Clin Soc Work J (2008) 36:281–291
DOI 10.1007/s10615-008-0148-2
ORIGINAL PAPER
The Therapeutic Action of Play in the Psychodynamic Treatment
of Children: A Critical Analysis
Alan J. Levy
Published online: 10 June 2008

Springer Science+Business Media, LLC 2008
Abstract This paper critically appraises the therapeutic
action of play in psychodynamic child therapy and identifies
obstacles to utilizing play therapeutically with children. An
examination of the functions of action and verbal means of
communication as well as their roles in shaping therapeutic
relationships in treating children is provided in light of
recent theoretical advances. The significance of engaging
children directly through play and for redressing the balance
between action and verbalization in child therapy is
discussed.
Keywords Child psychotherapy
Play therapy

Psychoanalysis
Therapeutic action
…what she was acting now was she herself; perhaps it
was that part of her being that had formerly been locked
up and that the pretext of the game had let out of its
cage. Perhaps the girl supposed that by means of the
game she was disowning herself, but wasn’t it the other
way around? Wasn’t she becoming herself only
through the game? Wasn’t she freeing herself through
the game? The Hitchhiking Game, Milan Kundera
Introduction
Writers long have recognized play as a significant com-
ponent in the lives of children. However, recent theoretical
A. J. Levy (&)
Loyola University Chicago, School of Social Work,
820 North Michigan Avenue, Chicago, IL 60611, USA
e-mail: alevy@luc.edu
advances necessitate a critical analysis of the action of play
itself as a therapeutic medium. Many child therapists find it
difficult to understand and respond therapeutically within
the frame of play (Frankel 1998). Gaines (2003) attributes
this lack of engagement directly through play in part to
child therapists’ struggles for legitimacy in the eyes of their
colleagues who treat adults, thus stifling innovation in child
treatment. He asserts that the result is psychodynamic child
therapists remaining mired in an outdated model that holds
neutrality, abstinence and anonymity as ideals.
Child therapists, like their counterparts who treat adults,
tend to be highly verbal individuals. As a result, play may
tend to be subordinated to talking as a means of therapeutic
communication (Spiegel 1989). This approach more clo-
sely resembles that of adults, with the modification of
adding play to ‘‘grease the wheels’’ so that a child will feel
comfortable enough to talk to the therapist (Frankel 1998).
The result is that therapists would be less likely to make
adequate use of play in their work with children.
Further, because the difficulties that are manifested by
the child during a play therapy session may be related to
historical or contemporary dilemmas that are located in the
child’s milieu, it is tempting to make interpretations of the
parallels between the behaviors enacted in play and the
dilemmas facing children outside of the treatment rela-
tionship. The importance of considering the role of these
factors in understanding children’s behavior and experi-
ence is not in question. However, by viewing play
primarily as a form of displacement and projection of core
conflicts that are enacted in the treatment session, the cli-
nician may fail to recognize adequately that children also
are enacting actual relational patterns in vivo that are no
less real or germane than elsewhere in their lives.
Some writers have questioned the value of interpretation
with children. For example, Barish (2004a), while allowing
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for the utility of interpretation, writes that ‘‘the question of on the suspension of reality-that is, the use and
how interpretation is helpful to children, or how a child practice of pretending or of making believe and of
makes use of interpretation, is problematic. Even when our trying on. In an important sense, play can be the
interpretations are not experienced as intrusions, or mis- dramatic expression of what later becomes metaphor
construed as criticisms, they are often of uncertain in language (p. 39).
therapeutic effect. The path from insight to change is often
Klein, perhaps more than any other theorist, viewed
obscure in work with adult patients, much more so with
interpretation as the sine qua non of analytic treatment of
children’’ (p. 386). Interpretation and other primarily ver-
children (1932). She asserted that children form transfer-
bal interventions, therefore, are only one component
ence neuroses with analysts, and that the roots of their
available to psychodynamic therapists. Indeed, interpreta-
conflicts are readily discernable in their play. Klein viewed
tions can be used defensively by the therapist to contain
play as equivalent to free association in analysis with adults
their difficult reactions to their clients (Aron 1996; Hoff-
(1955). She asserted that play, along with other elements of
man 1998; Slochower 1996; Winnicott 1971a).
children’s behavior, are means of expressing what adults
One consequence of over relying on interpretation is that
express through words. Child analysis, therefore, required
child therapists may fail to recognize opportunities to
the interpretation of ‘‘phantasies, feelings, anxieties, and
engage these difficulties as they are manifested currently in
expressed by play’’ (1955, p. 124). Klein viewed inter-
session and to interact with the child in new and therapeutic
pretation as crucial for the establishment of an analytic
ways (Barish 2004b). Such an approach risks losing the
frame, freeing children’s imaginations, and for helping
emotional immediacy that engagement of children’s diffi-
children to understand the purpose of psychoanalysis
culties in the context of play affords and the opportunity to
(1932). Interpretation in this model facilitates contact with
address it directly. In short, it is possible that, by focusing
the unconscious of child analysands and advances analysis
interpretations on other contexts, therapists essentially
by removing repression of intrapsychic material. Moreover,
displace onto others a relational difficulty that simulta-
Klein asserted that children are able to understand and
neously is manifested, to some degree, in the therapeutic
make use of interpretations if they are succinct, clear, and
relationship. In these cases, interpretations can be dis-
employ children’s words (1955). Interpretation of play
tancing and communicate a clinician’s desire to not know
permitted the analysis of transference and the tracing of
the client (Hoffman 1998).
conflicts to their (i.e. genetic) sources (1932).
Of note, Klein describes treatment attempts in which she
refrained from interpreting children’s play, all of which
The Role of Play in Psychoanalytic Theory
were unsuccessful. She writes that:
While the thrust of this article is that many child therapists I have never yet in any analysis seen any advantage
may rely too heavily on verbal forms of communication in follow from such a policy of non-interpretation. In
their work, there is a current in psychoanalytic writing that most cases I have very soon had to abandon it
recognizes the therapeutic the value of play itself. Indeed, because acute anxiety developed and there has been a
Freud (1908) noted that ‘‘every child at play behaves like risk of the analysis being broken off (1932, p. 69).
an imaginative writer, in that he creates a world of his own,
She viewed interpretations by analysts as ‘‘proof of
or more truly, he rearranges the things of his world and
confidence and love and help to alleviate (a patient’s)
orders it in a new way which pleases him better’’ (p. 174).
sense of guilt’’ (1932, p. 69). Interpretation was deemed
Marans et al. (1993) note that Freud stated that with older
necessary because of children’s weak egos and the
children, rather than disavowing reality (as does fantasy),
resultant massive repression of content and their obsessive
play involves suspension of reality in the service of
pre-occupation with reality (1932). For Klein, the content
reworking unpleasant experiences. Indeed, Freud recog-
of play is a vehicle for interpretation of what she con-
nized that play constitutes a ‘‘revolt against passivity and a
siders deeply unconscious phantasies. While she made
preference for the active role’’ (Freud 1931, p. 264). Ma-
pioneering contributions to child analysis, Klein viewed
rans et al. (1993) further the distinction between fantasy
the primary value of play as providing unconscious
and play by stating that ‘‘The critical difference between
material for interpretation. Klein did not tend, therefore,
fantasy and play is that in play the suspension of reality sets
to utilize play itself as a therapeutic vehicle (Winnicott
the stage for and is most often accompanied by action
1971b).
(p. 18). Solnit (1993) concurs with this view and notes that:
A close reading of Klein’s account of treatment sessions
simply, action can be a trial of thought, especially in which she refrained from interpretation indicated that,
when, as in play and playfulness, the action is based in the absence of interpretation, she remained almost

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completely silent, perhaps because she saw no other means
of analytic engagement. In one case she reported:
…I played with him for weeks in silence and made no
interpretations, simply trying to establish rapport by
playing with him…When, after some weeks, I clari-
fied this material to (him) in connection with what
was already understood it had a far-reaching effect’’
(1932, pp. 68–69).
The anxiety manifested by these patients and their
subsequent relief when she began to interpret, to some
extent, may be consequent to Klein’s more active
engagement and participation with them when she did
interpret, than to the specific content of the interpretations
themselves.
Anna Freud’s position on play diverged in some
important respects from that of Klein. She noted that in
child analysis, ‘‘the child’s play and his verbal expressions
gradually lose the characteristics of secondary process
thinking, such as logic, coherence, rationality, and display
instead characteristics of primary process functioning such
as generalizations, displacements, repetitiveness, distor-
tions, exaggerations’’ (1965). She asserted that because
play entails symbolic behavior, the meaning of the play is
more uncertain than language, and, as such, cannot func-
tion as the equivalent of free association in adult analysis.
Like Klein, she viewed child analysis as having the same
aims as other forms of analysis, which she defined as
increasing ego control by expanding consciousness. How-
ever, for Anna Freud, children were incapable of forming
the transference neuroses that were central to the analysis
of adults for two main reasons (1946). First, she believed
that because children’s relationships with their original
objects (i.e. parents) are contemporaneous with treatment,
they precluded children from transposing their neurotic
conflicts onto the child analyst. The second reason is that
she believed that child analysts cannot be neutral to child
analysands (1965). As such, they cannot function as blank
screens upon which children project their internal
dynamics.
In addition, Anna Freud noted that the analyst’s
dependence upon and work with parents of child patients
and others in the child’s environment made the analyst a
real object, and this precluded the development of a
transference neurosis as well. She also diverged from Klein
insofar as she did not consider play as equivalent to free
association for three main reasons. First, children do not
corroborate interpretations as do adults. Second, play does
not occur in the context of a full transference neurosis.
Third, children’s play is not dominated by the same pur-
posive attitudes as in adult free association (1926, 1945).
Anna Freud asserted that while children do form trans-
ferences with analysts, analysts also are new objects to
283
children. This creates a double relationship (1965). The
duality of the analytic relationship, the proclivity of chil-
dren to externalize conflicts, and children’s dependence
upon their environment require analysts to balance between
external and internal factors and to recognize when their
patients are using them in one or the other manner.
While she advocated a variety of treatment techniques
beyond interpretation, Anna Freud still viewed interpreta-
tion as central to child analysis. The focus of initial phases
of treatment sought to ‘‘induce an ego state conducive to
perceiving inner conflicts’’ via the interpretation of defen-
ses (Freud 1965, pp. 225–226). The role of interpretation
was seen as a means to help children become aware of the
defenses they employed because they were more rigid than
those of adults. Once a child was sufficiently prepared, the
analyst may then interpret transference and resistance,
thereby widening consciousness and increasing ego domi-
nance. She suggested that the analyst use interpretation
judiciously, and balance between internal and external
elements of the case. In addition to interpretation, Freud
employed other interventions including verbalization and
clarification of pre-conscious material, suggestion, and
reassurance. In this model, children select from among all
of these elements, and also utilize the analyst as an object
of identification (1965).
Winnicott (1971a) viewed play as a form of transitional
phenomena and recognized play as inherently therapeutic
because it opens potential space in which a child can
symbolically destroy, differentiate from, and use the ana-
lyst. Furthermore, Winnicott noted that deep psychotherapy
could be accomplished through play without interpretive
work (1971a). He noted that the pleasurable experience of
play is derived from the blending of intrapsychic reality
with the control of actual objects. Winnicott stated that the
‘‘area of playing is not inner psychic reality. It is outside the
individual, but it is not the external world’’ (1971a, p. 51).
Marans et al. (1993) state that, for Winnicott, ‘‘play is a
reflection of the child’s capacity to occupy a space between
psychic and external reality in which the child uses ele-
ments from both domains’’ (p. 15). This is significant since
transitional phenomena make it possible for children to
internalize their relationships with their caretakers and to
form representations of new and more successful ways of
experiencing self and others and of relating. Winnicott used
interpretation judiciously to shift unconscious transference
(1958). He was careful to present interpretations in a non-
dogmatic manner, which children were free to accept or
reject (1971a, b). Although he viewed interpretation as an
essential component to treatment, he noted that a source of
the beneficial changes that resulted from analysis depended
on the analyst surviving the patient’s attacks because it
established the analyst as independent of the client’s needs
and because it facilitated object usage (1971a).
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Slade (1994) noted that, by placing their experiences
within play rather than merely in words, children are
enabled to create new psychological structures. These
structures form the basis for children understanding
themselves and their world. They also are used to develop
their identities and to negotiate their environment. In its
most developed form, these models of self in relation to
others are encoded as narratives (Wall and Levy 1996;
Levy and Wall 2000). It follows that clinicians need to help
children explore their experiences and to integrate them
within structures that permit more adaptive functioning.
In order for children to form meaning, they need others
to respond in ways that recognize their experiences as
meaningful (Benjamin 1988; Frankel 1998). Slade (1994)
notes that ‘‘when we play with a child, we let the child
know that we are there to be told…Children learn to rep-
resent internal experiences because these experiences are
first made real by another’s recognition of them’’ (p. 95).
She recognized that verbal elements are necessary in play
therapy. Slade states that:
The process of naming feelings is a first step in dif-
ferentiating affect states: distinguishing one affect
from another, distinguishing speaking about emotion
from acting on it, and distinguishing one character
from those of another. It typically accompanies the
emergence of narrative (p. 94).
Therefore, through the medium of play, children’s
experiences can become ‘‘realized, integrated, and accep-
ted into the patient’s experience of himself’’ (Frankel 1998,
p. 154). A significant portion of the work of clinicians then,
is to help children form and re-form their experiences
through play and to derive meaning from them in order to
develop children’s integrity and coherence, and to enhance
their ability to relate to others in deeper, more satisfying
ways. It seems reasonable to conclude that play in child
therapy long has been seen as a useful medium. However,
psychoanalytic authors have differed regarding the role of
play itself as therapeutic, and the role of interpretation in
child treatment.
Recent Theoretical Advances and Their Implications
for Play Treatment
The main thesis of this paper is that the therapeutic benefit
of play derives, to a great extent from its less verbal nature
than other psychodynamic therapies. It significantly
involves actions that more or less are tied to spoken lan-
guage. This creates problems as well as opportunities for
child therapists. One of the main difficulties in working
clinically through play is that spoken language is far more
precise than are other forms of communication. This is not
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to say that spoken language necessarily is so very accurate,
but rather that its meaning often is far more apparent than
is play. As such, child therapists are much less certain
about the meanings of their clients’ actions (Sutton-Smith
1997). Since therapists’ constructed meanings of clients’
behaviors form the basis for action on the part of clinicians,
child therapists are usually less certain about how best to
respond to their clients. Child therapists, in contrast to
others, therefore must be more comfortable with ambiguity
in their encounters with their clients. They also need to
develop far greater capacity for understanding the semiot-
ics (i.e. the study of signs and symbols) of human
communication.
Bateson, a communication theorist, noted the parallel
between therapy and play. He stated that both play and
therapy occur within a delimited psychological frame, and
possess a temporal and spatial bounding of messages
(1972). Of particular note, Bateson stated that in both
therapy and play the messages have a particular relation-
ship to a more concrete and basic reality. That is, therapy
and play both are effective precisely because the interac-
tions and communications are not considered to be ‘‘real’’
within their respective frames and because the material
strongly relates to important elements of a person’s life
outside of these frames (Levenson 1985). Levenson notes
the parallels between speech and action. He states that they
are ‘‘transforms of each other; that is, they will be, in
musical terms, harmonic variations of the same
theme’’(1985, p. 81).
Play in therapy is immediate (Gaines 2003). In other
words, rather than a child discussing difficulties that are
seen as occurring outside the therapy space, play treatment
often results in enactments of these problems in vivo,
through the medium of play itself. Some child therapists,
like their colleagues who treat adults, believe that it is more
efficacious if their clients discuss and focus upon past
relationships. However, as Levenson (1985) asserts, ‘‘the
patient’s past, the patient’s present, and his interaction with
the therapist (also) become transforms of each other,
immensely useful as different parameters of the same
experience’’ (p. 52). Therefore, for child therapists, the use
of the present play experience is as essential to therapy as is
focusing upon the past histories and other key relationships
of the children they treat.
While play and verbal language are homologous to one
another, it is not the case that they are essentially identical.
While play lacks the precision of language (Sutton-Smith
1997), it affords the clinician certain advantages over other
means of communication. Aside from being children’s
natural forms of expression, play provides both clients and
therapists ‘‘plausible deniability’’ concerning troubling
material, i.e. it permits the parties to suspend, and, if
necessary, to disavow its reality. After all, it’s ‘‘only’’ a
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game. Play therefore frees the participants to express and analysand’s relational matrix, and, in so doing,
explore these issues in ways that would be far more diffi- offering the analysand a chance to broaden and
cult if one was to pursue a more exclusively verbal means expand that matrix (p. 295).
of communication.
In treating children, the struggle to engage, to become
There is literature that asserts that non-verbal pro-
unhinged, to find one’s footing, and to communicate one’s
cessing of experience independently contributes to the
understanding of the child’s experience is all the more
ways that people function. Lyons-Ruth et al. (1998) note
essential given the complications engendered by treating
that ‘‘implicit knowings governing interactions are not
children, and the essential ambiguity and immediacy
language-based and are not routinely translated into
engendered by play in child treatment.
semantic form’’ (p. 285). Since children’s play entails
more non-verbal elements, it provides greater access to
implicit relational knowledge and gives therapists a means
Case Presentation
for developing and expanding it with their clients, by
developing new models for being with others (Levy
The following is presented to demonstrate the relational
2007).
dilemmas and struggles that pervade therapeutic relation-
Play demands the participation of therapists in ways that
ships in psychodynamic play treatment. It is offered to
are unimaginable in more verbally oriented therapies. As a
illustrate how play in therapy constitutes a particular
result, the roles of child therapists are necessarily more
framework for encountering children and how it helps
active, and they find themselves in situations that allow
children to develop new ways of organizing themselves
little time to reflect upon the meaning of what transpires in
and of relating to others.
treatment prior to their actions (Gaines 2003). Perhaps an
adult therapist could labor under the illusion that one
Background
mainly needs to understand and empathize with one’s cli-
ents and offer interpretations, but such a mindset would
P is a cute, nine year old, bi-racial (African American and
handicap a child therapist. In a way, contemporary theory
Caucasian) boy who was adopted by his Caucasian parents
now fits better with the action oriented nature of play
at birth. He is large for his age and is overweight. P looks
treatment, as theorists realize the inherent limitations of a
more African American than Caucasian. The family resides
primarily verbal approach to treatment (Barish 2004a;
in an upper middle class suburb that is predominantly
Frankel 1998). Modern relational theorists (Aron 1996;
white.
Bromberg 1998; Levenson 1985; Mitchell 1988, 1997;
P’s parents were concerned about his aggressive and
Pizer 1998; Slochower 1996) have emphasized that clients
otherwise disruptive behavior. They reported that P has
must be encountered—that is that therapists must do
always been mercurial, shifting from being on an even keel
something more than listen and interpret.
to becoming angry very quickly. His parents also described
Mitchell (1988) asserted that therapists must not merely
P as always having been easily frustrated and difficult to
understand their clients, but that they must also find a voice
console. They report that P has had violent temper out-
to communicate that understanding in order to find a way
bursts in class and at home since he was six. These
out of the client’s usual patterns of hearing and experi-
outbursts reportedly occurred one to two times per week
encing others. Indeed, Mitchell (1997) further stated that a
and were usually serious enough to warrant P’s removal
therapist:
from class.
discovers himself as a co-actor in a passionate drama P has an Individualized Educational Plan (IEP) for
involving love and hate, sexuality and murder, which he is classified as having a behavioral/emotional
intrusion and abandonment, victims and executioners. disturbance. There is a behavior intervention plan in place
Whichever path he chooses, he falls into one of the at the school. The psychologist at P’s school noted P’s
patient’s pre-determined categories and is experi- strong desire for power and control, his inability to think
enced by the patient that way. The struggle is toward at the time of his outbursts, and his feeling different due
a new way of experiencing both himself and the to his status as a racial minority and his history of
patient, a different way of being with the analysand, adoption. In addition, the school psychologist reported
in which one is neither fused nor detached, seductive that P’s ability to use relationships to soothe him when he
nor rejecting, victim nor executioner. The struggle is becomes dysregulated is inconsistent. P says all the right
to find an authentic voice in which to speak to the things (e.g., how to act and what to do when he gets
analysand, a voice more fully one’s own, less shaped upset), but he is apparently unable to translate this into
by the configurations and limited options of the his behavior.

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Treatment
Initially, P presented as a very anxious boy. He was
reluctant to separate from either parent when they brought
him to session. P required the clinician to wait for him
immediately outside the bathroom when he needed to use
it. After some weeks, he eventually was comfortable
enough to enter the clinician’s office without his parents
and to go to the bathroom alone. As his anxiety subsided, P
became much more boisterous and provocative in session.
At first he elected to play board games. He initially
engaged the clinician with a good deal of bravado. During
the times that he was losing, he became increasingly anx-
ious, and had difficulty continuing to play. He usually was
able to resume the game with the clinician’s encourage-
ment. P tried to cheat on occasion although he did not do
this in a very clandestine manner. When the clinician
pointed out the apparent violation of rules by questioning
whether this was the correct way to play, P would become
disruptive and tease the clinician. P would usually make
fun of the therapist’s baldness, and of his intelligence. The
clinician agreed that indeed he was bald and said that he
felt fine about his appearance, so it wasn’t a big deal to him
to be called bald. He also told P that he wasn’t worried
about his intelligence, so it didn’t upset him to be called a
‘‘dummy’’. The clinician also told P that he thought
sometimes P felt that he wasn’t intelligent or good looking,
but that the clinician thought that P actually was very smart
and good looking. The feeling tone would change to one of
more playfulness, and P usually would then smile broadly
and then call the clinician another name. The clinician
responded to P by saying that he has no problem with a
little trash talk because he knew that they both liked one
another (which they did). P would then settle down and
finish the game with no further disruptions.
As treatment progressed, P’s language included more
swear words to taunt the therapist. He began to call the
clinician a ‘‘shittin’ ass’’ and a ‘‘fucking bitch’’, all the
while smiling in a provocative manner. The clinician
wondered aloud why people have such strong reactions to
these words, since everybody’s ass shits, and it just con-
firms what P, the clinician, and everybody else already
knows. When P called the worker a ‘‘fucking bitch’’, the
worker asked P if he knew what a bitch and fucking was.
When P accurately told the clinician that bitch meant
female dog and that fucking meant having sex, the worker
agreed. The clinician pointed out that P recently got a new
female dog as a pet. He said that he didn’t really under-
stand why being called a bitch became such a terrible insult
since many people, including the clinician and P, had bit-
ches that they loved. He also said that without sex, neither
P nor the clinician would have such great dogs because
their dogs’ mothers wouldn’t have given birth (P knew that
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Clin Soc Work J (2008) 36:281–291
sex could lead to pregnancy). At that point P said with a
warm smile that the clinician doesn’t get angry easily at
what he says. The clinician responded by saying that P
doesn’t make him angry when he calls him names because
he understands that P is partly doing it because he’s upset
with himself and that he (the clinician) cares about P. The
clinician said that he has no problem with P when he gets
angry with him, saying ‘‘What’s so bad about a little anger
between people who care about each other?’’ At that point
P beamed and said how much he liked the clinician.
The play progressed to the construction of toy weapons.
During these times, P would shoot and kill the clinician
repeatedly and require the clinician to enact his death
slowly and dramatically as P would shoot him with an
automatic weapon or stab him with a sword. P himself
would never be killed or wounded. On occasion P would
cross physical boundaries and become slightly too
aggressive and inadvertently hurt the clinician. P closely
watched how the clinician reacted during these times. The
clinician would just stop the play, look directly at P, and
calmly say that he thinks that that their play was getting out
of hand. He would then restate the rules about keeping each
other safe when they play and ask P if he could live with
them. The clinician pointed out that he doesn’t see the
problem as getting angry per se, but as how one feels about
oneself, the other person, and how one gets angry. The
clinician said that many people find it hard to know what to
do when they are angry, but that it is important for
everyone to get angry in a way that allows other people to
understand why they are feeling the way they do. P would
then continue playing with the same strong feelings, but
without any more disruptions.
Approximately 1 month later, P’s parents told the social
worker that P got into a fight with another boy who P
thought was his friend, and that P was very upset about it.
Immediately following this incident and for the few days
leading to the treatment session, P’s behavior regressed to
pre-treatment levels. When the clinician asked P about it, P
began to cry and said that this boy and he got into a verbal
fight over a ball on the school yard. The boy then told P
that he should go back to where he came from, and called
him a ‘‘nigger.’’ P could see that the clinician teared up as P
was recounting his story. The clinician asked him about the
boy and P said that they were friends and he thought that
they liked each other. When asked by the clinician, P said
that he didn’t know why the boy would say such things to
him. The clinician asked what P thought about what the
boy had said. P said that he belonged to the community as
much as the other boy and he had no right to tell him to
leave. When asked, P said that he knew ‘‘nigger’’ was a
curse word for Black people. The clinician asked P what it
felt like to be called a ‘‘nigger.’’ P wouldn’t answer this
directly, but instead said that he hated the boy who called
Clin Soc Work J (2008) 36:281–291
him this. When asked why the boy would call him a
‘‘nigger,’’ P said that he was ‘‘dark’’ and no one else looked
like him. This led to a long discussion about how he feels
that no one in his community likes him because he is
‘‘different’’ and ‘‘stupid.’’
After some time, the clinician stated that he knows that
P often doesn’t feel good about himself and wondered
whether being of mixed race was part of the reason why
this is so. The clinician said that it’s hard to feel good about
yourself when you and everyone else see you as so dif-
ferent. P then said ‘‘shut up baldy’’ to the clinician. The
clinician feigned being struck mute (A game that they play
when P gets overwhelmed, he tells the therapist to shut up.
The clinician then feigns being mute and trying to speak. P
enjoys the power and control that he has over the therapist
and that the therapist plays along with him. The silence
usually gets uncomfortable for P and he then says ‘‘OK,
stop shutting up,’’ at which point the session proceeds as it
did before the disruption occurred.). When P allowed the
clinician to speak again, the clinician said he didn’t like it
when he was going bald, but over time he began to feel OK
about it because he found ways to feel attractive and be
bald at the same time. The clinician said that now, he
couldn’t imagine what it would be like for him to have hair
on his head. In fact, if it was possible to re-grow his hair,
the clinician wouldn’t because being bald was so much a
part of him. The clinician said that he thought that P was a
‘‘great kid’’ and wished that it would be easier for P to feel
good about himself as well. The clinician acknowledged
how difficult it is to feel OK about yourself when you feel
so different and other people act like they don’t like you or
like how you look.
Treatment continues with P. He hardly has any more
incidents of disruptive behavior in school, although his
difficulties with self-esteem, self-image, and self-accep-
tance are still very much in evidence. Parents and school
both report substantial progress in P’s behavior, although
they also believe that P needs to continue to work on these
issues.
Discussion
There are multiple factors that contribute to P’s behavior,
and there are several facets to his treatment that are beyond
the scope of this paper, such as P’s feelings about being
adopted, work with his parents and with his school, as well
as the choice of community in which he lives. That said,
there are several aspects of the case that illustrate the
author’s points concerning psychodynamic play therapy
with children. Much of the therapy focused on playing
board games and games of violence and the verbal
exchanges that arose during their play. Through these
287
games, much of P’s dynamics were enacted with the
clinician.
It was apparent that P was projecting many of his feel-
ings of badness, inferiority and inadequacy onto the
therapist when he called the therapist names. However,
there seemed to be more going on than a simple projection.
P was also placing the therapist in his position while P.
assumed the relational position of others, actual and
evoked, that wounded him deeply (Altman et al. 2002).
The therapist struggled to hold and embody these projected
aspects of P. These self states were also mixed with the
clinician’s own history, and this posed particular difficul-
ties in relating to P therapeutically. Whether this is viewed
as identification with the aggressor (Freud 1966), projec-
tive identification (Ogden 1979), or enactment (Black
2003), the point is that it was as though P. was structuring
the relationship defensively in order to preserve his fragile
self-esteem, self-coherence, and interpersonal security.
Many therapists would mainly view this as an opportunity
to verbally interpret these dynamics to P. However, the
author believes that they would miss the point of the
interaction.
The non-verbal behavior (e.g. P’s facial expressions)
indicated that P was also inviting and challenging the
therapist to engage him in a game within the game that they
were playing. By calling the therapist names, or by vio-
lating his physical safety, P was inviting the therapist to
play a more dramatic game. On a less than conscious but
not wholly unconscious level, P was forcefully enacting the
relational dynamics that have hurt him for so long. Instead
of embodying the negative elements that he felt about
himself, he projected them onto the worker. This afforded
the therapist an opportunity to engage P in the struggle to
find another way out of his difficulties. In order to suc-
cessfully play this game, the worker had to viscerally and
emotionally immerse himself in elements of P’s difficul-
ties. This mode of intervention is congruent with newer
relational approaches to child treatment. Relational child
therapists, while accepting that interpretations have multi-
ple therapeutic effects, view the principal therapeutic
benefit of interpretation as facilitating a playful engage-
ment with the therapist. Altman et al. (2002) state that
‘‘nothing works so well as a concrete experience of greater
freedom or playfulness between the child and the thera-
pist’’ p. 209.
P was not just passively observing this process. By
engaging in this game, he was also struggling with his
difficulties, but from the safer relational position of the
aggressor. This permitted a greater degree of engagement
through the frame of play. Remaining within this frame, at
least initially, is inherently therapeutic because it permits
an admixture of enactment of old patterns with new modes
of experiencing oneself to appear. Playing with P in this
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288
way enabled him to struggle with the clinician and for
moments of connection to emerge. It also facilitated a
therapeutic relationship in which verbal interpretations,
when they were made, would be experienced as empathic
and supportive. Moreover, when the therapist offered
interpretations, they were made in the context of P’s play,
as the issues arose in the play, and primarily were focused
in the context of the treatment relationship.
P’s play in therapy paralleled other situations in his life
(school, friends, family, etc.), but, compared to other
contexts, it provided a potential space where P was free to
enact his dilemmas without real consequences. In this way,
play treatment affords children with a unique opportunity
to enact their difficulties with an adult who understands the
therapeutic efficacy of play, and it can provide children
with a means to explore old patterns, and to develop new
patterns of relating and experiencing self and others.
Hoffman (1998) states that when a client enacts a rela-
tional pattern that is similar to that developed with an
important figure, identifies with that figure and casts the
clinician in the position of the client, as did P, participation
in treatment becomes especially complex. He asserts that
the client has an interest in seeing the clinician react in
similar ways that the client did when interacting with that
figure. He notes, however, that the client may also desire
that the clinician’s actions reflect recognition of the dif-
ferences between the client and the original figure. Thus,
the dialectical nature of the play situation simultaneously
may permit both a recapitulation of earlier difficulties,
while also marking the differences from the original pat-
tern. Fonagy et al. (2004) note that the pretend nature of
play permits clients to establish second order representa-
tions and to mentalize their affective experience. In this
way, client and clinician are presented with an opportunity
to foster therapeutic growth. In treatment with P, the
relational dynamics were vivid and powerful. Simulta-
neously and paradoxically, it also felt quite different from
earlier life experiences that P and the clinician had had.
Play provided the space and the context to experience these
dynamics and to find new, useful ways of responding to
them. Moreover, the experience of engaging dynamics in a
different and more empowering manner feeds back on
these dynamics and alters them.
Self-disclosure
The therapist disclosed personal information in this case.
Indeed, it is hard for child therapists not to self-disclose
during treatment. Self-disclosure in play therapy can be
extremely complicated because of its’ action oriented,
immediate nature (Gaines 2003). While one survey of child
therapists noted the relative infrequency of deliberate self-
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Clin Soc Work J (2008) 36:281–291
disclosure among child therapists, respondents reported
disclosing more frequently to child patients than they did
with adult patients (Capobianco and Farber 2005). The
study noted that psychodynamic therapists reported that
they disclosed less than did therapists of other orientations.
When disclosures were reported by the entire sample (i.e.
child therapists of various orientations), they tended to be
made in response to client solicitations and were viewed by
therapists to be of little therapeutic benefit. These authors
were puzzled by the relative lack of reported disclosures by
psychodynamic therapists, given newer relational approa-
ches to psychoanalytic therapy. One possibility for these
results may be due to the reluctance of child therapists to
report self-disclosures because of the historical mind-set
that discouraged therapists from deliberately or inadver-
tently revealing personal information (Barish 2004b;
Gaines 2003).
Nonetheless, contemporary relational theorists recog-
nize the ubiquitous nature of self-disclosure and are
expanding theory to better encompass its roles in treatment
(Renik 1995). Aron (1996) asserts that self-disclosure is
inevitable and that the line between deliberate and inad-
vertent self-disclosure is unclear. He points out that,
despite a more mutual stance between therapist and client,
the therapeutic relationship is asymmetrical in that the
actions and reactions are examined by both parties for the
benefit of the client. He presents several varieties of self-
disclosure, but irrespective of the content of the disclosure,
Aron asserts that it is the clinician’s attitude toward the
disclosure that leads the client to feel safer or in danger
within the therapeutic relationship. Regardless of the nature
of the disclosure and of the clinician’s style of practice, the
disclosure and the relationship need to be open to reflection
and analysis by both client and clinician.
Bromberg (1998) states that self-disclosure derives its
meaning within the ongoing relational context created
between client and clinician. For self-disclosure to be
therapeutic, it must not be prescribed because it will lose its
relational nature. In a similar vein, Pizer (1998) states that:
The gauge of neutrality is whether a self-disclosure is
the product of a jointly developed negotiation that
exists between analyst and patient, that is evoked by
the patient’s need for something to go on, and that is
used as a ‘personal object’ for the patient’s self-
articulation; neutrality is violated to the extent that
self-disclosure entails some personal information
‘bestowed’ by the analyst out of his own urgency (p.
12).
Gaines (2003) notes that, from the point of view of the
child patient, the therapeutic value of self-disclosure fre-
quently has more to do with the therapist’s willingness to
self-disclose, than with the content of the disclosure itself.
Clin Soc Work J (2008) 36:281–291
In the case of P, the clinician disclosed important and
personal aspects of his own life and of his reactions to the
client. This material initially was used by P to ridicule the
therapist and to place him in the position that P experi-
enced with peers. When a disclosure is made, neither client
nor the clinician can predict what effect it will have on the
treatment relationship in any reliable way. This makes
guidelines for the therapeutic use of self-disclosure difficult
to state in any absolute terms. In general, like most other
interventions, a disclosure should not feel contrived or used
deliberately as a technique, because its role as a genuine
expression of the clinician’s subjectivity is central to its
therapeutic action.
The decisions about how to respond were made in the
context of the relationship, P’s situation, his vulnerability
and capacity to tolerate painful feelings, and the non-
verbal cues that were being communicated in the moment
and filtered through the theoretical orientation and life
experiences of the clinician. By disclosing his experience
with going bald, the clinician believed that he functioned
as a usable object for P. By accepting P’s taunts, the
clinician responded in a way that permitted P to feel held
and furthered the development of potential space where
vulnerability, anger, self-loathing, and self-acceptance
were possible and tolerable. Barish (2004b) states that
‘‘when we speak about ourselves, we speak readily of our
minor failings and disappointments or…our ineptitude
but seldom, and then reluctantly of our achievements’’
(p. 276). He considers these moments of ‘‘generative
empathy’’ whereby such disclosures promote the child’s
developing strengths. The author would add that such
moments only can occur spontaneously. The genuineness
of these disclosures is communicated via non-verbal
means such as the therapist’s prosody, facial expression,
posture, etc. In P’s case, such moments served to engage
him with the therapist in a more vital, human relationship
precisely when he was feeling de-valued and de-
humanized.
In psychodynamic play therapy with children, the cli-
nician is frequently confronted by these dilemmas. The
visceral, immediate impact of these interactions, coupled
with the inherent ambiguity of play, places particular
demands on clinicians because there is little room to
unpack such complicated phenomena in the moment.
Attention to the non-verbal aspects of treatment, often in
retrospect, is an extremely important reference to guide
clinicians in making genuine, therapeutic disclosures.
Implications for Psychotherapy with Children
As psychodynamic clinicians in general have come to
recognize that how they engage their clients is a major
289
factor in psychotherapy, they have had to address the
problem of therapeutic action in new ways. The emphasis
on spoken language has been derived from older theory
that was developed for the therapy of adults. By viewing
language primarily as verbal truncates the full spectrum of
communication. When contemporary theorists note the
primacy of language in human experience, they stress that
an analysis of the role of language in a hermeneutic or
constructivist paradigm must include non-verbal aspects of
language in order to be meaningful (Pizer 1998; Stern
1997). The relative lack of attention paid to the therapeutic
role of action as a means of communication may have led
some child therapists to overvalue verbal interpretations as
the key to child treatment (Bonovitz 2004; Spiegel 1989).
The consequent lack of engagement through the frame of
play may close off avenues for exploration and modes of
relating that are potentially therapeutic.
A more balanced approach between verbal interpreta-
tions and other therapeutic actions in child therapy is
needed. Over time, psychoanalytic theory and practice
have shifted to allow for more direct and genuine rela-
tionships with clients. In a new model of child treatment,
play is seen as a dynamic admixture of old and new rela-
tional patterns that are enacted and understood in the play
setting as well as in historical context and the broader
environmental milieu. Useful interpretations, whether or
not they are verbalized by the clinician, should aim to
facilitate the playful engagement of children. Play thus
would provide clinicians with a critical avenue for
engagement of children, for understanding possible
meanings of children’s difficulties, and for exploring and
facilitating new patterns of relating and experiencing with
children. Through play, these goals are realized through
interaction in the vital, immediate exchange between child
client and clinician. Our understanding of what occurs in
play sessions often occurs post-hoc (Altman et al. 2002).
These reflections upon therapeutic interactions, which
include one’s role in them, inform clinicians and it sensi-
tizes them, and thereby makes subsequent, genuine
therapeutic responses in the moment more likely.
As our understanding of the relation between action and
words has become more complex, their distinction has
become blurred. For example, Mitchell (1997) states that
‘‘the traditional notion that interpretation is a nonaction,
simply generating insight and therefore free of suggestive
influence, is an illusion. Rather, our choice is among dif-
ferent forms of participation and the interpretive
understandings and emotional experiences they offer’’ p.
16. Conversely, Ogden (1994) notes that actions and
interactions contain implicit interpretations. It is reasonable
to argue for diminishing the dichotomy between verbal
modes of communication and those of action, and for
redressing the balance between words and action in
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psychodynamic treatment. Indeed, as Aron (1996) states:
‘‘If words are acts, and if acts are communications, then
psychoanalysis can no longer be thought of as only a
talking cure; psychoanalysis must involve action and
interaction’’ p. 192. While relational theorists have
embraced therapeutic interaction as an essential component
in the treatment of adults, it is all the more central in play
therapy.
Play often constitutes metaphoric and implicit forms of
communication (Lyons-Ruth et al. 1998; Spiegel 1989)
and it is replete with model scenes. Lichtenberg et al.
(2002) assert that, in psychoanalysis, model scenes con-
stitute ‘‘extended metaphors’’ that permit processing in
both verbal and imagistic modes, and ‘‘invites reentrant
signaling from multiple sources’’ (p. 144). Play stimulates
both verbal, mainly left hemispheric brain activity and non-
verbal, primarily right hemispheric activity. Play thus
performs an important bridging function to permit a better
integration of experience for patients (Levy 2007). Thera-
pists simply can no longer privilege the linear, verbal realm
and subordinate the non-linear, non-verbal realm when
playing with children. Indeed, Altman et al. (2002) state
that:
… many important understandings that emerge in the
play process, particularly those involving the creation
of new meanings and self-understandings, are not
necessarily reducible to verbal formulation. The play
image or metaphor may be the best representation for
such experiences. To the extent that these new
meanings inhere in new senses of self, the interaction
with the therapist enacts new self-experiences and
quite possibly can be expressed in no other way.
p. 210.
When verbal interpretations are communicated to child
clients; in general they are made best with regard for the
emergent therapeutic relationship, the child’s emotional
and social status, and should mainly be made in the context
of the play itself. Moreover, clinicians should take care to
ensure that such interventions complement and not sup-
plant other modes of engagement.
The struggle for analytically informed child therapists,
as with their colleagues who treat adults, is to nurture,
recognize, and utilize ‘‘moments of connection’’ because
they shift implicit relational expectations and open up
new modes of experiencing and of relating. Fundamen-
tally, this process constitutes a blend of verbal and non-
verbal elements. The main challenge is to strive con-
stantly to engage children in relationships that recognize
their experiences so that they may become real, vital and
meaningful to them. It is by genuinely connecting with
children through play that therapists can help them shift
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Clin Soc Work J (2008) 36:281–291
their organizations of self and relationships and thereby
permit new possibilities to arise.
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Author Biography
Alan J. Levy DSW, LCSW is Associate Professor at Loyola Uni-
versity Chicago School of Social Work. He currently serves on the
Board of Directors of the Clinical Social Work Association. Dr. Levy
maintains a private practice in Northbrook, Illinois.
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