Abstract
Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist,
In Play Therapy: A Psychodynamic Primer for the Treatment of Young Children, Pamela Meersand and Karen Gilmore draw on their decades of clinical practice, supervising, teaching, and writing to provide a twenty-first-century volume that examines the current foundational psychoanalytic principles of play. They consider the developmental arc of play, the central role of play as the primary medium and language of childhood and in treatment, the mutative and growth-promoting aspects of play therapy, and common challenges found in treating children, and finally they offer practical guidance. This primer is an essential read for both child psychotherapists and psychoanalysts beginning practice with young children, as it captures the complex nonlinear ways one needs to think about children, play, and development. It is also a stimulating read for experienced psychoanalysts interested in the innovative conceptual integration of theory and in expanding their understanding of the potential of play and playfulness for development and therapeutic action.
This rich, dense, and ambitious book stands on its own as a comprehensive psychotherapy primer on working with younger children. The authors note that this volume can serve as a companion to their previous book, Normal Child and Adolescent Development: A Psychodynamic Primer (Gilmore and Meersand 2014). The two volumes, used in tandem, are invaluable teaching and supervisory tools.
The pluralistic approach articulated by these authors reflects a contemporary psychoanalytic view of child development, play, and treatment. This encompasses an integration of classical psychoanalytic principles, traditional ego psychological approaches, developmental research, nonlinear dynamic systems theory, and recent relational perspectives that privilege the unfolding of the child-therapist dyad in the here and now.
The primary focus of the book, as beautifully elucidated by the authors, is pretend, symbolic, and imaginary play: “the premier play form for play therapy, arises in tandem—and in dynamic concert—with important milestones in normal development: symbolic capacity, burgeoning language, expanded range of emotions (including ambivalence and guilt), evolving self-regulation, theory of mind, and a leap forward in the nature of object relations” (p. 171). Throughout the primer the authors illustrate the nuanced and reciprocal interplay between play and “remarkable developmental transformations” (p. 70).
The book comprises two parts. The first, “Theory of Play and Play Therapy,” contains seven chapters. The initial chapters include a thorough overview of the literature on the functions of play from the perspectives of human development, ethnological studies, cultural history, developmental research, and psychoanalysis. The authors provide a clear and concise discussion of the predictable developmental chronology and ascendance of play from infancy, where it emerges from the “intersubjective matrix of the mother-infant dyad” (p. 64), to imaginary play, social play, structured play, and a gradual waning in preadolescence, with sublimation in later adolescent and adult development into creative and cultural pursuits. The authors illuminate the major functions of play, including “mastery, wish fulfillment (pleasure), assimilation of overpowering experience, departure from reality: it has one root in the function of fantasy, and relief from superego pressures” (p. 41).
A notable chapter in this section, “Play in the Digital Age,” is an exploration of postmodern digital media culture, including electronic toys, smartphones, virtual realities, digital games, and social media platforms. The authors focus on aspects of working with “digital natives,” as technology is a central part of current culture, especially for latency-age children and teenagers, known as “screenagers” (Gergen 2015). There is a growing complexity captured in the literature attempting to understand the interface for children between digital technology, child development, and developmental lines (Gilmore 2017). Meersand and Gilmore recommend that child clinicians learn the “contemporary language of childhood” (p. 116), and remain flexible and open when smartphones/devices appear in the consultation room, always attending to possible conscious and unconscious communications. While the debate about the impact of digital technologies on development and its inclusion in treatment ensues, the authors encourage attending to the therapeutic potential and meanings, including a recent conceptualization that smartphones and cyber space may serve as transitional objects or space (Sugarman 2017).
The final chapters of part one cover fundamental psychoanalytic concepts in play therapy, including therapeutic action, the therapeutic alliance, transference and countertransference, developmental psychopathology, and the role of play capacity in diagnostic formulation. The authors address the imperative question that child therapists face from parents and colleagues alike: What is the therapeutic action in play therapy that is curative and growth-promoting? They succinctly describe the mutative aspects of treatment, including the co-creation of a mutual playing state facilitating the elaboration of the child’s narrative; the importance of the clinician’s role as developmental and new object; and work with parents. These mutative aspects of treatment all work toward the aim of softening of the child’s defenses for greater affect tolerance and self-regulation, improved relational capacity, and the scaffolding of evolving ego capacities essential for restoring developmental progression.
A highly engaging and enjoyable aspect of this primer is the inclusion of vivid clinical vignettes representing a broad range of child psychopathology, along with the challenges encountered in practice. While reading these vignettes, I found myself intrigued by the fact that their being drawn from supervision allows us to hear and imagine a multiplicity of vantage points. The vignettes take the reader through imagining and musing about the child from many perspectives, and illuminate the complexity of the myriad transference and countertransference reactions evoked, as child therapists interact with a multitude of individuals including parents/guardians, teachers, siblings, pediatricians, and other professionals, in addition to the child patient. The supervisory narration allows the reader to hear the integrative thinking of the experienced master clinician authors, and it brings to mind the valuable role of supervision and consultation.
The book’s second part, “Technique of Play Therapy,” includes six chapters that thoughtfully explore the logistics of planning a child-focused practice, building a collegial network, the assessment process, sustaining and deepening play narratives, working with parents, termination, and treatment considerations in working with serious psychopathology. Additionally, the authors have included as appendices a developmental history form, standardized measures of play, and a sample school observation narrative. These chapters and the appendices provide a comprehensive pragmatic guide on technique for child psychoanalytic practice.
Meersand and Gilmore discuss the unique aspects of establishing the frame with young children as a “gradual nonverbal process,” since one cannot explain the parameters to a child. The therapist, working in a fast-paced, spontaneous context, is simultaneously attempting to create a mutually open, trusting relationship and a safe place for a mutual playing state to unfold. Typical disruptions that occur in child sessions are aggression, attempts to use the therapist’s body, tantrums, attempts to disrupt others in the suite and/or waiting room, destruction of toys or office, and difficulties enacted around beginning and ending sessions. Meersand and Gilmore address the common behavioral dilemmas in dealing with aggression and sexual content that while considered developmentally normative may manifest at times as challenges to the therapist’s and/or child’s safety and/or the parameters of the frame. The authors note the many ways in which working with children requires that therapists reflect on their own tolerance for anxiety, aggression, childhood sexual fantasies, and enactments, as well as potential chaos and confusion often not limited to the consulting room.
Another clinically significant area addressed in this volume is “understanding moments of referral,” contextualizing the importance of distinguishing referrals at normative junctures in childhood, such as the birth of a sibling, divorce, losses, and gender dysphoria, from crisis referrals and other forms of developmental disorders. Also stressed is the importance of assessing play capacity/level for diagnostic purposes and expectations for treatment, especially in the context of neurodevelopmental or trauma disorders where play and other developmental processes—such as relational capacity, cognition, learning, language, executive functioning, self-regulation, sense of self—may have been derailed and impaired.
Once again Meersand and Gilmore have generously shared their clinical acumen and scholarly comprehensiveness to offer a volume expanding the conceptual understanding of imaginary play while also demonstrating the convergence of contemporary theory and practice that is a compelling read for all clinicians and/or psychoanalysts. It is difficult to imagine a training site or institute that would not want to include this book in its library. The book is an indispensable resource for clinicians, psychoanalytic candidates in training, and their teachers and supervisors.
Becoming and being a child clinician and/or analyst requires curiosity, flexibility, humility, the capacity to enter into a playing state, and a readiness and openness to manage conscious and unconscious conflicts that may manifest in the displacement of play, and/or in enactments that present quandaries and challenges particular to child analytic work. Meersand and Gilmore have remarkably captured—via extensive research, integration of theory, and a vast array of thought-provoking clinical vignettes—the demanding, messy, unpredictable, and joyful complexity of practicing the creative art of psychoanalytic play therapy.