Eliana Gil The Healing Power of Play Working With Abused Children The Guilford Press 1991

The Healing Power of Play
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THE HEALING
POWER OF PLAY
Working with Abused Children
ELIANA GIL, PH.D.
THE GUILFORD PRESS

New York London
© 1991 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
All rights reserved
No part of this book may be reproduced, stored in a retrieval system,
or transmitted, in any form in by any means, electronic, mechanical,
photocopying, microfilming, recording, or otherwise, without written
permission from the publisher.
This book is printed on acid-free paper

Last digit is print number: 2019 18 1716 15 1413
Library of Congress Cataloging-in-Publication Data

Gil, Eliana.
The healing power of play : working with abused children /
Eliana Gil.
p. cm-
Includes bibliographical references and index.
ISBN 0-89862-560-2. ISBN 0-89862-467-3 (pbk.)
1. Abused children—Mental health—Case studies. 2. Play
therapy—Case studies. I. Title.
[DNLM: Child Abuse—rehabilitation—case studies. 2. Play
Therapy—in infancy & childhood—case studies. WS 320 G4632h]
RJ507.A29G55 1991
618.92/891653—dc20
DNLM/DLC
for Library of Congress 91-6706
CIP
To Robert Jay Green, Ph.D., who
chose me as his trainee
recognized my capacity
encouraged my intellect
tells me to reach high
always makes me laugh
allows me to feel special
Acknowledgments
Writing this book was a stressful and happy experience.

While writing, I was reminded of my child clients, the
traumatic events in their lives, their incredible strength and
hope, and the unique ways they coped. Their courage,
resiliency, and joy amaze me and inspire me.
I thank my many colleagues who inspire and stimulate
me and I am greatly appreciative to my friends and family
who stand by me as I tackle large and small projects. My
gratitude to Toby Troffkin for her copyediting of the book, and
my research assistants, David Farinella and Coco Ishi.
Special thanks to my husband John, my source of strength
and joy; my in-laws Norm and Eileen; my mom, Eugenia, and
my brother Peter; my great kids Eric, Teresa, and Christy;
my best friends, Teresa and Tony Davi, Melissa and Melinda
Brown, Mary Herget, Kathy Baxter-Stern, Robert Green,
Jeff Bodmer-Turner, Steve Santini, Lou Fox, Sue Scoff, my
Wednesday group, and my colleagues at A STEP FORWARD.
The clinical material presented in this book is a compila-
tion of cases. To protect the confidentiality of my clients I
have changed all identifying information. Where dialogue or
vii
viii THE HEALING POWER OF PLAY
art work is provided, it is presented with the permission of

the parents.
A portion of the first chapter of this book entitled "The
Impact of Child Abuse" was adapted from the first chapter
("Behavioral Indicators of Abuse") of my book Treatment of
Adult Survivors of Childhood Abuse, which was published in
1988. This material was adapted and reproduced with per-
mission of Launch Press, Walnut Creek, CA.
Contents
The Abused Child: Treatment Issues 1

The Abused Child 1
Mediators in the Effects of Child Abuse 3
The Impact of Child Abuse 7
Clinical Observations 12
The Impact of Trauma 19
The Child Therapies: Application in Work with 26

Abused Children
The Historical Development of Play Therapy 28
The Techniques of Child Therapy 34
Directive versus Nondirective Play Therapy 35
The Treatment of Abused Children 37

Treatment Considerations in Working with
Abused Children 37
Application of Established Child Therapies to
Work with Abused Children 51
The Treatment Plan 52
ix
x THE HEALING POWER OF PLAY
CLINICAL EXAMPLES 83
Leroy: A Child Traumatized by Severe Parental 85

Neglect
Referral Information 85
Social/Family History 85
Presenting Problems 87
Initial Clinical Impressions 87
Treatment Planning 90
The Beginning Phase of Treatment 91
The Middle Phase of Treatment 96
Termination 102
Discussion 104
Johnny: A Child Traumatized by Sexual Abuse 106

Clinical Impressions 108
Discussion 124
Antony: A Child with Multiple Traumas 127

Discussion 142
Gabby: A Child Traumatized by a Single Episode 144

of Sexual Abuse
Discussion 156
Laurie: A Neglected Child Traumatized by a 158

Hospitalization
Contents xi

Discussion 174
Sharlene: A Child Traumatized by Chronic Sexual 177

Abuse
Discussion 190
Special Issues 192

Countertransference 192
Clinician Self-Care 193
Clinician Safety 194
Summary 194
References 197
Index 205
The Healing Power of Play
The Abused Child:
Treatment Issues
THE ABUSED CHILD
Children have been subjected to differing types of maltreat-

ment throughout history, and these atrocities are well docu-
mented (Radbill, 1980; Summit, 1988). For centuries society
condoned infanticide, physical abuse, sexual abuse, and the
exploitation of children's labor.
The prevalence of child maltreatment has endured
throughout time and has cultivated tenacious legacies that
have shaped societal response to child abuse. Those legacies
include the tenet that children are the property of their
parents—and expendable as well. These traditions con-
tributed to the slow societal response in defining and
responding to child abuse. In addition, society has suffered
from a denial of the problem's existence and prevalence. Even
the medical community, seeing the firsthand consequences
of abuse in emergency rooms, reacted more slowly than one
1
2 THE HEALING POWER OF PLAY
might expect. In the 1940s there was some documentation of

physical abuse cases appearing in hospital settings; the first
article stating the possibility of parental maltreatment was
written by Caffey (1946), a radiologist who cited subdural
hematomas in infants who had atypical fractures of the limbs
and ribs. Skepticism prevailed about the extent of this prob-
lem until 1962, when Dr. C. Henry Kempe coined the phrase
"the battered child syndrome" (Kempe & Heifer, 1980) and
finally succeeded in calling national attention to this persist-
ent social problem.
Major developments have occurred since that time, the
most noteworthy being the creation of laws to protect
children even from their biological parents. In 1962 the first
reporting law was written, and by 1964 every state had a
child abuse reporting law mandating physicians to report
suspected physical abuse.
The other significant evolution has been in the expan-
sion of the definition of child abuse. Most states currently
define child abuse in subcategories that include at least the
following: physical abuse, sexual abuse, and neglect. Many
states have formulated definitions that encompass psycho-
logical or emotional abuse as well as sexual exploitation,
which includes child pornography and child prostitution. The
list of professionals mandated to report known or suspected
abuse to the authorities continues to expand.
Since the late '60s literally hundreds of research projects
have focused on child abuse, particularly on child sexual
abuse (Herman, 1981). A body of research has accumulated
on the family dynamics of abuse, the short- and long-term
effects of abuse, victim and perpetrator characteristics, and
prevention and treatment strategies.
It appears that even though the empirical research is vast,
studies are fraught with methodological problems due to small
sample sizes and design difficulties. Finkelhor (1984) iden-
tifies a number of areas that require additional and more
refined research, including the differential effects of abuse on
preschoolers versus older children, the negative effects of
justice system intervention, cultural differences in abuse and
effects, and the differential effects by types of abuse.
Treatment Issues 3
Beginning with the '70s a great deal of interest has

converged on the subject of sexual abuse of children, and I
agree with Finkelhor (1984) that more quality research is
absolutely necessary on a variety of topics of child abuse,
including the differential effects of physical abuse, neglect,
and emotional abuse. This information will allow clinicians
to formulate more precise treatment strategies.
I will offer a brief summary of the most consistent find-
ings in the research. It appears that the experience of paren-
tal maltreatment of children, regardless of the form it takes,
has particular psychological and emotional implications for
the child victim. Perhaps nowhere do we find greater
evidence of this than in contemporary findings from both the
research and the clinical work done with adult survivors
(Briere, 1989; Courtois, 1989; Finkelhor, 1986; Gil, 1989).
MEDIATORS IN THE EFFECTS

OF CHILD ABUSE
Although findings have emerged from studies on child sexual

abuse (Finkelhor, 1986; Lusk & Waterman, 1986; Wyatt &
Powell, 1988), it appears that several factors mediate the
impact of any type of abuse on children. These factors include
the age of the child at the time of the abuse, the chronicity,
the severity, the relationship to the offender, the level of
threats to the child, the emotional climate of the child's
family prior to the abuse, the child's mental and emotional
health prior to the abuse, the amount of guilt the child feels,
the sex of the victim, and the parental response to the child's
victimization.
Age of the Child at the Time of Abuse

There is some discrepancy in the research on the effect of the
child's age on later outcome (Adams-Tucker, 1982; Ruch &
Chandler, 1982); however, a trend exists toward viewing the
younger child as more vulnerable to damage. Van der Kolk
(1987) states that childhood trauma is most damaging to
younger children because "uncontrollable terrifying ex-

periences may have their most profound effects when the
central nervous system and cognitive functions have not yet
fully matured, leading to a global impairment" (p. xii).
Chronicity
There is consensus in the research that the more chronic the
abuse, the greater the impact. If the abuse continues over a
period of time, the child's sense of helplessness and vul-
nerability can increase, and the child has greater oppor-
tunity to utilize and refine defense mechanisms, such as
dissociation, that can become problematic later in life.
Severity
Probably the more extensive the abuse, the greater the
damage. This is obvious in cases of severe physical abuse,
which can result in physical handicaps, brain damage, and
developmental delays, and in cases of neglect, which can
result in a nonorganic failure to thrive. In sexual abuse cases
more extensive genital contact, such as penetration, has been
associated with a greater negative impact (Adams-Tucker,
1982; Mrazek, 1980).
Relationship to Offender
It is generally believed that the closer the relationship
between the offender and the child, the greater the resul-
tant trauma (Adams-Tucker, 1982; Simari & Baskin, 1982).
The child who is abused outside the home is able to project
the badness outside the home and turn to the family for
protection and reassurance. The child abused by a loved one
learns that the person who loves him/her is also the hurtful
person.
Level of Threats
The use of threats, force, and violence also potentially wor-
sens a trauma (Ruch & Chandler, 1982). The presence of
Treatment Issues 5
threats may produce generalized anxiety and fear in the

child. The threat need not be explicit to manipulate a child;
a child can feel threatened and can feel as though he/she
must keep a secret even when the threat is nonverbally
communicated.
The Emotional Climate of the Child's Family

Azar and Wolfe (1989) state that "the pervasive effects on
abused children's psychological and behavioral development
that result from the many factors accompanying abuse in
families and affecting their behavior are less understood and
potentially more harmful to the children's development"
(p. 452). The family dysfunction includes patterns of inter-
generational abuse, inappropriate child-rearing patterns
and parenting skills, social incompetence and isolation from
support systems, emotional distress, inaccurate perceptions
and high expectations of children, and emotional arousal and
reactivity to child provocation (Wolfe, 1987). In discussing
neglecting families, Polansky, Chalmers, Buttenweiser, and
Williams (1979) cite generalized chaos and disorganization,
matched with rampant low functioning affecting all areas of
performance. Julian, Mohr, and Lapp (1980) found that the
factors most often associated with incest families are family
discord, mental health problems, broken family, alcohol de-
pendence, spouse abuse, social isolation, and insufficient
income. Barrett, Sykes, and Byrnes (1986) characterize in-
cestuous families as incohesive and inflexible, with poor
instrumental and affective communication and incongruent
hierarchies. These types of problems create a climate where
abuse can occur. Emslie and Rosenfeld (1983), in their com-
parison study of abused girls who were victims of incest and
those who were not, concluded that the psychopathology of
the girls was a consequence of severe family disorganization
and no specific effects of incest could be found.
The Child's Mental and Emotional Health

If the child has good psychological health prior to the abuse,
he/she is in a better position to resist the damaging effects
of abuse (Adams-Tucker, 1981; Leaman, 1980). Van der

Kolk (1987) asserts that "an adult with a firm sense of
identity and good social support is infinitely better
protected than a child, who has a lower level of cognitive
development" (p. 11).
The Guilt the Child Feels

In cases of sexual abuse, it is generally agreed that if the
child experiences some pleasure during sexual contact or
feels somehow responsible for causing the abuse, he/she is
more likely to feel guilt, which is associated with greater
impact (MacFarlane & Korbin, 1983).
The Sex of the Victim

It was initially thought that males suffered less trauma than
female victims (Adams-Tucker, 1982; Vander Mey & Neff,
1982); however, these beliefs were probably based on lack of
knowledge about male victims. Recent research on the sub-
ject (Briere, 1989) supports earlier speculation (Finch, 1973)
that male victims show long-range serious problems and
greater psychopathology. Nasjleti (1980), E. Porter (1986),
Risin and Koss (1987), Hunter (1990), Dimock (1988), and
Lew (1988) have offered valuable insights into the impact of
sexual abuse on boys and men.
Parental Responses to the Child's Victimization

Leaman (1980) and others (James & Nasjleti, 1983; Sgroi,
1982; Summit & Kryso, 1978) have repeatedly emphasized
the pivotal role the nonabusive parent plays in the healing
of the child. The child's recovery is greatly enhanced by a
parent who believes the child and is not accusatory but is
unequivocally supportive and reassuring. An unsupportive
or overreactive parental response results in greater trauma
(Tufts, 1984).
Treatment Issues 7
THE IMPACT OF CHILD ABUSE

The impact of sexual abuse more than likely can be measured
along a continuum. Friedrich (1990) says:
Sexual abuse and its impact should be seen along a con-

tinuum ranging from neutral to very negative. Sometimes
when we see only one type of child or family, we may believe
that abuse is either much more discrete in its impact or
primarily very negative. It is important to recognize this
variability because it reminds us again of the hopefulness
that can be present even in traumatic events and that the
possibility for positive change always exists. It also forces
us to realize that there are strengths and sources of
resilience in the individuals whom we see that exceed any
of the curative powers that we might be able to bring to
these dysfunctional systems, (p. 102)
Because children are unable to fully understand or ex-

plain the impact of abuse, professionals usually rely on the
development of symptomatic behaviors to signal underlying
emotional difficulties. The most common problems exhibited
by child victims include affective disorders; anxiety and fear;
depression; physical effects, including psychosomatic com-
plaints, injury, and pregnancy; cognitive and school-related
problems; learned helplessness; aggressive and antisocial
behaviors; withdrawal; self-destructive behaviors;
psychopathology; sexual problems; poor self-esteem; and
problems with interpersonal relationships (Lusk & Water-
man, 1986). The following categorization attempts to distin-
guish the most common symptomatic behaviors by type of
abuse.
Sexual Abuse
Finkelhor (1986) analyzed the empirical data on short-term
effects of sexual abuse and concluded that abused children
regularly exhibit the following signs:
• Fear or anxiety
• Depression
• Difficulties in school
• Anger or hostility
• Inappropriate sexualized behavior
• Running away or delinquency
Physical Abuse
In a ground breaking book Martin (1976) finds that physical-
ly abused children exhibit the following:
• Impaired capacity to enjoy life

• Psychiatric symptoms, enuresis, tantrums, hyper-
activity, bizarre behavior
• Low self-esteem
• Learning problems in school
• Withdrawal
• Opposition
• Hypervigilance
• Compulsivity
• Pseudomature behavior
Martin and Rodeheffer (1980) state that:

Physical abuse may result in a number of biological conse-
quences, including death, brain damage, mental retarda-
tion, cerebral palsy, learning disabilities and sensory
deficits. The neurological handicaps of physical abuse are
of particular interest because of their chronicity and sig-
nificance to the long-range functioning of the individual. It
is estimated that between 25 and 30% of abused children
who survive the attack have brain damage or neurological
dysfunction resulting directly from physical trauma about
the head. (p. 207)
Martin and Rodeheffer also quote a study conducted by

the National Center for Prevention of Child Abuse and
Neglect in Denver in 1976 that found that physically abused
children have deficits in gross motor development, speech,
and language. They go on to say that physically abused
children exhibit the following:
Treatment Issues 9
Interpersonal ambivalence
Hypervigilant preoccupation with the behavior of others
Constant mobilization of defenses in anticipation of
danger
Inability to perceive and act on the environment in
pursuit of mastery
Impaired socialization skills with peers
Frustration from inability to meet expectations of others
Defensiveness in social contacts
"Chameleon nature" (shifting behavior to accommodate
to others)
Learned helplessness ("To try a task and fail is more
dangerous than not to try at all")
Tendency to care for their parents physically and emo-
tionally
Lack of object permanence or object constancy (distor-
tion of normal object relations)
Reidy (1982), summarizing traits of physically abused

children, found that they exhibit aggression and hatred,
uncontrollable negativistic behavior and severe temper
tantrums, lack of impulse control, emotionally disturbed
behavior both at home and at school, and withdrawn or
inhibited behavior. Reidy in his own study (1982) finds that
abused children (1) express significantly more fantasy ag-
gression on the Thematic Apperception Test (TAT) than other
children; (2) exhibit aggressive behavior more frequently
than other children; and (3) express significantly more fan-
tasy aggression in their natural homes than they do in foster
homes.
Kent (1980) finds that physically abused children (1)
tend to have more problems managing aggressive behavior
than other children, and (2) tend to have more problems
establishing peer relationships than other children.
Martin (1976) makes an important point:
The child's personality is affected and shaped by the total
environment in which [the child] lives. The specific inci-
dents of physical assault are a psychic trauma. However,
the broader picture, which may include rejection, chaos,
deprivation, distorted parental perceptions, unrealistic ex-
pectations as well as hospitalization, separation, foster
placement and frequent home changes, is in the long run
more significant to the child's development, (p. 107)
Neglect
The dynamics of child neglect differ significantly from the
dynamics of physical and sexual abuse. The greatest single
difference is that physically and sexually abused children
receive attention from their parents. The attention is inap-
propriate, excessive, harsh, and damaging, but the parent is
definitely aware of the child's existence. Energy is directed
toward the child. Neglectful parents do the opposite; over-
whelmed, lethargic, and incapacitated, they feel or express
little interest in the child. They withhold attention; they do
not stimulate the child; they rarely make physical or emo-
tional contact. In extreme cases the neglectful parent seems
to be unaware that the child exists.
Polansky et al. (1981) finds that neglected children ex-
hibit the following:
• "Deprivation-detachment"
• Massive repression of feelings (affect inhibition)
• Impaired ability to empathize with others
• Violence
• Delinquency
• Decrease in general intellectual ability (due to lack of
cognitive stimulation on the part of the parent)
Kent (1980) also finds developmental delays in neglected

children.
Emotional Abuse
Garbarino, Guttmann, and Seeley (1986) describe emotion-
ally abused children as "showing evidence of psychosocial
harm," as evidenced by the following signs and symptoms:
Treatment Issues 11
• Behavioral problems (anxiety, aggression, hostility)

• Emotional disturbance (feelings of being unloved, un-
wanted, unworthy)
• Inappropriate social disturbance (negative view of the
world)
• In infants, irritability and, in some cases, nonorganic
failure to thrive
• Anxious attachment to parents
• Fear or distrust
• Low self-esteem
• Feelings of inferiority; withdrawal; lack of communica-
tion
• Self-destructive behavior (self-mutilation, depression,
suicidal tendencies)
• Tendency to act as caretaker to parents
• Delinquency or truancy
Garbarino et al. summarizes their findings:

The psychologically maltreated child is often identified by
personal characteristics, perceptions, and behaviors that
convey low self-esteem, a negative view of the world, and
internalized or externalized anxieties and aggressions.
Whether the child clings to adults or avoids them, his or her
social behavior and responses are inappropriate and excep-
tional, (p. 63)
It should be noted that some victims of child abuse seem

to emerge unscathed. Garbarino et al. discuss "stress-resis-
tant" children who become prosocial and competent in spite
of their harsh, or even hostile, upbringing. He concludes that
these children receive "compensatory doses of psychological
nurturance and sustenance [that] enable them to develop
social competence, that fortify self-esteem, and [that] offer a
positive social definition of self (p. 9).
Anthony and Cohler (1987), in their extensive studies of
resiliency, conclude:
The child shares with other organisms a biological tendency
to achieve wholeness—not as a static state, but as a
dynamic, flexible balance that permits recoil or regression
and rebound of progress. Biological rhythms of activity and
rest provide a basic pattern for acceptance of restitution
from the outside. The whole range of resources may be
involved: biochemical factors, including hormones and en-
dorphins; the interaction of cortical, subcortical, autonomic
nervous system, and glandular activity; and psychological
forces. All these resources interact, mobilizing regenerative
power. Residues of experiences of resilience after physical
or emotional disturbance contribute both a sense of "feeling
good" and also a consolidation of confidence, optimism, and
ability to respond to or seek help when faced with threats
in the future. The drive toward integration, then, utilizes
selective combinations of other drives and capacities avail-
able at a given stage of the child's development, (p. 101)
In the following section I offer some clinical observations

based on my own experience in providing therapy to abused
children. I do not attempt to categorize behavioral indicators
by type of abuse because they frequently overlap.
CLINICAL OBSERVATIONS
The problem behaviors of abused children are manifested

internally or externally. The behaviors described in the fol-
lowing paragraphs are ones that are regularly observed by
me and by those of my colleagues who specialize in the
treatment of abused children. I consider them, to be in-
dicators of abuse. However, these (and those already listed)
are not conclusive of abuse in and of themselves. Children
who are not abused but who live in dysfunctional families or
suffer crises such as divorce or parental death may also
exhibit these behaviors.
Internalized Behavior
Children who exhibit internalized behavior tend to be iso-
lated and withdrawn. They attempt to negotiate the abuse
by themselves; they do not interact with others. These
children frequently
Treatment Issues 13
Appear withdrawn and unmotivated to seek interactions

Exhibit clinical signs of depression
Lack spontaneity and playfulness
Are overcompliant
Develop phobias with unspecified precipitants
Appear hypervigilant and anxious
Experience sleep disorders or night terrors
Demonstrate regressed behavior
Have somatic complaints (headaches, stomachaches)
Develop eating disorders
Engage in substance and drug abuse
Make suicide gestures
Engage in self-mutilation1
Dissociate
Externalized Behavior
Conversely, children with externalized manifestations
engage in behavior directed toward others; they exhibit out-
ward expression of their emotions. Such children are aggres-
sive, hostile, and destructive; provocative (eliciting abuse);
violent, sometimes killing or torturing animals2; prone to
destructive behaviors including fire-setting; and sexualized.
1
Self-mutilation must be distinguished from suicide gesturing. Self-mutilation
seems to be utilized for a variety of reasons, including grounding (from dissocia-
tive or depressed states), comforting (especially when children have been
physically abused and believe love and pain go together), satisfaction of need
for parental care (as when foster children miss their parents and cannot see
them). Finally, some children use self-mutilation to ascertain their own
humanity. Self-mutilation is usually found in adolescents; however, younger
abused children can begin to develop the more typical ritualistic, hidden
behaviors associated with older children and adults. If left uninterrupted, this
coping mechanism can continue well into adulthood. Numerous adult clients
have stated this to be the case.
2
The killing and torturing of animals is a significant cry for help; these children
are in grievous distress. Two common clinical findings to explain this behavior
are the following: (1) the child is behaviorally reenacting his/her own abuse on
a smaller victim and (2) the child is rehearsing suicide. The stronger the child's
emotional attachment to the animal, the more alarming this behavior is.
They are often more readily identified because their behavior

creates a problem for other people.
Internalized and externalized behaviors can overlap;
children can have differing types of reactions to any specific
feeling. Fear, for example, has been observed to have three
types of reaction to perceived threat: (1) motor reactions,
such as avoidance, escape, and tentative approach; (2) sub-
jective reactions, such as verbal reports of discomfort, dis-
tress, and terror; and (3) physiological reactions, such as
heart palpitations, profuse sweating, and rapid breathing
(Barrios & O'Dell, 1989, p. 168). In my experience, a child may
present with internalized behaviors and develop or exhibit
externalized behaviors during treatment. My hypothesis is
that as these children learn to trust the therapist and are
encouraged to express their hidden emotions, they become
more able to show feelings such as anger and hostility.
Special Issues
Abused children can also develop two special behaviors:
dissociation and sexualization. Both are important to assess
and treat and seem to be frequently misunderstood, remain-
ing undiagnosed and untreated.
Dissociative Phenomena
The Diagnostic and Statistical Manual of Mental Disorders
defines dissociative phenomena as "a disturbance or altera-
tion in the normally integrative functions of identity,
memory, or consciousness" (1987, p. 269). The DSM-III-R
categorizes three types of dissociative phenomena: (1) multi-
ple personality disorder (disturbance in identity), (2) deper-
sonalization disorder (disturbance in identity), and (3)
psychogenic amnesia or fugue (disturbance in memory). Dis-
sociative phenomena may be represented along a continuum,
with multiple personality disorder, the most extreme form of
dissociation, occurring at the endpoint. Emerging empirical
data reveal an indisputable correlation between early severe
childhood abuse and multiple personality disorder (Kluft,
Treatment Issues 15
1985; Putnam, 1989). Multiplicity is believed to begin in

childhood, yet diagnosis usually occurs much later. Histori-
cally, there has been a speedier identification of dissociation
and multiplicity in adults. Clinicians working with severely
abused children are well advised to research the area of
childhood multiplicity (Kluft, 1985; Peterson, 1990).
Dissociative phenomena are clearly linked to trauma.
According to Eth and Pynoos (1985), psychic trauma occurs
"when an individual is exposed to an overwhelming event
resulting in helplessness in the face of intolerable danger,
anxiety, and instinctual arousal" (p. 38). Clearly, abuse is a
psychic trauma to children, the more so by virtue of their size,
dependency, and vulnerability.
Sexualized Behavior
Finkelhor (1986) has developed a four-factor conceptual
model for understanding the "traumagenic dynamics" occur-
ring in sexual abuse. The four factors are traumatic
sexualization, stigmatization, powerlessness, and betrayal,
each with its respective dynamics, psychological impact, and
behavioral manifestations (see Table 1.1). Finkelhor and
Browne (1985) define traumatic sexualization as "a process
in which a child's sexuality [including both sexual feelings
and sexual attitudes] is shaped in a developmentally inap-
propriate and interpersonally dysfunctional fashion as the
result of sexual abuse (p. 531). Finkelhor (1986, pp. 186-187)
provides information conceptualizing the sexualization of
child victims (see Table 1.1).
My own clinical observations of sexually abused children
are consistent with Finkelhor's concept of traumatic
sexualization as well as with the conclusions of Johnson-
Cavanaugh's (1988) and Friedrich's (1988) pioneering efforts
in this area. Sexually abused children develop an excessive
and abnormal interest in sex, an interest that is frequently
expressed in precocious sexual activity. One of the difficulties
that arise in assessing children's sexual behaviors is the
scarcity of contemporary normative data on the development
of children's sexuality. Sgroi, Bunk, and Wabrek (1988) have
TABLE 1.1. Traumatic Sexualization

Dynamics
Child rewarded for sexual behavior inappropriate to developmental
level
Offender exchanges attention and affection for sex
Sexual parts of child fetishized
Offender transmits misconceptions about sexual behavior and
morality
Conditioning of sexual activity with negative memories and emotions
Psychological impact
Increased salience of sexual issues
Confusion about sexual identity
Confusion about sexual norms
Confusion of sex with love and care getting or care giving
Negative associations to sexual activities and arousal sensations
Aversion to sex or intimacy
Behavioral manifestations
Sexual preoccupations and compulsive sexual behaviors
Precocious sexual activity
Aggressive sexual behaviors
Promiscuity
Prostitution
Sexual dysfunctions
combined their clinical experience working with normal and

troubled children to offer a developmental framework for
children's sexuality. I have found this framework (presented
in Table 1.2) helpful in determining whether a child's sexual
behavior indicates a need to intervene.
Berliner, Manaois, and Monastersky (1986) concur that
pathological sexual behaviors in children are distinguishable
from developmentally appropriate sexual play. In their
model, they see disturbances along dimensions of severity.
The most severe type of sexualized behavior is coercive,
including the use of physical force and resultant injury.
Berliner and associates describe another dimension as con-
sisting of developmentally precocious behavior that includes
attempted or completed intercourse without coercion. Lastly,
they list sexual behaviors considered inappropriate, which
Treatment Issues 17
TABLE 1.2. Children's Sexuality

Age range Patterns of activity Sexual behaviors
Preschool (0-5 Intense curiosity; Masturbation; looking
years) taking advantage of at others' bodies
opportunities to
explore the universe
Primary school Game playing with Masturbation; looking
(6-10 years) peers and with younger at others' bodies;
children; creating sexual exposure of self
opportunities to to others; sexual
explore the universe fondling of peers or
younger children in
play or game-like
atmosphere
Preadolescence Individuation; Masturbation; sexual
(10-12 years); separation from family; exposure; voyeurism;
adolescence distancing from open-mouth kissing;
(13-18 years) parents; developing sexual fondling;
relationships with simulated intercourse;
peers; practicing sexual penetration
intimacy with peers of behaviors and
both sexes; "falling in intercourse
love"
can include persistent, public masturbation that can cause

pain or irritation; touching or asking to touch others' geni-
tals; excessive interest in sexual matters, reflected in play,
art, or conversation; and sexually stylized behavior imitative
of adult sexual relationships.
As the framework of Sgroi and associates, as well as of
Berliner and her colleagues, clearly illustrates, children's
sexual behaviors tend to progress over time, with extreme
behavior being indicative of psychological disturbance. Pre-
mature sexual activity in children always suggests two pos-
sible stimulants: experience and exposure. The child exhibit-
ing premature sexual activity may have experienced sexual
contact with an adult or older child and may be mimicking the
learned behavior, or the child may have been overstimulated
by exposure to explicit sexual activity and may be acting this

activity out. Many young children have access to soft- or
hard-core pornography on their television sets.
An additional characteristic of many sexualized children
is a disinhibition of masturbatory behavior. A child who has
not been sexually abused will abruptly stop masturbating
when someone enters the room; sexually abused children,
possibly having learned the sexual behavior with another
person, may continue to masturbate.
Clinicians have reported sophisticated and focused
sexual behavior on the part of sexually abused children. This
behavior is always unusual and alarming. These children
may enter a room, remove their underwear, and masturbate,
hump, or attempt to engage the clinician in sexual activity.
This is understandable; they have been conditioned to be-
have this way. Nevertheless, the behavior must be extin-
guished for a variety of reasons. The child can literally
become a threat to younger (or older) children and may
request or force sexual contact. It is possible that the child
will approach someone who will be unable or unwilling to set
the appropriate limits; the child then becomes a potential
victim again. In addition, the more extreme masturbatory
behavior can cause injuries and infections that require medi-
cal attention. Lastly, a child who behaves in these inap-
propriate and potentially dangerous ways will elicit a nega-
tive response from others and be singled out for rejection.
The therapist must therefore set and speedily enforce
consistent and directive limits on the child and must suggest
alternative behaviors. These interventions must be shared
with parents and caretakers to maintain a consistent
response. The therapist might, for example, say, "It's not OK
for you to touch private parts of my body or to kiss my mouth"
or "It's not OK for you to take off your underwear in my
office." These limits must be followed immediately by the
suggestion of an alternative behavior: "I can see you're trying
to get my attention; to do that, you can touch my hand and
call my name" or "I can see you're trying to show me how you
feel. To do that, you can draw me a picture, write me a card,
tell me a story, or talk to me about your feelings."
Treatment Issues 19
Behavioral symptoms reveal the child's distress; they

are red flags that indicate underlying concerns in the child.
The symptomatic behavior usually draws attention to the
child; parents, school personnel, or others may seek counsel-
ing for the child upon noticing the inappropriate behaviors.
However, while symptomatic behaviors may respond prompt-
ly to treatment, the underlying issues frequently require
additional care.
THE IMPACT OF TRAUMA
Many victimized children may also be traumatized. While

the two terms are often used interchangeably, their mean-
ings are quite distinct. Victimization has evolved into a
concept with broad-based application. A person may report
feeling victimized by a strenuous job interview, a rigorous
exam, or a demanding funding source; minority groups often
feel victimized by policies or attitudes of the majority group;
students have stated their perception of themselves as vic-
tims of a male-dominated administration. A person can be
victimized without being traumatized. A person who ex-
periences trauma, however, will always be victimized during
the traumatic event.
In addition to treating such victimization issues as
those delineated by Herman (1981), Kempe and Kempe
(1984), Martin (1976), and Sgroi (1982), it becomes criti-
cal, when treating child victims of abuse, to assess the
diverse impact of trauma, as described by Eth and Pynoos
(1985), Kluft (1985), Putnam (1989), and van der Kolk
(1987). The clinician then devises a therapeutic motif that
encompasses a response to both victimization and
traumatization issues.
As mentioned previously, Eth and Pynoos (1985) believe
that a psychic trauma occurs "when an individual is exposed
to an overwhelming event resulting in helplessness in the
face of intolerable danger, anxiety, and instinctual arousal"
(p. 38). Van der Kolk (1987) notes that the trauma response
is affected by numerous factors, including the severity of the
assault and the genetic predisposition, developmental phase,

social support, prior trauma, and preexisting personality of
the child. Of special importance is van der Kolk's belief that
children are at greater risk for traumatic effects because they
do not have an established identity and their repertoire of
coping behaviors is limited.
Freud initially regarded psychiatric problems as
manifestations of early childhood traumas, interpreting the
cognitive, emotional, and behavioral symptoms of hysterical
patients as symbolic repetitions of early traumatic events.
He saw these repetitions as attempts to release excess energy
and gain mastery. When Freud withdrew these ideas in favor
of the notion of childhood fantasies, and "misperceptions of
actual events," the psychoanalytic interest in trauma was
temporarily lost.
In the last two decades, there has been a resurgence of
interest in the consequences of specific traumas. Van der
Kolk (1987) points out that while effects of specific traumas
such as war, concentration camps, and rape are described as
separate entities, closer examination makes it clear that "the
human response to overwhelming and uncontrollable life
events is remarkably consistent although the nature of the
trauma, the age of the victim, predisposing personality, and
community response all have an important effect on ultimate
posttraumatic adaptation" (p. 2). He goes on to state that the
core features of the posttraumatic syndrome are fairly con-
sistent. Thus, it becomes evident that many of the psycho-
logical consequences of child abuse can be considered
posttraumatic reenactments of unresolved trauma. Eth and
Pynoos (1985) believe that "children's early responses to
psychic trauma generally involve deleterious effects on cog-
nition (including memory, school performance, and learning),
affect, interpersonal relations, impulse control and behavior,
vegetative function, and the formation of symptoms" (p. 41).
Wolfenstein (1965) states that young traumatized children
feel the most helpless and passive and require the most
assistance from the outside in order to reestablish psychic
equilibrium.
Terr (1990) asserts that "traumatized children repeat in
Treatment Issues 21
actions. Whereas adults who are shocked or severely stressed

tend to talk about it, dream, or to visualize, children take far
more action" (p. 265). Terr also states that even though
traumatic events are external, they "quickly become incor-
porated into the mind," particularly when the individual
feels "utter helplessness" during the traumatic events (p. 8).
Others (Bergen, 1958; Eth & Pynoos, 1985; Maclean, 1977)
have observed the way preschool abused children engage in
play reenactment of the trauma. Wallerstein and Kelly
(1975) describe the posttraumatic play as "burdened, con-
stricted, and joyless."
Earlier I indicated that central to the treatment of adult
survivors is the assessment of trauma resolution. Trauma
can be resolved in positive, negative, and functional ways.
Positive resolution occurs when
the adult is able to process the trauma in a realistic way,

experiencing whatever levels of pain, anger, or loss are
elicited by a clear memory of the event,....perceives the
event accurately, and does not feel irrationally responsible
for having caused it....[The adult] is able to understand that
the experience occurred in the past, and no longer feels
devastated by the memory of the event, as if it were a clear
and recurring danger in the present...The person does not
feel compelled to repeat the event, either consciously or
unconsciously. (Gil, 1989, p. 114)
People who achieve this type of resolution break pre-

vious patterns of helplessness and feel more in control of
their lives. The trauma no longer dominates their mental
life.
A negative trauma resolution is in direct contrast to
positive resolution and is destructive and constrictive to the
individual. The person continues to live in the emotional
environment of the traumatic event. Kardiner (1941) recog-
nizes five features of human response to trauma:
• Persistence of a startle response and irritability

• Proclivity to explosive outbursts of anger
• Fixation on trauma
• Constriction of general level of personality functioning

• Atypical dream life
When the individual has a negative trauma resolution,

these symptoms persist and are exacerbated by stress. Most
typical of the negative effects of unresolved trauma are
feelings both of reliving the trauma through intrusive
thoughts or dreams and of numbing. These responses are
now understood to be psychologically and physiologically
based. (The diagnostic category Post-traumatic Stress Disor-
der [PTSD] was incorporated into the DSM-III-R in 1980.)
Many individuals with unresolved trauma have symptoms of
PTSD and seek counseling for relief of these symptoms,
which include nightmares, intrusive flashbacks,
emotionality, physical sensations, and auditory hallucina-
tions. Most clinicians who have experience working with
victims of trauma agree that the traumatic event must even-
tually be brought into awareness and put into perspective or
the intrusion will persist (Figley, 1985).
A functional trauma resolution is one that works on a
temporary basis but cannot be sustained over time. When
operative, such a resolution successfully avoids uncomfort-
able stimuli and relies on defenses such as denial and
suppression. However, external circumstances may render
the resolution ineffective, catapulting the survivor into a
crisis.
As stated earlier, dissociation is strongly correlated
with trauma. This connection was recognized very early:
Briquet first formulated the concept of dissociation in 1859,
and Janet (1889) first pointed out that dissociated states
often follow childhood sexual or physical abuse. Dissociation
is understood as a process of separating, segregating, and
isolating chunks of information, perceptions, memories,
motivations, and affects. Dissociation serves as a defense
against severe stress, allowing the individual to protect
against the original trauma but leaving a predisposition to
react to subsequent stress or familiar stimuli as if they were
a reoccurrence of the trauma. It is remarkable to observe
Treatment Issues 23
adult survivors of abuse experience affective and physiologic

reactions without knowing the original trauma in their
history.
Clinicians seeking to help abuse victims must become
conversant with the treatment of dissociation, since it is such
a common feature for trauma survivors. Braun (1988),
describes his BASK model, explaining that the main stream
of consciousness is made up of four processes—Behavior,
Affect, Sensation, and Knowledge—functioning along a time
continuum. When the integral BASK components are consis-
tently congruent over time, consciousness is stable and the
mental processes are healthy. Braun asserts that "the goal of
psychotherapy is to obtain congruence across the BASK
dimensions in space/time, thus yielding a decrease of dis-
sociated thought processes, a decreased need for the defense
of dissociation, and more control over interactions with the
environment" (p. 23).
Working with traumatized children affords us an in-
credible opportunity to address the trauma shortly after its
occurrence and prior to the strengthening of defensive
mechanisms.
Of particular interest is the concept that unresolved
traumas will leak into consciousness through dreams,
memories, sensations, and behavioral reenactments. These
events can be seen as the psyche's attempt to uncover the
trauma and discharge the accompanying feelings, which
were previously constricted in an attempt to postpone or
avoid emotional discomfort.
Provided with a safe and supportive environment,
children, closer to the source of their trauma, may generate
a distinctive type of play that indicates prior trauma. Terr
(1990) declares that traumatized children "appear to have
two behavioral options, to play or to reenact" (p. 265). She
goes on to say that this type of posttraumatic play is very
distinctive. Terr first observed this play during her work with
23 schoolchildren who had been kidnapped and buried in a
bus in Chowchilla, California. All the children returned home
safely and afforded Dr. Terr the opportunity to conduct a
longitudinal study on victims of trauma (in process). Terr

(1983) has defined 11 aspects of posttraumatic play:
Compulsive repetition; unconscious link between the play
and the traumatic event; literalness of play with simple
defenses only; failure to relieve anxiety; wide age range;
varying lag time prior to its development; carrying power
to nontraumatized youngsters; contagion to new genera-
tions of children; danger; use of doodling, talking, typing,
and audio duplication as modes of repeated play; and pos-
sibility of therapeutically retracing posttraumatic play to
an earlier trauma, (p. 309)
Terr (1983) states that it is very unusual to directly

observe posttraumatic play in the office, probably due to the
secretive nature of the play. However, in my experience,
setting a context for trauma work can facilitate the child's
posttraumatic play or behavioral re-enactments. It appears
that through this type of play we can assist the child toward
trauma resolution. Johnson (1989) notes that the central
tasks of posttrauma treatment include "reexperience,
release, and reorganization" (p. 119). The child who is unable
to relieve anxiety or move beyond the literal scenario that
has been recreated may benefit from the clinician's participa-
tion in the posttraumatic play. Techniques for setting the
context and suggested interventions during the play will be
discussed later in this volume and demonstrated in the case
vignettes.
In Terr's subsequent work (1990) she cautions that
posttraumatic play can fail to relieve the child's anxiety and,
in fact, "if the child reenacts often enough, his developing
character will be affected, leading to 'maladaptive character
structures'" (p. 269). Terr emphatically states that "fixing
these character realignments following traumatic malad-
justments is probably the most significant contribution a
psychiatrist can make to the traumatized child's future" (p.
270). Posttraumatic play, according to Terr, can be
"dangerous," since "posttraumatic play may create more ter-
ror than was consciously there when the game started"
(p. 239). She regards posttraumatic play as resistant to in-
Treatment Issues 25
terpretations or clarifications but adds that behavioral inter-

ventions may render effective results. This information high-
lights the need to teach parents and child victims alike the
strategies for coping with fear and anxiety.
The clinician who chooses to work with abused and
traumatized children is advised to establish a method for
assessing the need for trauma resolution work, providing
context and direction, facilitating posttraumatic play, and
making timely interventions. This cannot be done without a
thorough understanding of trauma and its impact. The
clinician also encounters few rules or guidelines, because
studies focusing on treatment outcomes of work with abused
children are "almost nonexistent" in the literature (Azar &
Wolfe, 1989, p. 481).
The Child Therapies:
Application in Work
with Abused Children
Closer than the moon, even closer than the

depths of the seas,
the minds of children seem to most people
not only mysterious,
but impenetrable.
—J. ALEXIS BURLAND & THEODORE B. COHEN
Child therapy is described by Sours (1980) as "a relationship

between the child and the therapist, aimed primarily at
symptom resolution and attaining adaptive stability" (p.
275). Child therapy, as a separate and distinct type of work,
has been evolving since 1909, when Freud first attempted
psychotherapy with the now historic patient Little Hans. The
term child therapy is often used interchangeably with the
termp/ay therapy although play was not used directly in the
therapy of children until 1920 when Hermine Hug-Hellmuth
26
Applying the Child Therapies 27
began using play for the diagnosis and treatment of

childhood emotional problems (Schaefer, 1980). Melanie
Klein and Anna Freud formulated the theory and practice of
psychoanalytic play therapy some 10 years later.
While most child therapists agree that play is the most
effective medium for conducting therapy with children,
others (Freiberg, 1965; Sandier, Kennedy, & Tyson, 1980)
have raised questions as to whether play produces structural
change, have pointed to the nebulous quality of play, and
have dismissed it as consisting of neither dream material nor
free association. Schaeffer (1983) contends that "it is some-
what difficult for anyone interested in play and play therapy
to gain a clear understanding of what is meant by the term
play because no single, comprehensive definition of the term
has been developed" (p. 2). However, the potential benefits of
play are well documented. In his literature review Schaeffer
found descriptions of play as "pleasurable," "intrinsically
complete," "independent from external rewards or other
people," "noninstrumental, with no goal," and "not occurring
in novel or frightening situations." Schaeffer suggests that
play is person- rather than object-dominated.
Schaeffer (1980) further asserts that "one of the most
firmly established principles of psychology is that play is a
process of development for a child" (p. 95). Play has been
alternately depicted as a mechanism for developing "prob-
lem-solving and competence skills" (White, 1966); a process
that allows children to "mentally digest" experiences and
situations (Piaget, 1969); an "emotional laboratory" in which
the child learns to cope with his/her environment (Erikson,
1963); a way that the child talks, with "toys as his words"
(Ginott, 1961); and a way to deal with behaviors and concerns
through "playing it out" (Erikson, 1963). Nickerson (1973)
views play activities as the main therapeutic approach for
children because it is a natural medium for self-expression,
facilitates a child's communication, allows for a cathartic
release of feelings, can be renewing and constructive, and
allows the adult a window to observe the child's world.
Nickerson points out that the child feels at home in a play
setting, readily relates to toys, and will play out concerns
with them. Chethik (1989) makes an important point about

the use of play as therapy: "Play in itself will not ordinarily
produce changes...the therapist's interventions and utiliza-
tions of the play are critical" (p. 49). In addition, the clinician
must serve as a participant—observer, rather than a
playmate. I believe that play in therapy must be facilitated
by an involved clinician in a meaningful way. Some of the
most frequent errors made in child therapy are allowing a
child to play randomly over an extended period of time,
ignoring the child's play, and providing the kind of toys that
do not promote self-expression.
As interest in child therapy has grown and as the num-
ber of child-specific referrals has increased, a variety of
therapeutic techniques, games, and toys have also evolved.
Play therapy has blossomed into a multifaceted and exciting
field of study.
THE HISTORICAL DEVELOPMENT

OF PLAY THERAPY
As mentioned earlier, Sigmund Freud in 1909 was the first
to use play to uncover his client's unconscious fears and
concerns. Hermine Hug-Hellmuth began using play as a part
of her treatment of children in 1920 (Hug-Hellmuth, 1921)
and 10 years later, Melanie Klein and Anna Freud formu-
lated the theory and practice of psychoanalytic play therapy.
This type of play therapy continues to be one of the most
respected forms of child therapy, usually conducted by
analysts.
Psychoanalytic Play Therapy

Anna Freud and Melanie Klein wrote extensively about how
they incorporated play into their psychoanalytic technique.
Whereas the former advocated using play mainly to build a
strong positive relationship between child and therapist,
the latter proposed using it as a direct substitute for ver-
balizations. The primary goal of their approach was "to help

children work through difficulties or trauma by helping
them gain insight" (Schaefer & O'Connor, 1983). Anna
Freud has repeatedly pointed out that "the essential task
[of therapy] is to remove the obstacles that impede [the
child's] development and to allow his progressive develop-
mental forces and ego resources to complete the task of
development" (Nagera, 1980, p. 22). Klein (1937) felt that
an analysis of the child's transference relationship with the
therapist was the main source of insight into the child's
underlying conflict.
Freud and Klein took the basic concept of free associa-
tion, one of the basic precepts of adult analysis, and in its
place substituted the child's natural tendency to play
(Nagera, 1980). They proposed that play uncovered the
child's unconscious conflicts and desires and that play was
the child's way of free-associating. While Klein proposed
that the child's play is "fully equivalent" to the adult's free
associations and "equally available for interpretation,"
Freud's theory viewed play not as an equivalent to adult free
associations but as an ego-mediated mode of behavior "yield-
ing a substantial body of data" but requiring supplementa-
tion from a variety of sources, including parents (Esman,
1983). Psychoanalytic play therapy, predicated on the
analysis of resistance and transference, emphasizes the use
of interpretation, recognizing the child's ability to use play
symbolically to manifest internal concerns. Nagera (1980)
documents that even though significant differences existed
in the theoretical tenets of Freud and Klein in the beginning,
throughout the years there has been more of a convergence
between the two theories. Fries (1937), a student of Anna
Freud's, delineates the distinctions between the two
theories, emphasizing Freud's preference to withhold inter-
pretation.
Esman (1983) describes the focus of play in psychoana-
lytic child therapy: "It allows for the communication of
wishes, fantasies, and conflicts in ways the child can tolerate
affectively and express at the level of his or her cognitive
capacities" (p. 19). He goes on to say that the therapist's

function is to "observe, attempt to understand, integrate, and
ultimately communicate the meanings of the child's play in
order to promote the child's understanding of his or her
conflict toward the end of more adaptive resolution" (p. 19).
Structured Play Therapies

In the late 1930s, a more goal-oriented therapy, known as
"structured therapy," was developed. This therapy emerged
from a psychoanalytic framework and from a belief in the
cathartic value of play and the active role of the therapist in
determining the course and focus of therapy (Schaefer &
O'Connor, 1983).
Anna Freud had initially found the use of affective
release useful, but on the basis of later experience she en-
couraged this type of work only in cases of severe traumatic
neuroses. David Levy (1939), stimulated by Anna Freud's
conclusion and by Sigmund Freud's concept of "repetition
compulsion," introduced the concept of "release therapy" for
children who had experienced trauma. Levy helped the child
recreate the traumatic event through play. The goal of this
type of play was to help the child assimilate the negative
thoughts and feelings associated with the trauma by reenact-
ing it over and over again. Levy cautioned against using this
technique too early in therapy, before a strong therapeutic
relationship had been formed. In addition, he took care to
avoid "flooding," in which the child is overcome by strong
emotions and thus unable to assimilate them.
Other well-known contributors to the literature on struc-
tured therapies include Hambidge and Solomon. Solomon
(1938) thought that helping a child express rage and fear
through play without experiencing the feared negative con-
sequences would have an abreactive effect. Hambidge (1955)
was even more directive than Levy, who provided toys to
facilitate the child's recreation of the trauma: Hambidge
facilitated the child's abreaction by directly recreating the
event or life situation in play.
Relationship Therapies
Otto Rank and Carl Rogers, also considered non-directive
therapists, were the major proponents of relationship
therapy, which is based on a particular theory of personality
"which assumes that an individual has within himself not
only the ability to solve his own problems but also a growth
force that makes mature behavior more satisfying than im-
mature behavior" (Schaefer, 1980, p. 101). This type of
therapy promotes the full acceptance of the child as he/she
is, and stresses the importance of the therapeutic relation-
ship. Moustakas (1966), another prominent leader in the
field of child therapy, emphasizes the genuineness of the
therapist as pivotal to the success of therapy. He strongly
advocates the importance of the here-and-now as the nucleus
of therapeutic success. Axline (1969) also gives credence to
the importance of the therapeutic relationship, viewing it as
the "deciding factor" (p. 74). Axline's writings, particularly
the widely touted book Dibbs in Search o/SreZ/"(1964), have
clearly delineated the benefits and desirability of nondirec-
tive therapy.
Behavior Therapies
In the 1960s the behavior therapies, based on the principles
of learning theory were developed. Such therapies apply the
concepts of reinforcement and modeling to relieve behavior
problems in children. The behavioral approaches are precise-
ly concerned with the problem behavior itself, not with the
past or with feelings that might have preceded or accom-
panied the behaviors. No attempts are made to achieve
affective release, to do cathartic or abreactive work, or to help
children express feelings. Behavioral approaches are applied
directly to children in the playroom or are taught to parents
for use in the home. This type of therapy has broad applica-
tion to childhood problems, particularly those that stem from
a lack of adult guidance and limit setting. Within this
framework play is used as a means to an end, not as inherent-
ly valuable in and of itself.
Group Therapy
Slavson (1947) experimented with group situations in 1947,
guiding latency-age children through activities, games, and
arts and crafts designed to help them "release emotional and
physical tensions" (p. 101). In 1950, Schiffer developed what
began to be known as "therapeutic play groups" (Rothenberg
& Schiffer, 1966) in which children could interact freely with
minimal intervention from the clinicians. The unique aspect
of this type of therapy, according to Schaefer (1980), is that
"the child has to learn to share an adult with other children"
(p. 101). Group therapy enjoys a certain contemporary
popularity, partly because it can be provided at lower cost
and partly because there has been a growing belief in the
effectiveness of this modality. Yalom (1975) documents
numerous "curative" benefits provided by group therapy,
including the following: installation of hope, universality,
imparting of information, altruism, corrective recapitulation
of the primary family group, development of socializing tech-
niques, imitative behavior, interpersonal learning, group
cohesiveness, catharsis, and existential factors. Kraft (1980)
elucidates that effective group treatment must contain the
following elements:
Leadership, preferably with male and female co-therapists,
involves developing cohesiveness, identifying goals for the
group, showing the group how to function, keeping the
group task-oriented, serving as a model, and representing
a value system. In carrying out these tasks, the leader may
offer clarification of reality, analysis of transactions, brief
educational input, empathic statements acknowledging his
own feelings and those of members, and at times delineat-
ing the feeling states at hand in the group, (p. 129)
Group therapy has traditionally been believed to have

application to the treatment of abusive parents (Kempe &
Heifer, 1980). A treatment approach used effectively with
abusive parents is known as Parents Anonymous (PA),
founded in California in 1970. PA uses a formerly abusive
parent as a group facilitator in addition to the mental health
professional. There are currently over 1,200 PA groups in the
United States.
Another very well-known treatment model, Parents

United, relies heavily on the group format. Parents United
was established in 1975 by Dr. Hank Giarretto as the self-
help component of the Child Sexual Abuse Treatment Pro-
gram (Giarretto, Giarretto, & Sgroi, 1984), now known as the
Community as Extended Family. Separate groups are formed
for the incestuous parents and for the non-abusive partners.
The children's groups are known as Daughters and Sons
United, and the groups for adult survivors are known as
Adults Molested as Children (AMAC) groups. There are
currently over 135 active Parents United programs across
the United States.
Mandell, Damon, et al. (1989) wrote a useful and timely
book on group treatment for abused children, with parallel
treatment for caretakers. Throughout the book the authors
use different play techniques to help the children open up
about their abuse and to build trust among themselves. They
defined the objectives of group treatment as follows:
• Define acceptable behavior of group members and intro-

duce a respect for boundaries.
• Promote group interaction and reinforce cooperative
efforts.
• Introduce and encourage the discussion of common ex-
periences to reinforce a feeling of togetherness and
promote group cohesion for both children and
caretakers.
• Improve self-esteem through validation of individual
feelings and ideas, acknowledging each member's im-
portance in contributing to the group experience.
• Help group members to understand the purpose of the
group.
• Enhance caretakers' capacity to begin to view their
children with increased sensitivity, understanding and
empathy, (p. 27)
Another pilot project, by Corder, Haizlip, and DeBoer

(1990), used structured group therapy to treat sexually
abused children ages 6 to 8, and focused on issues comparable
to those of Mandell and associates. The goals in the pilot
project included integrating the trauma, improving self-es-
teem, improving problem-solving skills, self-protection for
the future, improving ability to seek help, and enhancement

of the child's relationship to the nonabusive parent.
In another preliminary group project with sexually
abused boys, Friedrich, Berliner, Urquiza, and Beilke (1990)
advocate more open-ended therapy and selection of group
members by developmental level (not chronological age) in
order to promote better peer interaction.
Group therapy is not without its controversy. I have often
heard the concern that the group might inadvertently en-
courage the child to overidentify with the victim role and that
groups have the potential of "contaminating" one child with
the emotional concerns of another. Yet another concern,
which I share, is that sometimes groups are run in random
ways, g° on f°r indefinite periods of time, lack clear goals,
and suffer from inconsistent and inexperienced leadership.
However, these concerns are discussed in the book by Man-
dell and associates and do not undermine the potential
benefits of the group experience.
Sand Tray Therapy

No summary of the major models of child therapy would be
complete without making note of the significant contribution
of Dora Kalff (1980), who created sand therapy. Sand therapy,
based on the principles of Jungian therapy, sees the sand tray
as symbolic of the child's psyche. The sand therapist inter-
prets the child's use of symbols and placement of objects in
the tray and observes the child's passage through distinctive
phases of healing. While many child therapists use sand play
in their therapy, this type of play therapy stands alone,
embedded in its own theory and technique.
THE TECHNIQUES OF CHILD THERAPY

The theoretical frameworks highlighted earlier—the psycho-
analytic, existential, behavioral, and Jungian—are the major
frameworks for conducting child therapy; almost every
known technique can be subsumed under one of these head-
ings. It is important to distinguish between the child

therapies and the child therapy techniques. The child
therapies are based on a theoretical framework; the techni-
ques are chosen to implement therapy based on those con-
ceptual frameworks. Some of the child therapies are flexible
enough to incorporate a variety of techniques whereas others
restrict the therapeutic approach.
DIRECTIVE VERSUS NONDIRECTIVE

PLAY THERAPY
Yet another way to categorize the types of therapy employed
with children is to differentiate between directive and non-
directive styles of play therapy. Nondirective or client-
centered play therapy, promoted by the relationship
therapists, is nonintrusive; it parallels the client-centered
approach created by Carl Rogers (1951). Axline (1969) is
credited with the creation of this specific kind of play therapy,
and she distinguished between nondirective and directive
therapy by simply stating, "Play therapy may be directive in
form—that is, the therapist may assume responsibility for
guidance and interpretation—or it may be nondirective; the
therapist may leave responsibility and direction to the child"
(p. 9). The child is allowed and encouraged to choose the toys
to play with and is given the freedom to develop or terminate
any particular theme. Guerney (1980) cites two major fea-
tures of client-centered therapy: First, the client-centered
approach is "viewed as promoting the process of growth and
normalization" and, second, the therapist "must rely on the
child to direct this process at his or her own rate" (p. 58). The
non-directive therapist observes the child's play, often af-
firming verbally what is seen. Guerney states, "The realiza-
tion of selfhood via one's own map is the goal of non-directive
play therapy" (p. 21).
The nondirective therapist cultivates hypotheses that
are tested over time; interpretations are used sparingly and
then only after a great deal of observation. Nondirective
therapists give the child concentrated attention and refrain
from answering questions or giving directives. Axline (1964)

demonstrates the use of nondirective therapy in her classic
work Dibbs in Search of Self. Nondirective techniques are
always helpful in the diagnostic phase of treatment and, as
Guerney (1980) points out, have been shown to be effective
with a wide range of problems.
The basic difference between the nondirective and direc-
tive approaches rests in the clinician's activity in the therapy.
Directive therapists structure and create the play situation,
attempting to elicit, stimulate, and intrude upon the child's
unconscious, hidden processes or overt behavior by challeng-
ing the child's defensive mechanisms and encouraging or
leading the child in directions that are seen as beneficial.
Nondirective therapists are "actually controlled, always
centered on the child, and attuned to his/her communica-
tions, even the subtle ones" (Guerney, 1980, p. 58). Directive
therapies are by nature more short-term, more symptom-
oriented, and less dependent on the therapeutic transference
than are nondirective therapies.
The directive therapies are multitudinous and include,
among other things, behavior therapies, Gestalt therapy,
filial therapy, and family therapy. Certain specific techni-
ques, such as puppet play, story-telling techniques, certain
board games, and various forms of artistic endeavor, lend
themselves to being employed in therapy in different ways:
A nondirective therapist might provide the child with ample
opportunities for art work or story telling with puppets
whereas a directive therapist might ask the child to draw
specific things or tell an exact story.
The Treatment of
Abused Children
TREATMENT CONSIDERATIONS IN
WORKING WITH ABUSED CHILDREN
When assessing the treatment needs of abused children and

formulating treatment plans, it is vital to consider a number
of issues such as, among other things, the phenomenological
impact of the abuse, the family's level of dysfunction, the
environmental stability, the age of the child, and the child's
relationship to the offender.
The actual act of abuse is usually only one of myriad
experiences the child endures. More often than not, the recog-
nition and reporting of the abuse to the authorities sets into
motion a number of legal and protective interventions that are
perplexing and anxiety-provoking to the child. Consequently,
the treatment of abused children is multidimensional and will
likely include an array of services including individual,
parent-child, group, and family therapy—all delivered within
the context of social service and legal systems that operate
within their own regulations and limitations.
37
The therapy of abused children includes the monitoring

of risk factors, coordination with a variety of agencies, ad-
herence to requests for periodic reports, and a focus on
processing of the child and family's trauma, as well as inter-
vention in intricate family dynamics, observation of parent-
child interactions, work with foster families or other tem-
porary caretakers for the child, advocacy efforts, testifying
in court as needed, and other special activities that are
discussed in the final chapter of this book.
The Phenomenological Experience

First and foremost, it is urgent to view each child's ex-
perience as unique. References were made to "mediators of
abuse" earlier in this book, and there might be a temptation
to judge the impact of abuse by certain yardsticks, such as
the duration of the abuse, the severity, how many symptoms
arise, who the perpetrator was, or how the child appears. The
reality is that children react differently, and although the
research can serve as a kind of global map of common reper-
cussions, only close examination will reveal the subtle
landmarks.
I once worked with a family of five children, ages two,
four, seven, ten, and fifteen, whose home was burned down
as a result of a freak gas explosion. The parents made swift
and appropriate responses, buying the children duplicates of
their favorite things, talking to them in a group about the
experience, and bringing themselves and the children for
some family counseling sessions. The parents commanded
authority, coped well with their stress, and conveyed positive
feelings to the children, centering on the fact that they had
all survived and that that was the most miraculous and
important thing. The parents also had the financial means
to rent a comfortable home, and their insurance provided
substantial compensation for erecting a new home. The
children were involved in the plans and were awarded the
right to "design" their own space if interested. The counseling
sessions were almost redundant, since the parents had
engaged the children in effective verbal communication. It
was clear this was a close and communicative family, and

their skills were well applied during the crisis. Some of the
younger children's art work and play had elements of
reenactment, as they drew fires and tumbled buildings. The
children had also had fretful sleep, particularly the older
ones, who seemed to have a greater understanding of how
close they had come to death.
After six or eight conjoint meetings with the family, the
parents and I agreed that I would be available to the children
should any concerns arise in the future. Six months later the
parents brought their 7-year-old son into therapy because he
was unable to sleep, had lost his appetite (and 12 pounds),
and appeared to go into alternating states of panic and what
the parents described as "spacey" behavior—he sucked his
thumb in the corner and had a fixed stare. In addition, he
was afraid of the stove, the fireplace (which had not been
used), and even the hot water in the tub. He flinched at any
slight noise, and he had stopped playing outside. His
brothers and sisters were not able to elicit his participation
in either conversation or play. This is an example of how the
same event, with subsequent similar responses, can be ex-
perienced differently by one child than by others when there
has been no previous indication of marked personality dif-
ferences among the children. The only explanation is the
phenomenological nature of an individual's perception, in-
tegration, and processing of single or cumulative events, and
this uniqueness commands great respect.
No matter what initial intervention is made, there is an
inherent advantage in setting the therapeutic context for
future work. Many of my child clients have had ''discon-
tinuous therapy," which allows and encourages families to
return to therapy for "checkups" on an as-needed basis.
However, it is my belief that the sooner a trauma victim
enters treatment, the better.
Terr (1990) is quick to point out how quickly children and
their families can recover from a trauma and cautions
against postponing treatment:
Putting off treatment for trauma is about the worst thing

one can do. Trauma does not-ordinarily get "better" by itself.
It burrows down further and further under the child's
defenses and coping strategies. Suppression, displacement,
overgeneralization, identification with the aggressor, split-
ting, passive-into-active, undoing, and self-anesthesia take
over. The trauma may actually come to "look" better after
all these coping and defense mechanisms go into operation.
But the trauma will continue to affect the child's character,
dreams, feelings about sex, trust, and attitudes about the
future, (p. 293)
All presuppositions about abused children must be

halted in the face of a new child victim. Assuming a child feels
angry, sad, betrayed, depressed, or anything else is
counterproductive. We must enter the assessment phase free
from biases about the general effects of victimization or
traumatization and enter the realm of learning from each
child's singular experience. Only the children can tell or show
us what meaning the experience has had to them. Only they
can allow us to understand the incredible survival instincts
of victim^survivors. They will show or tell us what they need
although verbal directives are few and far between.
The clinician must set aside higher own agenda and
treatment plans must be individually designed and revised
on a continuous basis.
The Family's Level of Dysfunction

The therapist may or may not have access to the abusive
family when work is done with abused children. Abusive
families, particularly neglectful ones, are frequently multi-
problem families with high levels of dysfunction.
Even if the clinician has access to the family, their level
of functioning might be so low as to minimize the impact of
therapy. Therefore, it becomes critical for the clinician to
lower expectations and devise realistic goals. Also, the
clinician must take great care to ascertain how the child's
progress is viewed at home. For example, the clinician may
encourage the child to express his/her feelings and send the
child into an environment where verbalizing feelings will
elicit punishment. If the family is unresponsive and con-
tinues to organize around multiple crises, the most helpful
interventions will be those designed to help the child cope

with the realities of the environment.
Monitoring Risk Factors

Providing therapy to abused children, particularly those who
have not been removed from their families, involves a special
focus on risk factors to both the parents and the child clients.
As Green (1988) notes, "Any plan for the treatment of child
abuse must be designed to create a safe environment for the
child and to modify the potentiating factors underlying the
maltreatment...An effective treatment program must deal
specifically with the parental abuse-proneness, the charac-
teristics of the child that make him vulnerable, and the
environmental stress that triggers the abusive interaction"
(p. 859). It is therefore obligatory to have a clear under-
standing of the factors that led to the abuse and to have done
a comprehensive review of these factors with the parents. For
example, if one of the precipitators of the abuse was a
parent's alcohol abuse, efforts must be made to monitor the
parent's adherence to alcohol treatment programs. If one of
the conditions of the court is that the child attend a daily
child care program, it is important to verify that this is, in
fact, transpiring. If the parental treatment is being con-
ducted by another clinician, the child's clinician is advised to
obtain contact with the relevant professionals and coordinate
the risk management aspect of the therapeutic intervention.
Environmental Stability
As mentioned earlier, abusive families characteristically
have a wide range of problems. They may have housing
problems or frequent relocations, live in shelters, or even be
homeless. The primary focus of the treatment is on providing
the family and the child with as much information on resour-
ces and coping skills as possible. Clinicians who choose to
work with abusive families must familiarize themselves with
the multitude of prevention and treatment programs that
have surfaced over the past 15 years. Up-to-date information
is provided by local Child Abuse Councils, easily found in the
telephone directory. In addition, a National Child Abuse

Hotline maintains current resource information (1-800-4-A-
CHILD).
The Age of the Child

It is difficult to conduct play therapy with children under the
age of two. Two- to three-year-olds differ immensely in cog-
nitive, motor, and verbal abilities. Children in this age group
should be assessed to determine how amenable they are to
therapy. Little is written about the treatment of young
children, although a number of professionals are beginning
to gain and share their expertise (MacFarlane, Waterman, et
al., 1986). Even children this young can exhibit post-
traumatic play and reveal unconscious fears and concerns
through their play.
The Child's Relationship to the Offender

As noted earlier, the closer the relationship between the child
and the offender, the more potentially traumatic the event is
to the child. The clinician is once again advised to tread
lightly, suspending personal judgments about the child's
perpetrator. The child must sense that any and all feelings
he/she may have about the perpetrator are acceptable to the
clinician.
If, however, the child appears to be fixated on just one
feeling, the clinician can comment on that and gently direct
the child to other possible emotions. I once saw a young girl
who had been virtually abandoned by her mother and had
only sporadic contact with her. She was adamant that she
hated her mother, thought she was useless, and never
wanted to have anything to do with her. One day I softly said,
"You are really good at telling me about how angry you are
at your mother. And I bet you would be just as good at telling
me some of the other feelings you have or have had towards
her." She quickly retorted, "I don't feel anything else about
her." I added, "Maybe not now, but I bet when you were little
there might have been some other feelings." "Well yeah,
'cause I didn't know any better." Then I proceeded to ask what

those feelings had been, and she cried a little as she described
memories of wanting to go everywhere with her mother, and
of feeling worried about her when she went out drinking. Just
because a child emphasizes one primary feeling doesn't mean
that other feelings might not be just beneath the surface.
Another child, also overtly hostile toward his mother,
was unresponsive to queries about other feelings. I brought
out my cards with "feeling pictures" (Communication
Skillbuilders, 1988) and fanned them out in my hands. "Pick
one," I prompted. When he did I asked him to tell me a time
he had felt the (chosen) feeling about his mom. Because it
was a game and there were explicit rules, the child simply
acquiesced, and a lot of rich material sprang forward.
Treatment of the Child in His/Her Environment

Another difference in treating this population is the frequent
instability of the environment. Often children are placed in
foster homes (or a series of foster homes), group homes, or
residential facilities. I have had more than one treatment
interrupted by an abrupt transfer of my child client to
another county or state.
Foster homes differ in quality. I have had contact with
many highly qualified professionals, who have become part
of the treatment team. Children who are removed from their
home suffer the additional impact of separation from parents
and familiar environments and usually need help dealing
with separation anxiety, concern for their parents, and loyal-
ty conflicts (Itzkowitz, 1989).
The therapy must include an assessment of the child's
environment and an attempt to coordinate informational
exchange with the alternative family on a regular basis. My
experience has been that most foster parents welcome con-
tact with the therapist, appreciate being regarded as a mem-
ber of a professional team, offer many valuable insights, and
respond well to suggestions regarding the child. Too often,
foster families or other caretakers are not contacted, and
helpful information is unavailable to the clinician.
Discontinuous Therapy
As mentioned previously, working with abused children may
include intermittent participation from the child. Parents
may withdraw the child from treatment once the court man-
date is no longer present, or financial restrictions may in-
fluence the parent's decision to terminate the therapy. In
addition, the child may use the therapy well for a period of
time and later shift to periods when she/he does not seem to
want to come or does not engage in therapeutic play. These
are but some of the circumstances that can precipitate the
use of discontinuous therapy. Nevertheless, children can
benefit greatly from these short-term, task-focused, involve-
ments with therapy.
The Clinician's Gender

Children who are abused may develop idiosyncratic respon-
ses to persons of the same sex as their abusers, including
clinicians. In some instances it may be advantageous to
transfer the child so this issue can be resolved. For example,
I worked with a boy victim who was raped by his father for
over a year. This child was in therapy with me for over 2
years, became well adjusted to his long-term foster place-
ment, processed the trauma issues, and developed a sense of
competence, safety, and well-being. The combination of a safe
environment and therapy worked wonders; yet the boy al-
ways shied away from men and, I observed, exhibited startle
responses when he saw a male therapist in my office. His play
indicated a reticence toward men and a preference for contact
with women. Unfortunately, the foster parent was an unmar-
ried woman and the boy's teachers had been women, except
for the physical education teacher. The boy wanted to avoid
physical education because of the teacher, and the school
gave him a special dispensation based on his history. Thus,
the child had effectively managed to expel all men from his
life.
I decided to transfer the boy to a male therapist. At first
he resisted vehemently, but the joint sessions with the male
therapist intrigued him, and slowly but surely, I could see
him explore the boundaries of the new situation, asking

questions of the male therapist, handing him toys, and
making definitive statements about his preferences. Finally,
the day came for his first "alone" visit with the male
therapist; I waited outside the office at a designated place.
He came out of the office twice to make sure I was there but
tolerated the visit fairly well. The therapy continued for
another year, and even though I felt the child had already
made great strides, his progress with the male therapist was
very rewarding. The child became physically active, ap-
peared to grow due to his more erect stature, and joined a
soccer team. He no longer avoided men and had established
a good relationship with the soccer coach.
Symptoms of Distress and Treatment Modalities

Relatively little has been written about the treatment of
young abused children although the past 2 years has seen
a welcome surge in books about therapy with sexually
abused and traumatized children (Friedrich, 1990; James,
1989; Johnson, 1989; Terr, 1990). Treatment of sexually
abused children has probably been the most widely re-
searched and documented aspect of treatment of abused
children, and many of these findings are applicable to vic-
tims of other types of abuse. Long (1986), for example,
discusses relevant issues in the treatment of sexually
abused children: importance of teaming with the child's
mother; inappropriate attachment behavior; infant regres-
sive behavior; need for body contact and body awareness;
and need for education on feelings. All of these areas are
addressed in treatment of abused and neglected children in
general. Porter, Blick, and Sgroi (1982), referring to the
psychological issues that must be dealt with in work with
sexually abused children, list "damaged goods" syndrome,
guilt, fear, depression, low self-esteem, poor social skills,
repressed anger, and hostility. Added to these are traits
most characteristic of incest victims: impaired ability to
trust, blurred role boundary and role confusion, and pseu-
domaturity coupled with failure to accomplish developmen-
tal tasks, self-mastery, and control. Again, all victims of
child abuse and neglect will benefit from the clinician's

focus on these matters. Burgess, Holstrom, and Mc-
Causland (1978) emphasize the importance of decreasing
the child's anxiety and attempting to engender trust as a
first step in the treatment process. MacVicar (1979) stres-
ses that sexually abused children often confuse sex with
affection and need some help understanding sexuality.
Waterman (1986), reviewing the literature on the treat-
ment of sexually abused children, notes that many treat-
ment modalities have been used, including family systems;
a combination of behavior therapy for perpetrator, marital
therapy, and family therapy; individual short- or long-term
child therapy; group therapy; and art or play therapy. Terr
(1990) notes that traumatized children are characterized by
emotions of terror, rage, denial and numbing, unresolved
grief, shame, and guilt. She also states that such children
develop "traumatophobia," or fear of fear itself. This fear
that springs from psychic trauma, she says, "makes arch
conservatives out of formerly flexible children" (p. 37).
Beezeley, Martin, and Alexander (1976), in a study of 12
physically abused children who stayed in treatment over
one year, found that children's improvement was seen in
increased ability to trust, increased ability to delay
gratification, increased self-esteem, increased ability to
verbalize feelings, and increased capacity for pleasure.
Beezley and associates found that progress was greatest if
the parents were willing to let the child make changes and
were willing to make changes themselves and if the
therapist could influence the environment, that is, the
school setting, the playroom, and the child's relationships
with others (p. 210). Mann and McDermott (1983) point out
that the common areas of psychological disturbance requir-
ing clinical attention are fear of physical assault or fear of
abandonment, leading to depression and anxiety; failure to
meet parents' distorted expectations, leading to defective
object relationships, struggles over dependency, and inter-
nalization of a "bad child" self-image with poor self-esteem;
difficulty achieving separation and autonomy; and
prolonged and heightened separation anxiety and am-
bivalence over attachment to caretakers as a result of mul-

tiple rejections and out-of-home placements, including
hospitalizations (p. 285).
I can't imagine a situation in which an abused child
would not require or benefit from individual therapy. The
experience of victimization or traumatization is painful,
alarming, and confusing enough to warrant speedy inter-
vention. The individual therapy, which includes an ongoing
assessment, may be short-term and may precipitate the
need for family or group work. However, in my view, every
abused child deserves a one-on-one experience with a
trained professional.
At the same time, if the child is to be reunited with a
formerly abusive family—whether it be physical or sexual
abuse, neglect, or emotional maltreatment—it becomes req-
uisite to see the family with the child present. In addition, if
the child has been abused outside the home, the entire family
experiences the impact of the traumatic event, and all mem-
bers require assistance.
Probably nowhere else is the direct observation of the
parent—child relationship as indispensable as it is in situa-
tions of child abuse. Many inexperienced clinicians have been
baffled to learn of a new abusive incident after the parents
had religiously reported that they were using better discipli-
nary techniques and had not engaged in overt conflicts. A
parent can state that she/he has been making calm and
reasonable requests of a child, but direct observation may
lead to a different conclusion. The clinician may find that
while some improvement has been made, the tone and pitch
of the parent's voice, combined with nonverbal communica-
tion, continue to be harsh enough to terrify the child and
discourage voluntary compliance.
Family therapists encourage the presence of all family
members in therapy sessions, but they have been consider-
ably lax in demonstrating methods for conducting family
sessions with very young children (Scharff & Scharff, 1987).
The most typical family therapy scenario consists of the
family therapist meeting with the adults in the family while
the young children are relegated to the corner with toys or
drawing materials. Scharff and Scharff (1987) discuss family

therapy with very young children, offering interesting and
useful suggestions (p. 285).
Social Service Agencies and the Courts

Working with abusive families often necessitates contact
with court and social service agency personnel, who are
responsible for overseeing the protection of the child. This
type of contact can be seen as an act of treason by parents
who are nonvoluntary therapy clients. In order to maximize
the chances of forming a therapeutic alliance (often an
oxymoron) with these clients, I usually limit my contact with
social service agencies to written communications and show
the letters to my clients prior to mailing. In this way, trian-
gulation can be avoided and the clients may feel less helpless.
It's probably too much to expect that this simple action will
elicit total trust, but most clients respond well to this method
of compliance with the authorities.
In working with abusive families and children, it is
important to ascertain what the authorities expect from
them. In other words, what specific behaviors or activities
does the court or social service agency expect from the family
to avoid the child's removal or to bring about reunification.
Behavioral objectives, rather than broad goals, must be out-
lined. For example, "The parents should get along better" is
vague and can be better explained with an explicit statement
like "The parents must stop hitting and begin to have com-
munication with each other, resulting in at least two
decisions a week about the children and two decisions a week
about how to spend their money." This specificity will greatly
aid the clinician in assessing progress and in implementing
treatment in a purposeful way.
Confidentiality and the Reporting Law

The mental health professional encounters a serious dilem-
ma when treating allegedly abused or identified abused
children. The dilemma originates because clinicians create
an environment where, hopefully, a child feels safe and com-
fortable enough to share his/her inner thoughts, worries, or

fears. When this atmosphere is accomplished by competent
professionals and the child verbally or nonverbally shares or
signals that he/she is being abused, the therapist is legally
obligated to convey that information to the authorities. The
child may feel betrayed by this apparent breach of trust and
may withdraw into the uncomfortable or familiar position of
having to decide what information can and cannot be
divulged. And yet the reality is that the child abuse law was
developed as a mechanism to obtain necessary protection for
vulnerable children.
I find it necessary and desirable to tell the children from
the outset that there are limits to confidentiality, that
clinicians have certain legal obligations that supersede the
obligations of confidentiality. This can be done in a matter-
of-fact way in simple language, for example: "Everything we
talk about in here is private. I won't repeat things that you
tell me to anyone unless I get worried about a few things. I
will have to tell someone if I think you are hurting yourself,
hurting someone else, or if someone is hurting you, including
your parents or brothers and sisters. 'Hurting' means dif-
ferent things like hitting or touching on private parts of the
body." Then the child should be encouraged to ask questions
or get further clarification. The clinician's answers should be
confined to what is known. One of the ways that children will
definitely feel betrayed is if the clinician predicts or promises
a particular outcome, for example, the child will or will not
stay at home or protective services or police will or will not
come to the school.
Regardless of how many steps are taken to minimize the
impact of a child abuse report, the child almost always
regrets saying anything, particularly if the abuser is some-
one the child loves or depends on. The clinician must be
sensitive to the child's predicament and avoid using false
reassurances such as, "Everything will be all right now."
The Legal System

Probably one of the most disheartening aspects of therapy
with abused children is the unpredictability and length of
certain legal procedures. If the child must testify, this process

can feel endless to the professionals—to say nothing of the
children themselves. There are frequent continuances, and
even when the child is required to testify, busy calendars or
other external factors can require the child to return again
and again before he/she is actually put on the stand.
Clinicians are sometimes criticized by defense attorneys
for "preparing" a child to testify. A child's testimony can be
discredited if she/he states that the testimony has been
discussed with a therapist beforehand. Because of this, I
suggest that the content of the child's testimony not be
discussed during therapy sessions. The clinician can be help-
ful, however, in preparing the child to go to court. Caruso
(1986) developed a set of pictures depicting a courtroom, the
judge, the waiting room, and where the child sits. These
pictures can familiarize the child with the courtroom am-
bience. In particular, the child should have some concrete
idea of where she/he will sit to testify and of the distance from
the offender; it is helpful if children who will testify know
that they will be face-to-face with the offender, will likely be
asked to identify the person, and can look at their own
attorney or anywhere else if looking at the offender feels
awkward or disturbing.
Court-Mandated Evaluations. A child's treatment is cus-
tomarily suspended when the court requests an "inde-
pendent" evaluation and is resumed once the evaluation is
completed. The child's therapist and the evaluator prepare
the child for the evaluation process, clearly explaining the
projected length. Suspending the child's treatment sessions
during the evaluation process may maximize the evaluator's
potential to obtain important information from the child.
There are circumstances in which suspending treatment
might be contraindicated.
Report Writing. Working with abused children and their
families can often be accompanied by nagging subpoenas for
records. It has become my practice to write brief, matter-of-
fact notes limited to issues of concern regarding the protec-
tion of the child. It is also my practice to always make every
effort to protect my client's confidentiality, making phone

calls to my attorney in attempts to "block" subpoenas while
remaining fully cooperative.
Testifying. Yet another customary adjunct in the therapy
of abused children is the possibility of the clinician's having
to give depositions or testify in court. These are always
distracting and stressful, no matter how well accustomed the
clinician becomes to them. Recent information, indispen-
sable to clinicians who serve as expert witnesses or provide
other testimony in court, has become available (Myers et al.,
1989). I advise the clinician to secure an attorney well versed
in issues of family custody.
Advocacy Efforts. Finally, working with abused children

may precipitate a number of concerns regarding the social
service and legal system and how it operates. Some clinicians
find it worthwhile to channel some of their concerns into
letters to the legislature, participation in statewide organiza-
tions dedicated to these issues, or membership in local child
abuse councils.
Working with abused children and their families is chal-
lenging, stressful, and quite an opportunity. There are a
number of obstacles, and planning ahead will prevent many
of the typical problems associated with this work such as not
knowing what's expected, getting involved in interagency
conflicts, learning suddenly that new workers have been
assigned to the case, and feeling helpless and futile. The
clinician will be most successful working as part of a team,
talking with other professionals on a regular basis, asking
for guidelines in writing, and meeting periodically to discuss
the status of the case.
APPLICATION OF ESTABLISHED
CHILD THERAPIES TO WORK
WITH ABUSED CHILDREN
At no other time in history has the child therapy field had

such a rich array of therapeutic tools and props for therapists
to use. This is likely in response to the increase in childhood

problems (such as drug abuse, delinquency, child abuse,
suicide, youth prostitution) and a greater awareness within
the mental health profession and the general public of the
need for and efficacy of therapy for childhood problems.
Clinicians currently working with abused children are in the
enviable position of being able to draw from a growing litera-
ture reflecting many professionals' ground breaking and
dedicated work. This cumulative knowledge helps us design
more sensitive and effective treatment programs.
Some of the established child therapies are applicable to
the therapy of abused children. These children have chal-
lenged mental health professionals with an array of unique
behaviors that command a specialized response. The inter-
ventions are not offered as rigid, inflexible, or final in any
way. The field of play therapy in general, and play therapy
with abused children specifically, is in evolution; as more and
more clinicians become trained and experienced and as re-
search findings shape our understanding and thinking, more
directives will be available about effective therapeutic
strategies. The truth is that currently there are very few
"rules" about this type of treatment, and we must equip
ourselves with as much knowledge and experience as pos-
sible.
THE TREATMENT PLAN
As mentioned earlier, abused children are referred to treat-

ment with an assortment of clinical symptoms that manifest
underlying issues. The fundamental goal of therapy is to
provide corrective and reparative experiences for the child. A
corrective approach provides the child with the experience of
safe and appropriate interactions that engender a sense of
safety, trust, and well-being. In other words, there is an
attempt to demonstrate to the child through therapeutic
intervention the potentially rewarding nature of human in-
teraction. A reparative approach is designed to allow the
child to process the traumatic event in such a way that it can
be consciously understood and tolerated. The healing power
of play cannot be underestimated; likewise, the survival

instinct of humans cannot be underrated. If given a nurtur-
ing, safe environment, the child will inevitably gravitate
toward the reparative experience. Even in the unfortunate
situation where children are kept in actively abusive homes,
or returned prematurely after temporary foster care, the
reparative clinical experience tends to be stored and remem-
bered, later serving as a motivating factor. Of course, the
impact of the reparative experience will depend on many
external factors, such as the degree of continuity in the
therapeutic setting, how well parents or caretakers
cooperate, and how rigorous the efforts of social service
agencies and courts are in planning for the child's future.
When a treatment plan is being designed for an abused
child, the presenting symptoms must not be considered in
isolation. Beginning efforts are appropriately directed
toward the reduction of the child's symptoms, but
therapeutic efforts must persist long after the relief of
symptomatology. Too many children are terminated hastily
by relieved parents or shortsighted clinicians.
As stated previously, each child is unique and treatment
plans will vary according to the child's needs, level of
damage, ongoing response to therapy, and accessibility. In
the following pages I discuss various treatment areas and
include specific therapeutic suggestions for each area.
Relationship Therapy
Because abuse is interactional and usually occurs within the
framework of a family, the child can profit from an oppor-
tunity to experience a safe, appropriate, and rewarding inter-
action with a trusted other.
Children entering treatment are curious, reticent, and
often anxious or afraid. Physically or sexually abused
children, or children who have witnessed domestic violence,
have a background that can predispose them to feeling vul-
nerable. They have learned that the world is unsafe and have
met the challenge by cultivating such defensive mechanisms
as hypervigilance or extreme compliance. The neglected
child, conversely, may show little resistance to coming to
therapy and may appear uninterested in and unaffected by

the new surroundings. The neglected child is accustomed to
inattention and has probably lacked even the most basic
stimulation; he/she may sit still, expecting little. It is impor-
tant in these cases for the clinician to underwhelm the child,
then gradually introduce more stimulation. For example,
sitting next to the child, facing away, coloring, or playing with
some objects may be a good beginning; then, commenting on
what is being done, directing the child's attention to toys,
and, eventually, facing the child, asking questions, and en-
couraging the child's participation in a simple task like
coloring will be effective.
The clinician always proceeds with caution, gingerly
laying a foundation that advances a sense of security. (I have
often imagined this step as the creating of a kind of
sanctuary: quiet, accepting, stable, consistent, and free of
external conflict.) One of the ways to create a sense of safety
is to have a stable structure so the child can rely on certain
aspects being constant.
Structure means many things. The length of the session,
the location, the toys in the playroom, the "rules," the
therapist's presence, and the procedure followed during the
therapy hour are all features that can be used to build a
strong structure. Even the way the therapist introduces
himsel^herself to the child is carefully designed. I have
always found it best to be short and to the point in all
communications with children:
My name is Eliana. I am someone who talks and plays

with children. Sometimes I talk to kids about their
thoughts and feelings. Other times, I play whatever the
child wants.
Regarding rules I say the following:
There are lots of things you can do in here. You can play
with anything you see. You can talk if you want. You can
play or draw. You choose what to do. Sometimes I might
ask you some questions. You can answer or not.
There are a few rules. No hitting or breaking toys. No

hurting yourself or me. All the toys stay here.
Well meet together for 50 minutes. Ill set this timer
and when the bell goes off, it's time to stop until next
time.
Everything we talk about is private. I won't tell
anybody what you say unless you are hurting yourself,
hurting someone else, or someone is hurting you, includ-
ing your parents or brothers or sisters. If that happens,
111 need to tell someone else so we can make sure you're
OK, but 111 talk to you about it first.
Obviously, all these rules are not announced in the first

session. In that session I usually introduce myself and give
the general directives for what will happen. After that, I
scatter the rules throughout the succeeding sessions.
The clinician focuses on the child's needs and provides
the child with opportunities for self-exploration, adaptation,
and new (functional) behaviors. The nondirective, client-
centered therapies are most beneficial at the beginning of
treatment. The child is respected and accepted. The child
chooses what to do and what to talk about. The therapist
observes (actively) and documents the child's behavior, af-
fect, play themes, interactions, and so on. The therapist
makes a great effort to earn the child's trust, responds
honestly, does what is promised, and is present week after
week.
The therapist must resist the temptation to overgratify
or overstimulate the child; compliments and overattention
must be curtailed. Factual statements are best. "You have
new shoes on today" might be a more productive statement
than 'Tour new shoes are beautiful." It's always better to
inquire how children view something, as opposed to telling
them how they feel. "How do you like your new shoes?" is
more conducive to communication than "I bet you love your
new shoes." These children may find it difficult to disagree
with an adult's opinion.
Likewise, if questions are necessary (and sometimes
they are), they must be phrased to avoid a yes/no response.
It can be difficult to make the transition to open-ended

questions, but the results are most helpful to children. In
addition, I have learned through trial and error the relative
merits of using comments rather than questions—comments
that invoke the child's interest. My favorite and most suc-
cessful comment is "Humm, I wonder what that might be
like...." or "I wonder what other feelings might be there...."
Given the implied freedom to wonder along, children may
freely offer their own thoughts.
Assuming the therapeutic structure is well received and
the child begins to attend sessions more voluntarily—per-
haps even looking forward to them—the child may discern
positive regard from the clinician. Now the challenge com-
mences, since abused children have frequently learned that
intimacy implies threat.
One of the insidious lessons of physical, sexual, or emo-
tional abuse is that "people who love you will hurt you."
Neglected children learn that "people who love you abandon
you." Either way, intimacy implies threat, and the child who
feels reassured or consoled will inevitably feel endangered.
Feeling in peril, the abused child may attempt to take flight
emotionally, physically, or through some acting-out behavior.
Understanding the child's need to flee or need to evoke an
abusive response from the clinician provides direction for the
clinician's serene and persistent responses. Green (1983) has
postulated that the tendency of the child to provoke abuse
may serve a need to "obtain otherwise unavailable physical
contact and attention" (p. 92).
One memorable 6-year-old brought me a paddle four
months into treatment. "What's this?" I asked. "It's a paddle,"
she said, surprised by the question. "What's it for?" I con-
tinued. "For you to hit me," she announced. I looked puzzled,
stating, "Why would I want to hit you?" Her response was
simple. "You like me, don't you?" It was as simple and as sad
as that. She assumed that my regard for her would be
followed by an attack. Rather than tolerate the anticipatory
anxiety of waiting for the attack, she decided to take the
initiative and provide me with my weapon. Needless to say,
the next four months in therapy were quite a trial of wills.
She kept provoking and I continued to simply state, "I am

not going to hit you, yell at you, or get mad. I'm going to show
you that I care about you in different ways." I also said, "You
would really feel much better if I hit you or screamed at you
right now. But that is something that will not happen. I know
that you expect grown-ups will hurt you, and I also know that
you will learn that I will not hit or hurt you." The little girl
needed to learn to tolerate the anxiety of expecting an attack.
When I noticed her tension, I would say, "You're feeling
worried that I might hurt you right now...it's OK to worry a
little, until you know deep down that you'll be safe." Other
times I would say, "I know you're worried, and it's OK to tell
me when you feel that way. Sometimes, after you worry for a
little while and nothing happens to you, the worry gets
smaller and smaller." At the end of therapy she made me a
little stitched purse and gave me a card saying, "Eliana.
Thanks for liking me and not hitting me. Your friend always."
For neglected or needy children, the wish for attachment
may loom strongly. These children make indiscriminate con-
nections and seem desperate to be special to the therapist.
They may ask point-blank, "Do you like me the best of all the
children you see?" or "Do you miss me when I'm not here?"
For them, intimacy is not encumbered with threatening
feelings; it is an elusive sensation they long for. I respond to
these questions by asking what they imagine I might feel and
then commenting on how important being liked or missed is
to them. If children persist I will say, "I do like you," "You are
special," or "I think of you sometimes during the week" and
then inquire what it's like for them to hear these things.
Setting limits for these children, by gently asserting the
nature of the therapeutic relationship, is important. Not
setting limits can be counterproductive for the child and
his/her family. If the clinician becomes overly responsive to
the child's needs or begins to behave in unusual ways (such
as buying clothes and other presents for the child), the
abusive or neglectful parent will be affected inadvertently.
One therapist consulted with me when her 7-year-old client
proclaimed, "I want you to be my mommy. I don't like my
mommy as well as you." It is possible that a child could
develop this feeling without any encouragement, and yet I

have frequently met well-meaning therapists who regret that
they failed to keep clear boundaries in the therapeutic
relationship with the child (and who confide that keeping
clear boundaries is more difficult with children).
The psychodynamic concept of "transference" has ap-
plicability in work with abused children. Scharff and Scharff
(1987) reviewing Freud's concept of transference, explain
that Freud defined transference as "the repetition of a psy-
chological experience from the past applied to the person of
the physician: The physician is simply the present site for
the distribution of the libido, or sexual energy, of the patient"
(p. 203). Transference, therefore, refers to the relocation of
thoughts and feelings about a primary person in the child's
life to the clinician. The abused child is liable to experience
emotions such as distrust, fear, rage, and longing toward the
clinician. These feelings originate in the parental relation-
ship and get transferred to a person who may feel safer to the
child or who may require less caretaking or loyalty. As a
result the therapist must refrain from behaving in any set
way. Some therapists who work with abused children allow
countertransference issues to dictate their behavior.
As alluded to earlier, abused children may become
anxious and threatened by the unfamiliar (nonabusive) be-
havior of the clinician. These children feel helpless or be-
wildered by nonabusive behaviors, and in an effort to feel
more in control and less anxious, they may become provoca-
tive.
During my first internship with abused children I, in my
inexperience, brought with me, out of countertransference
needs, an enormous desire to be nurturing. Many of the
children literally attacked me, kicking my shins, punching
my arms, and biting me. Green (1983) has suggested that the
compulsion to repeat trauma and the identification with the
aggressor areplace[s] fear and helplessness with feelings of
omnipotence" (p. 9). This attacking behavior from children
can evoke disturbing responses in the clinician. It was when
I first confronted this behavior that I first acknowledged, as
I have often shared in lectures, having hostile feelings
toward children. I later came to recognize these angry feel-
ings not as a sign that I needed to find a new career but as a

sign that the children were provoking responses in me that
were familiar to them in an effort to take care of their needs.
Probably the greatest lesson I have learned from abused
children and adults is that everything they do after they have
been abused is designed to keep themselves feeling safe. This
concept is beneficial in evaluating even the most difficult or
irritating behavior. While early in the treatment I simply
document the child's responses, and set limits when needed,
once the therapeutic relationship is established, I make my
observations explicit by describing to the child the connection
between higher behavior and underlying issues.
Nonintrusive Therapy
Because physical and sexual abuse are intrusive acts, the
clinician's interventions should be nonintrusive, allowing the
child ample physical and emotional space.
Physical and sexual abuse are intrusive acts that violate
the child's boundaries. The body is hit or penetrated and the
child feels "too much" of the parent. In these families abuse
can be accompanied by emotional encroachment or detach-
ment, either of which makes the abuse more complex. Abused
children frequently have the experience of having extreme
and unreasonable directives about what to think, what to
feel, and what to do. The parents are either enmeshed with
or disengaged from the child and may either restrict the child
from any privacy or be totally apathetic. An abusive parent
may sporadically want to take care of all the child's hygiene
needs whereas a neglectful parent may fail to oversee any of
the child's hygiene practices. Moreover, the behaviors of
abusive and neglectful parents can fluctuate, particularly
when drug or alcohol abuse is involved.
Because of these boundary problems the clinician's early
interventions should be nonintrusive, allowing the child to
set the boundaries. The child should be allowed to move
around freely and choose desired activities. While the child
plays, the therapist is advised to sit nearby, without hovering
over the child's every movement. It is best to avoid a question
and answer format and, instead, allow the child to communi-
cate spontaneously as desired. The clinician may obtain

valuable information immediately. For example, some
children may throw things, break things, wander in and out
of the room, reset the timer, and generally test all of the
regulations defiantly. Other children do the opposite: They
sit quietly in a corner, avoiding interactions of any kind. They
seem to recoil from the therapist, creating their needed
seclusion; they are unresponsive and subdued. Sometimes
these initial behaviors taper off after a while; at other times
they linger beyond the expected period. All the child's be-
haviors are informative and purposeful. Both what the child
does and what he/she fails to do furnish details of the child's
inner world. If the child persists in a nonverbal mode or
appears to feel pressured to perform verbally, the clinician
may speak aloud, without addressing the child specifically.
This technique is called "talking to the wall," and may allow
a resistant child to listen in, and possibly respond. As the
therapy proceeds it may be necessary to become more direc-
tive, particularly if the child continues to be avoidant or too
guarded—especially about the abuse.
Some clinicians question what to do if the child avoids
the topic of abuse in therapy. Often when I inquire into the
details of the case, I find that the clinicians are relying on
verbal validation of some kind. One clinician, who described
the child's elaborate posttraumatic play, was frustrated that
the child never made verbal reference to his abuse.
One of the errors in child therapy is observing the child
passively rather than in an active mode. Active observation
requires the therapist to participate in the child's play, not
necessarily in a physical way but certainly in an emotional
way. The therapist remains interested and involved, mental-
ly logging the sequence of play, the themes, the conflicts and
resolution, the child's affect, and the verbal commentary as
it evolves.
The clinician must also refrain from inadvertently en-
couraging or permitting too much "random play," or play that
has symbolic obstruction. A recent (and I hope short-lived)
trend among therapists is to equip their offices with com-
puter games: Children become absorbed in these games, but
they are devoid of therapeutic usefulness. Therapists seem
to use these games the same way parents do: to entertain

and/or relax the child. Less obvious, but equally worthless,
is outfitting the therapy room with popular toys, such as
converters and electric cars. These toys will summon specific
types of play in children and do not lend themselves to
symbolic reenactment of internal concerns.
If the child is making good use of therapy, his/her play
will be sporadically significant to the clinician; it will almost
always be enriching for the child.
Ongoing Assessment
Probably in no other kind of therapy is an ongoing assessment
so necessary. Children may unfold during therapy, sharing
their emotions and feelings as they begin to trust. They are
also in a state of continuous developmental change with
accompanying personality transfigurations.
Unlike that of an adult client, a child's personality is
maturing during the course of treatment. A child is often "in
the midst of rapid and continuous developmental and en-
vironmental changes" (Diamond, 1988, p. 43). As Chethik
(1989) elucidates, "The child's personality is in a state of
evolution and flux/ with an immature ego, fragile defenses,
easily stimulated anxiety, and often feelings of magic and
omnipotence (p. 5). The child's ego is expanding; his/her
consciousness and self-consciousness are developing; he/she
is tentatively establishing identities; and he/she develops a
repertoire of defenses and coping skills. Depending on the
length of treatment, children's transformation can be im-
mense as they tackle the pertinent developmental tasks.
Children are influenced greatly by peers, and their behavior
may change drastically under the influence of friends or
teachers. As a result therapy strategies must sometimes
change to address these differences: A child who is suddenly
defiant and challenging may require firm limits; a child who
begins to question his/her competence may require a focus
on simple tasks that result in success; a child who suddenly
becomes extroverted and inquisitive may benefit from a
therapist who responds in an informative and directive
manner.
However, any and all changes in the clinician's strategies

must be well thought out and purposeful. I have frequently
told students of child therapy that a clinician should be able
to explain why she/he did what was done or said what was
said—and why it was done or said at a particular moment.
This can be more difficult with children who are less in-
hibited about their thoughts, actions, and behaviors and can
act more impulsively. The clinician has less response time,
which requires the ability to say, "I don't know," "Let me think
about that a minute," or "I think I have two thoughts about
that; let me take a second."
Effective assessments also require clear and measurable
treatment plans based on active observations. Making a treat-
ment plan with clear, concrete behavioral objectives allows the
clinician a way to gauge progress. As I intimated earlier, one
of the most common errors in working with children is an
unfortunate tendency to ignore the child's play. Some
clinicians seem lulled into passive participation in the therapy
hour with children, perhaps because play can be self-absorbing
for the child; many children require sparse interactions during
their play. Greenspan (1981) maintains that active observa-
tion occurs on a variety of levels, involving the physical in-
tegrity of the child; the child's emotional tone; how the child
relates to the clinician; the child's specific affects and
anxieties; the way the child uses the environment; thematic
development of the child's play (the way themes are developed
in terms of depth, richness, organization, and sequence); and
the therapist's subjective feelings about the child (p. 15). As
Cooper and Wanerman (1977) suggest, "allow yourself a grow-
ing fascination with and respect for the minutiae of human
behavior" (p. 107). The clinician who documents these levels
of information is by necessity involved in the therapy as an
observer-participant. Unless the therapist assumes this role,
he/she is disengaged and is not conducting therapy to its
fullest potential. If the therapist finds that the child is no
longer using the play in a therapeutic way, or is engaged in
stagnated or random and disorganized play, the therapist
must intervene. However, if the therapist begins to think that
the child's behavior is crystal-clear, the therapy warrants
review. Cooper and Wanerman (1977) caution: "Slow down
when you feel that you are beginning to understand the

meaning of a child's play behavior" (p. 107).
Facilitative Efforts
Because abused, neglected, or emotionally abused children
are frequently under- or overstimulated, they lack the ability
to explore, experiment, and even play. The clinician must
facilitate these natural, now constricted or disorganized ten-
dencies.
Children who have been physically or sexually abused
may be anxious, hypervigilant, dissociative, depressed,
and/or developmentally delayed. They may be socially imma-
ture and may rely on the environment for performance cues.
They may have had emotionally barren environments or
emotionally chaotic and inconsistent ones. In either case
their natural tendencies toward play may be interrupted,
leading to anxious, disorganized, or chaotic play.
The clinician is advised to inquire about the child's com-
mon play patterns before meeting with the child. Parents,
foster parents, day-care providers, or teachers may be able to
provide information about attention span, play preferences,
and other relevant issues. This knowledge is then used in
selecting the type of playroom or play materials to be made
available to the child. The chaotic, disorganized child will need
a more restrictive setting with fewer options. The restriction
can be accomplished by providing a large open space with
previously selected toys or a smaller room with a limited
number of toys to choose from. The worst possible combination
for a child with disorganized, frenzied play is a large room with
numerous toys and activities for selection.
The understimulated child will probably do the same in
either setting. With this child, the clinician is, by necessity,
more directive, selecting the toys and encouraging the child's
interest and play. The therapist first attempts to encourage
the child by modeling play behaviors, thus giving tacit permis-
sion for the child's participation. If the child continues to
retreat from the play, the therapist can slowly encourage the
child more directly. One of the major functions of play "is to
alter the raw, overwhelming affects that arise in children at
times of anxiety and provide a natural vehicle for the expres-

sion of these affects" (Chethik, 1989, p. 14). A child's continued
lack of involvement with play could signal a different kind of
problem, and medical and neurological exams are indicated.
The selection of toys for play therapy is critical. Axline
(1969) suggests a list of required materials, including the
following:
nursing bottles, a doll family, a doll house with furniture,
toy soldiers and army equipment, toy animals, playhouse
materials, including table, chairs, cot, doll, bed, stove, tin
dishes, pans, spoons, doll clothes, clothesline, clothespins,
and clothes basket, a didee doll, a large rag doll, puppets, a
puppet screen, crayons, clay, finger paints, sand, water, toy
guns, peg-pounding sets, wooden mallet, paper dolls, little
cars, airplanes, a table, an easel, an enamel-top table for
finger painting and clay work, toy telephone, shelves, basin,
small broom, mop, rags, drawing paper, finger-painting
paper, old newspapers, inexpensive cutting paper, pictures
of people, houses, animals, and other objects, and empty
berry baskets to smash, (p. 54)
Clearly, not all these items will be equally effective.

The doll house, family dolls, nursing bottles, puppets,
and art materials are the necessary minimum.
In working with abused children, I have found the fol-
lowing toys or techniques to be repeatedly successful in
encouraging the child's verbal or play communication:
• Telephones
• Sunglasses
• Feeling cards (i.e., illustrations of faces expressing
feelings)
• Therapeutic stories
• Mutual story-telling techniques
• Puppet play
• Sand play
• Nursing bottles and dishes and utensils
• Video therapy
Telephones connote intimate verbal communication to

the child. I usually sit with my back to the child and mimic
the confidential tone used in a phone call. The child usually

turns away through example, and a more private conversa-
tion can ensue.
Sunglasses are magical: Children believe that they be-
come invisible once they put sunglasses on. Wearing them
gives children a comfortable anonymity that can disinhibit
their communications, particularly when they have been
feeling embarrassed or reticent.
Therapeutic stories have been frequently used in child
therapy in a convincing way. Because children's imagination
and ability to identify is so powerful, they can easily enter a
story, making unconscious connections to heroes, conflicts,
and resolutions. Stories have been used to teach children
some basic concepts and to encourage their interest through
a familiar medium.
A wonderful book that offers therapeutic stories specifi-
cally for abused children was made available recently (Davis,
1990). The author, trained in Ericksonian hypnosis, found
that the use of metaphors in therapy could directly engage
the child's unconscious mind and facilitate lasting changes.
Her stories, specifically designed for an array of child-related
problems, are insightful and very effective, particularly with
latency-age children and preadolescent youngsters (and in
some instances younger children as well).
Gardner's (1971) Mutual Story-Telling Technique can
also have good results, but it necessitates the creation of a
story by the child. Some abused children have restricted
creativity and are anxious about their performance, so this
technique may be more successful later in therapy.
Puppet play has several benefits. The child creates a
story but does so anonymously, so to speak, using specific
characters to portray hidden conflicts or concerns. I find it
especially useful to have a sheet the child can sit behind, so
that she/he can conduct the play while hidden.
Sand play can be very evocative. Children tend to like
the sand (maybe because it's reminiscent of beaches) and
enjoy the tactile experience of molding and shaping it or
simply letting it rain through their fingers. My impression is
that some children use sand play as a way to feel nurtured
or soothed; they feel calmed by the play. Other children
immediately produce intricate scenarios, abundant with

symbolism. The play is in and of itself therapeutic and
provides the child with ample opportunities for a reparative
experience.
The use of videos in therapy is very worthwhile. Abused
children may be reticent to disclose their worries, fears, or
self-doubts. They often have impaired self-images and lack
the insight or confidence to recognize or express themselves
freely. Watching videos that discuss topics such as self-es-
teem, emotional abuse, secrets, drug abuse, or coping with
feelings, can be extremely beneficial for children for two
reasons. First, it gives them a little distance to consider
personal issues they may otherwise avoid, and second, the
issue is presented in the child's medium, story-telling, and
has the potential to engage the child's interest. I believe the
first step toward self-empathy is the ability to empathize
with others; the child watching a character in a videotape
has the option to identify with the character, empathizing
with his/her plight. The information presented in the tape is
then discussed between the clinician and the child. I have
been most impressed with a series created by J. Gary
Mitchell (MTI Productions, 1989) in which a character called
"Super Puppy" guides children through a variety of impor-
tant issues such as those mentioned previously.
It's worth noting that children with established play
patterns find it essential to have toys available to them on a
consistent basis. Toys must be protected and constancy main-
tained. Toys do not leave the playroom under any circumstan-
ces. In addition, the therapist must convey a sense of comfort
with the child's use of the toys (I have met therapists who
buy expensive or irreplaceable antiques for the playroom,
creating a kind of museum.)
Expressive Efforts
Because abused children are frequently forced or threatened
to keep the abuse secret, or somehow sense that the abuse
cannot be disclosed, efforts must be made to invite and
promote self-expression.
Sundry ways of stimulating expression must be under-

taken. Art, sand play, storytelling, doll play are all useful
attempts. However, a child who seems averse to overtly
expressing himseH^herself may require considerable effort.
One technique I've found fruitful is making the need and
use of secrecy explicit. I mark a paper bag "Secrets" and play
a game with the child in which, every now and then we each
pull out one of the secrets written on folded pieces of paper.
The child may choose to select another secret to read aloud.
The child sees this as a game and has less resistance to
disclosing scary or uncomfortable secrets.
Sometimes I draw cartoon figures, for example, of a
small child and an adult placing an empty cloud above their
heads the way cartoonists do. Then the child fills in what is
being said.
Caruso's Projective Story-Telling Cards (1986) are also
effective because they depict so many familiar situations for
children who live in dysfunctional families. The characters
are obviously experiencing conflict, danger, fear, or discom-
fort. Children have an opportunity to project their own wor-
ries or concerns into the characters in the drawing. The
clinician learns about the child and responds to hi^/her
concerns as the child's projected concerns become clear.
There are no strict rules about techniques that can be
employed to encourage the child to reveal inner thoughts and
feelings. The clinician must be as creative as possible, using
whatever interest areas the child displays. Perhaps no other
clinician contributed such a multitude of creative ideas as
James (1989). The more numerous the techniques available,
the better; abused children can be resistant to self-disclose
for a variety of external and internal reasons.
My impression has been that many children have dif-
ficulty with the expression of anger. They are afraid of the
emotion, probably because of their history. They need to see
anger as a normal emotion that can be expressed construc-
tively and safely, not just in inappropriate and dangerous
ways.
Most abused children have resentments and feelings of
anger; however, they frequently squelch these feelings to
stay safe. Providing them with permission to show anger can

generate a variety of experimental behaviors, some safer
than others. It is useful to model safe expressions of anger,
setting the necessary limits.
If the child shows more of a certain type of feeling than
others, the clinician must begin to inquire about the range,
for example, by saying, "You are very good at showing your
angry feelings. What do you do when you feel sad?" Some-
times feelings are shown through the body. Children may
tense up, bite their lip, or even scratch themselves during
specific discussions in the therapy. The child's posture can
help the clinician determine which concerns need attention.
Abuse affects the child physically. In physical abuse
there is a great deal of pain sustained by the child; the body
will develop physiologic responses, including muscle tension,
and evidence of anxiety, such as flinching. An abused child,
living with erratic violence, can literally prepare the body for
an attack by holding the body still and experiencing other
signs of physical distress such as shallow breathing, in-
creased heart rate, and flushing. In cases of sexual abuse the
child's body has usually been penetrated, creating a feeling
of vulnerability. The child's body feels unsafe, and the sexual-
ly abused child does not have a sense of physical control.
Finally, some emotionally abused and neglected children
do not receive normal physical attention or affection, and
since it has been clearly demonstrated that physical nurtur-
ing of a child is as important as alimentation, neglected
children can feel confused or inundated by a fear of or wish
for touching.
Because of the innate physical issues for abused
children, helping parents and caretakers encourage the
child's physical activity is vital. The child needs to engage in
the most basic of physical movements; walking, climbing,
and running can begin to give the child a sense of accomplish-
ment and pride as well as a knowledge of his/her physical
limitations. It is important to keep expectations to a mini-
mum until the child begins to thrive, allowing him/her to
experiment at an individual pace.
When the child appears to be more physically comfort-
able, less tense, and more prone toward physical activity, it
can be beneficial to enroll the child in some kind of team sport

at school or through a park and recreation department.
Participating in group activities can engender a sense of
well-being and belonging.
In addition, the formerly abused child may find self-
defense courses educational and worthwhile. The abused
child who learns principles of self-defense may feel em-
powered and less threatened by the environment. Most of the
self-defense classes do not teach violence; they teach self-
protection and respect for others. There is a great deal of
self-motivation and self-discipline involved in learning self-
defense, and many children I've worked with have responded
well to this instruction.
Although there are some sex differences regarding
preference of activity (boys prefer self-defense, girls prefer
dance or movement), children can be stimulated to develop
other interests if the activity is normalized. For example, one
boy who was in a group with two other boys who took dance
classes, developed an interest in dance classes after meeting
other boys who liked this activity.
Directive Efforts
Abused or traumatized children may also have a tendency to
try to suppress frightening or painful memories or thoughts
and in some cases may use denial and avoidance fully.
Suppression is a necessary defense that allows the in-
dividual to store intolerable material in the unconscious so
that it no longer interferes with current functioning.
Eventually, the abused child will be served by being able
to suppress or consciously inhibit a specific impulse, idea, or
affect associated with the trauma, but traumatic memories
are best suppressed after they have been processed and
understood. When this is done the individual has fewer
experiences with fragmentation or splitting and dissociation.
It is the repressed, or unconsciously stored memories, that
can leak out into consciousness through posttraumatic
symptoms.
The child's first and most natural tendency will be to use
the defense of denial or suppression; the family frequently
joins in to try to put the unpleasant or painful memory

behind. Families can reorganize quickly after a trauma,
taking care to avoid individuals or situations that can trigger
the memory.
The therapist can help a child who is avoiding the process-
ing of traumatic material by guiding him/her through a
thorough, time-limited review of the traumatic event so that
the event can be understood, felt, processed, and assimilated.
It appears that no matter how long this process is postponed,
eventually (for most people) the unconscious brings the event
back to consciousness through symptoms of posttraumatic
stress syndrome, including flashbacks, nightmares, auditory
hallucinations, or behavioral reenactment.
There is growing evidence in the literature that many
adult survivors have amnesia for the abuse for most of their
lives. This indicates how powerful and effective the defense
mechanisms can be. I believe we can give abused and
traumatized children a real advantage if we stimulate their
processing of the trauma. This does not mean that these
children won't need different levels of explanation and reas-
surance as they become more cognitively and emotionally
mature. It does mean that the foundation is set for future
exploration.
Privacy
Because in-home physical and sexual abuse and neglect are
family matters and children may feel loyal and protective of
their parents, it is important to expect the child's reticence and
to structure opportunities for him/her to divulge information
at his/her own pace.
Some abused children are threatened by their families
or caretakers to keep all family interactions to themselves.
They are told that they or loved ones will be harmed. Some
of the children I've worked with have had demonstrations of
what will happen to them if they tell others about secret
family situations. One child witnessed the murder of his dog.
The parent threw the dog against a wall, and brutally
crushed its head with a brick. This was the incident that
precipitated the mother's taking flight with the child. The
child suffered greatly about this for a number of years; since

the child's environment was so wanting, the child had formed
a strong tie with his pet.
Even when children are spared overt threats, many of
them sense the secrecy of family violence or sexual abuse.
They may not feel able to talk about feelings associated with
their abuse.
Privacy is very important for children; secrecy is not.
Establishing privacy empowers; keeping secrets engenders
feelings of helplessness. Children required to keep secrets
(through internal or external pressures) feel burdened, and
the secret takes on great importance for them, alienating
them from others and limiting the number of comfortable
interactions they can have.
A number of techniques to clarify the difference between
privacy and secrecy can be employed. Sometimes an abused
child is at the crossroads of making a disclosure about dis-
turbing thoughts or feelings. I might ask the child who
refuses to continue, "What will happen if you say more?" If
the child says "I don't know," I will explore possible alterna-
tives by having the child "guess" what might happen. More
frequently, the child has a specific reason for not telling, and
she/he might respond, "Daddy will be mad at me" or "Mommy
told me if I told, bad things would happen." I usually make
the following statement, "It's really hard to talk about things
when we're afraid. What might make it feel safer to talk
about how you feel?"
Some children prefer to tell a stuffed animal in the
playroom. I may ask them to pick out the animal they'd like
to tell, and they can whisper it to them. Once they've done
that, I ask how it feels to get these feelings out. Most of the
time the children feel good about talking; sometimes they
seem indifferent. I also might ask the child to imagine what
the stuffed animal might say to them about their secret.
I have on occasion brought out a tape recorder and left the
child alone in the playroom to tape what she/he wants to say
but can't. Children usually ask if I will listen to the tape, and
I answer that the tape belongs to them and they can let me
listen when they want. Every time I've done this, the child has
wanted to play the tape back to me right away. I then have an
opportunity to comment about the secret. I might say some-

thing like "It must be hard to be alone with that secret" or "It
must be hard to keep that just to yourself." I usually ask the
child whom he/she might feel safer telling and continue to talk
about the difficulties of keeping things to oneself.
Obviously, if the child's secret concerns an event such as
physical abuse or sexual abuse, the reporting law may enter
the picture. However, many of the secrets include situations
that are burdensome to the child but not necessarily
dangerous.
Posttraumatic Play
Because posttraumatic play often occurs in secret, the
therapeutic environment must create a climate for this type
of play. Once the play begins, it must be carefully monitored
for alterations, and at some point interrupted with suitable
interventions.
The traumatized child is often compelled to reenact the
traumatic event in an effort to master it. This concept was
first introduced by S. Freud as "repetition compulsion." As
Terr (1990) has affirmed, the reenactments can take the form
of behavioral manifestations as well as play dramatizations.
A reenactment is usually the result of an unconscious com-
pulsion that the child may not understand. Some children
claim that no matter how much they try, they cannot stop
thinking about the trauma and frequently feel as if it were
"happening again." Others claim that they no longer remem-
ber anything about the traumatic event and stubbornly deny
any and all feelings related to the event. Processing the
trauma can be achieved in a variety of ways. Some children
are more able to discuss their feelings and concerns and may
ask disarming questions about their abuse.
Because play provides a medium for communication,
some therapeutic play provides a mechanism for uncovering
concerns and releasing pent-up feelings. Some children simp-
ly go about the task of doing what they need to do to feel
better; they need little more than permission—and the
props—to do so. When this happens the clinician can observe,
document, and eventually comment on what transpires and

answer the child's questions or concerns.
For other children—perhaps those who have been more
harmed by the traumatic event—the clinician's direction and
stimulation will be needed before the frightening or over-
whelming feelings and sensations can be faced. In these
cases, forming a solid therapeutic relationship precedes any
gentle probing to assist the child in addressing intolerable
emotions. The goal of this work is to allow the child eventual-
ly to process the traumatic event, give it appropriate and
realistic meaning, and store it as a tolerable memory. It is
unnecessary to force the child into endless work on the
traumatic event, particularly when the child is not denying
or avoiding but has now redirected psychic energy into
developmental tasks.
The play of the traumatized child who reenacts is quite
unique. The child ritualistically sets up the same panorama
and acts out a series of sequential movements that result in
the identical outcome. The posttraumatic play is very literal
and devoid of apparent enjoyment or freedom of expression.
The potential benefit of this play is that while the child is
undergoing memories that are frightening or anxiety-
provoking, she/he is going from a passive to an active stance,
controlling the reenactment. In addition, the formerly over-
whelming event is occurring while the child is in a controlled,
safe environment. It is possible that the child gains a sense
of mastery and empowerment from this type of play therapy.
As Chethik (1989) says of a clinical example, "The repetitious
play, the comments of the player—observer, and his own new
solution helped him assimilate a past overpowering ex-
perience" (p. 61).
Posttraumatic play can remain fixed. Terr (1990) cau-
tions that allowing a child to continue long-term
posttraumatic play can be dangerous; the child may not
release any anxiety, and may have feelings of terror and
helplessness reinforced. For this reason, after observing that
the posttraumatic play remains static for a period of time
(eight to ten times), I attempt to intervene in the ritual play,
in the following ways:
• Asking the child to make physical movement, such as

standing up, moving arms, or taking deep breaths.
Physical movement can free up emotional constriction.
• Making verbal statements about the child's
posttraumatic play, suspending the self-absorption
and rigidity of the play.
• Interrupting the sequence of play by asking the child
to take a specific role, describing the perceptions and
feelings of one of the players.
• Manipulating the dolls, moving them around, and ask-
ing the child to respond to "what would happen if..."
• Encouraging the child to differentiate between the
traumatic event and current reality in terms of safety
and what has been learned.
• Videotaping the posttraumatic play and watching the
tape with the child, stopping it for discussion of what
is observed.
The goal of interrupting posttraumatic play is to

generate alternatives that might promote a sense of control,
help the child express fragmented thoughts and feelings, and
orient the child toward the future. It might take a number of
interruptions before the child allows the intervention to
change the posttraumatic play.
If the child is engaging in posttraumatic play at home
and the parents or caretakers have noticed it, two pos-
sibilities exist: The clinician either makes a home visit and
asks to witness the child's play directly or the clinician
creates the posttraumatic scenario (as described by parents
or caretakers) in the therapy hour. It is possible that the child
dissociates during the posttraumatic play. Treatment
strategies for dissociation (discussed later) must be imple-
mented as well.
The child whose play is random, disorganized, and
devoid of symbolism may need greater stimulation. If a child
persists in failing to address the underlying issues naturally,
the therapist, taking a directive position, must introduce the
stimulus in the therapy. Several techniques can work. A
puppet story told by the clinician in which the central char-
acter experiences the same trauma as the child may elicit a

response. The child may empathize with the puppet's plight;
empathy with others is a first step towards self-exploration
and self-empathy.
Some attempts at desensitization may also work. One
child I worked with was raped in a park, and yet she was
unable to offer verbal or nonverbal communications regard-
ing the trauma. Her silence was fueled by a fear that she
had brought on the rape by going to the park when she
should have gone directly home. The boys had told her she
"wanted" to be raped, and she was very confused because she
had indeed wanted to be noticed by the boys and had gone
to the park to be seen by them after overhearing mention of
their destination at school. I had the girl color a page in a
coloring book that depicted a park; I created a park scene
with dolls playing in a toy swing; I made a park in the sand.
I drove by a number of parks and, finally, asked the girl to
show me the park where she had been raped. We drove by it
first, then sat in the car outside the park, then walked
around the outside of the park, and finally walked inside.
Once inside, when I stated that the boys were very wrong to
rape her and hurt her, she cried almost instantly, saying
repeatedly, "I was bad, I was bad." This session, and six or
seven that followed, focused on the rape and the child's
feelings of guilt and shame. Eventually, she understood that
she had done nothing wrong and that wanting to be noticed
by boys was perfectly natural. This child also benefited
greatly by talking to another preteen who had also been a
rape victim.
Allowing the child to simply reenact without any ap-
parent resolution is, as Terr has noted, "dangerous." In addi-
tion, the repetition of a trauma without resolution will rein-
force the child's sense of helplessness and lack of control. The
clinician must take an active role in helping the child both
enter and maneuver the play, a role of actively commenting,
rearranging, or intruding upon the sequence of events the
child portrays. Reexperiencing alone is not enough. The
thoughts and feelings generated by the play must be acknow-
ledged and discussed. In addition, the child needs a struc-
tured way of "debriefing" from the play once it has ter-

minated. The clinician must take some time helping the child
reestablish a more comfortable emotional level. Guided im-
agery or simple relaxation techniques may have positive
results. Alerting the parents or caretakers to the difficult
work of the therapy, and asking them to plan appropriate
responses, is very important. During posttraumatic play the
child may appear more hypervigilant, anxious, and ex-
perience sleeping or eating disorders.
The overall goal of this work must be kept in the
forefront. As Scurfield (1985), describing his work with adult
survivors of various traumas, suggests the final step in the
stress recovery process is the integration of all aspects of the
trauma experience, both positive and negative, with the
survivor's notion of who he or she was before, during, and
after the trauma experience. Sours (1980), describing child
therapies, states that "child therapies in general, whether
they are supportive or expressive psychotherapies, tend to
rely on abreaction, clarification, manipulation, and the cor-
rective emotional experience of the new object" (p. 273).
Treatment of Dissociation
Victims of trauma may experience dissociation. The clinician
must assess for dissociation, and devise ways of addressing
the dissociative process.
The DSM-III-R defines dissociation as "a disturbance or
alteration in the normally integrative functions of identity,
memory, or consciousness" (p. 269). Dissociation occurs along
a continuum; everyone experiences dissociative episodes,
such as highway hypnosis. Boredom, fatigue, or fear may
facilitate dissociation; the individual enters a trance state
that can last for brief or extensive periods of time. Sometimes
during frightening situations, like an earthquake, in-
dividuals may have brief dissociative episodes, later being
unable to remember specifically what happened, or how they
got from one place to another.
At the most extreme end of the dissociative continuum
is multiple personality disorder. Other less extensive forms
of dissociation include depersonalization, psychogenic am-

nesia, and fugue states. Depersonalization is very common
among abuse victims. Children often describe "out of body"
experiences, in which they feel as if they are floating on the
ceiling. From that vantage point (while emotionally
detached) they look down on themselves. The ability to dis-
sociate allows the child to mentally escape the dangerous or
threatening situation. At the same time, the child may be-
come confused about higher own identity, having trouble
remembering what has occurred. Psychogenic amnesia, in
fact, is a disturbance in memory. Many child and adult
survivors are unable to remember specific events or periods
of their lives. Fugue states occur when an individual takes
physical flight, without conscious knowledge of how he/she
got from one location to another.
Dissociation is linked to trauma, particularly when the
traumatic situation is ongoing. The more chronic and severe
the trauma, the greater the likelihood of extensive dissocia-
tion. Lindemann (1944) wrote that "walling off awareness
or memory of the traumatic event is a valuable defense as
long as the threat persists. However, as I've mentioned pre-
viously, clinicians who work with trauma survivors believe
that the trauma must eventually be brought into awareness
and put into perspective, or the repressed memories will
appear in the form of intrusive thoughts, nightmares,
reenactments, or emotional problems.
In my experience, many clinicians observe dissociation
in children but remain unsure about how to proceed. Over
the years, I have developed the following specific techniques
for addressing dissociation:
Develop a language. The first step in addressing dis-
sociation is to develop a way to communicate about it. I ask
children about dissociation by saying, "Everybody has times
when they're doing something and suddenly they notice that
they seem to have gone away in their mind. Like when you're
on a long drive and you get bored and you start thinking
about different things, and suddenly you got to where you
were going and you're surprised. Does that ever happen to
you?" The child usually responds positively to the descrip-
tion. I then ask what name they give this process. Children
have many names for dissociation, including "spacing out,"
"getting little," "going inside," "fazing out," and others. Once
dissociation is labelled, it can be discussed.
Assess patterns of use. The next step is to inquire when
the child dissociates; I ask children to tell me about the last
time it happened, or when they think it happens most. As
their attention is focused on dissociation, children may notice
when they are using this defense.
The clinician and child can review similarities between
dissociative experiences. For example in one case, the child
seemed to dissociate more when he was alone, and when he
was reminded of his father.
Help determine dissociative sequencing. Everyone who
uses dissociation as a coping strategy has hi^/her own unique
ways of generating a dissociative response. I find it useful to
ask the child to "pretend to dissociate," paying particular
attention to the body, emotions, sensations, and thoughts.
Once the child is pretending to dissociate, either in the
therapy office or at home, I ask the child to notice: what
happens to his/her body and what feelings or sensations are
experienced; what kinds of feelings he/she has; and what
statements he/she might say internally.
The clinician points out the sequence to the child, pos-
sibly writing the information on a piece of paper so that the
child has a visual representation. This material becomes
particularly helpful when the clinician helps the child iden-
tify times when he/she might want to choose an alternative
response to dissociation. Using the sequence that has been
developed with the child's help, the clinician encourages the
child to pretend to dissociate, and then stop the dissociation
process at different points.
Explain it as adaptive. I always describe dissociation as
a helpful defense: "Sometimes when we have a situation
that's scary, or when it's too hard to feel our feelings, we
'space out' for a while. It's a really nice thing to be able to do."
At the same time, I want to convey a couple of other mes-
sages: There are other ways of coping, and the child will feel
more in control if a choice can be made about when to
dissociate and when to use other strategies.
Understandprecipitants. Once the child discusses times

when dissociation is a helpful defense, the clinician can
document the issues that seem to elicit this flight response.
With some children, it appears to be a singular issue such as
sexual arousal, physical pain, anger, or longing. For other
vulnerable children, the emotions that precipitate the dis-
sociative response may be numerous.
Address the troublesome emotion. Once identified, the
emotions or situations that are troublesome to the child must
be addressed in the therapy. The child needs to learn coping
strategies so that emotions are not avoided or repressed.
One initial technique I've found useful is to externalize
the specific emotion. For example, I'll ask the child to draw
a picture of anger. Then looking at the picture, 111 ask the
child to put words to the picture, and, finally, 111 give the
child some open-ended statements such as, "I feel angry
when..." "I feel angry because...." "I'm the angriest at..." As
the child tolerates the discussion, the frightening emotion is
desensitized. On one occasion a child drew a picture of fear,
and when I asked what she wanted to do with her picture of
fear, she crumpled it up, put it in a wastebasket, and covered
the wastebasket with a bunch of pillows. This was her way
of symbolically containing her fear, and over the weeks she
removed more and more of the pillows until the crumpled-up
piece of paper was visible. At that point she grabbed it,
announcing "this is little now." She then threw it in the big
garbage can outside my office. It was no longer an over-
whelming emotion to her. She had learned to tolerate her
uncomfortable feelings by talking to me and her father when-
ever she was worried or scared.
Give alternatives to the flight response. Once the feelings
are identified, and the child tolerates open discussion, alter-
natives can be articulated. "What can you do when you feel
sad?" I inquire, always asking for more than one option. "And
what else can you do?" I ask after the child responds. If the
child runs out of options, the clinician can volunteer other
helpful information by role-modeling, "When I feel sad, some-
times I do or say...." I may also mention "Some children I've
worked with tell me they feel lots of different ways, and one
of those ways is...." It's important to be in contact with the
child's caretakers to assure they will respond accordingly to

the child.
To summarize, dissociation is an adaptive and useful
strategy to defend against frightening memories, sensations,
or thoughts that occur in perceived threatening situations.
While dissociation is a valuable technique that allows the
child to escape immediately when threatened, it can later be
a reflexive response that perpetuates feelings of helplessness
and continued avoidance of reality. In addition, dissociation
can interfere with the child's potential to develop a repertoire
of necessary coping behaviors.
The clinician must evaluate the child's use of dissocia-
tion, developing techniques for discussing dissociation,
making the sequence of dissociation clear, establishing the
common patterns of use, and determining common feelings
or sensations that precipitate dissociation. The goal of treat-
ment with dissociation is to help the child feel in control of
choosing when he/she dissociates, and knowing the alterna-
tives to dissociation.
Transfer of Learning
The abused child may grow to trust the therapist and environ-
ment sufficiently to experiment with new behaviors. However,
unless the child can transfer the behaviors, or discern which
behaviors are transferable, the new knowledge can actually
become counterproductive.
In working with abused children it is an error to rein-
force behaviors that may precipitate attacks at home. For
example, one child client was encouraged to ask questions
and say how he felt in therapy. The clinician failed to alert
the child that the new behavior could be received differently
in different settings. When the child was reunited with his
natural family, his mother, threatened by her perceived in-
ability to provide information, would slap him each time he
asked a question. It was months before a teacher filed a child
abuse report and the child could be protected anew.
The therapist needs to help the child understand that
some behaviors may provoke different responses in different
settings. For example, when working with an abused child

who is learning to talk about feelings, the clinician might ask,
"How will it be if you tell your mom and dad how you feel?"
or "What do you think they will say or do?" It is necessary to
keep stressing, "It's OK to tell me about your feelings. Who
else can you tell your feelings to?" Eventually, all children
learn that people will respond to them differently and adjust
their behavior accordingly.
Prevention and Education

All abused children can benefit from learning skills to employ
in difficult, frightening, or abusive situations. Allowing the
child to anticipate and plan for crises is useful.
Before the child exits therapy, the clinician can spend
some time, in an educational mode, teaching the child about
child abuse and prevention. I concentrate on a couple of
important points: First, that children can say no, try to run
away, and get help if someone scares or bothers them and,
second, that if anyone asks them to keep a secret that scares
or confuses them, they need to tell someone. I always review
the child's support system, making sure they understand
whom they can contact when they need help. I also convey to
the child that he/she never causes someone to abuse him/her
and that the abuser always has problems and needs help.
Some of this education can be done in a group setting. If
groups are not available, this educational phase can occur
within the context of termination of therapy. While some
educational programs talk to young children about being
"safe, strong, and free," I prefer to use less abstract concepts.
I talk to children about the things that make them powerful;
since their physical limitations are painfully clear, I con-
centrate instead on the powers they all possess, including the
power to use words, the power to keep or share their
thoughts, the power to keep or share their feelings, and the
power to keep or share secrets.
Most children, particularly boys, have a tendency to talk
about physical power when asked to think what they would
do in the future if someone hurt them or did not take good
care of them. The children say they will kick, punch, or kill
the abuser. But the reality is that children can be easily
overpowered, and even though they don't like to see them-
selves as helpless, the reality is that they are. Because of
that, I tend to reinforce the abilities to think, to decide, to
choose, to act, to talk, to tell. These are indeed children's
powers and can sometimes help to prevent their victimiza-
tion. Recognizing these powers enhances self-esteem and
feelings of competence.
Finally, abused children are vulnerable to feelings of low
self-esteem. I spend considerable time helping children iden-
tify their strengths, and I validate them consistently. By the
time they leave therapy, my child clients should be using
positive affirmations, and relying less on external validation.
Children who leave therapy must also have some skills in
decision making, impulse control, and anger release; hope-
fully, the children also know what to do when they feel sad
or disappointed.
Clinical Examples
Leroy: A Child
Traumatized by
Severe Parental Neglect
REFERRAL INFORMATION
Leroy was referred for treatment by a placement worker at

the Department of Social Services following a dependency
petition and placement in foster care owing to severe paren-
tal neglect.
SOCIAL/FAMILY HISTORY
Leroy is a 7-year-old black male, the middle child of three
brothers. His mother was reportedly psychotic, and there had
been a multitude of suspected child neglect reports
throughout Leroy's life. He had been in foster care three
previous times and had lived in approximately five different
states.
Information on Leroy's mother remained sketchy
throughout treatment. Reportedly, she had lived most of her
85
life in Mississippi and was one of six children. Her own

mother had numerous relationships with men and only two
of the children shared the same natural father. Leroy's
mother had been a prostitute, a cook, and a waitress and was
currently unemployed and "living on the streets." She had a
history of psychiatric problems and drug addiction. She had
been hospitalized twice and had been unable to sustain a
drug-free lifestyle.
The social service agency had reconstructed enough in-
formation to present a picture of a very disruptive and incon-
sistent environment for the children. Although their mater-
nal grandmother had taken care of them some of the time,
the children often lived on the streets with their mother.
Six months prior to the referral for treatment, an
anonymous report was made to the Police Department of
what appeared to be a situation of unattended children in a
housing complex. The police entered the studio apartment to
find the three children, Leroy, age 7, Adam, age 5, and Alysha,
age 4, partially dressed, hungry, scared, and living in an
extremely dirty and disheveled large room. The children did
not have beds, and it appeared that they huddled together in
a corner to stay warm at night. The youngest child, Alysha,
was not toilet trained, and the smell of feces and urine
permeated the apartment. The children could not say when
their mother had left nor how long they had been alone.
After a medical exam Leroy was hospitalized for mal-
nutrition. He was severely dehydrated; it seemed that when-
ever food was available to the children, Leroy made sure the
younger children ate first. He later stated that his mother
mostly fed them uncooked spaghetti. Leroy remained in the
hospital until his weight increased beyond the dangerous
range. His younger brother was placed in a foster home, and
since Alysha had tested borderline mentally retarded, she
was placed in a specialized foster home. When Leroy was
discharged from the hospital, he was very worried about his
siblings (apparently he had been their primary caretaker),
was worried about his mother (it appeared he had tried to
take care of his mother as well), was depressed and anxious,
made indiscriminate attachments, and had nightmares and
Clinical Examples: Leroy 87
other sleep disturbances. In addition, he was hoarding food;

he had been found in the hospital ward attempting to store
leftover food from other children's meals.
PRESENTING PROBLEMS
The overriding concern for Leroy was his severe depression.

He had long periods of staring out a window from his bed; he
did not want to play with the other children. It was very
difficult to engage him in conversation: His responses were
monosyllabic. He did not seek contact with anyone and never
reached out for anything. Even at times when he seemed in
obvious physical discomfort, he was unable to ask for assis-
tance, but waited for the call nurse to check in on him. He
frequently arose from sleep in an agitated state, apparently
having had vivid dreams, which he claimed to forget instantly.
During the week prior to being released from the hospi-
tal Leroy's' depressed state had been replaced by hyperalert-
ness and anxiety focusing on alimentation. He would fre-
quently ask when his next meal would be, and he scavenged
the unit for treats; some of the nurses began bringing candy
bars and fruit from home in an attempt to relieve his anxiety.
It was as though his inevitable exit from the hospital had
triggered immense anxiety about what would happen next.
Leroy had stopped asking questions about his mother
and siblings, apparently resigned to the fact that their future
was as uncertain as his. He did not even ask about his foster
home and seemed to quietly await the next of a series of
placements. This child seemed certain that he had little, if
any, control over his life and seemed to acquiesce in silence.
INITIAL CLINICAL IMPRESSIONS
Leroy came to therapy during his first week in a new foster

home. The social service agency provided a transportation
worker to bring him back and forth to therapy. As he entered
my office for the first time, Leroy held the hand of the
transportation worker, whom he had just met, and kept his

eyes down, moving slowly. To my knowledge he had never
been in therapy before. He was very small for his age and
seemed to have difficulty walking.
Leroy said hello to me and little else. He seemed
cautious, walked slowly, said few words, and had awkward
and constricted movements. I greeted him in the waiting
room and took the transportation worker and Leroy to look
at the playroom, assuring Leroy that the worker would wait
for him and would be nearby. This seemed quite irrelevant to
him.
In the playroom Leroy seemed uninterested in the toys
and in me. He found a soft ball, which he held and squeezed.
I sat nearby and talked to him about the playroom: "Kids
come here and get to choose what to play with. Sometimes
we play and sometimes we talk. I talk to kids about their
thoughts and feelings." It was unclear to me if Leroy under-
stood what I said. I asked if there was anything he would like
to do. He said no somberly. I said that I sometimes liked to
draw with crayons, and I proceeded to take them out and
started coloring. As I did I commented, "I like to use lots of
colors" and "When you mix red and yellow you get something
that looks like orange." I didn't ask him questions or expect
a response, and that seemed to give Leroy the freedom to look
around. As I sneaked a peek at him he was scanning the
environment slowly; he seemed to be taking everything in
and recording it for posterity. It was impossible to know what
he was thinking or feeling. I kept drawing. Slowly, Leroy got
up and walked to the sink. "Is there water here?" he asked.
"Well," I responded, "there isn't any water in the room right
now, but I can go get some in the bucket." Leroy said, "I want
a drink. I'm thirsty." This was the first of countless requests
for food or drink. "Oh," I said, "you want water to drink. We
can go get some in the kitchen." We walked to the kitchen
together, and Leroy reached out for my hand; he seemed to
be accustomed to being led around. I held his hand and as we
approached the kitchen he noticed the refrigerator. "Is there
food in there?" he asked. "Yes Leroy, some of the people who
work here keep snacks and lunches in the refrigerator," I
explained. "Oh," he remarked. He drank two small cups of

water, and we filled up the bucket to take back to the room.
As we walked out he asked, "Do you keep snacks in there?"
"Sometimes," I said.
Back in the playroom Leroy grabbed the cups and
saucers and the teapot. He filled up the teapot and poured
tea into the cups, emptying and filling them over and over.
Leroy liked to get his hands wet and then dry them. Every
now and then he would fill the cup with water and "sneak a
drink." I commented, "You fill up the teapot, pour out the tea,
sometimes you drink the tea, sometimes you pour it out, and
you do it over again." A very small smile seemed to appear as
I told him what I had noticed him do. We spoke very little the
rest of the session.
I had told Leroy when we first entered the room that a
little bell would go off when it was time to leave. He seemed
startled when it did ring yet abruptly dropped everything
and went to the door. "Leroy," I told him, "I was glad to meet
you today, and I will see you next week." He opened the door
and we went to the waiting room. He asked the transporta-
tion worker if they could still go get a snack, and she quickly
said, "Of course, Leroy, I told you we would." He had already
extracted a promise from the worker to take care of his
anxiety about food, and she left asking him whether
MacDonald's or Kentucky Fried Chicken was preferable.
My notes after the first visit were as follows:
This child seems to have difficulty with attachment, as

expected. He has a great deal of anxiety about food and
eating. His play was focused on water, drinking, filling,
and emptying. He asked about the refrigerator
downstairs. I want to be careful to give him the space to
make choices and experience a sense of control. I will be
nondirective and document play themes, attempting to
build a therapeutic relationship. I believe trust will be
difficult to build. It seems his life has been full of disap-
pointments. Need to check in with his foster parents and
need to talk to the transportation worker about not
feeding him.
TREATMENT PLANNING
I called the social service agency following my first visit with

Leroy. I wanted to develop a treatment plan for this child and
wanted to know more about his current status and plan in
foster care. The social worker informed me that the mother
had never been located after the children were picked up and
taken to the hospital. There was speculation that the mother
was prostituting again and probably knew the children were
in custody. The hospital nurse stated that a black woman had
called to ask about the children but had hung up when she
was placed on hold. The social service agency had contacted
the maternal grandmother, who was ambivalent about
caring for the children at this time, particularly without the
mother's knowledge. The grandmother matter-of-factly
stated that her daughter would show up sooner or later and
she hoped it would be later. She said that her daughter's life
was hopeless and that she was "no good." "Those children are
better off without her/ she said, adding, "The good Lord's
tired of waiting." The grandmother was curt and uncoopera-
tive; it appeared she was accustomed to inquiries about the
children, and her frustration resounded loudly.
Long-term placement was planned for Leroy, given the
lack of familial resources at the time. The younger children
would be released for adoption because they were younger
and seen as easier to adopt. If the mother returned to Mis-
sissipi or was located locally, attempts would be made to
provide services to see if reunification was possible. Given
the mother's history, this was unlikely although there had
been periods in which she seemed to make reasonable efforts
to care for the children. If the mother did not surface after
one year, attempts would be made to terminate parental
rights for the younger children.
This information helped me structure a treatment plan.
Leroy would need some help separating from his siblings, his
mother, and his grandmother. Although some initial contact
with his siblings might decrease Leroy's anxiety about their
well-being, a permanent separation might become inevitable
and contact after an adoption might not be feasible. It was
also important for me to know that placement with the
grandmother was not realistic. Leroy would probably even-

tually ask about his future—doing so would, in fact, be a good
prognostic sign.
I was relieved to hear that the social worker had placed
Leroy in a home already structured to provide continuity of
care and planned to make contact with Mrs. G., the foster
parent, as soon as possible.
BEGINNING PHASE OF TREATMENT
During the next five visits a ritual was clearly established. I

would have the bucket full of water and the cups and saucers
within reach. Leroy did water play, said little, and seemed to
enjoy my verbal observations of his behavior. The fifth week
he asked, "Do you have snacks here today?" "No," I said, "I
don't." He seemed disappointed. "There's a refrigerator
downstairs," he stated.
"Yes, there is, Leroy."
"I want to see it."
"OK, we can walk downstairs." We went downstairs and
looked at the refrigerator; Leroy seemed fascinated.
"Lunches are in there."
"Yes," I said, "some lunches are probably in there."
"Can I see?" he asked with wide eyes.
"Yeah, we can open it up," I replied. His eyes were even
wider as he stood in front of the open refrigerator for what
seemed like an interminable time. He looked at every shelf,
every nook and cranny, with his hands by his side. "I have
apples at my house," he remarked. "Oh," I said, "you have
apples too." "Not me," he corrected, "Mrs. Glennis." "Oh," I
repeated, "Mrs. Glennis, your foster mother, has apples."
"Yeah," he stated proudly, "her refrigerator is bigger and
smells better." "OK," I said, as we went upstairs.
I had Mrs. Glennis come in at about this time. She was
a very kind black woman in her 50s. She had been a foster
parent for 18 years; she was obviously experienced and con-
cerned for Leroy. "That boy is always eating," she explained.
"No matter how much you give him, he always wants more.
His eyes are bigger than his stomach. Poor sweetie, just last
week I went to his room at night 'cause he was crying. I held

him for a long time and rocked him, asking him over and over
what was wrong. Finally/ she went on, "he said he was
thinking about his mama and what she was eating. He told
me sometimes his mama did bad things and sometimes the
bad men would hurt her and push her down the stairs. That
poor child," Mrs. Glennis said, "God only knows what kind of
goings on he's seen."
Mrs. Glennis was a single mother and had her two adult
children living with her. In addition to Leroy, there were two
other foster children, Roshad and Kelya. She said they were
all sweet children and got along just fine. The only problem
she acknowledged was that the children would fight with
Leroy when he stole money from them; they would call him
a "fat pig" and make snorting noises at him. Leroy would
appear hurt by this and would run to his room and hide.
Mrs. Glennis said that Leroy had improved a lot since
first moving in. "He asks me questions now, and he stays out
and watches TV with us at night. At first," she remarked, "he
would only want to be in his room."
When I asked Mrs. Glennis to describe the routine at
home, she said that things were pretty quiet until all the
children got home from school. (They all walked to a nearby
school together.) She usually had cookies, pies, or cakes
waiting for the children, with some milk. "I usually give
Leroy a big old piece, 'cause I got to fatten him up." Then the
children would do their homework or go out and play while
she warmed up dinner. "I usually cook the dinner while
they're in school and have everything ready for them when
they get home." After dinner, which she described as "quiet,"
the children would watch TV or play a game and then she
would get them ready for bed. They would take a bath or
shower, put out their clothes for the next day, and say their
prayers. Sometimes, she reported, Leroy would eat a little
piece of something that he had saved up before going to
sleep.
Mrs. Glennis said she had few disciplinary problems
with the children. "I used to get rowdy kids, but now I've told
Mrs. Calbot that I can only handle the quiet children." She
said, "They know when I'm mad. I just got to look their way
and they behave. They don't want me mad. Just as quiet as
I can be is as loud as I am when I'm mad."
When asked about other things she noticed about Leroy,
Mrs. Glennis stated that he seemed "a little strange some-
times." When I asked her to elaborate she said, "Well, some-
times you'll be talking with him and he seems to look like
through you, like you weren't even there. Sometimes," she
goes on, "when he's watching TV, he just sucks his thumb and
seems to be in another world. He does cry more than the other
two, and when they call him a 'crybaby,' he usually goes to
his room and falls asleep. If he gets really mad he tells the
others that they are not his real brother and sister and that
he has a real brother and sister that are better than them.
When the kids didn't believe him, he came running and
almost dragged me out to make sure they knew he was telling
the truth."
Mrs. Glennis also announced, with some discomfort, that
Leroy "touches himself down there a lot" and that he's very
shy about anybody seeing his body. When I asked what she
does with his masturbatory behavior, she replied, "I slap his
hands...not hard, just so he knows that touching isn't some-
thing I want to see." Mrs. Glennis volunteered that she
thought it might be good for Leroy to see his brother and
sister and stated that she knew the foster mother who was
keeping the children. This contact had certainly crossed my
mind as well.
I thanked Mrs. Glennis for all her insights. She was
providing a structured environment for Leroy, and he was
clearly responding in a positive light. I told her that instead
of slapping Leroy she might want to try giving him a ball or
something to do with his hands since children this age tend
to masturbate when they are tired or bored. She agreed to
try. In addition, I talked to Mrs. Glennis about Leroy's
anxiety about food. "I agree with you that he's had a very
difficult life so far," I began. "As you know, he could have died
from the severe malnutrition he had. I think now he's ex-
tremely worried about getting enough food. At the same time,
I worry that if people overfeed him, he might not have a
chance to learn to deal with his anxiety." Mrs. Glennis

seemed a little offended since she commented that she wasn't
overfeeding the child but only making sure "he got some meat
on his bones/ I told her I also wanted to see Leroy have good
physical health and encouraged her to try from time to time,
when she thought of it, to either say no to his request for more
food or tell him that if he was still hungry in an hour, he could
have more then. She did not seem as responsive to this
suggestion as she was to the one about the masturbatory
behavior.
I contacted Leroy's teacher to ask about his school be-
havior and discovered that he was doing fairly well in the
first grade. An initial educational assessment had found his
verbal and math skills almost nonexistent, and the social
service agency had been unable to locate any prior school
records. The teacher said that Leroy was very compliant in
class. "Sometimes," she declared, "you forget he's here." She
also mentioned his obsession with food and had noticed his
scavenging through trash cans during recess. She had also
seen him hide food in his backpack to take home. Some of the
children had ridiculed him for this and, like his foster si-
blings, labeled him a "hog" and a "pig." Academically, Leroy
was catching up nicely and seemed to be proud when he
earned a star or a happy face on his work. The teacher said
she saw no behavioral or unexpected academic problems at
this time, but saw Leroy as staying a little on the periphery
socially. "I encourage him to play team sports or try group
projects, but he prefers to be by himself." The only other
comment was that Leroy had taken a liking to an assistant
teacher and always looked forward to seeing her.
After seeing Leroy for ten more sessions (2l/2 months), I
saw several clear patterns. Leroy's play was ritualistic, and
he seemed to be reenacting his own deprivation and alimen-
tation. He was obsessed with getting enough of everything.
He had begun to pay close attention to setting the time and
would frequently say, "you set it on 48 minutes, not 50." On
several occasions he asked whether I had snacks in the
refrigerator. Using my nondirective approach, I would al-
ways answer, "You like to know whether or not I have food in
the refrigerator." "Well, do you?" he demanded once. I
answered, "Nope, not today." The refrigerator in my office

had become symbolic of food he could not access, and al-
though he was not yet comfortable to ask for food, or take
food, he almost always commented on the refrigerator.
During this time I always gave Leroy ample choice of
activities. Only once or twice did he want to color, and he
always turned to the same page, noting that "no one else"
colored on his page. He was meticulous about coloring inside
the lines. From time to time Leroy appeared glad to come into
the playroom, even rushing in. On one occasion when I was
5 minutes late, he immediately asked if he would still have
his whole time. I told him of course he would. This was his
first broad, although brief, smile.
Treatment Plan
My treatment plan for Leroy was outlined in the third month
and was documented in my records as follows:
1. Individual nondirective play therapy with Leroy

a. Document play themes and patterns; note symbols
used in play.
b. Observe and remain nonintrusive.
c. Encourage choice and a feeling of control.
d. Increase therapy to twice weekly.
2. Interactional issues
a. Observe level of interaction initiated by L.
b. Observe interactional play with toys/dolls.
c. Obtain information on ongoing interactions with
foster mother, foster siblings, teacher, assistant
teacher, and peers.
d. Define level of interaction with therapist: number
of questions asked, number of "F statements, num-
ber of spontaneous comments.
e. Encourage L.'s meeting his own needs, i.e., asking
to do something, demanding his time, etc.
3. Trauma work
a. Be attuned to symbols of trauma of malnutrition,
and separation from mother; watch for post-
traumatic play.
b. Become directive if material does not deepen over

time.
4. Coordination
a. Keep in touch with social worker; submit reports
as required.
b. Meet with foster mother at least once a month and
gauge progress in home (check on overfeeding).
Also, check on quality of attachment, anxious be-
haviors, and nightmares.
c. Attempt to have some contact initiated between
Leroy and his biological brother and sister.
MIDDLE PHASE OF TREATMENT
Meeting with Leroy twice a week was very successful. He

began to make an appropriate attachment to me and
deepened his therapeutic work tremendously. His play
shifted dramatically 2 months after beginning his biweekly
sessions. He stopped playing with the cups and saucers and
turned his attention to an array of baby bottles on display. I
am sure he had always noticed these, but now he abruptly
began to gather them up, fill them with water, and empty
them. His affect changed during these filling and emptying
sessions. He would breathe hard, become physically still, and
check with me frequently and nervously. Then one day, as if
mustering up all his strength, he put the nipple of the baby
bottle in his mouth and looked at me. I made eye contact with
him, and he did not look away. "You're drinking from the baby
bottle/ I said. He walked slowly to a stack of pillows, and lay
down on them, and sucked vigorously on the bottle. When he
finished all the water, the bottle fell from his mouth. "More,"
he said quietly. "You want to drink more from the baby
bottle," I said. I took the bottle, filled it up with water, and
gave it back to him. I went back to my seat next to the water
tray. Leroy lay with his legs curled up, on his side, sucking
on the nipple. He was no longer sucking hard, he was suck-
ling quietly. The bell of the timer disturbed him, and he
seemed angry that he had to get up. He threw the bottle
across the room and walked out the door. "Leroy," I shouted,
"let me say good-bye to you." I crouched down so that we could

make eye contact, and I said, "You had a lot to drink from the
baby bottles. You threw the bottle away when the bell rang.
You might have liked to stay and drink a little longer. The
bottles will be here next time you come. Ill see you then,
Leroy." He walked away; as he grabbed the transportation
worker's hand, he looked back at me and waved.
Leroy was shy when he came the next time; he may have
been embarrassed by his sucking on the baby bottle. He drew
for a while, and I took the opportunity to ask him to draw a
picture of himself. "What do you mean?" he asked. "Well, just
draw a picture of you," I said. Figure 1 is Leroy's first drawing
of himself. When I asked him to draw a picture of his family,
he drew Figure 2. It is striking to see how large he seems in
the picture and how overwhelmed by the inconsistent and
FIGURE 1
FIGURE 2
barren environment. His drawing is typical of drawings

produced by much younger children. In the drawing of a child
of Leroy's age and background, the lack of body is probably
symbolic of his lack of body image, due to his being so severely
malnourished, so developmentally delayed, and, now, so
physically uncomfortable with his predictable weight gain.
The family picture reflects his sense of isolation. None of the
family members has a mouth, and the mother's small size
indicates Leroy's view of himself as the caretaker.
While drawing his family Leroy stated, "I love my mom.
She's a nice mom. She's not bad." It was almost as if he were
reassuring himself rather than being self-revealing. "You
have a nice mom and you love her," I repeated. Before I could
say, "She's not bad," Leroy asserted, "AND SHE'S NOT BAD!"
I agreed, "That's right, Leroy, she's not a bad mommy. You
miss her," I added. Leroy went to the water tray to fill up his
bottles once again, then to the pillows to suckle quietly.
Unlike the first time, he seemed to accept the time limitation
and to get up feeling better, somehow, knowing that he could
control his nurturing and that I would fill up his bottle and
bring it back to him.
After about 10 or 12 of these nurturing sessions, some-
thing remarkable happened. As Leroy lay quietly I heard him
say, "Eliana." I came over to him and he motioned for me to
sit down. I did so, and he curled up so that his head was on
my lap; he lay comfortably and finished his bottle. As he left
that day he waved, then turned away.
Another month and a half followed of these nurturing
sessions. Sometimes Leroy would reach over and hold my
hand. Once he took my hand and put it on his head. Instinc-
tively, I stroked his head, and he fell asleep. He woke up to
the bell, apparently feeling nurtured. He was leaving these
sessions looking less anxious and somewhat happier. Mrs.
Glennis called me to tell me that something different was
happening at home. "He doesn't seem to want as much to eat,"
she said with surprise. "Last night he gave his piece of pie to
me. I went ahead and ate it; I figured this was no time to
worry about my diet."
Every now and then Leroy would take his bottle out of
his mouth and say, "You are not my mom."
"No, Leroy, I am not your mom."

"My mom's name is Loretta."
"Yes, Leroy, your mom's name is Loretta."
Then he would resume the suckling behaviors feeling
reassured. These statements seemed to be a sign that Leroy
was functioning in the real world and developing coping
strategies. This real world was one of feelings: he longed for
his mother's nurturing, yet he faced the reality of her limita-
tions. His mother was an unrewarding and inconsistent
object. He would need to rely on others and, eventually,
himself for emotional nurturance. He had found a way to deal
with his longing, and he seemed to be repairing himself
through this enactive play.
Every other week or so, Leroy stopped his nurturing
sessions. He would draw or build structures with building
blocks: Eventually, he ventured over to the dollhouse. At
first, he sat in front of the dollhouse and seemed to look
inside, afraid to move anything. I commented, "You sit quiet-
ly looking inside the house. You don't touch anything. You sit
outside, looking in." I brought out the small family figures
that could be used inside the dollhouse. (Leroy had always
avoided the shelf with human figures. His play until now had
always been with objects: blocks, crayons, even some trucks
and small cars that he drove around in circles.) He looked at
me surprised. This was the first time I had chosen something
for him to play with. "Is this their house?" he asked. "It could
be," I replied. I looked at the house and he looked at the dolls.
He grabbed the mother doll and put her in the kitchen. "She
cooks," he stated firmly. "The lady is in the kitchen cooking."
He moved away quickly and drew for the rest of the session.
He had learned some songs from his foster mother and
delighted in singing while he drew. I would always tell him,
"You sing pretty songs, Leroy; you remember all the words
and the tunes that go with them." He seemed to feel proud,
and over the weeks his voice was becoming stronger. He
would smile broadly when he finished his songs; I would
smile back. Leroy took my hand as we walked out of the play
sessions. He had had many transportation workers, and he
no longer took their hands as he left; he now walked beside
them, seemingly confident.
Eight months of therapy had transpired, and Leroy's

progress was tremendous. He had finished one full term in
the same school, and his grades had improved. (On one
occasion, Leroy ran into the waiting room anxious to see me.
He boasted appropriately that he had gotten an A in writing.
"Mrs. Esther is going to make me my own pie," he an-
nounced.) One area reminiscent of Leroy's malnutrition per-
sisted. Mrs. Glennis's attempts to stop overfeeding him had
been marginal at best. She would frequently tell me that,
try as she might, she could not say no to Leroy's requests for
extra food. Mrs. Glennis was an obese woman, and her
natural children were obese as well. It appeared that she
was convinced that children should be very round; it was
difficult to combat her established belief system. She had
continued to reward Leroy with food, and Leroy still
responded to this type of reward.
In therapy some headway was made in helping Leroy
cope with his anxiety about not getting enough food. He had
continued to ask about the refrigerator downstairs and
would frequently ask to look at what was inside; he would
remark about what he liked and what he didn't like. Usually,
the conversation ended with his assertion that Mrs.
Glennis's refrigerator had "bigger and better" things than
ours did.
I had purchased a toy refrigerator and toy foods for the
playroom. Leroy had noticed them immediately; he played
with them by taking the foods out, counting them, and put-
ting them back. Other children played with the toys, a fact
that Leroy had never overlooked. Leroy's play seemed to be
an attempt to verify that no one had taken any of the foods.
"Do other kids come here to play?"
"You want to know if other kids come here to play. Yes,
they do Leroy."
"Do you come here with other kids?"
"You want to know if I come to the playroom with other
children. Yes, Leroy, sometimes I come to the playroom with
other children," I replied. There followed countless questions
about the other children and their therapy. The foods were
recounted every week; eventually, some turned up missing.
Leroy was surprised and worried. He looked everywhere for

the missing items. When he couldn't find them he withdrew
into a corner. 'Those kids are bad to steal things/ he con-
cluded.
''You really don't like it when you've left things in their
place and they are missing," I said.
"Will you get new ones?"
"I don't know, Leroy."
"Well, you should."
"You really like it when things stay the same. You don't
like it when things disappear." We were now talking about
his mother. "I don't want to play with that anyway," he
announced. Thus he rejected the very toy that caused him
consternation. He would return to it eventually. "You have
feelings about things you miss," I observed.
Two weeks after this session Leroy asked to write a letter
to his mother. "Sure, Leroy. You can write a letter to your
mom," I said. In his best "A" handwriting he wrote, "I love
you Mom." "Send it to my mom," he said as he walked away.
"You want your mom to get this letter saying you love her," I
said. "Will you send it?" he asked. I was stumped but replied,
"Next time you come we'll send it together." I needed some
time to think this through.
The following week Leroy didn't mention the letter.
When he said he wanted to stop coloring, I said, "Last week
you wanted to send this letter to your mom. Here's an
envelope." We put his mother's name on the envelope. "I
don't know an address for your mom, Leroy. What shall we
put?" I asked. "Put Mississippi," he said. "OK," I agreed. We
took the letter to the mailbox, and Leroy could barely reach
to insert it in the box. "God will take it to her," he announced.
"OK," I said. "You really want her to know you love her." No
mention was made of a reply. Several months later Leroy
wanted to write a letter from his mother to him. He wrote,
"I love you, Mom." He wanted to walk to the mailbox again.
This time the envelope did have an address: Mrs. Glennis's
address. Leroy brought the letter in happily. "It came today,"
he announced. "I got my letter from Mom." He saved that
letter in his room.
TERMINATION
The social worker called one day and announced that Leroy
would be sent to Mississippi in the next few weeks. She stated
that Leroy's mother had been arrested and released to her
mother's care. The maternal grandmother had agreed to let
her live in the family home as long as she had a job. Leroy
and his brother were to be returned to Mississippi, where a
reunification plan would begin. I was stunned and concerned
about the abrupt way in which termination would occur.
Leroy had made great strides: He had formed an attachment
with his foster mother, had done well in school and in
therapy, and had begun to feel secure in his environment.
With one phone call, this was all disrupted. I saw Leroy
immediately to tell him that he would be moved back to his
mother in Mississippi. He looked away quietly. "Will Adam
and Alysha come too?" he asked. "I think so, Leroy, but well
have to check with Mrs. Calbot [the social worker]/ I replied.
Since the mother had been located within the 1-year time
frame, it was possible that termination of parental rights
would be deferred. Leroy asked where he would live and
when he had to go. I responded, "I think you'll be with your
grandma but, again, we'll talk together to Mrs. Calbot; you
should be leaving in about a week and a half. We'll be able to
meet three more times." Leroy appeared somber and began
to color quietly in the corner. Tm going to miss you, Leroy,"
I said. He continued his coloring. "It's hard to say good-bye
to people you like," I told him. "I like you," he said spon-
taneously. *I like you too," I said.
The following session I brought a scrapbook and a
Polaroid camera. I told Leroy that today would be special
because I was going to take some pictures for him that he
could take to Mississippi with him. I took pictures of the
playroom, the sink he played with initially, the baby bottles
(he wanted me to take a picture of him with the bottle on the
pillow he used to lay on), and a picture of the building from
the outside. He took a few pictures of me in the playroom,
and one of the staff took a picture of us together. We went to
his school, and we took pictures of his classroom and his
teacher. We then went to his foster home and took pictures
of Mrs. Glennis with Leroy, and of Leroy and the other

children. He had a bittersweet smile in most of the pictures,
and he carefully placed them on the pages. "I have lots of
pictures," he said happily. "Yes, you do," I agreed. ''Can I take
this with me on the plane?" he asked. "Yes, you can Leroy.
You can look at this whenever you want and remember what
it was like when you lived in California," I told him. "I like
California," he said, "and I like Mississippi."
In our last two sessions we talked about his leaving,
saying good-bye, writing letters, and the people and things
he would miss in California. He brought the scrapbook to
each session and made some drawings inside. He also showed
me the other mementos he had included. There were ticket
stubs from the movies, his report cards, some homework with
stars and happy faces, and some candy bar wrappers. Each
session I helped him say good-bye to the playroom and the
toys he had played with—but Leroy didn't touch the bottles.
It was almost as if he were unable to say good-bye to them.
The last session I gave Leroy a going-away present; he
opened it with anticipation. It was a brand-new baby bottle,
small enough to be unobtrusive. On the card I had written
the following:
Dear Leroy:
I will think of you in Mississippi with your mother,
grandmother, and brother and sister. I know that people
are helping your mom so she learns how to keep you safe
and feed you well. When you look at this little bottle I
hope you will remember how you learned to feed yourself
and make yourself feel better inside. If you ever feel
hungry for food, be sure you talk to your grandmother or
teacher. If you ever feel hungry for love, ask a grown-up
you trust for a hug or kiss or close your eyes and remem-
ber the way you learned to make yourself feel better. I
will think of you and remember you always.
Eliana
"This one is just mine?" he asked incredulously. "Just for
you," I said. He hugged me spontaneously clutching his little
bottle.
DISCUSSION
Leroy was a youngster traumatized by severe parental

neglect. He had experienced a chronic sense of helplessness
and coped with inconsistent care, separations, relocations,
and danger with a sense of resignation. His mother had been
drug-dependent for years and had a chaotic lifestyle. Like
many victims of malnutrition, Leroy had developed anxiety
about getting enough to eat, manifested by his attempts to
scavenge for and hoard food. He was lethargic, slept a great
deal, and seemed to avoid interpersonal contact. It appeared
that Leroy was the primary caretaker for his two younger
siblings—and probably for his mother as well. Leroy's
presenting problem was depression. Underlying problems
included learned helplessness, making indiscriminate at-
tachments, anxiety about his nutritional needs, nightmares,
and interactional problems.
In therapy, I decided to use the nondirective approach in
an attempt to give Leroy a sense of self-control. I wanted him
to make choices, to ask for things, to try to get his own needs
met. I wanted him to experience and cope with the anxiety
of forming a relationship with me. In time, he would face his
fear of and wish for dependency and consistency.
I provided Leroy with play materials that would help him
reenact the underlying primary issues of fear, deprivation, and
longing. Materials such as cups and saucers, water, baby
bottles, a supermarket cart, a refrigerator, and toy food became
very significant to Leroy. In addition, he was eventually able
to overcome the discomfort they generated and to use the
dollhouse and family dolls to act out some of his fantasies
about family life. Leroy's perception of houses and homes was
somewhat distorted by his experiences: He had moved con-
stantly and had frequently slept huddled on sidewalks.
Leroy's play themes consistently reflected his ap-
propriate preoccupation with nurturing: He was always
emptying and filling objects. He symbolized his need for
physical nurturance by drinking out of the baby bottles
during the sessions and his need for emotional nurturance
by suckling on the bottle while lying curled up on the pillows.
Leroy's interactions improved significantly during treat-

ment. He was able to ask questions, direct my participation
in the play, and attempt to get his needs met. It was obvious
that the therapy became important to him and that he looked
forward to coming to therapy. He always made sure he set
the timer to the exact time, and he respected the limits
imposed. He learned to deal with the anxiety of not eating
during our sessions while knowing that there was food in the
building. He was also able to tolerate the fact that other
children played with "his" (toy) food.
Leroy learned to self-nurture during the treatment. He
satisfied primitive urges to suckle, got more to drink when
he wanted, and directed me to make physical contact with
him during some of his reenactments all the while success-
fully differentiating between reality and fantasy, his mother
and me. Through fantasy he was able to compensate for his
early experiences of deprivation. He stopped making indis-
criminate attachments and remained polite but distant with
new transportation workers. He made an important attach-
ment to his foster mother, feeling secure and loved in the
foster home environment; at the same time, he seemed to
have an internal restriction, understanding full well that
foster care is temporary and can be changed abruptly.
I used directive play minimally with Leroy; I guided his
involvement in the dollhouse play, perceiving his am-
bivalence. Had he avoided play when I brought the dolls out,
I would have noted this response, and allowed him to choose
what to do next.
Unfortunately, termination was premature and abrupt.
Under the circumstances, I thought it best to prepare Leroy
to leave in a structured way. He had made tremendous
strides and had some skills he could use in the future, which
would surely be uncertain at best. It was difficult to reassure
him about how things would be. The social worker assured
us both that she would make a comprehensive transfer of
material, including my termination summary. She was also
determined to make sure that his therapy continued in Mis-
sissippi. Leroy went back to his mother stronger and a little
more self-defined and confident.
Johnny: A Child
Traumatized by
Sexual Abuse
Johnny was referred for treatment by a Child Protective

Services worker after an allegation of sexual abuse by an
unrelated male adult who boarded with the paternal
grandmother at the same time that Johnny and his mother
lived with her.
Johnny was nearly 5 years old at the time of the referral. He

was the only child of David and Maggie, who had divorced
shortly after his birth. David had been violent with both
mother and child and all ties between natural father and
child were severed at the time of the divorce. Maggie had fled
with Johnny to her mother-in-law, who had offered shelter.
Maggie's own mother and father had died in a car accident
when she was 11; she then had lived in a number of foster
106
Clinical Examples: Johnny 107
homes and had lived two years in a group home prior to

reaching majority age. It was during her stay at the group
home that Maggie had met David and become pregnant.
Their first child was stillborn, and Johnny was conceived two
years later.
David was the oldest of five brothers. He had been a ward
of the court since the age of 14, when he stole a car and drove
it across the state line to sell. David had spent most of his
adolescence in juvenile detention and group homes; he had a
long-standing drug-dependency problem.
Maggie called Child Protective Services (CPS) when
Johnny told her that Larry, the boarder, was hurting him.
Johnny told CPS that Larry had "hurt his bottom." A medical
exam revealed positive findings for a sexually transmitted
disease. Larry had fled upon learning that Johnny had been
taken to the doctor; the police found him, placed him under
arrest, and held him for a hearing. Johnny's paternal
grandmother was incredulous about Larry's involvement in
molesting the child. She knew Larry's parents and refused
to believe Johnny, seeing him as confused. She questioned
Johnny relentlessly, encouraging him to say that it was
"someone else" who had hurt him and that he had never been
alone with Larry. In spite of the grandmother's incredulity,
the district attorney charged Larry with lewd and lascivious
conduct with a minor under the age of 14, and a preliminary
hearing ensued. The district attorney had prepared Johnny
to testify, and it appeared the boy would be able to testify
about the abuse in a clear enough fashion.
At the preliminary hearing Johnny was articulate
enough to state that Larry had "hurt his bottom." Upon
cross-examination he was asked, "What did you do when
Larry hurt you?"; Johnny replied, "I stabbed Larry's eyes,
broke his knees, and pushed him off a mountain." Johnny's
case was dismissed because he was not seen as a credible
witness even though there were medical findings conclusive
of sexual abuse. There was little doubt that something sexual
had happened to the child, but it was difficult to ascertain
exactly what it was and who the perpetrator was.
Johnny had an array of problem behaviors. He had
nightmares and clung to his mother. He was suddenly
frightened of noises, new people, and of being alone. His

mother and caretakers were concerned witlvhis excessive
masturbation, his aggression, and his constant preoccupa-
tion with the devil. Mother and paternal grandmother had
both been perplexed by the latter; they denied ever teaching
Johnny anything about the devil.
Because Johnny's grandmother had refused to believe
his allegations against Larry, Maggie moved out of her house
and relocated in a nearby county. It was after this move that
she and Johnny were referred to me for treatment.
CLINICAL IMPRESSIONS
Johnny was a very attractive but disruptive 5-year old. He

was articulate and bright but unresponsive to limits and
found it difficult to contain his curiosity. When he entered
the office, his agitation elicited everyone's attention. He
opened doors into other therapists' offices, drank numerous
cups of water, crumpling up the cups and throwing them
everywhere, climbed the chairs, turned the music up, tried
to take fish out of a fish tank in the waiting room, and
generally created chaos.
Johnny's mother was ineffective and inconsistent. She
seemed mortified by his behavior and was alternately
threatening, helpless, and solicitous. She asserted that
Johnny's "terrible behavior" was new and had appeared after
he was molested by Larry. Prior to the molestation, she noted,
Johnny had been quiet and obedient. Mother was very eager
to have her son receive some help and to receive guidance
and support for herself as well.
The first few sessions Johnny entered and exited the
playroom every few minutes. He didn't seem able to tolerate
being alone with me. When he went to the waiting room to
verify his mother's presence, he usually did something to
elicit her concern, such as climb and fall, push the hot water
lever on the water fountain, or tear up some brochures in the
waiting room.
I quickly began to set limits. *Johnny, look. This is a
timer. We have 50 minutes together, and when the bell rings
it's time to leave/ I told him. "Let me see that/ he said,

grabbing the clock and resetting it. The third time he grabbed
it I put it up high and told him, "This timer stays here during
our sessions." He got mad at me and went running to his
mother. I came out and offered him my hand, saying "Come
and see the toys I have in my playroom." He would not take
my hand, yet he followed me as I turned my back and went
to the playroom.
The first two meetings I could not contain him. He took
down every toy from the shelves without looking at them. He
threw the toys down, scattering them all over the room. At
one point I said, "Johnny, the toys all have a place on the
shelves. Let's put them back." "No," he said decisively as he
ran out of the room.
It occurred to me that Johnny might want the door open.
Sometime during the end of the second session, I said, "Let's
leave the door a little bit open; that way you can look out and
know that you can leave if you really want." He responded
very well to the door being ajar and sat down to color. When
I asked him what his drawing was about, he yelled loudly,
"It's Larry, stupid." "What's he doing?" I asked. Johnny left
the room. By the third session he stayed in the playroom with
few interruptions. Every now and then he would take some-
thing out to his mother or ask to go to the bathroom.
Johnny had a short attention span. He changed from one
toy or type of play to another every 6 minutes or so. "Put this
back, stupid," he would say, handing me the toy he no longer
wanted. I put the toys back and noted that he had begun to
create a structure around his play, organizing a beginning, a
middle, and an end.
I met with Johnny's mother weekly. She described
Johnny's obsessive articulation about Larry and the devil.
She noted that this behavior exacerbated at nighttime;
Johnny was afraid to go to sleep, and bedtime was now the
center for conflict. Johnny wanted the light on and the door
open and came to her bedroom five to ten times a night.
About the third session I asked Johnny about his
dreams: "What happens after you go to sleep at night?" He
looked at me with wide eyes and spoke quietly: "The devil
comes to take me to his bosom."
"What's the devil look like?"

"He's red with horns."
"You know, Johnny, I have a little doll that looks like the
devil."
"No you don't," he challenged.
"Would you like to see it?"
"No." He seemed afraid.
"That's fine, Johnny. Here's a piece of paper. Draw me a
picture of the devil that comes at night."
Johnny took the paper and drew a picture bright with
reds and blacks (Figure 1). He was very purposeful as he
chose the colors for his devil picture, closing his eyes in
apparent deep concentration. When the picture was com-
plete, he rushed out to show it to his mother. "Mom, Mom,
this is the devil that comes in the nighttime. Eliana has a
devil too." I explained to the mother and Johnny that I had
FIGURE 1
a small figure of the devil in the playroom; I said that Johnny

and I had been talking about his scary dreams. Johnny
spontaneously said, "The devil has powers. Hell kill you too."
I kneeled down so I could make eye contact, looked at him,
and said, "Johnny, I know someone has talked to you a lot
about the devil and how scary he can be. I want you to know
that God protects us from the devil, and God will take good
care of you and your mommy now." "No, he won't," he said.
"God doesn't like bad children." I decided to be assertive and
stated firmly, "God loves good and bad children just the same.
God understands that the devil scares kids and makes kids
think they're bad. You and I will talk more and ask God to
help us fight off the devil, OK?" Johnny grabbed his mother's
hand, saying, "Let's go, Mom."
The next time he came Johnny again emphasized, "God
doesn't love bad children."
"What do you do that's bad?"
"Nothing," Johnny answered, "but I do bad things to
Larry."
"What bad things do you do?"
"I can't tell you."
"What will happen if you tell?"
"Larry will kill us."
"Who will Larry kill?"
"Me and my mommy."
"Did Larry tell you that?" I asked. He nodded yes. "You
know what Johnny?"
"Huh?"
"Larry is gone now. He won't hurt you or your mom. He
lives somewhere far away now, and he doesn't know where
you live."
"Yes he does."
"I don't think so," I said calmly.
"Your mom hasn't told anybody where you live so you can
be very, very safe."
"Larry can find us," Johnny said sadly.
"You're really scared of Larry."
"He hurts me."
"How does he do that?"
"He puts a stick in my bottom."
"He's wrong to do that. Grown-ups shouldn't hurt kids

like that."
"Kids are stupid," Johnny responded.
"Why, Johnny, why are kids stupid?"
"Because they can't make the bad things stop."
"Kids aren't stupid, Johnny. They're just little, and they
can't fight great big mean people." Johnny looked despon-
dent. "Look, Johnny," I said as I grabbed a large and a small
cloth doll. "This is you and this is Larry. What's the dif-
ference?"
Johnny started beating the big "Larry" doll with his fist,
saying, "He's big and tall. He has a beard."
"That's right. The grown-up man is big and tall. The kid
is little."
"He's bad," Johnny added.
"Yes, Johnny, when he puts a stick in your bottom and
hurts you, he's doing bad things."
"Yeah," he repeated, now turning the male doll over and
hitting the doll's buttocks with his fist.
"Is the kid bad?" I asked.
"Yeah, he's bad too."
"How come? What makes him bad?"
"I don't know," Johnny said as he kicked both dolls away.
"How much time do we have left?"
"Oh, about 25 minutes."
"I want to make some cookies with clay."
"Sounds good to me," I said. "We talked about Larry, the
devil, and scary things for a long time. We can make cookies
now."
Johnny came to the next session with a pressing ques-
tion. "Where is God?" he asked. "People say God is every-
where, watching over us," I stated. I made a mental note to
ask his mother about her religious beliefs and if and how she
had explained the concept of God to Johnny. He immediately
asked what God looked like. I told him everyone had a
different picture of God in his or her mind, and maybe he
could draw a picture of what he thought God might look like.
Johnny thought for a long while before choosing the yellow
crayon and making a large yellow ball that filled the page.
He then made a smile. Eyes were notably missing (Figure 2).
FIGURE 2
"God is strong and big," he said in a steady voice. "Yes,

Johnny, he is," I agreed. "He can't beat up the devil," Johnny
said, adding in a soft voice, "maybe sometimes."
I once again talked about nighttime dreams. "Remember
you told me the devil comes after you go to sleep." "Yeah,"
Johnny replied. "Maybe you can keep your picture of God
under the pillow and the devil might not want to come around
so much," I suggested. Johnny seemed intrigued by this idea,
yet he appeared troubled as well. "What are you thinking?"
I asked. "I want to make a copy on the machine," he replied.
Johnny had been very interested in the photocopy machine,
and I had shown him how it worked. When he made his
pictures, he would sometimes leave the original in my office
and take a copy home with him. It was clear that he wanted
to leave a copy of his God picture in the playroom. He also
made a second copy for the secretary, stating, "God is
everywhere. This is what God looks like." She had thanked
him and put the picture on the wall.
His mother reported that Johnny's nightmares had

decreased and that his devil talk was now usually concluded
with a discussion of God and God's powers. She said that
Johnny had stated that he wasn't really bad, that the devil
might have tricked him. "God knows I'm really good," he had
told his mother; she had agreed.
These themes of good and bad, devil and God, and being
watched and protected by God continued over time. Johnny
had periods of greater or lesser concern, and I asked his
mother to monitor his TV and movie watching. Scary movies
on TV usually caused regression: His insomnia and night
terrors resurfaced. I also asked his mother to keep her con-
versations about Larry out of Johnny's earshot (she would
sometimes become agitated talking to friends about what had
happened to her son and how her mother-in-law hadn't
believed him and how the courts had failed to prosecute
Larry.)
I turned my attention to Johnny's ongoing aggressive
behavior. He had continued to exhibit aggressive behavior
with children he knew and had been expelled from his pre-
school after a number of suspensions. His mother had taken
Johnny to four child-care workers, all of whom refused to
keep him, citing his relentlessly cruel treatment of other
children. Johnny was reportedly hitting, biting, kicking,
pushing, and yelling at peers; varied attempts to curb his
behavior had failed.
I raised the question directly with Johnny. "I hear that
you can't go back to Mrs. Jenkins's school anymore. How
come?" Johnny stated that his teacher was mean, the kids
were stupid, and he didn't like it there anyway. I asked again
what had happened that made Mrs. Jenkins ask him to leave.
Finally, he said, "I'm bad to the other kids."
"What do you do or say that's bad," I inquired. And he
honestly stated that he hit kids and hurt them. "Why do you
think you do that?"
"I don't know. I just want to."
"What do you think about it after you do it?"
"Nothing. Just...well, I'm bad."
"You know, Johnny, I want to help you stop hurting other
kids. Do you think we can work together on that?"
"I don't know/ he again answered honestly.

My hypothesis was that Johnny's aggression reflected
the following: He was manifesting anxiety about being hurt
and helpless; he was feeling potentially threatened in his
caretaking environment; and he was still struggling with his
confusion about good and bad: Bad people were powerful,
good people were weak and defenseless. He would usually
only attack bigger boys. When he elicited negative attention
and was punished for his badness, he might also have been
asking for limits on his bad behavior.
My first intervention was to talk with Johnny about good
and bad power. I explained that it was OK to be and to feel
powerful and strong. I specified that some people used power
in a good way and others used power in a bad way. I asked
him to help me come up with good and bad ways to show
power. Bad ways were clear to him. He listed the following:
"making people do what you want; hitting people; pushing
people around; biting people; kicking a dog; having millions
of dollars because then people do what you want." He couldn't
think of any ways to use power in a good way. When I asked
him to think about ways that being strong could help, he
arrived at, "carrying heavy things." I agreed. He then got up
and tried to lift a heavy box. "I'm really strong," he said. "I
can see that," I remarked as he carried the box out of the
room to show his mother. I told her, "This is a way that
Johnny can use his power in a good way." She smiled, under-
standing my meaning.
In the next few sessions I kept reminding Johnny about
good ways to use power. In fact, in one session we talked
about the kinds of power children have. "They can punch
people out," said Johnny.
"Yeah," I noted, "but littler kids can't punch out bigger
kids."
"Sometimes they can."
"Yeah, sometimes, but when it comes to punching out,
sometimes you win, sometimes you lose. Think about the
kind of power no one can take away."
Johnny drew, raced toy cars, and just before leaving he
said, "I know...I know...if I don't want to tell you something,
you can't make me."
"That's right, that's a power you have. You have the

power to keep your thoughts to yourself."
Once we had established this, Johnny came up with a
number of powers children have, including the power to have
their own thoughts, their own feelings, to use their own
words, to make choices, to go to sleep or stay awake. It was
interesting to note that when we talked about choices,
Johnny said "I can hit somebody or kick them." I added,
"Yeah, and you can hit somebody or not hit somebody."
Johnny's mother told me that the child-care worker had
called to describe a few altercations with Johnny and had
reported that, overall, Johnny was doing better and seemed
to be making an effort to do as he was told and avoid fights.
I brought BOBO, a punching bag clown, to the playroom.
It was not necessary to explain its use to Johnny. He imme-
diately delighted in hitting it and letting it bounce back for
yet another punch. He was tireless; the first time he saw the
bag, he spent his entire 50 minutes punching it. The punch-
ing had a random quality. Two weeks later, an opportunity
arose to alter this type of random release. Johnny came in
after having had a fight with a boy at his day-care center. "He
makes me mad," he said, charging into the playroom. "I hate
him."
"What does he say or do that makes you feel that way?"
"He pushes me around...he thinks he's so tough."
"What did you do with those feelings?"
"I hit him hard."
I pulled out the bag and asked him to pretend this was
the little boy and show him how he felt. He socked him with
a vengeance. Then I stopped him, asking, "Now put words to
your punch. If you were using your words instead of your
punch what would you say to him?" He instinctively made
fists and took some punches. "Don't use your hands," I
directed; "hold your hands together and think about punch-
ing Stevie out. What would you be saying to him with your
punches?"
Johnny yelled out, "I hate you," "You make me sick," and
"You're a big jerk" when I instructed him to talk about how
he felt. He looked at the bag and stated in a moderately loud
voice, "You make me feel mad; you hurt my feelings; you scare
me." When he made the last statement I asked some more
about feeling afraid. "What's scary about Stevie?" When
Johnny could not respond, I told him it was OK, that I wanted
him to think about it some more. To conclude I said, "Just
like it's not OK for you to hit Stevie, it's not OK for him to hit
you. When he hits you, he's doing a bad thing." "He's bad,"
Johnny punctuated. "When he hits you he does a bad thing,"
I corrected. I wanted to clarify the difference between being
inherently bad and doing bad things. Johnny had struggled
with self-recriminations about his own hurtful behavior.
Then Johnny corrected me, "Larry was bad and he did bad
things." I did not respond. I asked Johnny to think some more
about what was scary about Stevie. My guess was that what
scared him the most was the threat of being overwhelmed.
His strategy was to be pugnacious as a defense against the
threat.
I had met with Johnny for approximately 12 sessions.
The first part of the treatment had been purely reactive; we
had dealt with the behaviors that were causing the most
difficulty to those persons providing his care. Johnny's inter-
nal controls were not developed enough to cope with the
anxiety, fear, and sense of helplessness originating from his
trauma and elicited by normal interactions with peers,
caretakers, and his mother. I developed the following treat-
ment plan:
1. Play therapy with Johnny

a. Set limits on aggressive behavior in and out of
treatment.
b. Continue to discuss good and bad behaviors.
c. Discuss God and the devil as needed.
d. Teach appropriate and nondestructive ways to ex-
press anger.
e. Teach Johnny to verbalize feelings of anger.
f. Discuss and explain children's powers, particularly
about choice.
g. Discuss fears and anxieties and ways of coping,
h. Discuss sexuality.
2. Parent-child interactions
a. Help mother set limits with clear and reasonable
consequences.
b. Offer support and direct mother to support services
for parents of molested children.
c. Discuss mother's feelings of guilt about failure to
protect Johnny from molestation and her sub-
sequent anger at Johnny's grandmother.
d. Direct mother away from agitated and nondis-
criminatory recounting of the molestation.
e. Direct mother to provide concrete reassurance to
child regarding physical safety (e.g., new locks).
3. Coordination
a. Make contact with referring party, particularly to
discuss what type of information might be neces-
sary to prosecute this case anew.
MIDDLE PHASE OF TREATMENT
As his aggressive behavior seemed to decrease to the normal

range for a 5V2-year-old boy, Johnny became more verbal
regarding sexuality. He had, on occasion, taken a look at my
"anatomically correct dolls," exploring the bodies of the male
dolls. (He seemed uninterested in the female dolls.) He had
usually spent no more than a few seconds in exploration
before shoving the dolls away.
At this point in the therapy Johnny turned his attention
to the dolls, selecting the small male doll and undressing him
completely. He would then take his finger and insert it into
the anus of the doll and push inward. He said nothing during
this play, avoiding eye contact with me. He would then take
down the pants of the adult male doll, being careful to keep
them draped around the doll's ankles. He placed the small
doll on his stomach and laid the big doll on top. It was weeks
before he took the adult doll's penis and put it inside the anus
of the small doll. During this time his mother and caretaker
reported an escalation of his masturbatory behavior and
"dirty talk." I noticed that Johnny became very stiff during
this sexual play: He held his breath and appeared dissocia-
tive. His play had become fixed at the same instant as he

inserted the penis into the small doll's anus.
After I observed this sequence of behavior about ten
times, I decided to intervene. The next time he did the sex
play I commented, "Larry was wrong to put his penis in your
butt." Johnny looked at me extremely surprised. "I want to
tell Larry what I think," I continued. "Would that be OK with
you?" He acquiesced. "Larry, you were very wrong to put your
penis in Johnny's butt. That is a bad thing for a grown-up to
do to a child. You made Johnny feel lots of things. Like you
made him feel..." I hesitated and leaned over to Johnny,
whispering, "What did he make you feel?" "Mad," Johnny
mumbled. "Johnny felt mad at you, Larry, because you hurt
him and did something bad to him. You also made him feel..."
I repeated my cue to Johnny and he again mumbled,
"Scared." I talked to Larry in this fashion for quite a while,
and Johnny volunteered feelings such as hurt, confused, bad,
like crying, like lying, like running, pretending, and "like I
couldn't move."
In the subsequent session Johnny took down the pants
of the adult male doll and pulled on the doll's penis, attempt-
ing to elongate it enough to stick it behind his legs into his
own anus. These attempts were not successful, and finally
Johnny turned the doll around and inserted a small knife
that belonged to one of the toy warriors in the adult doll's
anus. "Put that into words," I advised him. Johnny said, "I
hate you. I want you to hurt. You feel bad." I affirmed the
feeling and not the behavior: "You are mad and want him to
feel the same pain you did. Tell him how you feel. Telling him
makes you powerful." He yelled insults for a while and
seemed satisfied to do so. He threw the Larry doll against the
wall, and without prompting he stated, "You were bad to hurt
me."
Child Protective Services (CPS) called me because one of
Johnny's friends told his mother that Johnny had pulled his
pants down in the bathroom. Apparently, Johnny had asked
to see his friend's privates, and when the boy refused, Johnny
forcibly pulled his pants down. "Johnny," I asked calmly, "did
you pull Max's pants down?"
"No," he stated angrily. "Who told you that?"
"Well, Max's mother found out about it, and she called
Mrs. Peters because she doesn't want anyone to hurt Max."
"I didn't hurt him," Johni^y said. "I could have, but I
didn't. I just wanted to see."
"What did you want to see?"
"I wanted to see his privates."
"Why?" I persisted.
"Because...."
"Yes?"
"Because I wanted to."
"Johnny, I want to make a deal with you. When you want
to see privates, or talk about privates, or touch privates, I
want you to come and talk to me about it. It's not OK to pull
kids' pants down, look at their privates, or touch their
privates, but we can talk about it together."
"OK," he said unhappily. After obtaining a signed release
of information form from his mother, I called the school and
told the teacher that I would like her to monitor his play and
not allow Johnny to go to the bathroom alone with other
children. She informed me that his being alone in the
bathroom with another child, which led to the GPS report,
had been an isolated incident. Johnny didn't forget my offer
to discuss genitals or sexuality. When he first asked to "see"
privates, I brought out a set of anatomical drawings (Groth,
1984) and showed him a nude picture of a young male child.
I made photocopies of the male child; Johnny asked for a
clean copy each week. As he looked at the drawings he
laughed, touched the genitalia in the drawing, and used
crayons to cover the naked body; afterward, he always
crumpled up the drawings and threw them in the garbage.
Eventually, Johnny asked if I had a drawing of the adult
male. I brought out some photocopies of an anatomical draw-
ing, and he noted that grown-up males have pubic hair. He
used a black crayon to cover the midsection of the adult male
figure and then made some red spots around the drawing.
When I asked him to tell me about the picture, he replied,
"Larry cut himself shaving." He smiled and said he was glad
Larry was hurt; then he punctured a hole in the drawing.
Johnny seemed to be releasing his anger at himself for being
unable to stop the abuse and at Larry for abusing him. I
usually ended the session by declaring that Larry had been

wrong to hurt him and it was not OK to touch or hurt other
people's privates.
Johnny was less aggressive in his kindergarten class and
in the day-care program after school. He was not, however,
an easygoing child; his deportment was oppositional. As his
teachers put it, "if you say it's warm, he says it's freezing."
This trend was apparent in the therapy sessions. It was
critical for Johnny to be correct about everything and have
his way all of the time. He claimed to have done everything
from skydiving to playing hockey with Prince Charles. His
mother found this particularly annoying and frequently ac-
cused him of being a liar.
This need to be unconditionally in control seemed to be
Johnny's way of managing any feelings of anxiety or help-
lessness. Although he no longer beat children up or over-
powered them physically, he frequently engaged in verbal
altercations; as a result, children did not seek him out, and
he frequently felt isolated and rejected. These feelings
caused him to cultivate a number of defenses including an
unyielding stance in which he declared that he liked no one
and did not care if anybody liked him or not. Since his social
interactions had become so onerous and elicited a consistent-
ly disapproving response from others, I decided to put
Johnny in a group for little boys with acting-out behavior. He
was initially very resistant to attending; by the third session,
however, he had developed a camaraderie with the other five
boys in the group and seemed to look forward to more meet-
ings.
The group provided Johnny with an opportunity to make
contact with other boys his age who had been molested.
Johnny announced to me, "Bad things happened to those kids
too" when he came to his first individual session following
the group meeting. The children were allowed and en-
couraged to talk about their molestation, asking questions
and dealing with specific issues of concern to boy victims,
issues like helplessness and homophobia. The children
shared generalized fears and anxieties as well as some com-
mon problems, such as the struggle to be strong and power-
ful. In addition, all the children benefited from some explora-
tion of their self-image, self-esteem, aggression, and

sexuality. While they had prematurely learned what was not
all right regarding sexual touching, the group leaders
provided information about safe and appropriate touching.
When conflicts arose in the group, they were addressed
quickly. The boys soon quickly bonded and the results were
immediately visible in individual therapy. For example,
Johnny asked quite simply, "How do you get gay?" Apparent-
ly, even at his young age, there was some concern that being
molested might indicate homosexuality. I referred the ques-
tion back to the group and consulted with Johnny's mother
and the group therapists about a response we could all agree
on. The decision was to tell Johnny that no one "becomes" gay
because of having been hurt as children; also, children don't
get selected to be hurt because of any special reason.
The first year in therapy consisted of addressing themes
of aggression, sexuality, social and peer interactions, the
victim and perpetrator dyad, helplessness, and empower-
ment. Johnny had developed a number of defenses to cope
with peer rejection that reinforced his feelings of being stig-
matized.
An unexpected event altered the course of treatment.
Mother had decided to send Johnny to a friend of hers for the
holidays. (This friend had a child Johnny's age, and the two
children had developed a strong relationship during the
school year that was interrupted by the friend's move to a
nearby city.) During the visit an unrelated male adult, also
spending his holiday with this family, raped Johnny in the
middle of the night. The mother called me in despair before
picking Johnny up at the airport. Johnny had called her the
morning after the abuse and told her what had happened.
The family was unaware of the reason for Johnny's sudden
decision to return home early, and his mother wanted to see
Johnny before telling them more. The rapist had left the
house early in the morning.
Johnny was taken directly to the hospital where physical
findings were conclusive of sodomy; numerous internal and
external injuries confirmed the fact that Johnny had been
beaten by the rapist. Immediately following the medical
exam, Johnny came to my office. He went into the playroom,

grabbed a large stuffed rabbit, and, uncharacteristically, lay
on the pillows. He was physically and emotionally fatigued.
"I'm so sorry you were hurt," I said. "I can see you want to
rest...ril sit here beside you...If you want to talk, I'll listen."
He closed his eyes and seemed almost asleep, and I sat next
to him quietly, sharing his pain and fatigue.
The next four months in treatment were unlike any other
sessions with Johnny. He was quiet, physically still, and
unresponsive. His eyes drooped considerably and he always
entered the room and lay down. He was totally shut down.
The bruises on his arm had begun to disappear, but his
internal scars were quite apparent. Everything gained had
been lost. It was a time of despair. Any and all attempts to
interact with Johnny were futile. He was uninterested in
contact with me, his mother, or the environment. He needed
help to stand up, open the door, and find his mother. He was
severely depressed and slept a great deal. He lost 10 pounds,
which contributed to his frail appearance.
I decided to take Johnny out of the office. We went to the
park and although he wouldn't get on the slide or swings, we
walked around the park hand in hand. I stopped to get some
popcorn for the ducks and noted that Johnny would eat some
without prompting. He seemed to enjoy the park, and I asked
his mother to try to do some outdoor activities with him, even
if he claimed he'd rather stay inside. Mother was unable to
get Johnny to go out to the park; since the rape Johnny had
been both distant and hostile toward his mother. My inter-
pretation of this was that Johnny felt angry that his mother
had failed to protect him from the rape. The twice-weekly
outdoor sessions were very successful. Johnny became less
physically constricted, eventually running and skipping. He
would run ahead of me, more each time; eventually, he played
hide-and-seek and did not appear anxious. He climbed trees
and reveled in his flourishing physical prowess.
Approximately 4 months after the rape Johnny's mother
attended a court hearing, and the rapist was convicted and
sent to jail. Johnny proudly proclaimed that "that man has
to go to jail. I hope they kill him in jail."
"You're glad the judge sent him to jail," I said.

"Yeah, and now I hope they'll kill him."
"You want him to get hurt the way you were hurt."
"Yeah. I want someone to hurt him."
"He was wrong to hurt you, Johnny."
Johnny seemed to want to stay in the playroom, and the
Larry doll was now used interchangeably with the "that man"
doll. Johnny would bring the doll down from the shelf, climb-
ing on the sand tray to bring it down himself. He would put
the doll behind a chair or hide it under pillows. "He's in jail,"
he would declare and then throw gorillas, soldiers, dinosaurs,
and Ninja Turtles to hurt "that man." "We can't let him out
yet," he would whisper. Sometimes he would leave the doll
buried from week to week; other times he would return the
doll to the shelf before leaving. Often he would ask, "Is Larry
in jail too?" I honestly didn't know. Sometimes he would
repeat that "Larry was bad" and hurt him when he was
"really little." When I asked if he remembered how Larry had
hurt him, he said he couldn't remember anymore. He often
said that Larry was a "son of Satan" and had "real powers
even God can't stop." When Johnny became frightened at
night, he would usually verbalize a special fear that Larry
might come and "kidnap [him] to a very dark place where no
one would ever find [him] again."
DISCUSSION
Johnny was a victim of repeated trauma and suffered from

symptoms of posttraumatic stress disorder, including
emotionality, nightmares, physical sensations, fear and
anxiety, and intrusive flashbacks. These symptoms were
manifested by a profusion of behaviors: aggression and
sexualized behavior, clinginess and regression, expressed
conflict between good and bad (Lucifer and God), and an
impaired self-image, including a sense of inherent badness.
The first rape had done severe damage, which was exacer-
bated by a repetition of the same trauma 12 short months
later. Johnny's increased sense of well-being and control
was greatly diminished by his inability to protect himself

from the second rape. His hypervigilance increased and was
accompanied by a deep sense of depression and hopeless-
ness.
Fortunately, the therapeutic relationship was well es-
tablished by the time of the second rape. Johnny was able to
come to the therapy sessions and regress without concern for
me. This phase of treatment was reparative and focused on
Johnny's physical and emotional healing. The first rape had
shocked and frightened him; the second one devastated him
and generated feelings of futility.
Johnny had periods of time in which he felt and acted
helpless. In response, I encouraged autonomy, assigned tasks
that could be easily completed, and took Johnny for outdoor
sessions, helping him to build physical strength and dex-
terity by walking, running, climbing.
There were other phases of treatment when Johnny
exhibited sexualized and aggressive behaviors toward other
children. To assist him in these unrewarding exchanges,
which elicited negative and rejecting responses from others,
I had his mother bring him to group therapy. In this small,
controlled environment his interactions could be carefully
monitored, and the interventions from the therapist were
consistent and appropriate. The group experience focused on
teaching and rewarding positive behaviors and boosting
Johnny's identity and self-esteem. Within the group setting
the therapists also taught group members about sexuality
and types of proper touching between children.
Lastly, the relationship between Johnny and his mother
remained afflicted and complicated by the mother's discovery
of her own sexual abuse, her ambivalence toward her son,
and her guilt for failing to protect him.
The course of treatment included individual therapy,
group therapy, family therapy, and two "breaks" from
therapy. The first break was during the summer months; the
second was related to significant progress in Johnny's social
behavior and his now stable enhanced sense of self. There
were periodic regressions. Johnny had appendicitis and the
sense of helplessness he experienced during his recovery
from surgery invoked memories of the rape and his sub-

sequent feelings of physical and emotional fragility. His
recovery was slow, fueled by his mother's solicitous behavior.
In addition, anniversary dates for the rapes, sometimes con-
sciously acknowledged, summoned dysphoric feelings and/or
acting-out behaviors.
Antony: A Child
with Multiple Traumas
Antony was referred for treatment by his social worker.

Antony was physically and sexually abused and neglected; a
dependent of the court, Antony lived in a specialized foster
home.
Antony, a Hispanic child, was 9 years old at the time of
referral. He was one of five children, all of whom had dif-
ferent fathers. The three younger siblings had been released
for adoption; Antony and his 15-year-old sister, Sarah, were
in separate long-term foster homes.
Antony's parents, Jose and Lupe, had a fleeting relation-
ship that ended abruptly when Jose was shot during a drug
transaction. Lupe had numerous brief encounters; her
children never had contact with their respective fathers.
127
Lupe had been drug-dependent since she was a

teenager. She was sexually abused by her father and ex-
pelled from her family when she disclosed this fact; she had
been called a slut by her mother and older sisters and told
never to return to the house. She told the social worker that
she had then stayed with some girlfriends off and on and
eventually met a man who took her in, fed her, bought her
clothes, and seemed to ask little in return. Unfortunately,
the man turned out to be a pimp, and Lupe was introduced
into the "working life" on the streets of Los Angeles. Lupe
claims that her first encounter with marijuana was with a
"trick* who offered her a quick high. She found that being
stoned allowed her to go numb, a sensation she very much
enjoyed. Since that time she had smoked marijuana daily
and in the last 2 years had become a multiple-drug user,
trading sex for drugs.
In spite of the drug dependency and prostitution, Lupe
was able to provide sporadic marginal care for her two older
children. She had occasionally been able to pay rent and live
with her children, and some of her friends had offered them
temporary respite. She had always wanted children and held
firm to her assertion that she loved them all very much;
releasing her small children for adoption was viewed by Lupe
as her most noble gift to them. She had a tubal ligation
following the birth of her last child, who was born with
massive brain damage due to Lupe's drug use.
Lupe has entered drug treatment programs cyclically.
She is currently in a state-funded residential drug rehabilita-
tion program, and her prognosis is guarded. She has had less
than three visits with each of her elder children in the last 2
years. Sarah has been in the same foster home for the last 4
years, and she has made a good adjustment to her foster
parents, who have expressed an interest in adopting her.
Lupe has been reluctant to release this child, her firstborn,
for adoption.
Antony's experience in foster homes has been unstable:
He has been in approximately eight different foster homes.
He was also considered for adoption at one time, yet Lupe
was reluctant to release him for adoption as well; no steps
were taken to terminate parental rights. Antony has had a
Clinical Examples: Antony 129
range of troublesome behaviors n foster care; some of his

transfers were precipitated by requests from the foster
parents.
When treatment began, Antony had been transferred to
a "specialized" foster home after stealing some money in his
foster home. The social work department viewed the child's
stealing as a "child failing placement," and requested
therapy for Antony's "acting-out behavior."
Antony was a small, shy boy with constricted movement and
flattened affect. He said little, moved slowly, and seemed
resistant to being in my office; his foster mother stated that
he had locked himself in his room, refusing to come to the
session. Antony had acquiesced to come out of his room and
come to therapy because she offered him a dollar's worth of
quarters for the video machine near the house.
I had met with the foster mother, Mrs. R., prior to the
appointment with Antony. She described Antony as a quiet,
shy child who seemed to be "totally shut down." She reported
no problems at the time of our meeting, adding that the social
worker had cautioned her that Antony is always at his best
when he first arrives at a new foster home. Mrs. R. stated
that Antony would not eat during mealtime but raided the
refrigerator constantly. His sleeping pattern seemed erratic;
often, she would awaken at night to find him listening to his
radio or reading some comic books he had brought with him.
He seemed to have a particular penchant for superheroes,
not uncommon for children his age.
The most difficult problem she noted was Antony's
hygiene: He played hard, sweating profusely, and refused to
take showers. In the 2 weeks he had been with her, he had
taken one shower and then only when he was offered a
reward. He took his dirty clothes out of the clothes hamper
and wanted to wear the same clothes 3 or 4 days in a row.
Mrs. R. had not forced him to change and had asked for
suggestions regarding this behavior. I told her that she was
doing the right thing by not insisting that Antony bathe or
change and that I would give her some advice as soon as I

met with him and got to know him a little.
Mrs. R. had been a specialized foster parent for 4 years,
and her home was licensed for four children who required
special attention. When Antony was placed with her, there
were two smaller girls in the home. Antony had reportedly
displayed some aggression toward boys in other settings but
seemed protective of girls.
THE BEGINNING PHASE OF TREATMENT

Antony did not display any acting-out behavior initially. The
social worker had reiterated her observation to me that
Antony always made a very good first impression and
developed difficult behavior later on.
At first, Antony was quiet and lethargic; he entered the
playroom displaying little interest or enthusiasm. He asked
nothing and picked out a book to read; he read continuously
for most of the session, hardly interacting with me. He spoke
few words, did not make eye contact with me, and did not ask
to play with any of the toys within reach or on the top shelves.
My only comment to him was, "I am someone kids can talk
with and share their thoughts and feelings with." I added,
"Lots of kids don't like coming here at first." I had explained
that the bell on the timer would ring when it was time for
him to leave. He seemed oblivious when the bell rang, ap-
parently impartial about leaving or staying.
I decided to be nondirective with Antony. He had ex-
perienced numerous placements and had encountered an
assortment of new environments and caretakers. According
to the social worker, he had been interviewed myriad times
by police and by personnel of the child protective services
agency. Some of his foster parents had remarked with disdain
that Antony "never gave anything back, except trouble." He
had been labeled "uncooperative, capricious, and selfish."
Apparently, his caretakers had expected a reciprocal
relationship, and Antony was not motivated to socialize.
My nondirective approach was respectful of Antony's
attachment disorder. I did not expect him to trust me or be
interested in yet another short-lived relationship. My job

was to become trustworthy and to become consistent in his
life.
Weekly appointments were unremarkable for the first 3
months. Antony would bring books to read to himself, play
quietly with small cars that crashed into each other, listen
to music on a Walkman, and generally ignore me. I sat nearby
on the floor and engaged in parallel play. Sometimes I read
or colored or took small cars off the shelf to examine. I noted
the position of power he retained throughout the sessions. I
could understand how caretakers had difficulty with his
apathetic yet provocative behavior.
During the fourth month of treatment, Mrs. R. was
hospitalized for emergency surgery, and her sister moved in
as temporary caretaker. This event engendered the first shift
in the therapy. Antony came into the playroom with a sense
of urgency; he sat on the big pillows and crossed his arms in
front of him. "I hate her," he announced. "You hate who?" I
inquired. "Rosa—she thinks she's in charge of me, but she's
not. Nobody's in charge of me. Fuck that bitch." I had never
heard Antony speak so much, and with so much affect. I was
very pleased.
"You don't like Rosa telling you what to do."
"Hell no. And if she doesn't chill out, I'm going to show
her what's what."
"What are you feeling right now, Antony?"
"I'm pissed."
"What are you pissed about?"
"Rosa. She thinks she can make me do stuff."
"What did she say or do that made you feel pissed?"
"She says I got to wear a clean shirt to school. I don't like
doing that. I feel like a wimp when I'm all clean."
"What do you usually do when Mrs. R. is home?"
"She lets me decide."
"Maybe Rosa doesn't know."
"She won't listen to me. She thinks she's so smart."
I took a big risk. "Antony, let me have Rosa come in here
for just a few minutes, and let's see if we can get this worked
out."
"Hell no. I'm outahere if she comes."
"Antony. You don't have to do or say anything. Just let

me see if I can help her understand."
"She won't."
"OK. Let me try."
I walked out of the playroom and spoke to Rosa, telling
her that I understood how difficult it must be to be worried
about her sister and to take care of these children who missed
her. She teared up and said she thought she was in over her
head. I offered to meet with her the next day if she could
arrange child care for the younger children. I asked if she
was aware that Antony was angry; she was not. He had been
very sullen about something, but she wasn't sure why. When
I explained about the shirt, she remembered the incident in
the morning but was unaware of the significance the incident
held for him. I was eager to facilitate a positive exchange
between Rosa and Antony.
We all sat down and I said, "Antony is angry because he
wants to decide what to wear to school." Rosa spontaneously
said, "Antony, I'm sorry, I didn't know you could decide...the
shirt looked a little dirty to me. I didn't want you to be
embarrassed at school." Antony sat, arms crossed, silent.
"Antony is really good at listening and paying attention. He
doesn't always use words to express himself," I told her.
"I know how that can be," Rosa added. "I get shy myself
with people I don't know."
I took the opportunity to say to Rosa, "It must be so hard
for all of you that Mrs. R. is in the hospital. You must be
worried." "She's going to be fine," Rosa responded, "It was
just so sudden." "I don't like surprises myself," I said, "and
for the children it must be twice as hard, because they've had
lots of surprises in their lives."
Rosa left and Antony blurted, "She was nice 'cause you
were here."
"Well, I'm glad you don't have to be angry about your
school clothes anymore."
"I wouldn't have put them on anyway."
"Anything else you might be angry about, Antony?"
"No."
He took down the cars and crashed them into the walls.
By the time he left his body was less tense. Surprisingly he

said, "See you next week."
From that session on there was verbal dialogue—never-
theless. Mrs. R. was out of the home for 3 weeks, and when
she returned a live-in nurse provided assistance. When Mrs.
R. came home, she brought the children little presents. An-
tony brought in his present: a game of Chinese checkers. It
was brand-new and, apparently, the first brand-new toy he
had ever had: He delighted in telling me that it had come
with a plastic wrapper and that he had torn it off himself. He
played intensely, concentrating on every move. He was proud
when he won and eager to play again when he lost. His losses
were infrequent.
Although there had been a shift in the therapy when
Antony was able to talk to me about his anger, he continued
to constrict the expression of his feelings. I used a set of cards
that had illustrations of faces demonstrating a wide range of
feelings. I thought that Antony might be able to select the
cards depicting feelings like those he had about people or
situations, and I was impressed by his ability to use the cards
in a variety of ways. I brought in the cards in their wrapper
and told Antony I had just gotten something new in the mail.
He was intrigued and opened the box. At first, we played by
picking a card and telling each other about a time we remem-
bered having the feeling depicted on the card. Later, I would
ask Antony to communicate using the cards. For example, I
inquired, "When Mrs. R. went to the hospital, how did you
feel?" He picked three cards: "Mad," "Sad," and "Disap-
pointed."
"I remember how angry you were when you came to see
me the week Mrs. R. went to the hospital. You remember
that?"
"Yeah."
"You were mad because Rosa made you wear your clean
shirt that day."
"That's right."
"What else do you think you were angry about?"
"My foster mom going to the hospital." It was the first
time he'd ever called her mom. He had become attached to
Mrs. R., perhaps responding to her gentle, nonintrusive

approach.
"I understand being mad about that, Antony.* He
reached his tolerance level and brought out the Chinese
checkers.
Treatment Plan
1. Be consistent; become trustworthy. Avoid cancella-
tions or rescheduling.
2. Be nondirective: Give Antony a sense of freedom; don't
intrude.
3. Assess for underlying depression.
4. Document play themes and sequence of play.
5. Introduce nonintrusive interactions, parallel play.
6. Assist in the expression of feelings.
7. Long-term goals: discuss feelings about biological
family; father's shooting; siblings' adoption.
8. Meet monthly with Mrs. R. or as necessary.
9. Stay in touch with social worker regarding the foster
placement, mother's treatment progress, and any
reunification plans.
THE MIDDLE PHASE OF TREATMENT
The "feeling cards" remained an effectual means of com-

munication between Antony and me, and other techniques
became useful as well. Antony discovered the puppets and
storytelling: He would crawl behind something, hold his
puppets high above himself, and tell stories rich with sym-
bolism. One of his favorite stories follows:
RABBIT: Welcome to my land of surprises. Many things happen

in this world. But I can't say more. Someone's coining. I've
got to go.
SPIDER: Well, I've got some surprises in store. I'm a tarantula,
and I have strong poison, and I come up behind someone
and attack quickly. Death is quick. No one knows what
causes death. I surprise them all with death. I have much

deadly power. I run fast, and no one knows how to catch me.
Just watch.
TEDDY BEAR: Ho hum, what a nice day. The sun is out; the sky
is blue. Honey's in the tree. Yum, yum. OUCH! WHAT WAS
THAT??? THAT HURTS. (He falls down dead.)
SQUIRREL: Ho hum, what a nice day. The sun is out, the sky is
blue. Nuts are in the tree. Yum, yum. OUCH! WHAT WAS
THAT??? THAT HURTS. (He falls down dead.)
RABBIT: You have to be really careful around here. Even
though you can't see it, there are dangers all around. I've
had to take great precautions. See my muscles. I've had to
pump myself up. I stay away, 'cause I always know just
when to take off. And now's the time.
There are several themes of relevance in this story. There

is a perceived but camouflaged danger. The danger, symbol-
ized by the spider, is lethal and attacks quickly. The spider
enjoys the power of killing and seems to select vulnerable
targets (symbolized by a squirrel and a teddy bear).
Although Antony's stories always reflected a dangerous
environment and potential death, in the middle phase of
therapy he developed the rabbit character, who always told
the story and always managed to escape. The rabbit was
always hypervigilant, always resourceful, and intent on
developing physical strength. This was a good prognostic
sign and marked Antony's switch from learned helplessness
to an increased sense of empowerment. Also, the stories
reflected optimism, not futility.
Throughout the middle phase of treatment the rabbit
continued to appear in sundry stories, and he encountered
earthquakes, floods, and other catastrophes. He always es-
caped, sometimes just in the nick of time. His physical
strength enabled him to leap great distances, fight numerous
adversaries, and climb steep mountains. Concurrently, An-
tony was on a soccer team with a winning record, and he was
exhilarated by his indisputable skills in kicking, running,
and manipulating the ball. His self-esteem and confidence
were greatly enhanced by the fact that his teammates
heralded him for his propensity for making goals, and Antony
greatly enjoyed winning. Moreover, Mrs. R. attended every
game, a fact that did not go unnoticed by Antony.
Antony continued to avoid verbalizing his feelings. At
the same time, he was most receptive to communicating
through other means. I would often draw a figure of a man
or woman with a circle above them, as cartoonists do with
their characters' dialogue. "Who is this?" I would ask Antony,
and he would volunteer names, such as those of his foster
mother, his teacher, or a girl he liked. He would sometimes
direct me to draw a new figure of a "kid in a karate suit," and
he would then speak through this character. One day I drew
a woman with a smaller figure at her side. "This is you, and
this is your mom," I said. I sat back and commented, "I
wonder what you would say to your mom and she would say
to you." He filled in the cartoon mother's circle with: "You
sure are strong." He left his blank. The topic of his mother
was tremendously onerous for Antony.
During one memorable session, I told a story about a
mother squirrel and her baby squirrel. The story consisted of
a mother squirrel who very much loved her baby and yet was
always leaving him behind, citing work responsibilities and
urgent appointments that had to be kept. The little squirrel
was very confused. How could a mother who loved her baby
leave him alone? "No way," Antony said, "she's full of ex-
cuses." Antony had both a fear of discussing his mother and
a wish to do so. The symbolism allowed the distance he
wanted and needed. "I don't want to talk about this
anymore," he said. He abruptly began kicking the punching
bag. My opening was made.
The next session I had placed the baby squirrel under a
pillow. "Look," I told Antony, "the baby's feeling really down.
He misses his mom so much." "I know," he said, "let's make
her come back." "OK," I agreed. (I would follow his lead on
this theme, no matter where he wanted to go.) He got the
mother squirrel and brought her out. "OK, OK, quit your
balling," said Antony in a high pitched voice as he took the
mother to the pillow. "You need to take care of yourself; I
won't always be around." I jumped in and asked Antony what
the baby should say. He whispered what I should make the

baby say, and I relayed his message: "Mom, I'm too little to
be by myself." The mother was harsh as she said, "No you're
not. You're a boy. You've got to be tough. If you're not tough,
other guys will hurt you and make mince pie out of you." I
asked him how the baby would respond and he didn't know.
I whimpered and had the baby squirrel say, "Mommy, please
don't leave me. I want you to be with me." Antony threw the
mother squirrel into the wall, and the role play abruptly
ended. I waited. Antony went to the corner and sat there,
holding his face in his hands. He seemed to be crying, and I
didn't want to do or say anything to deter his first show of
appropriate sadness at the loss of his mother. Finally, he said,
"Why can't my mom take care of me?"
"Why do you think?" I asked softly.
"She can't stop taking drugs."
"That's right," I said, "and because she's on drugs she can
barely take care of herself, let alone take care of you."
"Shit...why is she so stupid?"
"It's OK to be angry at her, Antony. You want her to be a
mom to you."
"She's so stupid," he went on. "She meets these
dopeheads and brings them home. They pay her to have sex
with her. It's gross." I had always suspected that Antony had
witnessed his mother's prostitution; he had been overheard
making explicit sexual comments to other children. "You
worry she might get hurt, huh?"
"Once," Antony gained momentum, "a guy was beating
her up, and I took a bottle and broke it over his head. Then
my mom and I got away."
"You've taken care of her sometimes, Antony."
"Can we go out?" he asked.
"Sure," I responded. "I know it's hard to talk about your
mom...you have so many different feelings about her."
After this session talking about his mother was easier
for Antony. When he wanted to say or ask something or ask
about her, he would grab the small squirrel. "Do you think
she thinks about me?" he asked sincerely.
"I'm sure she does."
"Will I ever live with her again?" he asked another time.

"I honestly don't know/ I told him. "It depends on
whether she can get off the drugs and learn to take care of
herself."
And still another time he asked, "How old do you think
I'll be when I get to live with her?" I was sorry to give him
yet another "I don't know" answer.
Since Antony had opened the door, I approached him
with an idea early in one of our sessions: "What would you
think about writing a letter to your mom?" He seemed defen-
sive as he asked what I meant. I explained that it would be
possible for us to work on writing a letter together, and he
could then decide if he wanted to mail it to her. I had recently
contacted the social worker, and I was aware that Antony's
mother was reportedly making progress in the rehabilitation
program she had entered after a detoxification program. The
social worker had been quick to caution that his mother
usually made progress early in the treatment. We had dis-
cussed the fact that if the progress continued, we might
arrange a phone or face-to-face contact between Antony and
his mother, supervised by me.
The possibility of Antony having contact with his
mother seemed somewhat realistic. Antony had made great
strides himself. He was more communicative, expressing
some of his feelings. He had made a good attachment to his
foster mother, and he was involved in a soccer team at
school. His aggressive behaviors were on the decline, and he
had improved his personal hygiene. Most important, he
relied on the therapy and used it to his benefit, frequently
bringing in questions and concerns. He would always tell me
about altercations with friends and/or teachers at school;
likewise, he would bring in school papers and report cards,
proudly showing areas of improvement. Antony was
responding well to the continuity provided by his foster
placement, his therapy, his karate lessons, and other ac-
tivities promoted by his foster mother, such as Sunday
school. He had made a friend, he had lost 8 pounds, and he
bathed every other day. In addition, Mrs. R.'s dog had pup-
pies, and one of them had been given to Antony as a reward
for his cooperative spirit and his helpful attitude around the
house. It was clear that a special bond had developed be-

tween Mrs. R. and Antony, perhaps inspired by their shared
cultural background.
I wondered if Antony's progress would be impeded if
there were contact between Antony and his mother; his sense
of well-being was newly found and fragile. Although positive
changes had occurred, sustaining them over time was uncer-
tain. If Antony could use his new skills and apply his new
confidence to challenges, disappointments, and difficulties in
the future, he would be fortified by his strengths rather than
devastated by life's difficulties.
Antony thought long and hard before deciding to write a
letter to his mother, and he approached the piece of paper
with visible trepidation. Several times he simply stated, "I
got nothing to say." I encouraged him by saying, "I'm sure
something will come to you." His first letter was painfully
brief, and yet he seemed anxious to try again. The first letter
read as follows:
"Dear mom. How are you? It's been a long time. Maybe
you can write. Antony."
The second letter:
"Dear mom. How are you? I think about you. I hope you
are eating good foods."
And the third:
"Dear mom. I think about you sometimes. How are you
doing?"
Antony did not persevere. He was uninterested in con-
tact with his mother. His mother, however, encouraged by her
drug counselor, decided to write a letter to Antony. He
brought the letter to me 3 weeks after receipt. "My mom sent
me this letter."
"Oh," I responded. "What does she say?"
"I didn't read it yet."
"I see," I responded, again proceeding with extreme cau-
tion. "Do you think you might read it sometime?"
Antony responded without hesitation, "I want you to
read it."
I remarked, "You want me to read it to you." He turned
away from me and mumbled a positive response. I opened the
letter and read aloud:
Dear Tony:
It seems so strange to be writing you. I close my eyes and
think of you as you were when I last saw you. I am happy
to hear that you are doing well in your foster home. I
have called and talked to the social worker and she says
you and Sarita are doing good. That is what I want for
both of you. I am just learning about me and how to stop
making the mistakes I have in the past. One thing I want
you to know is that I never stop loving you and hoping
your life can be better. I do want to keep getting clean
and sober. After that, I hope maybe we can talk, or meet
to say hello. I know I have a long way to go and I hope
when you think of me you have forgiveness in your heart.
I find that praying to our God helps me forgive. I hope
you will turn to God too. If you can, send me a picture of
you. I want to see how big you are now.
Your mother
I folded the letter and held it, waiting for Antony to say
something or turn around. I heard a sniffle, and he touched
his face. He was holding some little cars and handed me one
asking for a race. We played with the cars for a while, and I
waited for him to say something. He did not.
The session passed slowly. Antony was obviously af-
fected by the words he heard, but he would not comment.
When the bell rang, I handed him the letter saying, "Thanks
for bringing it here and letting me read it to you, Antony.
Maybe next week you can tell me how you felt hearing from
your mom."
The next session he brought a letter he had written to
his mom and a school picture he wanted to include. His letter
was brief and moving:
Dear Mami:
Thanks for writing me. I think of you sometimes too and
I am happy you are not using drugs now. If you learns
how to stay away from the drugs—at school they teach us
to Just Say No—maybe someday we can see each other.
I play soccer very good now and in the picture I have my

uniform on. I do pray some nights.
Tony
He wanted me to correct his spelling; and there were just

a few minor errors. He copied the letter to a new piece of
paper, and we called the social worker to get his mother's
address. We walked to the corner, and when Antony put the
letter in the mailbox, he looked happy.
The following week Antony greeted me and stated, "She
hasn't written me again."
I said, "How will you feel if she does?"
Antony responded, "Like it, I guess."
"And how will you feel if she doesn't?"
Antony shrugged his shoulders. "She probably won't."
"And if she doesn't, how will you feel?"
"I don't care," he said quickly.
I took his hand to get his attention and stated, "Antony,
it's OK to want something to happen. If it doesn't, you might
feel disappointed, angry, or sad. That would be normal.
You've been disappointed by your mom a lot."
He didn't pull away and said, "Yeah." Then he asked, "Do
you think she'll get off the drugs?"
I answered honestly: "It's a very hard thing to do, and
your mom has been on drugs a very long time. We can all hope
for the best, and pray for her, but I don't know if the treat-
ment will work or not."
"I know. She's been in lots of programs before."
Antony was in treatment for another 8 months following
the sessions just described. He began wanting to do other
things after school and asked me if he could go to soccer
practice or football practice instead of coming to see me. I told
him that it was all right with me, since so many things had
changed for him and he was no longer having the kind of
problems he had before.
I asked him if he thought anything could happen that
would make him feel bad or angry or sad and make him feel
like coming to see me again. He said, "If I had to go live with
someone else" and added, "If I had to go live with my mom
again." His mother had not made contact again, and Antony
seemed to reconcile himself to not expecting anything from
her in order to avoid the disappointment that could follow.
As soon as he told me these things he looked up and said, "I
can come back if I have to, right?" It was as if he wanted to
make sure I wasn't going anywhere. "Of course," I responded.
"You have my number and can call me anytime."
We had four termination sessions, in which we reviewed
Antony's drawings and talked about all the different things
we had discussed and the different ways we had communi-
cated feelings. We also talked about his resources in the
future and who he felt he could turn to if he needed help of
any kind. He named Mrs. R., his soccer coach, and his friend
Pablo from the team. Antony had clearly formed some posi-
tive attachments. Mrs. R. was a long-term placement, and
chances were that Antony would continue in her care until
majority unless something unforeseen occurred.
DISCUSSION
Antony was a victim of physical and sexual abuse and
neglect. The specifics of his abuse never surfaced during
therapy. He was referred because of his alternately depressed
and aggressive behaviors. This child had suffered great in-
stability during his formative years and had experienced few
positive attachments or consistency. He seemed unmotivated
to socialize with others, and his poor hygiene might have
been a way to isolate himself from others.
During the course of treatment numerous significant
events occurred. Antony formed a strong affinity for Mrs. R.,
his foster mother, and she was tender and affectionate with
him. She signed Antony up for the soccer team at school and
took him to Sunday school at her church. Antony thrived
physically in soccer and enjoyed being part of a team. He also
showed a quiet interest in Catholicism.
In treatment, Antony learned to identify his feelings and
express them. Although he could not express them verbally
at first, eventually he learned to communicate in a more
direct way. Antony's relationship to his mother remained

conflicted. He had extremely ambivalent feelings toward her;
he both wanted her and wanted to reject her. His best defense
was to appear indifferent to her in an effort to escape unhurt.
He responded to her overture to him but remained uncertain
about approaching her. As is typical of neglected children,
Antony responded well to appropriate and positive interac-
tions with others.
Gabby: A Child
Traumatized by a Single
Episode of Sexual Abuse
Gabby, a 3V2-year-old girl, was referred to treatment by her

mother after she was orally copulated and digitally
penetrated by two adolescent boys, who had occasionally
babysat for the child. Her mother had been referred by the
pediatrician who treated the child for genital trauma.
Gabby was the second child of divorced parents, Denise and

Gustavo. She had an older sibling, Matthew, age 12. Denise
and Gustavo were divorced soon after Gabby's birth, after
years of a "difficult and strained" relationship. There had
been a custody dispute and joint custody was awarded. Gus-
tavo had accused Denise of being "cold and distant" with him
144
Clinical Examples: Gabby 145
and the children and spending more time and energy on her
career than on taking care of the home. Denise had accused
Gustavo of being practically a "stranger" to his own children.
She claimed the only reason he was disputing her sole cus-
tody of the children was because he thought that meant he
would have to pay more in child support. The parents had
unresolved issues between them, reflected in their curt and
tense communication. I asked Denise to notify Gustavo about
her request to have Gabby in therapy with me and about my
desire to meet with both of them individually to get their
important perceptions about Gabby. Gustavo had been un-
convinced that therapy was necessary but deferred to the
pediatrician, whose opinion he valued.
Gustavo was the oldest sibling of his family and had
three younger sisters. He described his childhood as happy
and referred to his mother with great reverence, citing her
sacrificial commitment to the family. His father was depicted
as a stern disciplinarian and a scholar. His mother main-
tained a close relationship with Gustavo and, he reported,
would give her eyeteeth to raise Gabby "properly."
Denise was the only child in her family. Her mother was
the first in her family to obtain a college degree and to get a
divorce. Denise quickly added that her mother balanced
home and career extremely well and that she felt the divorce
had little impact on her. She stated that her relationship with
her father had been positive and that she had always been
able to count on him even though he lived on the East Coast
and she and her mother had moved to the West Coast after
the divorce. Denise added that her mother had been a
wonderful and available grandmother, who was able to keep
her opinions to herself and let Denise make the parental
decisions regarding Gabby.
Denise and Gustavo had met in college and been good
friends prior to becoming romantic. Denise described their
marriage as "never having a chance," due to her mother-in-
law's meddling. She stated that Gustavo always compared
her to his mother and that she never rose to his expectations
of what a good wife should be.
Gustavo claimed that he would have been willing to work
on the marriage but felt that Denise's feminist ideas would
not permit her to be a "decent" mother and a scientist at the

same time.
Denise worked in a university-based cancer research
program, and Gustavo worked as an architect with the City
Planning Commission.
Both parents spoke positively about both children. They
exulted in their son's academic achievements and his abun-
dant awards in gymnastics. They both agreed that the
children had a warm and easygoing relationship with each
other, with occasional "normal* manifestations of sibling
rivalry. In particular, when Gustavo took Matthew for hiking
or fishing outings, Gabby sulked for hours because her Papi
had left her behind.
Both parents also acknowledged the sadness and fears
expressed by both children when they were told of the
divorce. Gustavo noted that the children had complained to
him that they missed him and wished he would come home
soon.
The sexual abuse of Gabby took place when the parents'
usual babysitter, a girl of 13 who lived nearby, entertained
her boyfriend and his two friends in Gabby's home. While the
children slept and the babysitter and her boyfriend were
necking in the living room, the other two boys found and
entered Gabby's bedroom, apparently fondling her in her
sleep. The sexual molestation escalated; one of the boys
performed oral sex while the other one masturbated himself
and inserted his fingers in the little girl's vagina. Some
bruising around Gabby's mouth suggested that one of the
boys had covered her mouth during the abuse. The boys later
told police that they scared the little girl and told her if she
told anybody what they did, they would kill her.
When Denise came home from a late meeting, she paid
the babysitter and went to sleep. When Gabby came into her
bedroom in the morning, she knew immediately something
was wrong. The child had blood around her legs and black-
and-blue marks around her mouth. Mother rushed the child
to the pediatrician, who filed a report with Child Protective
Services. Mother gave the police the babysitter's name, and
a meeting with her uncovered the boys' presence at the house.
The boys went to juvenile court, were placed on probation,

and were referred for treatment.
During my intake meetings with both Denise and Gus-
tavo, they concurred that Gabby was anxious, fearful, and
insomniac, waking frequently with nightmares. She wanted
to sleep with her mother, and Denise had acquiesced in order
to make her feel safe enough to sleep through the night.
Gabby had shied away from her brother and father, ap-
parently reluctant to have physical contact with them. (She
did sleep through the night at her father's house, usually
fretfully) Her parents also reported that Gabby was lethar-
gic and was exhibiting regressed behavior such as
thumbsucking and baby talk. In addition, she was no longer
able or willing to use the toilet by herself and insisted that
her mother anchor her day-care worker take her to the toilet
and keep diapers on her. Both parents expressed concern for
Matthew, who was feeling guilty that he had not awakened
when his sister was in trouble and who was furious at the
boys who had hurt her. I referred him to a colleague for an
assessment and brief therapy.
My first meeting with Gabby was brief. She would not
separate from her mother and dug her face into her mother's
lap, unwilling to speak to me or come look at the playroom.
I assured Denise that this was to be expected and told her
that I wanted her to take the child into the playroom without
me and show her around. Denise told me that Gabby had
looked around with moderate attention but had resisted
touching anything and wanted to leave soon after they
entered the room.
At the second meeting Gabby continued to avoid eye
contact with me. There were some other children her age in
the waiting room, playing with building blocks, and Gabby
appeared somewhat interested. I sat in the waiting room
with her, encouraging her interest and participation in play
with the others. Eventually, Gabby approached and stood
next to them but ran back to her mother when the children
greeted her.
I invited Denise and Gabby into the playroom, and Gabby
seemed to look around as I told her about the different things
in the room. I introduced myself in typical fashion, that is, as
someone who talks to children about their thoughts and feel-
ings. I explained she could choose the toys she wanted to play
with, and I reviewed the use of the timer. I talked to her mother
so that Gabby would feel safer, telling her that some children
like to color in the coloring books, some children like to play
with the cups and saucers, and so forth.
Gabby looked upward when I told her that all the children
who came to see me had been hurt by somebody. "Some of the
kids have hurts on their bodies; some of them have hurt
feelings." She actually gave a little smile when I mentioned
that the children don't ever have to talk about their hurts, that
sometimes they just play. Gabby sucked her thumb as I colored
in the book with her mother, the two of us conversing about
her early history. Gabby listened quietly as her mother
described her as a baby and told about the kinds of things she
had liked to do. Denise said that one of Gabby's favorite things
was the beach and swimming. They had taken a vacation to
Hawaii not too long ago, and Gabby, with a mask on her face,
had loved peering into the water and watching the fish. I told
Gabby that I had also been in Hawaii and loved the fish and
the beaches and the hula dancers. (She smiled again.)
In the third session I brought out my sand tray, and
Gabby became consumed with interest in the sand play—so
much so that I told Gabby her mother would be waiting
outside the playroom today, that I would place a chair for her
right outside the door and leave the door open. At one point
Gabby looked up and seemed to panic as she asked for her
mother. "She's right outside the door. Go look," I said; Gabby
ran to make sure her mother was there. She then returned
on her own and continued her play in the sand.
The initial sessions consisted of Gabby's filling up cups
and emptying them, and wetting the sand and building little
hills she would then poke holes in. She loved smoothing out
the sand and bunching it up. She had noticed the shelves full
of little miniatures that stood next to the sand tray. She had
picked some of the miniatures up, quickly returning them to

their exact location.
Her mother's chair was still next to the door by the fifth
session, but the door remained closed. Gabby separated
quietly, apparently no longer disturbed by the separation,
more confident that her mother would wait for her to finish
her session. Eventually, I moved the chair back to the waiting
room; after checking once to see that her mother was still
there, Gabby never required her mother's presence in or near
the playroom again.
Treatment Planning
I developed the following treatment plan:
1. Individual play therapy

a. Allow nondirective, nonintrusive play.
b. Document play themes and interpret symbolism.
c. Facilitate posttraumatic play.
d. Facilitate Cabby's sharing of dreams.
2. Parent-child sessions
a. Meet with parents and discuss Gabby's behaviors
and suggested responses.
b. Discourage overprotective responses.
c. Discuss sleeping arrangements.
3. Sibling
a. Meet with siblings together; Matt might want to
share his feelings with sister, if appropriate.
b. Encourage renewed physical contact through
specific games.
4. Family
a. Family meeting to symbolize the abuse being in the
past and to discuss ways that Gabby will be safe in
the future.
Gabby had endured a terrifying traumatic event, the terror

intensified by the fact that the event had occurred in the
safety of her home. When the trauma is external to the

home, the child seeks, and hopefully obtains, reassurance
from her immediate environment; when the trauma occurs
in the immediate environment, reassurance is less possible.
Because of Cabby's young age, I postulated that the
sexual abuse had not been perceived necessarily as a
sexual event but, rather, as an act of violence and physical
intrusion. It was also likely that she had been terrorized
by having her mouth and nose covered, and may even have
lost consciousness (as the boys who abused her had
"guessed").
The child had regressed developmentally: She was
clingy, wanted diapers, and resorted to single words to signal
what she wanted rather than the full sentences she had used
prior to the trauma. She exhibited symptoms of post-
traumatic stress, including night terrors, intrusive flash-
backs, emotionality, dissociative episodes, and feelings of
numbing. Gabby also had specific trepidation associated
with males, both within and outside her family. Both her
mother and father had observed that Gabby could not
tolerate talking with men or being around them. (Denise
said Gabby would not look at men and started to cry; Gus-
tavo stated that when a male appeared, she became insistent
on leaving the surroundings straightaway.)
My immediate goals were to create a safe environment
and to facilitate Gabby's processing of the traumatic event.
I kept verbal communication to a minimum and allowed the
child to choose her preferred play materials. I had gently
introduced her to the playroom, allowing her mother to
reassure and comfort her as needed. Slowly, Gabby began to
tolerate being alone with me in the playroom. I told her she
could say as much or as little as she wanted, choose what to
play with, enter or exit the room as needed, and stay until
the timer went off. She had permission to check on her
mother outside the playroom, and did so sporadically for the
first few months in therapy.
Although initially Gabby colored, used the cups and
saucers in the sand, and even combed the hair on some of the
dolls, eventually the sand tray became the nucleus of her
attention as she began her difficult journey into recovery. The
sand tray was always smoothed down first. Then Gabby

would begin the slow and purposeful process of selecting
small miniatures for her tray, placing them carefully on a
platform that slid out from under the tray. She took painstak-
ing care to dip each little figure in a cup of water, eliminating
the grains of sand that had become attached during play. She
always organized the figures, making a line of dinosaurs,
lions and tigers, spiders and bugs, and soldiers with swords
and guns. Then she picked out green, yellow, and white
fences. The green fences were the tallest; the white and
yellow ones served as reinforcers and were placed in front of
the green. The last level collected were the trees, and Gabby
picked both tall and shorter ones, placing them in front of the
fence.
Cabby's play was identical each week for the first 3
months of therapy: She would smooth out the sand, clean and
dry each figure, set them out in lines, and begin to fill in the
sand tray. First, she would put a small figure, Garfield the
cat, in the left hand corner of the tray. She covered it midway
with sand and then proceeded to place the tallest fence about
3 inches in front of the Garfield figure. She would reinforce
the fence, and then place the trees in front of the fences.
Then, starting from the farthest end of the tray, she would
fill in the remaining three-quarters of the tray with
(threatening) figures, including dinosaurs, spiders and bugs,
lions and tigers, and soldiers, the latter being closest to the
fence (see Figure 1). Spontaneously, Gabby noted, "They
climb trees and jump fences." The implication was clear: The
boundaries were permeable and attack was inevitable. The
single object in the corner could not hide, and no one was
around to come to his aid.
At the beginning this was a stable, undynamic tray; the
figures would not move. Gabby seemed to have an internal
clock so that she would finish setting up the tray just when
it was time for her session to end. Gabby was absorbed by the
play, seemingly unaware of my presence or outside noises.
She would become visibly anxious as she placed all the
threatening objects in the tray. She could not tolerate looking
at them for too long, and sometimes she mumbled "Oh, oh/
as if something bad were going to happen.
FIGURE 1
A shift in Gabby's sand play scenario began to take place ever

so subtly. The fence was retreating from the Garfield object,
the space with the threatening objects was contracting, and
fewer threatening objects were invading.
By the end of the fourth month half the tray was filled
with soldiers and a few random animals; Garfield was now
joined by a giraffe, towering over the fences, and a bear,
looking confident and unperturbed by all the danger. When
she worked on the tray during this phase of her treatment,
Gabby would sometimes turn her attention to another toy
before the bell rang; she was leaving herself some time to do
something akin to reorienting to the environment. And she
always waved good-bye to the tray and to me as she left.
Gabby's behavior had progressed tremendously at home.
She was sleeping through the night more frequently, with

only occasional nightmares. She had responded well to an
intervention of finger painting with her brother, sharing the
same piece of paper. This gave the siblings an opportunity to
have nonthreatening physical contact while having a posi-
tive experience together. They had also shared the task of
kneading dough for a pizza, laughing and having fun while
they had close contact with each other. Gustavo had even
joined in the finger painting once, and although Gabby had
liked it, she had wondered why her dad was acting so silly.
Denise reported that Cabby's crying bouts had
decreased, as had those periods in which she seemed to "stare
out into the wilderness." Gustavo acknowledged the recovery
that had occurred and felt it was time to terminate treat-
ment. I met with both parents and asked them to allow Gabby
to continue in treatment for a while longer in spite of the
obvious progress she had made.
In the last 2 months of therapy, the child's tray was
completely reversed (see Figure 2). Three-quarters of the
tray was now occupied by Garfield, the giraffe, and the bear.
The other quarter of the tray included four to six soldiers and
tigers, separated from Garfield by a single fence, with no
trees to facilitate climbing. "You know/' I observed looking at
the tray, "I think that Garfield is much safer now." "Yeah,"
Gabby replied, "the giraffe and the bear stay with her, and
watch out for her." It was not necessary to say more. The
healing had occurred in the sand work. There was no need
for further interpretation.
I took three sessions to do termination work—two with
Gabby alone and one that included her mother, father, and
brother. During her last two sessions Gabby took out and
"gave a bath" to all my miniatures and returned to her earlier
play of filling up the cups with sand and pouring them out.
When I told her that she would only be coming another two
times, she didn't say much. I wondered what she would tell
her mother about the termination, and when I inquired,
Denise said that the night of the last meeting, right before
going to sleep, Gabby had said, "I can go see Eliana when I
want." Denise had told her she could, and Gabby had said,
"Maybe some other time if my head aches."
FIGURE 2
In the last session I talked to Gabby about when she had

first come to see me, reminding her that she had come in
slowly, with her mom, and hadn't played with too many
things in the playroom until later. I also reminded her that
at first she wanted her mom in the room, then mom was right
outside the door, and then mom waited with the other moms.
I also told Gabby that she had come to see me because I was
someone who talked to kids who had been hurt.
"I got hurt once," she said. "Those boys did bad things."
"Yes, they did, Gabby, and I'm sorry you got hurt."
"They got spanked, and their mommies were mad with
them and punished them."
"Yes Gabby, I bet that's so."
"But some boys are nice. Matt is nice."
"That's right, Gabby, lots of boys are nice."
Gabby played with the velcro darts and then remarked,

"My mommy didn't know the bad kids came to my house."
"No Gabby. And your babysitter didn't know those boys
would hurt you."
"They scared me," she said as her thumb found its way
to her mouth.
"That was very scary, Gabby."
"They used to scare my nighttime."
"I remember, you used to have scary dreams." Gabby sat
quietly and I asked her if she could draw a picture of the scary
feeling. She grabbed the colors and made a picture full of
black scribbles. Then I asked her to make a happy picture,
and she drew a sun and a rainbow. I made a copy of each when
she left. Gabby took her happy picture home but didn't want
to take the scary one, telling me to keep it. Gabby ran back
to the playroom to tell me, "My brother will kick their butts
if they try to hurted me again." I assumed she had heard her
brother say this, and then I summarized, "Your mom, dad,
and brother—everyone who loves you—will take good care of
you." "I know," she said. "My hurted is better now."
This was the most dialogue we had exchanged, and our
last family meeting went very well. I said aloud, "When you
brought Gabby to see me she had been hurt by those boys in
the nighttime. She was very afraid, and all of you were
worried for her, angry at the boys, and felt bad that you
weren't there to take care of her." Denise and Gustavo in-
stinctively added that they wished they had known what was
going on; they would have come in and kept her safe. Matt
added he'd kick anybody's butt who tried to hurt her again.
Gabby giggled as Gustavo told Matthew to watch his lan-
guage.
I noted that Gabby seemed to feel better now, safer, and
that even though this was true, it was important that she
knew that she could talk to her parents about the sexual
abuse anytime she remembered it in the future. The parents
again chimed in without prompting, reassuring her that she
could always talk about how the boys had hurt her and ask
any questions she had.
Finally, I asked Gabby if she and I could show everybody
her picture of the scary thing that happened. She grabbed it

out of my hands, apparently pleased with the suggestion. She
took it to her mother, father, and Matthew. I brought out
some big easel paper and asked everyone to make a group
picture of the bad thing that had happened to Gabby. They
followed Cabby's lead and used colors rather than symbols.
Then I asked them to draw a picture of a time when they all
had a good time together, and they agreed on their vacation
to Hawaii. (No one disillusioned Gabby by telling her that
the vacation to Hawaii had not included her father, although
the four of them had gone to Hawaii on a family vacation
shortly after she was born.)
The family took approximately 5 minutes to draw the
first picture and spent the remainder of the time working
together on the family picture of Hawaii, drawing some
tropical fish, which Gabby colored.
Before ending the session I asked the family to crumple
up their drawing of the scary thing that had happened to
Gabby and to throw it in a trash can I had brought to the
center of the room. They passed the picture around, each one
crumpling it more and more; then Matthew took the picture
and jammed it into the trash can, imitating a Michael Jordan
slam dunk. Gabby then asked where her scary picture was,
crumpled it up herself, and mimicked her brother as she
threw it into the can.
I told the family I was glad to have met them and been
of assistance. I told Gabby she knew where I was if she ever
wanted to come back and see me. She has never called,
although she sent me a Valentine Day's card 2 years in a row.
DISCUSSION
The child's young age, specific symptomatology, and interest
in sand tray therapy guided the therapy toward nondirective,
nonintrusive play therapy.
Sand tray therapy is inherently self-healing and in
this case was a miraculous process to watch. The child
processed her trauma in her own way, at her own pace,
carefully symbolizing the overwhelming experience

through her play.
The sand tray illustrated her sense of entrapment and
feeling of defenselessness. She had felt isolated, without
internal or external resources to fight off her attackers. She
had been left afraid, hyperaroused, and avoidant of poten-
tially threatening people and situations.
Certain issues that could be problematic were addressed
in the family session. Gabby heard and seemed to understand
that her parents did not know the boys were going to hurt
her and would have stopped them if they had known. A
termination ritual (with the drawings) symbolically em-
powered the family to place the past behind them and
negotiate for a safe future.
Gabby responded favorably to nondirective therapy, and
symbolically processed the trauma, while discharging her
feelings of fear and worry as she played in the sand. This
child also benefited greatly from having an appropriate fami-
ly who followed therapeutic suggestions carefully.
Laurie: A Neglected Child
Traumatized by
a Hospitalization
Laurie was a 7-year-old girl referred to me by her social

worker for "reunification" treatment. Laurie, identified as a
neglect victim, had been in foster care for the past year and
a half while her parents completed a drug rehabilitation
program in another county. Laurie had been returned to her
biological parents 2 days before the social worker phoned me.
The social worker provided fragmentary information about

the biological parents; the case had been transferred from
another worker, and the records were in disarray. What was
known is that prior to her placement in a foster home Laurie
had been brought to an emergency room with appendicitis.
158
Clinical Examples: Laurie 159
Her parents could not be found and were finally located after
the child had been in the hospital for 4 days. The physician
found Laurie to be a classic victim of neglect—under-
nourished, dirty, and suffering from minor infections, im-
petigo, and an untreated visual problem. Since the parents
could not be located, the child was made a dependent of the
court.
I met with both parents the day after the social worker's
phone call and obtained a little more information. I found
them to be guarded and slightly contentious. They immedi-
ately communicated their anger about being mandated into
therapy. "We probably would have gone to counseling on our
own/ the father contended; he failed to understand the
urgency of our appointment. The parents were also irate
about having to pay for therapy and about the fact that
Laurie was still a dependent of the court, overseen by a social
worker for at least 6 months.
I reassured the parents that I understood all their com-
plaints, and I quickly focused on how they felt about being
reunited with Laurie after such a long separation. The
parents slowly let down their guard and confided that they
were afraid. They had been drug-free for a year and a half
and had gone through daily counseling. They understood
that they had been "less than perfect" parents and they
seemed remorseful. When I inquired about their lives prior
to the drug rehabilitation program, they described "hitting
bottom," quickly adding, "The worse part of the whole thing
is we dragged Laurie down with us." I remarked about the
appropriateness of their concern for the child, and I told them
that the more information I could get from them, the better
I could help the child.
The parents described their history fleetingly and curtly.
The father seemed to speak for the couple: "Both of us grew
up with drunks as parents." He described how they had both
been beaten and cast aside. The mother, Glenda, added that
she had been useful to her family because she took care of
her younger siblings. She said she had hated every minute
of every day of her life and had quit school, running away
with a drug-dealing boyfriend who used to sleep with her
mother. Glenda commented, "I would say it was all downhill
from there, but it was all downhill when I was brought home
from the hospital." Glenda's drinking began at age 10, be-
cause sometimes there was little else to eat or drink around
the house; she added, "when I drank was the only time I saw
my mother laugh and look happy."
Laurie's father, Rob, likewise started drinking and
smoking marijuana at a very early age. He said that he and
his buddies would skip school, work on cars, and get stoned
every day. His parents didn't care if he went to school or not.
He was very proud of the fact that he could make good money
working at a garage, and he now had a new job with an old
employer who had taken a chance on him, as long as he
stayed clean. Rob started living with his buddies in an
abandoned shack when he was about 12 years old. "Remem-
ber the movie Lost Boys!" he asked. "That was what it was
like."
I commented that both their lives seemed very unhappy
and it was remarkable that they had taken such an impor-
tant step in getting into a recovery program and committing
themselves to staying sober. Mother said somberly, "Unfor-
tunately, we had to hit bottom to get the message. I just hope
Laurie isn't going to hate us for everything we did."
Both parents disavowed any contact with their biological
parents. Glenda had a younger sister she kept in touch with
but said she didn't care to see her mother or father ever again.
Rob knew his father was alive, he would sometimes see him
around, but, again, he seemed unmotivated to make contact.
Both Glenda and Rob had truly rejected their own parents in
an effort to escape their painful histories.
I asked the parents to describe the events that led to
Laurie's being removed from them. They were visibly dis-
tressed as they spoke and had to take numerous cigarette
breaks to endure the 2V2-hour initial interview. They stated
that they had been "heavily into the drug scene" since the
time of Laurie's birtL. Glenda said she made an effort to cut
down on the drinking—but did drink throughout the preg-
nancy. Laurie was born underweight and fretful. She was
kept in the hospital for weeks, and even then there were
concerns about releasing her to her parents' care. A social
worker and public health nurse visited for about 4 months;
the baby seemed to do pretty well except that she was dif-
ficult to feed and slept a lot.
Both parents stated that they had not planned to have a
baby but liked the idea as soon as Laurie was born. Rob
emphasized that he held a steady job and brought home
enough money to feed the baby and buy diapers. He added
that he and Glenda didn't eat too much in those days, so the
money was just for Laurie.
The parents described Laurie as "quiet and really help-
ful" when she was older. Glenda said she was surprised that
at the age of 5 the child could feed herself, go shopping at the
store, and put herself to sleep watching TV. Rob said that
Laurie liked to hang around the house: Even though she
could come out with them when they went drinking, she
preferred to stay at home. When I heard this, I spontaneously
asked, "Did she stay home alone?" Noticing my concern,
Glenda responded, "I know. Now when I think back on it, I
can see how wrong that was. At the time, though, I thought
I was being a good mom, letting her do what she wanted."
Glenda and Rob seemed earnestly concerned for the
child and worried about the impact of their actions. They
wanted to tell me the worst of what they had done. They
described frequent drinking parties and said that drunks
spent the night on Laurie's bed. Glenda became visibly dis-
traught when she told me that some people had sex in their
house; once she had walked into Laurie's room and found the
child curled up in a corner crying while a couple was having
sex on her bed.
Rob said that he had several drug-using friends and that
Laurie had witnessed the use of needles and the snorting of
cocaine. Sometimes people—including Glenda and Rob—
passed out after taking drugs; the house was filthy because
people used to vomit everywhere. Laurie was the one who
tried to keep the place clean, her parents said, but it was
really useless.
Glenda and Rob had been out drinking during Laurie's
appendicitis. She had gone upstairs and had asked a neigh-
bor for an aspirin. Neighbors noticed the child's fever and
took her to the hospital (Laurie did not have a regular
pediatrician, having had immunizations from the public
health department and at school). When they talked about

the appendicitis, both parents were in tears. Nevertheless,
Rob added that it was the "best thing that ever happened to
[them]/
I asked how much contact Rob and Glenda had had with
Laurie during her placement. They said the contact was
minimal; they had sent the social worker a few letters for
Laurie, but they weren't sure she had received them.
When I asked them to describe Laurie during the last 2
days, they said she was really quiet and didn't smile much.
"She was a little afraid of us at first," Rob said, "but she's
beginning to warm up." The parents said that Laurie had
been crying in her bed at night, so they had put her in their
bed. When I commented that it was a good idea to let her get
accustomed to her own room, Glenda agreed to do this on a
temporary basis.
I reviewed with the parents what to tell Laurie about
coming to see me. I told them this was a difficult time for all
of them because they were, in fact, reconstructing a family,
with few role models and few skills. They revealed that they
were both attending AA meetings every day and had also
joined a Parents Anonymous meeting to discuss parenting.
Glenda asked if I knew where they could take classes, and I
gave them a local resource, which they hesitated to contact.
I also told them that I thought it would be beneficial for them
to be in couples therapy to discuss the multitude of issues
that would surface during these initial months. I referred
them to a colleague for short-term therapy that would cul-
minate in family therapy with the child.
Before the parents left, I asked them what they knew
about Laurie's foster family and about how her separation
from them had transpired. This was one area the parents
had little insight into, and they seemed defensive. "I don't
know, and I don't vyant to know," Rob said. "The social worker
was trying to make some big deal about how Laurie would
miss them, but I'm sure she's glad to be home." I stated that
sometimes the children have two feelings at the same time
when they go home: They're happy to see their parents and
sad to leave the people who have been taking care of them.
(I was careful not to use the term foster parents at this point,
since this was obviously a sensitive topic.) Glenda seemed

to understand this; Rob mumbled something under his
breath.
Laurie was an extremely shy, slow moving, reticent, and

compliant child. She was physically small, fragile-looking,
very neat, and well groomed. There was a stark contrast
between her pretty, bright, colorful dress, with bows along
the edges of the skirt that matched the bows in her hair,
and the somber, cautious look in her eyes and quiet man-
nerisms.
Laurie's hand was held by her mother. When Glenda
removed her hand to do something, Laurie's arm dropped
limply to her side. Mother held Laurie's hand again as they
sat in the waiting room. I came out and introduced myself to
the little girl, then took her on a tour of the playroom,
indicating where we would be and where her mother would
be. She offered no resistance as her mother prompted her to
come with me.
Laurie looked around the playroom, thumb in mouth. I
talked to her a little about the kinds of things she could play
with. She wanted to color and sat at a little desk, coloring
pages from a book. "Is it time to go yet?" became a standard
question. At first I thought this indicated anxiety about being
alone with me; I realized later that it was her desire to stay
longer in this quiet, safe little place.
I decided to be very nondirective with this child. The
parents had told me how they had tried to get her to tell them
everything that had happened to her since they last had been
together. I felt it was best to allow Laurie to come forward,
rather than pressing in any way. I decided to sit next to her
and do some coloring myself; as soon as I was engaged in my
own activity, Laurie seemed to breathe easier.
The first four or five sessions followed suit. Laurie would
enter the playroom quietly and engage in some coloring or
reading activity. Because she had expressed a desire to read,
I prominently displayed a book written for children in foster
care called Only One Oliver (Rutter, 1978). This book talks
about the loyalty issues felt by children who have warm
feelings toward two sets of parents. Laurie read it quietly to
herself a number of times. Then I asked, "You were in foster
care, weren't you, Laurie?"
"Uh, huh/ she said.
"Who did you live with?"
"Jack and Leona and Steffi and Harry."
"Who are they?"
"My mom...foster mom and dad and my...the other kids
who lived there."
"Do you think about them sometimes?"
"Uh, Hum."
"How does that make you feel, to miss them?"
"I don't know," she said as she turned away. We had made
a beginning.
Once she was familiar with the environment and the struc-
ture and could tolerate talking with me, Laurie seemed to
relax. In addition, she was obviously more comfortable with
her mother than she had been when I first met her, as
reflected by her posture and flexibility in the waiting room.
Laurie slowly made her way over to the dollhouse and
began some play involving a mother, father, and three
children. My hypothesis was that she was recreating the
foster home, not her current home. She had the mother cook
breakfast and make sure the children had clean clothes; the
father watched TV when he came home from work. The
family laughed when the father told jokes; they would fre-
quently prepare a picnic basket and go outside to play ball.
Laurie said that she was a good "catcher," and when I told
her I had a ball in the playroom, she asked me to throw to
her and she would catch. She greatly enjoyed this activity,
apparently reminiscent of happier times. "Jack is the bestest
catcher; he taught me how to catch," she said loudly.
The parents' therapist and I had been in touch: She was
disheartened by their continued failure to understand the

child's feelings toward her foster parents. Glenda and Rob
had forbidden Laurie to mention the foster parents' names
and had become very distressed when Laurie inadvertently
referred to the foster mother as "Mom." The parents'
therapist felt that they held the foster parents in some way
responsible for their not seeing their child for almost 2 years
and that this illogical view did not allow for other percep-
tions. After the first month of therapy I made an appoint-
ment with the foster parents and I asked the parents to
attend. Rob and Glenda were furious that I felt it necessary
to talk to "those people" but felt they had to attend the
meeting.
The meeting was tense and awkward for the first half
hour. Glenda and Rob had been 15 minutes late, and I was
afraid to start without them. When they arrived I expressed
my delight at seeing them and made an opening statement
regarding the purpose of the meeting: "As I've told Laurie's
parents, I wanted to meet with you, Leona and Jack, so you
could tell us how Laurie was during the time she was in your
home." Leona and Jack, obviously real professionals, imme-
diately reassured Laurie's parents. "We are so glad to meet
you. We found Laurie a real delight. She was so well behaved
and so sweet. When a child is like that, you know they've had
some good parents." Glenda and Rob looked shocked and
couldn't find a response; they looked at each other and held
hands. Rob talked first, as usual: "Did she have any problems
at your house?" Leona and Jack described a passive, com-
pliant, helpful child. They portrayed these as positive be-
haviors, yet I knew they were communicating the child's
weaknesses as well. "Sometimes you hardly knew she was
there—she would melt into the woodwork." I had often heard
this phrase used to describe abused or neglected children
who learn to stay safe by staying out of the way.
Jack and Leona said they were an active family; they
took frequent trips to parks, lakes, and camping sites. They
said Laurie loved the outdoors and was good at hiking,
running, swimming, and playing ball. Glenda said quietly, "I
didn't know she could swim." Laurie's foster parents said
they had taught her to swim because the doctors had sug-
gested she resume normal activity after her surgery. Since
they didn't know what she liked, they thought they would try
swimming.
Rob wanted to know if she ever asked about him or
Glenda. The foster parents quickly exchanged glances, and
Jack answered, "She would talk about both of you often,
saying how you used to have big parties and had lots of
friends." Jack added, "We also talked to her about her
mommy and daddy too, letting her know what a good thing
you were doing getting some help with your problem." Jack,
himself a recovering alcoholic, made an astonishing divul-
gence: "Rob, I know firsthand what it's like. I have 15 years
recovery, and every day I remind myself how far down I got
before I could pull myself up."
Whatever antagonism, jealousy, or displaced anger ex-
isted before was dissipated during this meeting. Both sets of
parents went out for coffee and, miraculously, Rob and Glen-
da invited Jack and Leona to come over for dinner. Laurie
came in excitedly the following week and told me Jack and
Leona were coming over to see her. She was plainly thrilled
and, fortunately, she no longer felt she had to keep her
excitement under tap.
Treatment Plan
After the first month I made a treatment plan consisting of
individual treatment and conjoint family sessions:
1. Individual treatment
a. Use nondirective play therapy sessions to establish
a strong therapeutic alliance.
b. Document play themes (e.g., foster care separa-
tion).
c. Become directive by talking about her life with her
biological parents, now and then.
d. Discuss her surgery.
2. Conjoint family sessions
a. Discuss structural issues such as boundaries,
privacy, limits.
b. Discuss parenting issues such as discipline,

guidance, and fun activities.
c. Discuss how family members feel about being
reunited and what problems they have encountered.
d. Make sure child has regular medical care, updated
immunization plans, and that family has nutri-
tional counseling.
3. Coordination
a. Discuss a plan for contact with foster parents.
b. Talk to school personnel about Laurie's school per-
formance and behavior.
c. Contact social worker about dependency issue.
I asked Laurie to draw me a picture of herself, and she made

a very small, very faint picture of a little girl with no hands
and feet and a hole in the middle (Figure 1). When I asked
her to draw a picture of her family, she made several at-
tempts, erased them, and seemed very frustrated. Sensing
her dilemma, I asked, "Which family do you want to draw
first?" "I don't know," she responded, Tin not a good drawer."
"I think you're a fine drawer," I stated and took the initiative.
"I know what—since Glenda and Rob were your first family,
FIGURE 1
draw them first." As can be seen in Figure 2, Laurie drew her

mother lying down and her father watching TV. There is no
structure or foundation in the drawing, and it seems as
though the figures are floating. The disparity between this
drawing and Figure 3, a drawing of Jack and Leona, is
striking. Not only is the latter picture more detailed but it
has emotional content and contact between family members.
The foster home had clearly been an emotionally rewarding
and nurturing environment for the child.
>M>
>M>
FIGURE 2
FIGURE 3
Laurie had relaxed in the therapy hour (and, from the

parents' reports, had become more relaxed in the home set-
ting as well). She was more talkative and directed her play
well. She would choose the dollhouse frequently—to show
her "ideal* family. She would ask me to throw the ball; she
felt competent and proud as her catching skills improved.
When she began throwing the ball into the hoop, she couldn't
wait to show her foster father what she had learned. Al-
though she talked about her parents in a guarded fashion, it
appeared that all Laurie's associations with fun or recreation
had to do with the foster parents. (I talked to her parents'
therapist about helping them plan a weekend picnic or trip,
and they had been responsive.)
Soon Laurie's own self-portrait began to change (Figure
4), gaining in size and accuracy. Her schoolwork was going
well, and she always made a point of telling me how her
mother helped her with her homework. (I verified that this
was the case and not just the child's unfulfilled wish.)
The therapy shifted one day when Laurie made her
self-portrait and I noticed that the middle part of her picture
FIGURE 4
looked different. "It's getting better," she said, adding quick-

ly, "I can hardly feel it anymore." She was referring to her
surgery, and I seized the opportunity. I brought down some
toys of hospital equipment from the shelf and showed them
to her; they became her primary source of play for the next
eight sessions. Each week Laurie would scurry in, ask for the
boxes with the hospital equipment, and enact an elaborate
scenario, including a ride in an ambulance, a hospital operat-
ing room, and a recovery room. She would bring a girl doll to
the hospital, get her into surgery, and give her jello and soup
in the recovery room. Immediately after surgery she would
wrap the girl doll in tissue and with a red felt-tip pen she
would put some red dots on the tissue. "It's bleeding...she's
not well yet," she explained.
Affectively, Laurie was constricted and robot-like during
this play. During the surgery itself she was perfectly still and
appeared worried and afraid. In the recovery room she looked
sad and lonely, and, finally, when the play was over, she
would play catch with me, apparently in an effort to make
herself feel better.
Glenda and Rob called because Laurie had been having
some nightmares and was sucking her thumb again. I reas-
sured them that she was doing fine and that we were working
on some painful memories. "About us?" the parents asked,
with their characteristic defensiveness. "No," I responded,
"it's about her surgery." When I asked if they had noticed any
other unusual behavior, they said she had lost her appetite
and was complaining of a stomachache.
Laurie's posttraumatic play was triggering off a number
of regressed behaviors. The play was repetitive, and Laurie's
anxiety remained constant. At the ninth session I decided to
intervene, since the anxiety generated in the play was ap-
parently having some negative repercussions on the child.
My first intervention was to provide a commentary on events
throughout the play. Laurie seemed almost shocked at first
but gradually seemed to pace her play so that I had a chance
to describe each sequence. "The little girl is put in an am-
bulance. I bet the ambulance goes fast, and I bet there's a
siren." "No," she said, "their siren was broken that day." "Oh,"
I continued, "the ambulance with the broken siren is going
very fast. The little girl has a stomachache...." "And a

headache/ Laurie editorialized. I would incorporate Laurie's
own comments and continue narrating the events. I finished
with "The little girl is in her own room now, eating soup and
jello and getting stronger every day." "Yeah," Laurie added.
When I said, "I wonder how this little girl feels eating her
jello and soup," Laurie did not respond.
She repeated this play the following week. A noticeable
addition occurred: Laurie responded to the last question
about the little girl's feelings by saying, "I think she's scared
and lonely." "Oh," I said, "the little girl is feeling afraid and
lonely as her body gets stronger and heals." When Laurie
nodded, I continued: "I wonder why she might feel afraid."
Laurie softly added, "She doesn't know where her mommy
and daddy are." "Oh," I agreed, "not knowing where your
mommy and daddy are would be a really scary thing."
In the following weeks, using this basic approach, Laurie
was able to talk about the feelings she had while she was
recuperating in the hospital: worrying about her parents; not
knowing who was feeding a stray cat she looked after; being
scared about the shots, the tube in her arm, the stitches that
had to come out; and not knowing where she would go when
she left the hospital. "Ooooh," I said, "that's a lot to worry
about. Was there anybody who you could talk with?"
"No...wait, yeah. A nice lady came to see me." I checked the
hospital records and found that a hospital counselor had been
to see Laurie every other day. Once she had come with the
social worker to tell Laurie that they had found a new home
for her where she would stay until they knew where her
parents were. Laurie seemed to suddenly remember: "The
lady came to tell me when they found Mom and Dad, and she
told me they were going to go to the hospital to get better
from their drinking problem."
The second level of intervention was to review the se-
quence of events in Laurie's play scenario and interject some
mechanism for releasing affect as we went along. For ex-
ample, when the girl doll was in the ambulance, I asked
Laurie to "put the little girl's feelings into words." I
prompted, "What is she feeling right now?" "She's really
scared," Laurie answered, "Not just a little, either." This
method revealed that Laurie thought she had done some-

thing wrong and was being taken away to be punished.
The third stage came when I began to call the girl doll
"Laurie" instead of saying "the little girl." Laurie didn't flinch
or question this change.
And then, as a final elaboration of her play, I had Laurie
speak to the ambulance people, the doctors, the "nice lady"
counselor, the social worker, and her parents. When I first
directed her to speak to her parents, she froze. "I can't," she
said.
"What would happen if you did?"
"Maybe they would get mad."
"And what do they say or do when they're mad?"
"I don't know."
"Have you ever seen them mad?"
"No," she answered, and this was likely true, based on
the parents' description of themselves as "mellow, sleepy
drunks." I told her that she could speak for Laurie, and I
would answer for her parents. She seemed to like that,
unaware that when I came to my part of the roleplay, I would
take a helpless position and ask her for direction. At times
she was unable to speak; I would instruct her to take deep
breaths, move her arms, jump up and down, and then I
would inquire again.
When she spoke as Laurie for the first time, she cried
and sucked her thumb. "Why did you go away?" she
sobbed. "I did something bad, didn't I?" And finally, "Did
you want me to die?" I let her cry for a long time and sat
next to her quietly. Laurie held her big bunny tightly and
rocked a little in place. Her questions were so heartfelt
and basic. When I asked how I, playing the part of her
parents, should respond, she didn't know. Feeling I should
refrain from "fixing things" immediately, I said, "You
know, Laurie, I bet your mom and dad would like to
answer these questions. How would it be if we had them
come in with you one day, and we could give them a chance
to explain." Laurie seemed hesitant and yet willing. "I
can't cry if they come," she said. "How come?" I asked.
"What will happen if you do?" "They'll feel bad," she
stated, reflecting her characteristic caretaker role. "Some-
times, Laurie/ I explained, "it's OK to feel bad for mis-

takes we've made. Everyone makes mistakes and feels bad
later."
We played catch for a little while, and when we went to
the waiting room at the end of the therapy session, I told
Laurie's mother that Laurie and I would like to invite her
and Rob to meet with us. Glenda, knowing this would even-
tually happen, seemed resigned and nervous. We set a ten-
tative time for the following week.
The parents' therapist prepared them for the meeting.
Glenda and Rob seemed eager to clarify any concerns Laurie
may have felt about being unloved. During the meeting they
were exceptional in their ability to be open, reassure the
child, and allow themselves to cry in front of Laurie and yet
relieve her of the need to offer any caretaking responses.
Their years of counseling had paid off: They were appropriate
and very nurturing. The parents had complained about their
child's lack of physical response to their hugs and kisses; this
was the first time Laurie clung to them both as they engulfed
her with a caring hug.
And as comforting and as necessary as this work was, I
brought up yet another difficult emotion: anger. "Laurie," I
said, "I'm really glad that your mom and dad have answered
your questions." I had given her many opportunities to ask
additional questions and make other statements she wanted.
"One more thing I just want you all to think about is that
when things like this happen, even when there are good
explanations, the person who has felt scared or lonely can
also feel angry at the people who went away." Laurie buried
her head in her father's shoulder. Rob picked up on what I
was saying immediately and said, "That's right, honey. You
have every right to feel mad at us, not only because we left
you at home alone and you got sick but also because we had
to be separated when we went to the hospital and you went
to Leona and Jack's house. It's OK for you to feel mad about
that. I would if I were you." Laurie smiled as her dad tickled
her a little, but I knew that the last stage of therapy would
concentrate on this more difficult emotion.
Indeed, the work that remained was difficult and pain-
ful. Not only was I working with Laurie on her anger but the
parents' therapist reported that Glenda was working on her

immense guilt over drinking while pregnant. Father was
processing the guilt he had at putting his child at such risk
from drug dealers and "sex perverts/
Meanwhile, the family developed a good relationship
with the foster parents. At first, because of too flexible boun-
daries, Rob and Glenda had spent too much time with the
foster family. At their therapist's suggestion, they made a
commitment to get together no more than once a month. That
way, Laurie could make her transition more easily.
Laurie's status as a dependent of the court was ter-
minated at the 6-month review of her case, with recommen-
dations for this action from both the parents' and child's
therapists.
When therapy was terminated, after a total of 9 months,
I made an exception to my rule about toys not leaving the
playroom and gave the little girl doll to Laurie. I told her that
the little doll would be a reminder of all the work we had done
on her thoughts and feelings during a very difficult time. The
parents later told me that the little girl doll had been
prominently displayed in Laurie's room and that they had
frequently spotted Laurie discussing her feelings with the
doll. Immediately following termination of the therapy, I had
told Laurie she could call me if she wanted to say hello or
talk. She had called a couple of times just to say hello, and I
had received Christmas and Thanksgiving cards from her.
The parents called me 2 years after termination asking
for some help for a sexual problem in their relationship. I
referred them to a sex therapist and inquired about Laurie.
She had become a member of a swim team, was doing very
well in school, and had responded with ambivalence to the
news of a new brother or sister.
DISCUSSION
Laurie was a 7-year-old child recently reunited with severely

neglecting parents. She had lived in a foster home for the
past year and a half, while her parents successfully par-
ticipated in a drug rehabilitation program. Laurie had sur-
Clinical Examples: Laurie 175 175
vived in her neglectful home by becoming pseudomature and

caretaking her parents. She had initially been extremely
worried for them when they could not be found and had
suffered severe loneliness when she underwent surgery
without them.
Laurie was regressed, had difficulty making attach-
ments, appeared lethargic, and was seemingly depressed and
unresponsive. During treatment her strong bond to the foster
family became clear, and an intervention was made to ad-
vance a proper separation from the foster parents. Laurie
had apparently made a positive attachment to the foster
parents, enjoying family outings and partaking in physical
activity previously unknown to her. She felt acute loyalty
conflicts between her foster parents and biological parents,
having concrete positive memories of the foster home and
abstract negative memories of her own family.
In therapy Laurie engaged in posttraumatic play once
she was exposed to some hospital toys in my office. She
ritualistically acted out her fear, worry, and loneliness. She
had interpreted her parents' absence during her hospitaliza-
tion as a complete rejection and punishment for imagined
wrongs she had committed. After being reunited with her
parents Laurie was reserved about physical contact with
them until she heard directly from their mouths the answers
to all her questions about their abandonment of her.
Laurie's posttraumatic play produced great anxiety,
manifested by her labored movement, constricted breathing,
and facial rigidity. There were occasions during the play
when she shook and appeared to perspire. I intervened in the
posttraumatic play by verbally depicting each sequence, al-
lowing Laurie to correct my commentary. It seems that these
interventions had the effect of enabling her to observe, while
experiencing and processing difficult and frightening nega-
tive feelings associated with the traumatic event. At the
same time, because she was having the troubling feelings
while she was in a safe setting, it was easier for her to
separate the past from the present. As Laurie observed and
helped me verbalize what had happened to "the little girl" in
the ambulance, I shifted to asking about her feelings and
thoughts, not the little girl's. She responded immediately,
sharing some of what she remembered about her hospitaliza-

tion. The props, detailed as they are, allowed her to remem-
ber many things she might otherwise have forgotten (like
how bright the lights were in the operating room and how
white the hospital gowns were).
In her play Laurie was able to cry, seemingly recreating
her sense of loneliness. This affect led to verbalizations that
clearly reflected the worries she had had in the hospital
about being bad, unworthy, and rejected. The family sessions
were momentous for this child. Rather than giving in to the
temptation to answer her questions during the play, I told
Laurie that I would help her to share her feelings with her
parents directly.
This child suffered considerable damage from extremely
neglectful parents who had placed her at great risk of abuse
from others. She had been exposed to explicit sexual behavior
of adults and had frequently been left to fend for herself. The
parents continued marital and family therapy; the year and
a half in a drug treatment program had been invaluable.
They faced many painful feelings of guilt and shame and
were very committed to helping repair the damage done to
their child.
Sharlene: A Child
Traumatized by
Severe Sexual ^buse
Sharlene, an 8-year-old girl, was referred to treatment upon

the advice of a social worker. Sharlene had been placed in a
foster home when she was removed from her natural father
at age 5. The foster parents had noticed some "bizarre"
behaviors and wanted the child seen by a professional. Shar-
lene had previously been in counseling for a year and a half;
her counselor had since died.
The police reports and court documents painted a bleak

picture of Sharlene's life. Her mother died from a drug
overdose when the child was 2 years old. Nothing is known
about Sharlene's mother or her level of care for the child.
The natural father, Walter, was a convicted felon who had
177
been incarcerated for numerous drug possession charges.

He had also been charged with aggravated assault at a
younger age.
The child was discovered at the age of 5 years through
pornographic pictures that were developed at a local camera
shop. Required to report suspected child abuse, the camera
shop owner gave police the photographs of Sharlene in
numerous sexual positions with a variety of men.
Apparently, Walt was not a child molester himself but
served as a kind of pimp for his 4-year-old daughter. He had
made a large sum of money selling the pictures of his child
having sex with adults. Aside from keeping her well fed and
photogenic, her father had no apparent regard for Sharlene's
well-being. In addition to the photographs, the police un-
covered videotapes in which the child, appearing drugged,
was penetrated by adolescent boys. Several videotapes
showed her performing fellatio on adolescent boys, riding
them cowboy-style in the nude, and having cherries and
candies sucked out of her yagina.
Needless to say, this child had been severely sexually
abused; her initial treatment focused on the symptomatic
sexualized behavior she had developed, which included ex-
cessive masturbation. In addition, upon placement, Sharlene
had suffered from nightmares, somnambulism, and un-
provoked outbursts of anger and emotionality. She was vir-
tually nonverbal and developmentally delayed; she had very
few social skills, frequently stripping her clothes off, even in
public places.
The foster parents, Ann and Phillip, had expressed an
interest in and a willingness to adopt the child. They had no
children of their own and wanted to eventually adopt two
more children.
When I met with Ann and Phillip, I affirmed the ap-
propriateness of the referral. Sharlene was doing well in
many ways, yet they had observed bizarre behaviors, best
summarized as follows:
1. Trance-like behaviors
2. Forgetfulness and denial of observed behavior
3. Sporadic amnesia for the abuse
Clinical Examples: Sharlene 179
4. Fluctuations in ability
5. Self-mutilation
6. Hurting animals
7. Using another name
8. Fluctuations and polarizations in behavior

Sharlene was an overweight, appealing child who appeared
older than her 8 years of age. She dressed in a provocative
manner, resembling a teenager more than a latency-age
child.
Sharlene entered treatment easily, almost eagerly. She
asked where my playroom was and seemed indifferent to her
foster mother and where she would remain. She inspected
the playroom aggressively, opening things, taking things out
of containers, and throwing things aside to get to something
she wanted. Uncharacteristically, I laid out all the rules of
the playroom right away. "That's cool," she said as she con-
tinued her exploration of the room. She had a tremendous
amount of energy and spoke almost nonstop.
"Do you know why your mom has brought you to coun-
seling?" I asked.
"She's not my mom. She's my adoptive mom," she as-
serted. This was interesting since I had asked her foster
mother what labels were used at home and she told me that
Sharlene had called them "Mommy" and "Daddy" almost
immediately.
"What do you usually call her?" I asked.
"Annie," she responded. "That's what Phil calls her."
"Oh," I persevered, "and what did Phil and Annie tell you
about coming to counseling?"
She took a big breath, "They said I have to come here
because they're worried 'cause I forget things a lot."
"What do you think?" I inquired.
"I think that's for me to know and you to find out."
I smiled and said, "OK...you've just met me; I guess you'll
feel like talking more as you know me better." I realized
quickly that whatever I said, Sharlene disagreed with it.
"Nah, no problem. I don't need more time. I forget lots of

things. Like sometimes they say I said something I didn't."
"Give me an example," I directed.
"Well, like yesterday. Annie got bent out of shape because
she said that I had told her I wasn't getting any new books
in school. Well, I know I didn't say that because I got to get
some new books, it's the beginning of the year."
"Do you usually forget things that you say?"
"I don't know...I forgot," she said and laughed heartily in
my face.
"You've got a sense of humor," I noted.
Then she responded, "Phil said I took my bike out for a
ride and got a flat tire...it wasn't me; I don't like to ride my
stupid old bike."
Sharlene found a game of Chinese checkers and, setting
it down on the floor, said, "I used to beat my old doctor all the
time. You want to bet money?" I replied, "Nope. No money for
me. But let's set them up; I'll take blue." As I said that she
took the blue for herself and gave me the reds; "Too late, too
late, I already picked the blue," she said. Every time Sharlene
advanced she teased me about being behind. Every time she
got a new marble into the triangle, she danced around the
room, saying, "I'm going to skunk you, I'm going to skunk
you."
My exhaustion was only matched by her apparent surge
in enthusiasm as she left my office, announcing loudly that
she had beaten the pants off of me—an interesting choice of
words. As they left the first session Ann remarked that
Sharlene wasn't always so loud.
The following session I observed a markedly changed
child. Sharlene's clothing was subdued, and her manner was
constrained and gentle. She didn't seem to remember much
about the playroom, asking if certain things had been there
the week before. When I asked her what she remembered
about the previous session, she said she remembered that I
was a little fat and that we had played a game on the floor.
She couldn't remember the name of the game, and when I
reminded her, she said she didn't know how to play Chinese
checkers but liked to color. She made some attempts at a tree
and flowers, chastising herself for being unartistic. While she
was coloring, I asked her what she thought about my being

a little fat.
"Oh, I didn't mean to hurt your feelings."
"You didn't," I said. "I was just wondering what you
thought about it."
"Some kids at school would laugh at you."
"How come?" I asked.
"Because you're a little fat."
"Oh," I remarked, "does that happen to kids that are a
little fat at school?"
"Yeah," she said quietly, "it hurts my feelings when they
laugh at me."
"I can understand your feelings being hurt." I paused,
then asked, "How do you feel when your feelings are hurt?"
"I feel like crying a lot, but I won't," she said in a
declarative voice.
"What would happen if you cried?" I asked.
Sharlene looked up at me and said, "If I start crying, I'm
scared I may never stop."
"Oh," I said, "That's an interesting thought."
"I know. I have lots of funny ideas."
I realized that using the word interesting might have
sounded strange to Sharlene. I tried to expand on the mean-
ing by saying, "I've heard other kids say that sometimes, that
they get worried they may cry forever."
She looked up in shock. "Somebody else said that?" she
asked with intense interest.
"Yeah."
"What happened to her?"
"Well," I replied, taking my time, "she had lots of things
to cry about, and found she could cry a little at a time."
Sharlene began to draw a picture of a little girl, her tears
being caught in little cups. "See," she said, "she cried little
bits at a time." "Yeah," I said, "you got a picture of that in
your mind, and now you drew it out. You're pretty smart."
"That's what my mom says," she reported, as she stood up
and began to look around. She found the baby dolls and
changed their clothes, bathed them, and combed their hair.
"I like it here," she commented and seemed disappointed that
the timer's bell marked the end of the session. I sat be-
wildered for a few minutes, understanding the parents' con-

cerns.
In the third and fourth sessions, Sharlene played with
the dolls exclusively, repeatedly dressing and undressing
them, diapering them, bathing them, feeding them, and
combing their hair. My treatment plan revealed the ex-
ploratory nature of the treatment to date:
1. Individual play therapy

a. Observe fluctuations in behavior.
b. Have weekly contact with parents re. child's be-
havior at home.
c. Be nondirective.
d. Provide art materials; she uses them well.
2. Coordination
a. Talk to teachers about her behavior at school.
b. Obtain copies of the police report.
c. Ascertain legal status of Walter.
3. Working hypothesis
a. Assess for dissociative disorders.
b. Assess for multiple personality disorder (MPD).
The fifth and sixth sessions changed drastically. Shar-

lene behaved in a manner identical to that displayed in her
first visit, playing in a chaotic way, choosing many games she
would start and not finish, and being loud and disruptive.
These sessions reflected her internal disorganization. I asked
Sharlene's foster parents how the week had been and learned
that her difficult behavior at home was consistent with the
chaotic therapy sessions. (I also learned that the 3 sessions
in which she had been calm and soft-spoken had coincided
with good weeks at home.)
My plan was to have the quieter Sharlene draw me a
self-portrait the next time she was available. In the following
session I seized the opportunity, and Sharlene drew a faint
little person on a bed in the middle of the page. She folded it
up and said that was all the drawing she wanted to do for
today. When she came back for her sessions over the following
three weeks, she unfolded her piece of paper and added
another drawing to it (see Figure 1). As she made her draw-
FIGURE 1
ings I would ask, "Who's that?" and "What's she or he doing?"

The first figure drawn (the child in the bed in the center) she
would not speak about. The second figure (a child in a window
with big eyes) she said was "Chuck, a boy who is watching to
make sure no bad people come." The third figure (a little
person in a closet) was Marsha ("she's little and she's
pretending to be dead"). The fourth figure (a person under a
bed) was "Linda," who was really mad and was going to kill
Daddy." Since no other figures were added to the drawings,
I asked again about the first one, and this time Sharlene said,
"That's Josie and she likes what the bad men do to her."
Sharlene always folded up this drawing carefully and stored
it in a box that we set high up on a shelf in the corner of the
playroom so no one could see it. This reflected the child's
ambivalence about visibility.
The next time the loud Sharlene came, I welcomed her
and brought out the Chinese checkers. We sat and played,
and I commented, "Did you come to therapy last week?"
"Nope...I had things to do."
"I wonder who that was that came instead."

"What are you, bonkers?" she replied, "That was Shar-
lene." "Oh, Sharlene...I see." I waited for a while and asked
very sincerely, "What's your name?"
"My name's Charlie," she responded. "Don't you know
anything?"
"Well, I'm glad to meet you officially, Charlie." Later in
the game I asked Charlie how she liked Sharlene.
"She's a bore...she lets people walk all over her. At school
they call her a wimp."
"What do they call you?" I asked.
"They don't call me nothing, or I'll kick their ass," she
told me.
It appeared to me that this child had developed multi-
plicity as a response to severe, chronic, and overwhelming
abuse. The signs of multiplicity had become more apparent
as Sharlene gained weight and began to be ridiculed at
school. These experiences of people pointing at her, laughing
at her, and hurting her feelings had caused enough stress to
create or stimulate fragmented parts of her personality or
"alters," probably created to defend against the sexual abuse.
Sharlene's self-portrait had been telling in that she had
portrayed herself as all the different characters of her per-
sonality. Since it appeared that the divergent parts were
little, I suspected that they had originated during the years
of abuse, when Sharlene was small.
The key seemed to lie in the self-portrait. Sharlene's next
session gave us a chance to talk more about it. Sharlene went
to the box on the shelf to pull out her drawing; unfolding it,
she seemed eager to review it with me, as had become her
habit. In previous sessions I would ask her questions about
the drawing, but this time, when she told me about the
different parts of herself ("alters"), I inquired about their
ages and if they had other names they used. When we got to
Chuck, Sharlene said in a matter-of-fact way that Chuck
sometimes called himself Charlie. When I asked what she
knew about Charlie, Sharlene said that he was "tough and
strong" and liked to take care of people. During this session,
I took a chance and made the following statement to Shar-
lene: "Sharlene, is this a picture of you?" She calmly folded
up the picture, stored it away, and waited for the session to

end. Charlie appeared at the next two sessions. When Shar-
lene returned, she once again took out the picture. I asked
again, "Sharlene, is this a picture of you?"
"I think so," she said.
"Some children who have been hurt very badly, have lots
of different parts that make up who they are."
"Do you know the bad things that happened to me?" she
asked bewildered.
"Yes, Sharlene, your foster mom told me."
"OOOh," she said, "I don't like people to know that."
"What will they think?"
"They'll think I'm bad."
I controlled my instinct to reassure her and responded,
"It's really hard to think people think you're bad. You have
to remember that when you got hurt, you were a little kid,
and it was the grown-ups who did something wrong, not
you."
A little tear appeared. "I sort of liked some of it," she said.
"That's OK too." I needed to give her some information:
"Sometimes kids who get hurt sexually talk about how their
bodies felt good or some of the games were fun."
"Marty told me I did it the best of anybody."
"Did what?"
"You know."
"I'm not sure what you mean."
Sharlene, in her sweet little voice, said, "sucked him off."
She looked away, but I couldn't tell if she was embarrassed
or scared or pleased she had spoken.
"Sharlene, everybody likes to be told they do something
better than anybody else. You're not bad because you like to
do something well." She had said and heard enough, and she
looked at the timer. "What was it like to talk about what
happened to you?"
"Well, I guess it was OK."
I told Sharlene that my job was to talk to kids about their
thoughts and feelings and that there wasn't anything she
could say that would scare me or make me think she was bad.
I think that was the wrong thing to say because Charlie came
in with a chip on higher shoulder the next session, calling
me a slew of bad names and testing all my limits. At one point

during the session he/she reached between my legs and
grabbed my genitals firmly. I removed higher hand and said,
"Charlie, it's not OK for you to touch private parts of my body,
and I won't touch private parts of your body. I'm sure you're
trying to find out if this is OK, because other grown-ups
you've known have asked to be touched or have touched you.
For me, this is not OK to do. Any questions?" Charlie
mumbled, "Yeah, yeah, you prude," but I knew I had made
my point. I had responded swiftly and nonpunitively and had
set a clear limit. Sharlene was showing me the "bad" part of
herself, and I did not reject her or punish her.
Sharlene came to therapy for the next 3 months. She
was much more comfortable talking about the abuse and, in
fact, began some posttraumatic play that lasted for over 3
months.
I was now in a much more directive phase of treatment,
and it appeared that Sharlene needed acceptance and active
engagement, information, and assistance in acknowledging
and expressing her feelings. She found an unused silk pillow
with a shiny surface and placed a Barbie doll in the center of
the pillow, posing her in a variety of suggestive positions,
including explicit sexual play with the Ken doll and with
other male dolls. She used a toy camera to take pictures and
play the part of the director. Thus, Sharlene was acting out
the role of her father, Walt, and had chosen the Barbie doll
to represent herself.
During this play Sharlene would always have a bowl and
spoon handy and she would do something that resembled
dissolving a pill and force-feeding it to the Barbie doll. Some-
times Barbie resisted swallowing the medicine, but most of
the time she complied. Walt was alternately menacing and
kind: He would offer Barbie milk-shakes and candy if she did
what she was told; other times he threatened to whip her
"shapely little butt" if she didn't cooperate.
The Barbie doll made grunting sounds resembling an
adult woman enjoying sex; Sharlene also forced the doll's
pelvis up and down, making suggestive adult comments.
When I asked how she knew to do that, she said Walt had
shown her lots of movies of women having sex. Her

knowledge of sexual toys and positions seemed endless, and
she had learned the most crude descriptive terms. During
these sessions Sharlene was obviously aroused, and I was
concerned about the reinforcement of arousal to these nega-
tive sexual experiences. I was also concerned about my own
observer role, since many individuals had apparently wit-
nessed her sexual exploitation.
I decided, therefore, to intervene in the ritualized play.
"Where are the different parts of you, Sharlene?" She replied,
"That's a good idea; I'll put them out." She selected dolls to
represent the different parts of herself, and situated them
near the central scene of the play. "Let's have Chuckie talk
to the cameraman," I said. Sharlene seemed irritated by my
interrupting her play, yet she agreed and placed the Chuck
doll in her hand. "Hey, Walt. Hey butthead," she screamed
out. "If you have to be so secretive about this, it must be really
wrong. I'm tired of you making me stand guard. I'm tired of
being your guard." She intuitively and immediately assumed
the personality of Marsha, whom she had earlier drawn as
the little girl in the closet, and said in a weak and miserable
little voice, "Walt, can't you hear me...I'm dying here. I'm not
going to be around to make your movies anymore. I'm dying
here, can you hear me?" Sharlene threw down the doll and
went out of the office. I caught up with her, but she wanted
to leave. She had done more than she could. I sat with her
outside for a while, looking at the flowers and a spider's nest
and letting her show me how she could jump rope.
I reminded myself about pacing. This child was now
entering the trauma, and the associated feelings of despair,
fear, and helplessness were entering the treatment hour. She
had apparently resisted coming to therapy the following
week, and her foster mother called to report that she was
sick. I talked to her briefly on the phone, telling her that we
were talking about some really hard memories right now and
it was OK for her to take a little break. When she came back,
I assured her, we would take it a little at a time.
The play ceased spontaneously at this point, but Shar-
lene wanted to use her drawings to act out the various parts.
Eventually, I asked her to have Charlie talk to some of the

other alters and encouraged the alters to interact with each
other. I also talked to the alters about the feelings they held
and asked for them by name when I did. Only the catatonic
alter (the child pretending to be dead in the drawing) refused
to come out and talk to me directly; I realized later that even
though Sharlene had tried to role-play this part of her per-
sonality, this alter was nonverbal.
I had begun to see Charlie less in therapy; I asked
Sharlene if I could show the self-portrait to Charlie, and she
agreed. "He won't like it," she said. "He doesn't like anything
that I do."
"Why do you think that is?" I inquired.
"Because...he thinks I'm wimpy."
"I think he worries about you and wants you to take care
of yourself better. He wants to make sure no one hurts you.
He's there just to help you."
Sharlene seemed to like this idea and said, "Yeah, like
my bodyguard."
"Yeah," I repeated, "just like a bodyguard, but he wishes
you didn't need one."
"I get it," she announced.
I showed Charlie the self-portrait and she/he was
unimpressed. "She doesn't draw very well."
"I think she draws fine. Do you know who these people
are?"
"Yep, the slut, the goonie, and the dyke." Charlie was so
cryptic. I asked further and learned that he called the little
girl who wanted to die a "goonie" because he thought that
was less than a wimp. He called the sexualized girl "the slut"
but said "she didn't know any better...women are stupid." He
called the aggressive one "the dyke," his way of referring to
strong women. I assumed he had learned these judgmental
concepts from Walt. "What do you call yourself?" I asked.
"They call me Chuck," he replied. "Yeah," I persisted, "but
what do you call yourself?" I had never seen him drop the
facade as he did this one time, stating concisely, "Rambo."
That pretty much summed it up. This alter had been created
to try to fight unbeatable odds on his own, just as Rambo had
done with armies. "You and I are going to need to teach

Sharlene how to be more assertive and not let people hurt
her feelings as much." "Yeah,* he agreed, "she should learn
to kick ass." I thanked Chuck for his idea and encouraged
him to think of some ways other than fighting to help Shar-
lene.
I had made Sharlene's internal personality system exter-
nal, and it appeared to me it was now fruitful to allow the
system to internalize again, helping to strengthen the valu-
able aspects of a built-in support system while encouraging
internal cooperation and assistance among the alters. I
asked Sharlene to have an "inside meeting" with all the
different parts of herself to see how many ideas they could
find for how to help Sharlene not have her feelings hurt so
much. Likewise, I encouraged Sharlene to have "group meet-
ings" about whether or not they wanted to be adopted by Ann
and Phillip, how they felt about Walt being in prison, and
what they wanted to be when they grew up. Over time
Sharlene came in and reported "We decided we want to be a
therapist like you," "We decided we want Ann and Phillip to
be our mother and father," and, finally, "We don't think we
need to come to counseling anymore."
Sharlene's foster parents reported that her worrisome
behavior had peaked during the weeks that the
posttraumatic play was in high gear. Then her behavior had
become more consistent, and there were fewer bouts of fluc-
tuating behavior and forgotten statements and behaviors.
I had three or four sessions with the family to explain
Multiplicity, why it had developed, what it meant, and how
to respond to the alters. Together, we read a book about
multiplicity (Gil, 1990) to Sharlene. The parents responded
very well, confirming to Sharlene that she was a good child
and the grown-ups had been the ones who were bad. They
clearly affirmed that they loved her and wanted her to be
their special first daughter for the rest of their lives. They
told her how much they loved her and how lucky they felt to
have her as their daughter. The final statement of our last
meeting came from Sharlene to her parents: "We love you
too."
DISCUSSION
Sharlene was a victim of severe, heartless chronic abuse

during her formative years. As a result of the brutal nature
of the abuse, she had developed the ability to dissociate in
order to mentally escape the abuse. Sharlene had developed
a number of symptoms commonly associated with dissocia-
tive disorders, including forgetfulness, amnesia for the prior
abuse, fluctuations in behavior, and destructive behavior to
self and others.
Dissociation occurs along a continuum, with its most
extreme form being a fragmentation into distinct personality
types. This type of dissociation is known as multiple per-
sonality disorder (MPD) and is viewed as an adaptive
response to an overwhelming reality. What is known about
MPD is that it usually develops in children who endure
overwhelming and extreme abuse. Usually, it is not diag-
nosed until adulthood, although a recent emergence of litera-
ture on the subject (Putnam, 1989; Ross, 1989) will make
delayed diagnosis a less likely occurrence in the future.
The treatment of choice with individuals with multiple
personalities includes verbal psychotherapy, hypnotherapy
to access alters, and, eventually, an attempt to help the
individual integrate the fragmented parts by encouraging
co-consciousness and cooperation among the alters, internal
communication, and processing of the trauma (Putnam,
1989). The other tenet of therapy seems to be the sharing of
the diagnosis with the patient; Sharlene and I used her
drawing of four separate alters on one page to help her
understand that all her alters constituted her self.
Sharlene had fragmented enough to have two primary
personalities attending the therapy. In my work with other
clients with multiple personalities the alters have not been
this clear-cut and available. The emergence of the alters was
probably a result of the intense stress Sharlene faced on a
daily basis: She had become obese and was being ridiculed
and ostracized at school. Reportedly, the children at school
frequently pointed at her and gathered in groups to laugh at
her. This experience and the sensation of being watched
penetrated Sharlene's defenses and triggered off the uncon-

scious memory of being watched during the forced sexual
activity of her early childhood.
The art work, role-playing, and accessibility to the two
alters who came to therapy facilitated the treatment process
for this child. However, the posttraumatic play had elements
of danger in that it seemed to exacerbate the sexual arousal
and resultant conditioning to abusive memories. The inter-
vention of having the alters enter the posttraumatic play and
speak directly for themselves redirected Sharlene's energy
into more appropriate channels and proved to be my link
between the two alters who came to treatment.
Family sessions were undertaken to discuss the multi-
plicity and the adoption. Fortunately, the foster parents were
receptive to the notion of multiplicity as a creative survival
strategy, and they were eager to learn how to respond to
Sharlene and her alters. The family members pledged their
love and commitment to each other during a family session
after Sharlene's multiplicity was apparent; the content and
timing of this session was reaffirming and beneficial to Shar-
lene.
Sharlene's treatment lasted 9 months. Her foster
parents reported a happier, less sullen child, who made
friends, joined the basketball team, and attended school
more willingly. She had nightmares and periods of staying in
her room alone, but overall she seemed to have greater
self-confidence and communicated more freely when she felt
upset.
Special Issues
COUNTERTRANSFERENCE
I have alluded to countertransference issues throughout the
book but deal with them at length here to emphasize the
relevance of countertransference to work with abused
children. These children are extremely vulnerable, with
tumultuous histories of abuse, neglect, and deprivation. Con-
sequently, they elicit a multitude of responses from the
therapist, including intense hostility, sadness, protective im-
pulses, and/or feelings of helplessness.
During the course of therapy the child may face a variety
of disappointments and stresses from such external sources
as child protection services, courts, parents, foster parents,
or caretakers. In particular, abused children might have to
talk to police personnel and social workers, undergo physical
exams, consillt with district attorneys regarding court tes-
timony, and be totally reliant on others for their future
well-being.
The clinician may become invested in recommendations
that are requested from authorities and may share the child's
192
Special Issues 193
frustration and disappointment when the outcome is incom-

patible with expectations. On occasion, a child's plight
demands special attention, and highly qualified profes-
sionals may find themselves behaving in unexpected ways.
For example, one clinician treating an abused child got her-
self licensed as a foster parent and entered into a dual role
with the child. Another clinician, whose rescuing instinct
was strongly evoked, adopted a child. While these may be
extremes, the clinician must carefully assess any personal
conduct that threatens to develop outside the boundaries of
a strict therapeutic relationship.
CLINICIAN SELF-CARE
This type of work is simultaneously rewarding and demand-

ing. It is critical for the clinician to set limits on the number
of child abuse clients seen, on the number of cases seen per
day and per week, and on the number of clients accepted who
have the same difficult diagnosis. For example, treating
individuals with multiple personalities requires a great deal
of time and effort. To build a practice limited to individuals
with multiplicity would be a disservice to both clients and
clinician.
Because the work is so compelling, some clinicians be-
come literally consumed with the subject, reading only books
on child abuse, attending seminars only on child abuse, and
listening to hours upon hours of audiotapes on child abuse
while driving.
The clinician is advised to replenish himsel^herself
through physical activity, vacations, and frequent changes of
environment. In addition, it is important to balance the child
abuse work with treatment of other, less urgent, problems. I
have found balance absolutely vital to preventing burnout. I
am fortunate to have the opportunity to teach, write, and do
my clinical work. The rest I have learned the hard way, and
I encourage every clinician to work hard on preventing bur-
nout, which is inevitable when working in this challenging
field.
CLINICIAN SAFETY
Working with abused children by necessity requires working

with parents who exhibit a range of disturbing behaviors,
including violence, impulsivity, and antisocial, dependent,
infantilized, and histrionic personalities. The circumstances
under which clinicians encounter abusive parents frequently
involve coerced and involuntary contact. Therefore, some
confrontations may be, at best, awkward and, at worst,
dangerous.
Again, learning through trial and error, I believe
clinicians working with this population should be equipped
with information about handling crises. For example, it is
important to meet with overtly hostile parents while another
colleague is nearby. The police and district attorney should
be consulted regarding obtaining restraining orders, if
needed. The clinician is advised to see families with
cotherapists when there is impending danger and to reserve
the right to refer to another therapist if the client is threaten-
ing. In addition, the clinician may want to take self-defense
classes, carry a whistle, or outfit the office with some alarm
system. The clinician may also want to take some courses on
working with violent people or defusing a potentially ex-
plosive situation.
Hopefully, these techniques will not become necessary,
but it is best to anticipate dangerous situations rather than
regret having ignored this aspect of the clinical work.
SUMMARY
The impact of child abuse and trauma can be long-term.

Working with abused children provides us with a unique
opportunity to help them process the painful and frightening
events before the defensive mechanisms solidify in the per-
sonality, causing denial, avoidance, behavioral or play
reenactments, or a variety of symptomatic behaviors.
There are few "rules" about working with abused and
traumatized children; however, we can make inferences from
Special Issues 195
the growing body of literature on adult survivors of abuse

and other victims of trauma. The last two decades have seen
an increase in interest and activity in researching the impact
of childhood trauma and in determining treatment pos-
sibilities. We are now in a position to postulate treatment
preferences for child victims of abuse and trauma.
The field of child therapy in general and therapy of
abused children in particular is in evolution. The material
contained in this book is intended to stimulate the creativity
of sensitive and concerned professionals who have chosen to
work with abused children and their families.
The case studies demonstrate the necessity of choosing
the type of play therapy and treatment modality on a case by
case basis. The child therapist must select the approaches
and techniques carefully and observe the child's play active-
ly. Children can communicate and demonstrate their hidden
fears and concerns in a variety of ways. It is up to the
clinician to recognize the child's attempts to communicate
and to set the context for safety and learn to decode the
child's words and actions. The child's medium for com-
munication is not the spoken word. The child reveals him-
seli/herself through play. The clinician must be patient, be-
come fascinated by small nuances, and make purposeful
choices.
The clinician must also take chances, recognizing the
subtle messages from the child. The child will pace the
therapy, and the therapist must respect the child's ability to
go at a rate that can be tolerated.
Children who process an abusive or traumatic episode
need input about the event, after their own perspective has
been explored. The therapist must continue to struggle to
find the perfect fit between technique and child; the prop or
technique that allows the child to communicate freely.
Many traumatized children retreat into secrecy to deal
with the frightening event. The clinician must make the
playroom a safe sanctuary where secrecy can be shared with
a trusted other. If the child avoids the work, the therapist
gently but steadfastly stimulates the child's attention,
providing a variety of relevant props, stories, or pictures. And
once the material is being processed, the child requires as-

sistance to feel higher feelings, discharge them, and reor-
ganize their perceptions of the abuse and what it means
about who they were, who they are, and who they will be.
Every opportunity to instill hope and a vision towards the
future must be taken, so that the child feels less futile and
more motivated towards growth. Every abusecl/traumatized
child changes because of the trauma. The clinician's primary
goal is to provide a reparative and corrective experience for
the child.
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Index
Abreaction, 30 B
Abused child (see Child abuse)
Active observation, 60, 62 BASK model, 23
Adults Molested as Children "Battered child syndrome," 2
groups, 33 Behavior therapies, 31
Advocacy, 51 Behavioral objectives, 62
Affective disorders, 7 Betrayal, 15
Age factors Boundary setting, 58
child abuse impact, 3, 4 Boys
and treatment, 42 activity preferences, 69
Aggressive behavior, 9, 10, 13 child abuse impact, 6
Amnesia, 70, 77 group therapy, 34
Anger
abused children, 13, 14
expressive therapies, 67, 68 C
trauma response, 22
Animal torture, 13 Catharsis, 30
Anticipatory anxiety, 56, 57 Child abuse (see also Sexual
Anxiety abuse)
abused children, 56, 57 definition, 2
posttraumatic play, 24 and dissociation, 14, 15, 76-
Assessment, in therapy, 61-63 80
Attachment needs, 57 education, 81, 82
Avoidance, 69, 70 empirical research, 2, 3
205
Child abuse (continued) Compulsive repetition (see

externalized behavior, 13, 14 Repetition compulsion)
family emotional climate, 5 Computer games, 60
impact, 3-19 Confidentiality, 48, 49
internalized behavior, 12, 13 Corrective therapy approach,
intimacy threat, 56 52,53
parental response, 6 Countertransference, 58, 192,
physical effects, therapy, 68 193
prevention, 81, 82 Court-mandated evaluations,
societal response, 1, 2 50
symptomatic behaviors, 7—19 Court system, 48-51
treatment, 37-82 Courtroom ambience, 50
Child Abuse Councils, 41
Child advocacy, 51
Child neglect D
attachment need, 57
clinical examples, 85—105, "Damaged goods" syndrome, 45
158-176 Daughters and Sons United, 33
family emotional climate, 5, Defense attorneys, 50
40 Denial
impact, 10 directive therapy, 69, 70
physical effects, therapy, 68 trauma response, 22
Child-rearing, 5 Depersonalization, 76, 77
Child Sexual Abuse Treatment Depositions, 51
Program, 33 Depression, 7
Child therapy, definition, 26, Desensitization, 75
27 Developmental changes, 61
Chronicity of child abuse, 4 Dibbs in Search of Self
Client-centered therapy (Axline), 35
versus directive therapy, 35, Direct observation, 47
36 Directive therapy
play therapy models, 30, 31 versus non-directive therapy,
timing, 55 35,36
Clinician and repression, 69, 70
gender effects, 44, 45 Discontinuous therapy, 44
nondirective versus directive Dissociation
therapy, 36 BASK model, 23
safety of, 194 child-abuse impact, 14, 15
self-care, 193 clinical example, 190
Communication, families, 5 precipitants, 78, 79
Community as Extended Fami- trauma correlation, 22, 23
ly,33 treatment, 23, 76-80
Index 207
Dissociative sequencing, 78 Group activities, 69

Dreams, 22, 23 Group therapy, 31-34
objectives, 33
E for parents, 32, 33
Guided imagery, 76
Ego development, 61 Guilt, 6
Emotional space, 59
Emotionally abused children H
impact, 10, 11
physical effects, therapy, 68 Hospitalization, trauma of,
Environmental factors, 158-176
families, 41, 42 Hotlines, 42
Expressive therapies, 66—69 Hysteria, 20
Externalized behavior
child abuse effect, 13, 14 I
dissociation, 79
Incest
F
family emotional climate, 5
victim personality traits, 45,
Family dysfunction 46
and child abuse, 5 Individual therapy, 47
treatment considerations, Internalized behavior, 12, 13
40,41 Interpretation, 29
Family therapy, 47, 48 Intimacy, 56
Fear
abused children, 14 J
in trauma victims, 46
"Feeling pictures/' 43 Jungian therapy, 34
Fixation on trauma, 22
Flashbacks, 22 K
Flight response, 79
"Flooding," 30 Klein, Melanie, 28-30
Foster homes, 43
Free association, 29 L:
Freud, Anna, 28-30
Freud, Sigmund, 20 Legal system, 49, 50
Fugue states, 77 Limit setting, 57-59
G M
Gender of clinician, 44, 45 Male therapists, 44, 45
Girls, activity preferences, 69 Male victims, 6
Masturbation Parents Anonymous, 32

disinhibition, 19 Parents United, 32, 33
sexual abuse impact, 16-18 Participant-observation, 28
Memory, trauma effects, 20 Personality development, 61
Metaphors, 65 Personality traits, 9, 10
Modeling, 31 Physical activity, 68, 69
Multiple personality Physical abuse
child abuse impact, 14, 15 aggressive behavior, 9. 10
clinical example, 190 impact, 8—10
treatment, 76, 77 physical effects, therapy, 68
Mutual Story-Telling Tech- Play, definition, 26-28
nique, 65 Play reenactment, 21, 23, 24
Playroom, 63
N Posttraumatic play
general aspects, 21, 23-25,
National Child Abuse Hotline, 72-76
42 harmfulness, 24, 25
Neglected children (see Child interruption of, 74
neglect) intervention, 72-76
Nightmares, 22 Posttraumatic syndrome
Non-directive therapy core features, 20, 21
child therapy models, 30, 31 directive therapy, 69
clinician's role, 31 resolution of, 21, 22
versus directive therapy, 35, treatment modalities, 46, 47
36 Powerlessness, 15
timing, 55 Precocious sexual behavior, 15,
Nonintrusive therapy, 59—61 16
Nonverbal communication, 47 Preschoolers
Numbing, 22 family therapy, 47, 48
treatment potential, 42
O Prevention, 81, 82
Privacy, 70-72
Observation, 47 versus secrets, 71
Offender, 42, 43 Projective Story-Telling Cards,
Open-ended questions, 56 67
Overstimulated child, 63 Psychoanalytic play therapy,
28-30
P Psychogenic amnesia, 77
Psychotherapy, 23
Parenting, 5 Puppet play
Parents benefits, 65
child abuse response, 6 in posttraumatic syndrome,
group therapy, 32, 33 74,75
Index 209
R versus privacy, 70
therapeutic technique, 67
Rank, Otto, 30 "Secrets" game, 67
Rape victims Self-defense courses, 69
clinical example, 106-126 Self-disclosure, 67
desensitization, 75 Self-esteem, 82
Reinforcement, 31 Self-expression, 66-69
Relationship therapies, 30, 31, Self-mutilation, 13
53-59 Separation anxiety, 43
overview, 30, 31 Severity of child abuse, 4
setting limits, 57-59 Sex differences
structure, 54, 55 activity preferences, 69
Relaxation techniques, 76 child abuse impact, 6
"Release therapy," 30 clinician effects, 44, 45
Reparative therapy approach, Sexual abuse
52,53 and child abuse definition, 2
Repetition compulsion clinical examples, 106-126,
function, 58 144-157, 177-191
posttraumatic play, 24, 72- family emotional climate, 5
76 group therapy, 33, 34
and structured play therapy, and guilt, 6
30 impact, 7, 8, 45, 46
Report writing, 50, 51 physical effects, therapy, 68
Reporting law, 48, 49 severity impact, 4
Resiliency, abused children, and sexualized behavior, 15—
11,12 19
Resistance treatment modalities, 45-^8
in nonintrusive therapy, 60 Sexual play, 16, 17
psychoanalytic play therapy, Sexuality
29 developmental framework,
Risk factors, monitoring, 41 15,16
Ritual play, 73, 74 incest victims, 46
Rogers, Carl, 30 Sexualized behavior, 15—19
Social service agencies, 48-51
Sports, 69
S Startle response, 21
Stigmatization, 15
Safety of clinician, 194 Story-telling, 65
Sand tray therapy Stress, monitoring of, 41
benefits, 65, 66 "Stress-resistant" children, 11
child therapy models, 34 Structured play therapy, 30
Secrets Suicidal behavior, 13n
disclosing of, 70, 71 Sunglasses, 65
"Super Puppy," 66 play reenactment, 23-25, 72-

Suppression, 69, 70 76
Symbolism resolution, 21, 22, 75, 76
psychoanalytic theory, 29 timing of treatment, 39, 40
sand tray therapy, 34 treatment modalities, 46, 47
"Traumatophobia," 46
Treatment, 37-82
T Trust, 49
"Talking to the wall" tech-

nique, 60 U
Tape recordings, 71, 72
Team sports, 69 Unconscious
Telephones, 64, 65 psychoanalytic theory, 29
Termination, 102, 103 and trauma, 69
Testimony, 50, 51 Understimulated child, 63, 64
Therapeutic alliance, 48
Therapeutic relationship
and boundaries, 58, 59 V
in relationship therapies, 31
Therapeutic stories, 65 Verbal communication, 64, 65
Therapist (see Clinician) Victimization, 40
Threats Video therapy, 66
impact, 5 Videotaping of play, 74
and intimacy, 56 Voice quality, 47
Timing of treatment, 39, 40
Toy selection, 64-66
Toys W
availability of, 66
in structured therapy, 30 Writing reports, 50, 51
Transfer of learning, 80, 81
Transference, 29, 58
Trauma Y
directive therapy, 69
dissociative phenomena, 15, Young children
22,23 family therapy, 47, 48
impact of, 19-25, 46 treatment potential, 42

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The Healing Power of Play

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ELIANA GIL, PH.D.

THE GUILFORD PRESS

This book is printed on acid-free paper

Library of Congress Cataloging-in-Publication Data

Writing this book was a stressful and happy experience.

art work is provided, it is presented with the permission of

The Abused Child: Treatment Issues 1

The Child Therapies: Application in Work with 26

The Treatment of Abused Children 37

Leroy: A Child Traumatized by Severe Parental 85

Johnny: A Child Traumatized by Sexual Abuse 106

Antony: A Child with Multiple Traumas 127

Gabby: A Child Traumatized by a Single Episode 144

Laurie: A Neglected Child Traumatized by a 158

Clinical Impressions 163

Sharlene: A Child Traumatized by Chronic Sexual 177

Special Issues 192

THE ABUSED CHILD

Children have been subjected to differing types of maltreat-

might expect. In the 1940s there was some documentation of

Beginning with the '70s a great deal of interest has

MEDIATORS IN THE EFFECTS

Although findings have emerged from studies on child sexual

Age of the Child at the Time of Abuse

younger children because "uncontrollable terrifying ex-

threats may produce generalized anxiety and fear in the

The Emotional Climate of the Child's Family

The Child's Mental and Emotional Health

of abuse (Adams-Tucker, 1981; Leaman, 1980). Van der

The Guilt the Child Feels

The Sex of the Victim

Parental Responses to the Child's Victimization

THE IMPACT OF CHILD ABUSE

Sexual abuse and its impact should be seen along a con-

Because children are unable to fully understand or ex-

• Impaired capacity to enjoy life

Martin and Rodeheffer (1980) state that:

Martin and Rodeheffer also quote a study conducted by

Reidy (1982), summarizing traits of physically abused

Kent (1980) also finds developmental delays in neglected

• Behavioral problems (anxiety, aggression, hostility)

Garbarino et al. summarizes their findings:

It should be noted that some victims of child abuse seem

In the following section I offer some clinical observations

The problem behaviors of abused children are manifested

Appear withdrawn and unmotivated to seek interactions

They are often more readily identified because their behavior

1985; Putnam, 1989). Multiplicity is believed to begin in

TABLE 1.1. Traumatic Sexualization

combined their clinical experience working with normal and

TABLE 1.2. Children's Sexuality

can include persistent, public masturbation that can cause

by exposure to explicit sexual activity and may be acting this

Behavioral symptoms reveal the child's distress; they

THE IMPACT OF TRAUMA

Many victimized children may also be traumatized. While

assault and the genetic predisposition, developmental phase,