Chapter 13.Play Therapy, Variations in Child Development, and Serious Psychopathology

When a child between ages 3 and 7 or 8 years—the developmental “high season” for play (see Chapter 3, “Pretend Play”)—manifests limited access to pretense, the clinician is confronted with immediate questions: Does the restricted play represent a set of factors or transient conditions that will likely shift over time, allowing for fuller engagement in the psychodynamic play process? Or does the initial presentation signify a true absence of imaginary play, perhaps alerting the therapist to more serious underlying deficits in the necessary symbolic and relational capacities that might impede child–clinician mutuality and ultimately limit the deepening of play treatment? A child’s inability to participate fluidly and pleasurably in play with the clinician may reflect temporary reactions to the novel treatment situation (e.g., initial discomfort with the clinician, reluctance to separate from caregivers, or resistance to beginning therapy, as described in Chapter 9, “Getting Started, Creating an Alliance, and Facilitating Play”); normative variations of temperament (e.g., shyness and inhibition); the presence of conflicts that lead to avoidance of or disruption of play themes and affects; mild immaturities in development (e.g., slight delays in language or self-regulation); the deployment of normative defenses (e.g., preference of school-age children for rule-bound games that support recently acquired capacities for self-control); or more serious conditions (e.g., a history of environmental deprivation and trauma, or ego impairments and relational deficits) that derail not only play but also the child’s overall developmental progression (Gilmore 2005; Sugarman 2008). Any of these conditions potentially distorts a child’s access to play by dampening joy and spontaneity, limiting absorption in pretense, causing disruption as the play elicits intense affective reactions, and interfering with the capacity to achieve a mutual playing state with the clinician. The presence of serious psychopathology and developmental delays, discussed in the subsequent sections of this chapter, may result in far greater restrictions and even absence of the child’s imaginary capacities. Differentiating among the interrelated developmental systems that impact play—biologically based conditions, unresolved conflicts, defensive styles, and environmental factors—is a complex undertaking that requires the clinician’s careful and unhurried assessment (Fonagy and Moran 1991). The evaluation includes the following necessary components: play sessions with the child that help clarify ego functions and relational capacities; the parents’ provision of developmental history; the therapist’s impressions of their parenting style; and reports from the school and other caregivers.