Profiles of Play: Assessing and Observing Structure and Process in Play Therapy (Book Review)

Author:  Chazan, Saralea
Publisher: Jessica Kingsley, 2002
Reviewed By: Johanna Krout Tabin, Spring 2003, pp. 25-27

PLAY AS PROJECTIVE TECHNIQUE: ASSESSING THERAPEUTIC PROGRESS ON THE GO
Play therapy is a confusing name for a serious enterprise. To make its meaning clear, Saralea Chazan quotes Freud in her latest publication, Profiles of Play: “The opposite of play is not what is serious but what is real.” (p. 202) Chazan’s book explicates in great detail the vital role of play in ego development and how to chart ego development through play in the vicissitudes of growth during treatment. The basic theme is that play is possible only when a child experiences agency; thus, achieving and expanding an ability to play is the hallmark of overcoming obstacles to ego development. The text is full of concrete points of analysis and clinical examples, amplified with good scholarship, including recent findings from infant research. In keeping with the goal of greater ego integration for patients, the reader is treated to references to the literature that place the work in the context of previous theorists’ contributions, and according to crisply organized principles of interpretation. This book is a manual for understanding the process of play therapy. It presumes that the reader is already aware of the method of play therapy, as so fully given in a book by Sophie Lovinger, another Division 39 member, Child Psychotherapy: From Initial Therapeutic Contact to Termination. When I first opened the Chazan book, I expected something of the sort. In fact, I had to adjust consciously to the actual purpose here.

There is nothing playful about the presentation. The book’s subtitle is about observing and assessing structure and process in play therapy. Chazan, with Paulina Kernberg and Linda Normandin, created a scheme for the thorough study of the elements of therapy sessions with a child, and the qualities of play as they arise. They call this scheme the Children’s Play Therapy Instrument (CPTI). The structure of play therapy reflects the amount of play in comparison with other uses of the time. The structure of sessions is meticulously examined in terms of segments of different activities. The process of therapy is tracked by the nature and amount of play of which the child is capable, analyzed meticulously. Chazan applies the CPTI to vignettes from the treatment of several children, providing an outline that is consistently filled out in each example. The object of the CPTI is to enable the therapist to see quantitatively and qualitatively what is happening in the child, as revealed by its play. Chazan uses it to show how crucial it is in a child’s progress for him or her to increase the amount of time spent in play, a necessary ego-enhancing activity that bridges for the child its inner and outer worlds. Play automatically involves a sense of agency, a sense of self. Play is specifically defined as activity that absorbs the child in focused concentration, purposeful choice of toys or other objects and specific affective expression, ultimately resulting in pleasure. It may or may not include verbalization and it may or may not involve the therapist. Other segments within the therapy hour may be in pre-play. This is defined as setting the stage for play. It encompasses preparations for more elaborate play, as in selection of objects. Everything else is non-play: talking about daily events, eating, reading, etc. One final category is interruptions, such as leaving the room, going to the bathroom, etc. These are understood in the fabric of the session to be signs of tension that the child finds to be intolerable.

Chazan organizes her account around vignettes from the treatment of seven children. In each case, the CPTI outline first requires a narrative description of the entire session by the therapist from process notes. The first order of business in applying the CPTI format is to identify the segments within a session devoted to each type of activity. Charts are made of the proportion of time spent in play at various stages of the treatment. To give an idea of how finely the child’s behavior is studied, thirteen types of play activity are listed. Then there is attention to script description of the play activity. This includes initiation, facilitation, inhibition, and ending. In each of these categories, note is taken of whether the process is determined by the child or the therapist. Next, the child’s level of relationship to the external world is measured in terms of spheres of play activity. If the amount of autonomy the child feels is restricted to bodily sensations and needs, the play is in the child’s autosphere. The microsphere, small representations of the real world in miniature toys, etc., permits exploration of a small world that is thus manageable. Play in the macrosphere requires ability to deal with the world as it is, including the child’s relative smallness and dependency. This part of the evaluation gives significant information about the child’s perspective on itself and its world.

Readers of this review might wonder about the relational and affective aspects of therapy sessions. Lack of completeness is not a problem with this book. In addition to all of the categories listed above, seven components of the affective nature of the child’s play are scored on a scale from one to four. These are the overall hedonic tone, spectrum of affects, regulation and modulation of affects, transitions between affects (smoothness or abruptness), appropriateness of affect to context, child’s affective tone to therapist, and therapist’s affective tone toward child. Next, the cognitive components in the play are recorded. These include role representation (complex-dyadic, solitary, precursor), stability of representation--persons and objects (fluid/stable, voluntary/involuntary), use of the play object (realistic, substitution, miming, source of activity), and style of representation--persons and objects (realistic, fantasy, bizarre).

Narrative components observed in play get their due focus: Topic of the play activity, level of relationship portrayed within the narrative (self, dyadic, triadic, oedipal), quality of relationship portrayed within the narrative (autonomous, parallel, dependent, twinning, malevolent, destructive, annihilating), use of language by the child/by the therapist (silence, imitation, pun/rhyme, single role, multiple roles, metaphor, meaning, about something other than the play, describing). Finally, developmental components observed in play activity are considered: Chronologically-developmental level of play activity (very immature, somewhat immature, age appropriate, somewhat advanced, very advanced), gender identity of the play activity (predominantly male, predominately female, no predominance), social level of the play activity--interaction with therapist (isolated/unaware, isolated/aware, parallel, reciprocal, cooperative), psychosexual level (oral, anal, phallic, oedipal, latency), and separation/individuation level (differentiation, practicing, rapprochement, object constancy).

Chazan discusses the meaning, significance, and value of every one of these aspects of observation. She offers her rationale for including them. She also cautions that variability must be expected both in different levels of achievement by a child in the possible aspects of its play, and in the steadiness of appearance of behaviors. Case by case, she evaluates the vignettes according to each category included in the CPTI outline of what took place. In her Introduction, Chazan offers descriptions of three children whose play patterns differ widely, but all of whom are reasonably well adapted to their lives. Then, using the same three names for three other children, she describes how similar-seeming patterns of play actually reveal poorly adapted behavior. She uses elements of the CPTI analysis with these made up examples to prepare the reader for close attention to actual case vignettes. Four overall diagnoses cover the actual children whose material is examined. They are the adaptive player, the conflicted player, the rigid/polarized player, and the extremely anxious/polarized player. Chazan applies the CPTI categories meticulously in discussing these children.

The strategies used by the adaptive player, presumably unconsciously, are adaptation, anticipation, problem solving, suppression, sublimation, altruism, affiliation (playing includes joining or being joined), identification, and humor. The conflicted player uses intellectualization, rationalization, isolation, doing and undoing, negation, reaction formation, repression, projection, introjection, regression, somatization, turning aggression against the self, and avoidance. Rigidity and polarization are grouped together because they both require constriction. Characteristic strategies (or in more common parlance, defenses) used by children in this condition include denial, splitting, projective identification, primitive idealization, primitive devaluation, omnipotent control, and identification with the aggressor. The defensive strategies of the extremely anxious/isolated child include de-differentiation, constriction, de-animation, dispersal (or fragmentation), dismantling, autistic encapsulation, fusion, freezing (halting the functioning of self or other), hypochondriasis, and reversal of affect.

In spite of this almost precious degree of organization, the flavor of Chazan’s understanding of the unconscious comes through in her explanations of categories. She adds in quotation marks the unconscious statement the child is making. Her understanding of hypochondriasis, for example, is that “The terror is taken in again and hurts me.” Or, for dispersal: “It is broken into pieces and spread around so it will not be dangerous anymore.” Her understanding of projective identification would please Melanie Klein, who broke with her followers over their idea that the projector succeeds in putting disavowed feelings into another. Chazan, with Klein, considers it as a more intense effort than projection. In the latter use, one believes the disavowed feelings belong to another so that one feels safe from them. In projective identifications, the object of the projection is experienced as dangerous. “The attribute (or experience) is outside of me. ‘I’ am actively holding it at arm’s length so it does not return to me.” Material of this kind makes Chazan’s observations valuable. Still, manuals do not make for lively reading. At times, the actual material in the selections seems forced into fulfilling the outline and/or the diagnosis.

One difficulty probably stems from the fact that the first four cases were treated not by Charzan, but by others. She also has the advantage, one guesses, of knowing more of what happened during a given session than a small vignette can show. A reader might see a therapist’s quoted remarks as negative in tone, while Chazan refers to them as positive. Chazan must have discussed the vignettes with the therapists, which plausibly gave her a sense of how things were said, as the printed page cannot do. Beginning with the fifth case, the book becomes a pleasure to read. It is obvious that Chazan saw this child. Only as I prepared this review did I realize that in her acknowledgments, Chazan identified the therapists of the first four cases as other than herself. It is an interesting lesson in how even a rigid code of interpretation can be dynamic when someone is close to the material.

When I began Profiles in Play, I expected more emphasis upon meaning to the child in the process than emphasis upon the structure of therapy sessions. As with the formal scoring of the Rorschach, content analysis here seems an after-thought. Also, while a behavioral description of the child appears at the start of material from its sessions, there is almost no reference to what is evinced by the child in ego development outside of the therapy room, even at the end of treatment. The value of the changes that the therapist observes seems great to me, too, as a clinician. Nonetheless, from the scientific standpoint, it would be of great interest to correlate the changes with behavior in the larger macrosphere.

I found myself summoning all possible obsessive proclivities to get through the first half of this book. In the second half, Chazan uses her own clinical experience and the book springs to life. I will not disagree, however, with the choices she made. This is not a book for bedside reading. It is a blueprint for pinpointing a child’s ego development and progress in therapy. Someone without a deadline for writing a review can take the sections gradually and see how they apply to children, and perhaps adult patients. Albert Brok (1991) presented relevant views to Division 39. He underscored the advantage, for adult patients, of a psychic space that is illusion embedded in reality, and vice versa. Play on a verbal level confirms that thought is not deed. Some of the parameters that Chazan uses for evaluating ego development among children are useful in thinking about adult patients, too.

In any case, Profiles of Play is a good source for tracking the progress of young patients. I have been bemused at my own awareness of some of the issues that come clear, clinically, with the CPTI format, without my taking the trouble to fill out the outline. The CPTI format seems excellent to me for designing clinical research projects in psychoanalysis, as we clinicians have found it hard to do satisfactorily until now. The book is not for beginners, as Sophie Lovinger’s book is. It is useful to sensitize advanced students to the complexities of ego development, appreciating both strengths and difficulties of the child. Some of Chazan’s authoritative statements on the meaning of play in the treatment process might make useful handouts to give parents of new child-patients who are bewildered why anyone should be paid for just playing with their troubled children. The whole book impresses one with the richness of the enterprise.

References

Brok, A.J. (1991). The playing alliance in film and on the couch. Paper presented
Division 39 (Psychoanalysis) of the American Psychological Association, Eleventh
Annual Spring Meeting. Chicago, Illinois, April 12.
Lovinger, S.L. (1998). Child psychotherapy: From initial therapeutic contact to
termination
. Northvale, New Jersey: Jason Aronson.

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