Clinical Applications of Drama Therapy in Child and Adolescent Treatment

Anna Marie Weber, Craig Haen, Anna Marie Weber, Craig Haen

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781135934866
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

As an emerging psychotherapeutic discipline, drama therapy has been gaining global attention over the last decade for its demonstrated efficacy in the treatment of child and adolescent populations. However, despite this attention and despite the current turbulent state of the world and the increasing population of disturbed and at-risk children, the field of drama therapy has so far lacked a standard text. Weber and Haen's book fills this need, providing a core text for graduate students and established professionals alike.

Clinical Applications of Drama Therapy in Child and Adolescent Treatment is guided by theory, but firmly rooted in practice, providing a survey of the many different possibilities and techniques for incorporating drama therapy within child and adolescent therapy. More than merely a survey of the existing literature on drama therapy, this text represents a true expansion of the field: one which articulates the breadth of possibilities and applications for drama therapy in the larger context of psychotherapy.

SECTION I
Individual Drama Therapy

CHAPTER 1

Facilitating Play with Non-Players

A Developmental Perspective

ELEANOR C. IRWIN

The Many Faces of Play

Since play is a natural way for children to express themselves and learn about the world, it is normal to expect that anyone and everyone can play. But play is an activity about which there are many points of view. Millar (1969) has captured the nebulous, multi-faceted quality of this activity in commenting that “the term play has long been a linguistic wastebasket for behavior which looks voluntary, but seems to have no obvious biological or social use” (p. 11). Most parents, educators, and therapists, however, think they know play when they see it. Asked to describe play, many observers would emphasize its spontaneous and free-flowing quality, would stress its imaginary elements and comment on the transparency of the child’s wishes and fears as revealed in play activities.

It is this revealing quality of play, especially fantasy or dramatic play, that endeared this activity to psychoanalysts. When the field was in its infancy, Anna Freud (1927) and Melanie Klein (1964/1948), pioneering child psychoanalysts with different theoretical approaches and styles, began to use play as a way of understanding and treating children. Klein, whose focus on early, deep interpretations was the source of much controversy, likened the spontaneity of child play to the adult’s efforts at free association in psychoanalysis. Anna Freud, on the other hand, stressed that it was necessary to have a preparatory period to form a “therapeutic alliance” with the child before making interpretations.

Other analysts, like Erik Erikson (1963), soon added to our understanding of play in the theory and practice of child therapy. Erikson thought of play as “the road to the understanding of the synthesis of the ego” (p. 209). Calling play the child’s “work,” Erikson stressed that through the “recreation and self cure” afforded by play, the child can learn about the world and his or her place in it. In detailed treatment vignettes, Erikson pointed to the role of anxiety, saying that when emotion becomes too intense, playfulness is disrupted (p. 223).

Donald W. Winnicott, a pediatrician and psychoanalyst, followed Klein in focusing attention away from the oedipal period to the crucial importance of the early mother–child relationship. Winnicott (1989), whose contributions are now in the mainstream of therapeutic practice, drew many analogies between the mother–child and therapist–patient relationships and the importance of play. Winnicott spoke of the mother’s need to establish a “holding environment,” or a “facilitating environment,” that allows play and development to proceed.

Winnicott places play squarely in the center of psychotherapy with patients of all ages. Play, he said, takes place in the period of illusion, or in the “transitional space” between the imaginary and the real world, between the “me” and the “not-me” (1958, p. 215). Psychotherapy, Winnicott wrote, “has to do with two people playing together. . . . If the therapist cannot play, then he is not suitable for the work. If the patient cannot play, then something needs to be done to enable the patient to be able to play, after which psychotherapy may begin” (1971, p. 54). Winnicott further underscored the linkages between play, self development, and creativity in saying, “It is in playing and only in playing that the individual child or adult is able to be creative and to use the whole personality, and it is only in being creative that the individual discovers the self ” (1971, p. 54).

Drama Therapy: Players and Non-Players

Just as there are many definitions of play, so are there many definitions of drama therapy (e.g., see Jennings et al., 1994; Lewis & Johnson, 2000). A working definition of the term is, in fact, part and parcel of each drama therapist’s necessary search for a professional identity. My own description, written many years ago (Irwin, 1979), began with the attempt to distinguish between “therapeutic” and “therapy,” both words stemming from the Greek word therapeutikos, meaning “to nurse, serve, cure.” I went on to say that many activities can serve a therapeutic or healing function, particularly the creative arts.

While there is great overlap in the meaning of the two words, there are also clear distinctions between them that center on the issues of product versus process; goal and purpose; and the role of the leader. In the marriage of drama and therapy, the term, to me, implies the use of drama/theater techniques in an intentional, planned way as a specific form of intervention, designed to bring about intrapsychic, interpersonal, or behavioral changes. In drama therapy, the process, the therapeutic relationship, and the transforming power of affect (Fosha, 2000) are key aspects of treatment.

Drawn to the field because of a deeply felt wish to better understand themselves and those with whom they work, most drama therapists are empathic, introspective, and well trained in theater, drama and spontaneous play techniques. Relying on their intuition and training, most drama therapists try to find creative ways of connecting to others. The drama therapist works with individuals and/or groups, spanning the ages from preschool to senescence, in a variety of settings and with many populations.

Definitions aside, however, it seems to me that most drama therapists work toward the general goals of:

1. facilitating imaginative play at the highest possible level;
2. strengthening self control and affect regulation;
3. helping individuals put feelings and behaviors into words.

A core aspect of the drama therapist’s work is the integration of spontaneous play and the dramatic structures of characters, plot, setting, climax, denouement, and so on. This is the stuff of which drama is made. The development and maturation of these abilities make drama possible, but more importantly, also promote creativity and social, cognitive, emotional and interpersonal growth.

The ability to be self reflective, expressive and playful in one’s thoughts, feelings, and actions is the sine qua non of most forms of psychodynamic therapy. Unfortunately, many children and adults, burdened by a variety of difficulties, are unable to “play” in the way that Winnicott envisioned. These individuals, who might be called non-players, cannot be spontaneous, symbolize thoughts and feelings, and engage with others in an imaginative way. Non-players guard against the awareness of thoughts and feelings, often functioning at a preverbal level. While these children and adults present problems for all therapists (Greenspan, 1997), they present a particular dilemma for drama therapists, whose stock in trade is fantasy and imagination, facilitated through individual and/or group stories and enactments.

Often, the inability to play is the result of congenital, environmental or developmental difficulties. As Anna Freud pointed out (1965), development is complex and depends on the mutual interaction of constitutional, neurological, maturational and environmental factors. When one or more of these abilities is compromised, there may be impairment in many areas, including that of play. Non-players are difficult, even exasperating, to treat; mired as they are in pre-symbolic, magical, or concrete ways of thinking, unable to engage in sustained interaction with others. In such situations, it helps to have a developmental framework to understand what might be limiting or foreclosing the ability to play.

Knowledge of normal and arrested development can help the drama therapist make educated guesses about the child’s difficulties, suggesting the kinds of approaches, activities, and interventions that might be successful in facilitating play. Awareness of developmental difficulties can also help the drama therapist to be patient, sensitive to the therapeutic process, and alert to the potential healing power of the relationship over time.

To illustrate work with non-players, case examples of three youngsters will be presented. This material will be supplemented with a discussion of regulation, factors such as attachment, self and other representations, and affect regulation, since difficulties in these areas often interfere with the ability to use play in the service of growth.

Children Who Are Non-Players

What might a non-player look like? Both Joey and Max had experienced significant developmental problems, as the following vignettes will illustrate.

Joey, A Frozen, Traumatized Child

In his first session, 5-year-old Joey entered the playroom hesitantly, standing as though transfixed. I pointed out the creative materials that were available for dramatic play, such as costumes, masks, puppets, sandbox materials, miniature toys, and the like (Irwin, 1983), but Joey made no move toward them. After standing still for some minutes, Joey turned his back to me and stiffly lowered himself into the nearest available chair. Taking a pencil from his pocket, he stared at it for some time and then began to make vertical marks on the blank, white paper in front of him. My empathic remarks seemed to be unheard. And there he sat for most of the hour, saying nothing, but motorically conveying a state of frozen rigidity and seeming numbness, while I sat beside him feeling increasingly out of touch.

Joey’s first hour was similar to many that followed. For many sessions, I had no clue what was behind the enacted and embodied meanings conveyed through his ritualized, black pencil marks, now being “stabbed” with increased energy on white paper. Three months later, perhaps reassured that he was in a safe space (Winnicott, 1965), Joey began to make rough drawings of monster faces. By 5 months, feeling psychologically freer, Joey began to draw monsters violently attacking tiny, stick-like people, playing with his markers as though they were aggressor and victim. Becoming more verbal, Joey used puppets and doll figures to play out his stories, supplying words of anguish and rage for the victims like “Stop!” and “Get away!” It was not until he had been in therapy for 18 months that he could begin to elaborate on these attacks, linking them to beatings by his (now jailed) father. Following the monster play, Joey shifted to games of peek-a-boo and hide-and-seek, suggesting that he was working out long-delayed separation issues (Bergman, 1999).

Max: An Action-Oriented Child

Enraged because he was unable to get the devil mask and flowing red cape to stay in place for his drama, Max reacted immediately. Tearing off his costume, this twelve-year-old became the devil he was about to pretend to be. But, for Max, there was no pretend, no “as if.” Picking up the plastic pitchfork, Max advanced dangerously close toward me. In a menacing voice, with narrowed eyes, he hissed, “I’m going to KILL you!” In a split second, he had moved from a position of tenuous control to one in which he had none. Max’s fantasy of killing another slipped over the pretend boundary and became real. Only my firm re-statement of the rule: “PRETEND. No hurting for real!” averted an imminent attack.

Max laughed nervously at my intervention and backed away. I said what had been said before during similar episodes: “Max, you’re ready to lose control. Let’s take a breather and talk about the pictures and stories in your head.” Still angry, Max narrowed his eyes and yelled, “I’m gonna stab you!”

As calmly as I could, I said that there would be no stabbing for real, but that he could draw a picture of what he wanted to do and throw darts at the picture if he wanted. Or, he could tell a story about the devil and I would write it down for him; that might help us to understand what he was thinking. Resentfully, Max chose both. Drawing a picture of a robot, he told a confused and confusing story of a devil robot that roamed the earth and killed people, especially at night. I wondered if this was the devil in the story that was about to kill me. When Max affirmed that it was so, I wondered what had happened to make the devil want to kill me. Max glowered and yelled, “’Cause you don’t do what I want! Yeah! I’m the boss here. I’m the devil! And I can do it!”

Attachment Theory, Development of Self and Other Representations, and Affect Regulation

Joey’s and Max’s difficulties in play can be better understood through an examination of attachment theory, recent research about the development of object relations, and affect regulation. Understanding these developmental concepts can help the drama therapist navigate worrisome therapeutic paths more comfortably, especially those dangerous areas that often get bogged down in transference/countertransference swamps, particularly in work with troubled children like Joey and Max.

Attachment Theory

Our understanding of attachment, which has been the lynchpin of recent research, began with the pioneering research of John Bowlby (1969–1980), an English psychoanalyst. Studying attachment behaviors in animals and humans, Bowlby theorized that the function of early attachment to the mother is to protect the child from predators. On the evolutionary level, the attachment shields the infant from harm; on the psychological level, the attachment serves to reduce anxiety and to impart a sense of security. If the child has a secure base of attachment to the mother, Bowlby hypothesized, several important achievements can follow: (1) the still-vulnerable child can comfortably explore the environment with less fear and arousal, knowing that the mother is available in times of danger; (2) the secure child will have less need to develop psychological defenses; and (3) the child can form an internal mental representation of the caring protector and, over time, can identify with that internalized image. Bowlby believed that the need for attachment is never outgrown but endures throughout one’s life, albeit in an attenuated way.

A proliferation of research in psychoanalysis, infant psychiatry, developmental psychology, and developmental psychopathology flowed from Bowlby’s work. Researchers like Ainsworth et al. (1978), Main and Solomon (1990) and others (see Cassidy & Shaver, 1999) began to examine the attachment patterns of young children through the “Strange Situation Test.” In time, researchers classified attachment patterns along a continuum from healthy to pathological. The attachment patterns they proposed include: (1) secure; (2) insecure (insecure-avoidant, insecure-ambivalent, or insecurenarcissistic); and (3) disorganized/disoriented.

Joey and Max manifest disorganized/disoriented behaviors. An examination of this category of attachment and the cumulative risk factors associated with it (e.g., low I.Q., family problems, and so on) help us to understand the multiple interrelationships between development and psychopathology. Unstable environments, financial problems, and self-preoccupied parents— who are unprepared for parenting and not able to adequately support the child’s development—are common in the histories of disorganized/ disoriented attachment. Because parents in such situations cannot promote self-regulation, increase sensitivity to others, or aid brain development, the child is at risk for future emotional, social, cognitive and psychological problems.

In disorganized attachment situations, the caregiver often has unresolved trauma that can easily be tapped by ongoing events. If this happens, the child may be faced with the mother’s frightening, confusing, dissociated behavior. The child’s core dilemma in such a situation is “fear without approach solution” (Lyons-Ruth & Jacobvitz, 1999, p. 549). The child can neither the mother, who is supposed to offer support, nor can the child flee. In such an “unresolvable paradox” (p. 549), the child often freezes, immobilized. In time, this kind of attachment pattern is followed by a host of psychological and interpersonal problems. The child may be controlling with caregivers, may be aggressive or avoidant with peers, may have academic difficulties, and often shows psychopathology in adolescence and adulthood.

Development of Self and Other Representations

Fonagy and Target (2000) stress that attachment is not an end in itself, but is of interest principally because it provides a model “for the integration of early childhood experience and later development, particularly the emergence of psychopathology” (p. 310). They and others (Schore, 2003; Siegel, 1999; Stern, 1985) have pointed out that crucial aspects of development are contingent upon and flow from attachment. Primary among these structures is the development of the brain, the central role of emotion, and their respective contributions to the development of the self and the self in interaction with others (often called object relations). Whether the attachment pattern is secure, insecure, or disorganized, there are ongoing patterns of emotional communication between mother and child over time, patterns that indelibly shape behaviors, emotions, and perception. From birth onward, through increasingly complex modes of relatedness with others, a core sense of self evolves (Broussard, 1984). The self-in-formation is a mixture of what is constitutionally innate and what is conveyed through the environment, for better or worse, in a continuous, dialectical way. Along with the development of “self-representations,” are “object representations” (e.g., an internal image of the self and an internalized image of others, respectively). These self and other representations become linked with feelings, or affect states (Kernberg, 1976), that emotionally color our view of ourselves and our interactions with significant others, in time becoming a way of seeing ourselves in the world.

The child’s experiences and interactions with caretakers (including fathers) and the environment are thus ingrained on the developing personality, long before the child has an autobiographical memory. These experiences and interactions, although preverbal, are remembered through bodily sensations, nonverbal behaviors, and interactions with others.

Affect Regulation

Early life events are crucial because secure attachment experiences facilitate the development of the brain, promote self-regulation, and aid in the shaping of subsequent relationships (Fonagy, 1991; Fonagy, Gergely, Jurist, & Target, 2002; Fosha, 2000; Schore, 1998, 2003; Siegel, 1999). The infant...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Editors
• Contributors
• Foreword
• Acknowledgments
• Introduction
• Section I Individual Drama Therapy
• Section II Group Drama Therapy and Integrated Models
• Section III Families and the Larger System