sense of what the child patient might be able to tolerate hearing from the therapist at a given moment.
By sprinkling their observations liberally throughout the process material, Tuber and Caflisch offer a glimpse into how the therapist thinks about the work in a lively and spontaneous way. They demonstrate how rapidly a child might move from aggressive impulses that interrupt play, to an increased sense of control and security as the therapist repeatedly survives attacks, and finally to the creation of a play space in which patient and therapist can form a safe attachment. This kind of material is challenging to even the most seasoned of therapists, and the authors are skilled at breaking the session into manageable parts for the reader, showing through close analysis how subtle shifts in the child’s affect throughout the session allow for the gradual building of a fragile yet unmistakable alliance. The reader is caught in the grip of this material, as well, and can appreciate the bravery of both therapist and patient in withstanding the intensity of such sessions.
Becoming a child therapist requires the capacity to enter into the world of the child’s play—to peer down into the rabbit hole, even to reach in and explore, but not to tumble all the way down, not to lose one’s footing while trying to keep up with the child’s imagination and unconscious conflict. In this book, Tuber and Caflisch, like trusted and compassionate guides in the wilderness, invite novice clinicians to enter into the work of child therapy with open minds, with the willingness to make mistakes and be baffled, and with the hope that the work will ultimately bring deep satisfaction and have enduring effects for the children who enter our consulting rooms.