001

Table of Contents
 
Title Page
Copyright Page
Dedication
Preface
Contributors
Orientation to the Text
JASON L.
CASSIE
REFERENCES
 
CHAPTER 1 - Psychoanalytic Play Therapy
 
INTRODUCTION
PERSONALITY THEORY: FREUDIAN AND OBJECT RELATIONS PERSPECTIVES OF ATTACHMENT ...
MODEL OF PSYCHOPATHOLOGY: CONFLICT AND STRESS; NEUROPSYCHOLOGICAL UNDERPINNINGS ...
GOALS OF TREATMENT: INTRAPSYCHIC AND EXTRAPSYCHIC EQUILIBRIUM IN THE CONTEXT OF DEVELOPMENT
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
DEFINITION OF TERMS
REFERENCES
 
CHAPTER 2 - Jungian Analytical Play Therapy
 
INTRODUCTION
PERSONALITY DEVELOPMENT
MODEL OF PSYCHOPATHOLOGY
GOALS OF TREATMENT
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
DEFINITION OF TERMS
REFERENCES
 
CHAPTER 3 - Child-Centered Play Therapy
 
INTRODUCTION
PERSONALITY THEORY
MODEL OF PSYCHOPATHOLOGY
GOALS OF TREATMENT
RESEARCH ON CHILD-CENTERED PLAY THERAPY
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
CHAPTER 4 - Filial Therapy
 
INTRODUCTION
PERSONALITY THEORY
MODEL OF PSYCHOPATHOLOGY
GOALS OF TREATMENT
RESEARCH
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
CHAPTER 5 - Cognitive-Behavioral Play Therapy
 
INTRODUCTION
PERSONALITY THEORY
MODEL OF PSYCHOPATHOLOGY
BASIC CONCEPTS OF COGNITIVE-BEHAVIORAL PLAY THERAPY
GOALS OF TREATMENT
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
CHAPTER 6 - Adlerian Play Therapy
 
INTRODUCTION
PERSONALITY THEORY
MODEL OF PSYCHOPATHOLOGY
GOALS OF TREATMENT
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
CHAPTER 7 - Gestalt Play Therapy
 
INTRODUCTION
THEORY OF PERSONALITY AND HEALTHY FUNCTIONING
MODEL OF PSYCHOPATHOLOGY
GOALS OF TREATMENT
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
CHAPTER 8 - Theraplay: Supporting Attachment Relationships
 
INTRODUCTION
PERSONALITY THEORY
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
CHAPTER 9 - Ecosystemic Play Therapy
 
INTRODUCTION
THE ECOSYSTEMIC MODEL
ECOSYSTEMIC PLAY THERAPY THEORY
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
APPENDIX A - Parent Handout
 
CHAPTER 10 - Prescriptive Play Therapy
 
INTRODUCTION
PERSONALITY THEORY
MODEL OF PSYCHOPATHOLOGY
BASIC CONCEPTS OF PRESCRIPTIVE PLAY THERAPY
GOALS OF TREATMENT
CASE STUDY 1: JASON L.
CASE STUDY 2: CASSIE B.
CONCLUSION
REFERENCES
 
AUTHOR INDEX
SUBJECT INDEX

001

In memory of Robert Luce, whose loving support over two decades enabled me to become the person, therapist, and professional I am today.—Kevin J. O’Connor
 
 
To Anna and Sam, who enrich my understanding of children in the most
marvelous ways and fill my days with love.—Lisa D. Braverman

Preface
RECENTLY, THE NUMBER of publications on the topic of play therapy has increased dramatically. These include works describing both numerous theoretical models and intervention techniques. This proliferation has resulted in a body of literature so large that it is difficult for either students or practitioners to evaluate or compare the information presented. The goal of this text is to provide a forum for the direct comparison of the major theoretical models of play therapy and their implications for treatment.
In order to present information in this book that is accurate and current, we have asked leading authorities on various theoretical models of play therapy to write original chapters that both describe their theoretical model of play therapy treatment and demonstrate the application of that model. Each author will apply their model to the same cases, thus providing the reader with a basis for direct comparison. By virtue of being interdisciplinary in its approach, diverse in theoretical orientation, and comparative in nature, this book will prove to be a landmark reference source for years to come.
Play Therapy Theory and Practice: Comparing Theories and Techniques, 2nd edition, begins with an overall presentation of the two case histories that will be used in each of the following chapters. The remaining chapters present the following theoretical models of play therapy: Psychoanalytic, Jungian, Child-Centered, Filial, Cognitive-Behavioral, Adlerian, Gestalt, Theraplay, Ecosystemic, and Prescriptive.
Psychiatrists, psychologists, social workers, nurses, and counselors at all levels of training and experience will find Play Therapy Theory and Practice: Comparing Theories and Techniques, 2nd edition, informative, thought provoking, and clinically useful.
 
Kevin J. O’Connor
Lisa D. Braverman

Contributors
Phyllis B. Booth, M.A., LMFT, RPT-S,
is Clinical Director of The Theraplay Institute in Chicago. She is also a licensed Clinical Professional Counselor. She collaborated with Ann Jernberg in developing the Theraplay method for helping children and families with attachment and relationship problems. She is the primary author of the second edition of Theraplay : Helping Parents and Children Build Better Relationships Through Attachment-Based Play, Jossey-Bass, 1999. She received her training at the University of Chicago in Human Development and Clinical Psychology; at the Tavistock Centre, London, under John Bowlby and D. W. Winnicott; at the Anna Freud Centre, London; and at the Family Institute at Northwestern University, Evan ston, Illinois. She has conducted workshops and training in the Theraplay method for working with children and families throughout the United States, Canada, England, Finland, and South Korea.
 
Susan Bundy-Myrow, Ph.D., RPT-S,
is a licensed psychologist in private practice. She treats children and adolescents with emotional disorders and developmental disabilities and is a consultant to school districts. As a Clinical Assistant Professor of Psychiatry at the University of Buffalo Medical School, she teaches child and play therapy approaches to psychiatric residents. Dr. Bundy-Myrow is a Registered Supervisor with the Association for Play Therapy, and Professor of Child Psychotherapy and Play Therapy with the International Board of Examiners of Certified Child and Play Therapists. She served as a Director of the New York Association for Play Therapy. Dr. Bundy-Myrow first became involved with Theraplay in 1980, studying with Ann Jernberg and Phyllis Booth. As an Affiliate Trainer of the Theraplay Institute, she has helped bring Theraplay to professionals in Finland, South Korea, Scotland, Ireland, and England. Dr. Bundy-Myrow has developed a model for Multiple Family Group Theraplay for children with autism. Her most recent chapter, “Theraplay for Children with Self-Regulation Problems,” appears in the International Handbook of Play Therapy: Advances in Assessment, Theory, Research and Practice.
 
Felicia Carroll, M.Ed., M.A., LMFT, RPT-S,
is in private practice in Solvang, California. She is the Founder-Director of the West Coast Institute for Gestalt Play Therapy. She has studied and been a training co-leader with Violet Oaklander, Ph.D., for more than 25 years. She has credentials in educational psychology, child development, and counseling psychology and was a classroom teacher for 12 years. She is a certified member of the Gestalt Therapy Institute of Los Angeles and is a Certified Supervisor through the California Association of Marriage and Family Therapy. Felicia teaches at Gestalt Institutes in Europe in addition to offering training programs in the United States. She has published several chapters and articles about Gestalt therapy with children and on topics related to Gestalt theory and practice. She is invited editor for a special edition of the International Journal of Gestalt Therapy on Gestalt therapy with children and adolescents.
 
Eliana Gil, Ph.D., ATR, RPT-S,
is Director of Clinical Services for Childhelp, Inc., a national organization providing prevention and treatment services to maltreated children and at-risk youth. She works in Fairfax, Virginia, with Childhelp Children’s Center of Virginia, and oversees the development and implementation of therapy services for abused children and their families. Dr. Gil provides training in the United States and abroad, particularly in the areas of child abuse prevention and treatment, play therapy, sand therapy, and family play therapy. She provides many intensive trainings through her training program, Starbright Training Institute. She specializes in working with young abused children as well as children with problem sexual behaviors, utilizing an integrated approach that includes expressive therapies and cognitive-behavioral work. Dr. Gil has written several books specific to play therapy, including The Healing Power of Play and Play in Family Therapy. Her most recent book reflects her current integrated approach and is titled Helping Abused and Traumatized Children: Integrating Directive and Nondirective Strategies. Dr. Gil is bilingual and bicultural, and Ecuador is her country of origin.
 
Eric J. Green, Ph.D., LMFT, RPT-S,
is an assistant professor and coordinates the play therapy graduate certificate program in the Department of Counseling and Human Services at Johns Hopkins University in Baltimore, Maryland. Dr. Green first developed an interest for Jungian psychology at an early age while under the tutelage of his mentor, Rev. Paul Metrejean, a Jungian-oriented Catholic priest. He continued with his studies in depth psychology throughout college and credits his interests in Jungian analytical play therapy to the significant contributions of Michael Fordham, Mara Sidoli, and especially, John Allan. He presents regularly at national counseling conferences on depth psychology, child advocacy, and evidenced-based counseling interventions for traumatized children. His most recent work on this topic includes a book chapter on Jungian analytical play therapy with the children of Hurricane Katrina in Play Therapy with Children in Crisis, 3rd edition. Dr. Green maintains a part-time, private practice in child analytical psychotherapy and is a member of the Jung Society of Washington in Washington, D.C.
 
Susan M. Knell, Ph.D.,
a licensed psychologist, is author of Cognitive-Behavioral Play Therapy (1993), as well as numerous articles and chapters. She developed the cognitive-behavioral approach to play therapy, a developmentally sensitive framework to help children develop more adaptive thoughts and behaviors. Her work demonstrates that the methods of cognitive-behavioral therapy can be modeled for children indirectly through play. She conducts seminars and workshops throughout the country on this innovative approach. Dr. Knell received her Ph.D. in Clinical Psychology from Case Western Reserve University; M.A. in developmental psychology from The Ohio State University; and an A.B. from Mount Holyoke College. Dr. Knell has worked in a variety of settings, training and supervising staff, conducting research, and providing clinical services. She is currently a psychologist and partner at Spectrum Psychological Associates, as well as a Clinical Assistant Professor at Case Western Reserve University.
 
Terry Kottman, Ph.D., NCC, LMHC, RPT-S,
founded The Encouragement Zone, a center where she provides life coaching, play therapy, play therapy training, and playshops for adults. Terry developed Adlerian play therapy, an integration of Adlerian theory with the modality of play therapy. She has written many book chapters and articles related to play therapy and school counseling. She regularly teaches a variety of workshops on the national and international levels on topics related to applying play therapy to work with children and their families, using storytelling and art as therapeutic techniques, integrating life coaching with play therapy, and using play therapy strategies with adolescents and adults. Terry is the author of Partners in Play: An Adlerian Approach to Play Therapy and Play Therapy: Basics and Beyond and coauthor (with Drs. Jeff Ashby and Don De-Graaf) of Active Interventions for Kids and Teens and Adventures in Guidance. She recently edited (with Dr. Ann Vernon) Counseling Theories: Practical Applications with Children and Adolescents in School Settings.
 
Garry L. Landreth, Ed.D., LPC, RPT-S,
is a Regents Professor in the Department of Counseling and Higher Education at the University of North Texas, Denton. He is the founder of the Center for Play Therapy, the largest play therapy training program in the country. Dr. Landreth is a frequent speaker at play therapy conferences around the world. His more than 150 journal articles, books, and videos include his award-winning book Play Therapy: The Art of the Relationship, which has been translated into several international languages. His latest books are Child Parent Relationship Therapy (CPRT): A 10-Session Filial Therapy Model and an accompanying Child Parent Relationship Therapy (CPRT) Treatment Manual. Dr. Landreth is Director Emeritus of the Association for Play Therapy (APT) and received the APT Lifetime Achievement Award and the APT Research Award. He is also the recipient of the Virginia Axline Distinguished Professional Award for his work in conceptualizing and advancing the child-centered approach to play therapy.
 
Anna C. Lee, Ph.D.,
is a clinical psychologist and psychoanalyst who specializes in diagnostic assessment and therapy of children and adolescents and the psychoanalysis of adults. She is currently a Clinical Child Psychologist at the Merrifield-Kaiser Permanente Behavioral Health Plan. She is an affiliate member of the Baltimore-Washington Society for Psychoanalysis and the Northern Virginia Society of Clinical Psychologists. She lives and maintains a private practice in Fairfax, Virginia.
 
Kevin J. O’Connor, Ph.D., RPT-S,
is Professor and Director of the Clinical Ph.D. and Clinical Psy.D. Programs at the California School of Professional Psychology of Alliant International University’s Fresno Campus. He is also the Director of the Ecosystemic Clinical Psychology Emphasis, which cuts across both doctoral programs. Dr. O’Connor developed ecosystemic play therapy (EPT) as a way of conceptualizing children’s difficulties in an environmental context and designing interventions to ensure that children’s needs are consistently and appropriately met. EPT promotes active, developmentally grounded interventions that engage children in problem solving. Dr. O’Connor was the co-founder of the Association for Play Therapy with Dr. Charles Schaefer in 1982. He served as that organization’s President and Executive Director for 21 years. He is now a Director Emeritus. Dr. O’Connor maintains a small private practice in Fresno, California, specializing in the treatment of severely traumatized children and attachment-related disorders. Dr. O’Connor also publishes extensively and has presented his work to play therapists around the world, including Canada, Mexico, Japan, Korea, Singapore, the Netherlands, Italy, South Africa, and Kuwait. He is the coauthor, with Lisa D. Braverman, Ph.D., of The Play Therapy Primer, 2nd edition, and the coauthor, with Sue Ammen, Ph.D., of Play Therapy Treatment Planning and Interventions.
 
Jennifer A. Shaw, MA,
is a therapist and Program Coordinator for an assessment and treatment program for children with problem sexual behaviors at the Multicultural Clinical Center in Springfield, Virginia. Dr. Shaw conducts psychological evaluations and provides group therapy for adolescent sexual offenders. Dr. Shaw works part-time providing play therapy services for abused children at Childhelp Children’s Center of Virginia in Fairfax, Virginia.
 
Daniel S. Sweeney, Ph.D., LPC, LMFT, RPT-S,
is a Professor of Counseling and Director of the NorthWest Center for Play Therapy Studies at George Fox University in Port-land, Oregon. He is a board member and the President of the Association for Play Therapy. Dr. Sweeney has extensive experience in working with children, couples, and families in a variety of settings, including therapeutic foster care, community mental health, private practice, and pastoral counseling. He has presented at numerous national and international conferences on the topics of play therapy, filial therapy, and sandtray therapy. Dr. Sweeney has published articles and book chapters on child counseling, play therapy issues, families, and parenting. He is also author or coauthor of several books, including Play Therapy Interventions with Children’s Problems, Counseling Children Through the World of Play, Sandtray Therapy: A Practical Manual, and The Handbook of Group Play Therapy. His books have been translated into Chinese, Korean, and Russian.
 
Risë VanFleet, Ph.D., RPT-S,
is the President of the Family Enhancement and Play Therapy Center in Boiling Springs, Pennsylvania, through which she trains and supervises clinicians in play therapy, filial therapy, and canine-assisted play therapy. She is a licensed psychologist, registered play therapist-supervisor, and certified filial therapy instructor with 35 years of experience. She initially learned filial therapy from its co-founders, Drs. Bernard and Louise Guerney. Risë is the author of four books on filial therapy, one book on canine-assisted play therapy, numerous chapters and articles on play therapy, and is featured on several DVD workshops. She has received three national awards for her play therapy-related training programs, and she has trained thousands of practitioners internationally. Dr. VanFleet is the founder of the International Collaborative on Play Therapy and a Past President/Board Chair of the Association for Play Therapy. Risë is also a pianist and an award-winning nature photographer specializing in Alaskan wild-life. She can be reached through her websites: www.play-therapy.com and www.playfulpooch.org.

Orientation to the Text
The Cases of Jason L. and Cassie B.
KEVIN J. O’CONNOR and LISA D. BRAVERMAN
 
 
 
IN PLANNING THIS text, our goal, as editors, was to provide a way for those who are interested in the practice of play therapy to directly compare both the major existing theories and the newly evolving ones with one another. Aside from the academic value of making such comparisons, it is our belief that to become a competent play therapist, one must find a theoretical model that meshes well with both one’s personality and the needs of one’s particular client base. A problem inherent in most texts that include a variety of theories presented by different authors is that the authors select case material specifically to illustrate their own theories. The reader is usually left with the sense that no other theoretical model could have addressed the needs of the client better than the one being presented. The cases are often so disparate that comparison of either the theory or the methods used is difficult, if not impossible. In this text, the editors sought to overcome this problem and to enhance the reader’s ability to compare the theories and applications presented by requiring all of the authors to use the same case materials.
In an attempt to demonstrate each model’s flexibility and range, the two cases used in this book are markedly different from one another. The case of Jason L. is representative of constitutional and internally driven difficulties that often require long-term treatment. At the other end of the spectrum, Cassie B.’s difficulties are a reaction to external issues that are often amenable to short-term intervention.
The sequence of the chapters is as follows: The first portion of this text represents the major psychological theories of psychotherapy and their derivatives as they have been adapted to the practice of play therapy. As the oldest of these major theories, Psychoanalytic Play Therapy is presented first, followed by its offshoot, Jungian Analytical Play Therapy. Child-Centered Play Therapy is then followed by its derivative, Filial Therapy. The third major psychological model presented is Cognitive-Behavioral Play Therapy. The more recently developed models—Adlerian, Gestalt, Theraplay, Ecosystemic, and Prescriptive—represent the increasing diversity of theoretical models being applied to the practice of play therapy.
The chapters are also structured to be as comparable as possible. A fairly detailed outline for the chapters was developed by the editors and submitted to the authors for review. They were encouraged to add to, delete from, or alter the outline so that it would best facilitate the presentation of their theory and practice. Once the outline was finalized, all of the authors were required to adhere strictly to the use of the first- and second-order headings. This requirement forced a parallel structure for each chapter. Although the editors insisted on the comparability of the structure, they did not control the style of presentation or the content of the chapters. The result is that the chapters vary considerably in the amount of detail presented and the degree to which the theories are internally consistent or organized. This variability indicates two things: (1) even the most established theories of play therapy are constantly evolving as psychological theory grows and develops; and (2) some of the theories are so new that they have not yet achieved the same level of stability and organization as the older theories . In many ways, this text is a report on work in progress that is exciting and dynamic and sure to contribute to the richness of every practitioner’s thinking and technical repertoire.
The cases of Jason L. and Cassie B. were used by each author in this text as the foundation on which to present both a specific theoretical model of play therapy and the application of that model. These are entirely fictional cases representing a composite of many of the editors’ clinical experiences. The goal was the creation of two cases that included both many of the problems commonly seen in outpatient treatment settings and the types of problems common to children in the early 21st century. Once the original cases were developed, we sent them to each of the authors for review. They were encouraged to add to, delete from, or alter the information the cases contained so that they would best facilitate their presentation. Several authors requested the addition of some material, most of which focused on a more complete description of the family dynamics. Interestingly, despite the enormous diversity of theories they represented, none of the authors said that they would be unable to address this case from their theoretical orientation. Where possible, all of the requested changes were incorporated into the final cases that follow.

JASON L.

INTAKE

Identifying Information Jason is a seven-year-old male. He is the older of two children. His younger sister, Carla, is three and a half years old. His mother, Mary, is 30 years old, of Anglo descent, and is employed as a clerical worker in a small law office. His father, Emilio, is 31 years old, of Mexican-American descent, and works as a factory supervisor. The parents share traditional Catholic beliefs and attend church regularly. All of the following data was obtained through Child Protective Services reports, Mary L., Emilio L., and Jason. The source of the information is Mary L. unless otherwise indicated.
 
Logistics Mary called to schedule the initial appointment, saying that she had some concerns about her son Jason’s behavior. She did not describe the problem in any detail, nor did she impart any sense of urgency. She did not mention that she had been referred to treatment by Child Protective Services. The initial interview was scheduled and completed with Mary and Emilio. Mary brought Carla to the interview despite the interviewer’s suggestion that she not do so. During this session, information regarding the Presenting Problem, Developmental History, and Family History and Dynamics was gathered. The Developmental Teaching Objectives Rating Form—Revised (DTORF-R) was also completed over the course of the interview. This session lasted approximately one and one-half hours. At the end of this session, each parent was given the Child Behavior Checklist (CBCL) to complete and return the following week.
The second and third sessions consisted of an intake interview with Jason and the administration of a complete individual test battery. Each session lasted almost two hours, including short breaks between tests. The length of the intake was greatly increased by Jason’s irritability and his variable performance. At times he would be very interested in the evaluation process and remain quite focused. At other times he would barely respond when questioned and tended to wander around the room or complain of being bored.
The fourth and fifth sessions were scheduled several days apart during the third week. At the fourth session, Mary completed the Marschak Interaction Method (MIM) with the children. At the fifth session, Emilio completed the same MIM tasks with the children. Each of these sessions lasted about one-half hour. The last session before treatment initiation was a feedback and treatment contracting session attended by both Mary and Emilio. This session lasted one hour.1
Presenting Problem Jason was brought to therapy by his mother following a referral by Child Protective Services. Mary was reported to CPS by Jason’s teacher when Jason told her that bruises on his face were the result of having been smacked by his mother. Mary reports that Jason is difficult to manage. He is often angry and unresponsive to the directions or punishments she imposes. For example, he will come home from school and throw down his books as he enters the house. When Mary tells him to pick the books up, he acts as if he did not hear her. If she persists, he picks up the books and throws them across his own room, making as much noise as he can. If she does not withdraw her request, Jason has been known to fly into a full-blown rage, becoming destructive and violent. These episodes can last for more than an hour. At times, Emilio has had to physically restrain Jason in order to keep him safe.
On the other hand, both parents agree Jason can be a delight when he is in the right mood. At those times where he engages fully with his parents or sister in an activity, he is pleasant and cheerful. However, the slightest thing can set him off. Jason is most susceptible to bad moods when he complains of boredom. At these times, he seems restless, agitated, and unable to focus, even on things he usually enjoys.
Jason was initially unable to describe any problems. He interpreted the word problems to mean things he was doing wrong and adamantly denied that any of his behavior was problematic. In fact, he made it very clear that he did not think he would even be in the office if it were not for the fact that his mother hit him. When the concept of problems was reframed to mean things about his current life situation that he did not like, he became more forthcoming. With encouragement, he reported that he dislikes the fact that his mother is always yelling at him and that the teachers at school seem to be following her lead. He complained of being bored often.
Both parents reported that Jason’s behavior seems to be the most difficult when he is tired or sick. This includes being very irritable during the first hour or so after he gets home from school. As described previously, Mary said the book throwing was typical of his after-school moods. She said that she leaves Jason alone for an hour or more, after which he usually approaches her asking for a snack or help with his homework. Emilio said that he responded to Jason’s negative moods more actively. He typically tries to engage Jason in something physical like playing catch or wrestling. He said that Jason usually starts out quite aggressive, but that “when he blows off some steam, he settles right down.” Mary added that while such activity usually calmed Jason, there were also times where he got carried away and became hyperaggressive and explosive in response to the stimulation. Jason denied being moody after school, although he did admit that school can “be a real pain sometimes.” He also denied having any explosive outbursts.
Both Mary and Emilio reported that Jason’s relationship with his sister is very unpredictable. Both reported that he tends to be very directive when they play together but that, as he seems quite sensitive to her developmental abilities, he finds things she can do to participate in joint play. The only time things do not go well is when Carla does not seem to be in the mood to take directions or has an idea of her own. If Jason cannot get compliance from her, he becomes frustrated and yells or breaks something. Jason says that playing with his sister is just okay. He likes it when they engage in pretend play of any sort, but says he would rather play with his remote control car.
 
Developmental History Jason was the result of a planned pregnancy two years after Mary and Emilio were married. There were some complications with the pregnancy that required Mary to remain in bed from her 26th week until the delivery. Mary denies any alcohol or substance use (including cigarettes) during her pregnancy. The labor and delivery were attended by Emilio and Mary’s mother. After a 12-hour labor, Jason was born weighing 5.0 lbs. The delivery was generally uncomplicated, although Mary reports having had difficulty pushing during her contractions due to weakness that was the result of having been bedridden for so long.
Jason was quite healthy despite his small size. He was observed in the Neonatal Intensive Care Unit for about 12 hours and then moved to the general newborn unit. He was treated for jaundice on the second and third days following the delivery and responded well. Mary’s contact with him was sporadic during these first few days, although she was able to hold him for at least 3 hours out of every 12. Mother and child were discharged on the third day after delivery.
Mary reports that Jason was an irritable baby when he was awake and that it was difficult to get him to sleep for more than a few hours at a time. She says she held him often and worried constantly about his health because she was afraid that the complications of the pregnancy might cause him to be sickly or even to die. Jason was less irritable when held and would sleep soundly for several hours at a time if carried or rocked. Mary also reported that Jason seemed overly sensitive to many normal events. He protested if his clothes were the least bit uncomfortable and cried when she cut his nails or washed his hair.
Jason was breastfed until he was about 11 months old. Mary stayed at home and took care of him because of her concerns about his well-being. She was his primary caretaker from his birth until he began school, except for a period of about six months as described later. She did send him to preschool when he was four years old, because she was having difficulty caring for both him and his baby sister, Carla. Mary reports that Jason cried a great deal when it was time to go to preschool, but then seemed to enjoy it once she left. She noted that Jason seemed distant when she would come to pick him up, and it would take several hours before he would warm to her again. Despite her concerns, Jason has been a healthy child.
Jason walked at 10 months and talked at 12 months. He was toilet trained at 30 months. Mary reports that he was a difficult toddler who tended to be quite noncompliant and had frequent, cataclysmic temper tantrums. For example, Jason liked to explore the environment often to the point of endangering himself. If his mother attempted to contain him in any way, he would rage. Once calm, he would soon become very focused on finding his way to his original destination or around any barriers Mary had erected. She disciplined him somewhat inconsistently, occasionally using time-outs and sometimes resorting to spanking.
As previously stated, Jason entered preschool at age four. At age five, he entered kindergarten and an after-school program so that Mary could return to work.
Other significant events in Jason’s early development are reported in the Family History and Dynamics section.
 
Mental Status Jason presents as an average-size male who appears distinctly Hispanic, with dark hair, skin, and eyes. During the interview, he was somewhat more active than would be expected for his age. He appeared indifferent to both the CPS report and to his own difficulties. He initially denied that anything was wrong and tended to minimize the impact of both past and current events. Despite this attitude, he related very well to the interviewer, so long as he did not have to discuss himself or focus on anything he considered potentially serious or problematic. He was easily engaged, verbal, and active. His speech productivity was in the normal range. When the interviewer focused on Jason’s history or current difficulties, Jason became virtually nonverbal. His affect tended to be positive though somewhat labile. His affect seemed grounded in reality but often exceeded what would be expected given the stimulus. His control of both his positive and negative affect seemed poor. His three wishes were for (1) lots of money; (2) mom and dad to let him do whatever he wanted; and (3) lots of baseball cards. His thought processes and content were within normal limits.
Jason was oriented times three. His long- and short-term memory were intact. His concentration was quite variable, ranging from excellent to almost nonexistent when he did not like a particular task or if he was in a difficult mood. He appeared to be of average intellect but tended to be overly concrete when discussing his experiences. His judgment seemed moderately impaired, and his insight was very limited. He reported no suicidal ideation, though Mary reported that he sometimes says that he wishes he were dead. He reports no homicidal ideation and, other than the abuse by his mother, there is no history of family violence.
A significant portion of the intake interview with Jason focused on obtaining a sense of how much of the intake information obtained from his parents Jason was aware of or could verify. When asked to describe his parents, his family, and his interactions with his sister, he reported material that was almost entirely consistent with that of his parents. The primary difference between his descriptions and those of his parents was that he avoided mentioning experiencing any negative affect. He tended to say that everything was fine.
Jason is currently in second grade in a public school. Academically, he does very well without exerting a great deal of effort. Behaviorally, he has always been somewhat of a problem. In kindergarten and first grade, his behavior was simply labeled “all boy.” Over the past few months, however, his teacher, Mrs. J., has found him to be increasingly distractible, noncompliant, and disruptive. Although he rarely plays with his peers for any length of time and tends to be rather bossy when he does, he is admired by the other boys, who see him as independent and self-assured. Additionally, his teacher reported that Jason seems to do very well on tasks that he is allowed to complete individually or with the help of her student aide, a 20-year-old male college student.
Jason’s most problematic behavior was involvement in a recent episode of fire setting. On his way home from school, he and another boy from his class lit the contents of a trash can on fire. A neighbor called the police. Jason’s initial reaction to the police was one of general indifference. When they separated him from the other boy and became more confrontational, he broke down and sobbed for nearly 15 minutes, repeatedly promising that he would never do the same kind of thing ever again. As the investigation proceeded, it became apparent that the fire setting had been initiated by the other boy. The police decided to release Jason without any additional consequences. Subsequently, attempts by adults to talk to Jason about this incident have been met with apparent indifference, and he reports that he was not ever really frightened by the police. When asked about the incident during the intake, Jason dismissed it, saying it had been no big deal.
 
Family History and Dynamics Mary indicated that she is the oldest of three girls born to a fairly traditional Catholic couple. Mary’s parents divorced when she was in grade school. The divorce was the culmination of years of conflict between her parents over her father’s drinking and unpredictable and sometimes violent mood swings. Mary became quite depressed at the time but did not receive any mental health treatment. Her father died of a sudden coronary when she was an adolescent. Mary had not had much contact with him after the divorce and says she grieved only moderately. Her mother continues to live nearby and helps Mary when she can. Mary likes the practical assistance she gets from her mother but says she prefers not to interact with her much socially. She says her mother can be depressing by constantly reminding Mary about the difficulties she (Mary’s mother) had as a single parent, seemingly minimizing the difficulties Mary is having. Mary does not have much contact with her sisters. Both married very upwardly mobile men and now live in other states. Her family of origin was generally middle class, although money was often tight.
Emilio’s parents are first-generation Mexican Americans who are still married. Emilio’s father and brother have a history of moderate to heavy alcohol use, but the family history is otherwise unremarkable. Emilio has dinner with his extended family every Sunday. He says he loves his mother very much but describes her as fairly invisible in the family. “She cooks and cleans and takes care of everybody.” He and his father and brother watch sports together on television or occasionally go fishing together.
No immediate or extended family members are known to have received mental health services, although Mary’s father and grandfather are both described as being very volatile men who experienced mood swings that would last from a few days to a few weeks at a time. Mary has a history of fairly serious depressive episodes. At these times, she reports decreased motor activity, decreased appetite, increased time spent in bed, and intermittent teariness. She has not sought treatment and says that the episodes usually spontaneously remit after a few weeks.
Mary and Emilio were married after having dated for several years. Both had solid jobs and took the responsibility of marriage very seriously. Both report that they were very much in love for the first few years of the marriage. They saved money and eagerly planned for their first child. Jason’s birth made both parents extremely happy, and their marriage seemed to grow better and more solid. Both were very involved in child-rearing. As Jason got older, he was more difficult to focus and manage, and there was some marital conflict, but nothing either parent described as serious.
Both were surprised when Mary became pregnant for the second time in the midst of Jason’s ongoing terrible twos. They had been hoping to delay having a second child until Jason became easier to manage. Mary’s second pregnancy went very badly, again requiring bed rest to prevent premature labor. During this time, Emilio’s and Mary’s mothers both took over the responsibility of caring for Jason. Carla was born a month early when Jason was three and a half years old. Luckily, Carla seemed to thrive and displayed none of the irritability or sleep problems that Jason had experienced. To some extent, time with Carla became a way for Mary to take a break from Jason when he was being particularly difficult.
After about a year, Mary decided to return to work. Jason attended preschool and then an after-school program while his mother worked. Carla entered full-time day care. Mary’s mother helped with child care when she could, but Mary still tended to be exhausted at the end of each day and to be short with the children. Mary reports that Jason becomes both verbally and physically affectionate toward her as the weekend progresses.
As the children got older, Emilio became more interested in them. He tends to spoil them with gifts. He plays board games with Jason that they modify to include Carla if at all possible. He also plays a fairly unstructured version of football with the children where everyone runs after the person who has the ball. He builds models with Jason when Carla is napping. Despite this attention, he finds it difficult to predict when Jason will respond to him positively. Sometimes Jason seems to get so excited by an activity that he has trouble actually engaging in it. This often leads to frustration and tantrums.
Mary stated that she does not like her current job very much. She is a secretary in a small law office. She feels that it is a rather mechanical job with few prospects for advancement. She would like to return to school and get a business degree. Emilio reports that he is quite happy with his current position. He has worked his way up to being a supervisor after having started on an evening cleaning crew in the factory. He is happy with his salary, benefits, and job security. He does not even seem to see the concept of enjoying the content of his work as particularly relevant. He works to make a living. He gets enjoyment from interacting with friends outside work and from doing things with his children.
Both parents report that Carla is a very easy and compliant child. Mary describes Carla as the warmest and most loving child a mother could hope for. At the intake, the interviewer noted that Carla was dressed in a very pretty and frilly pink dress. She wore tiny gold earrings and a gold chain bracelet (both presents from her mother). Mary and Carla were almost constantly within arm’s reach of one another during the intake process. Emilio seemed enamored with Carla, but she tended to be more independent around him. When both children were in the room with their father, it tended to be Jason who was physically closer to his father.

PRETREATMENT ASSESSMENT DATA

Individual Assessment Jason was given a full battery of psychological tests to determine his present level of developmental functioning in all spheres. The specific tests administered are described in the following section.

Tests Administered

Thematic Apperception Test (TAT) This test is a standard projective instrument (Murray et al., 1938; Anastasi, 1982). The child is presented with a series of pictures and asked to tell a story about each one in turn. The child is instructed to tell a story that has a beginning, middle, and end and includes what each of the characters is thinking and feeling. Both the style and the content of the child’s responses are usually interpreted according to one of a variety of primarily psychoanalytic strategies.
 
Rorschach This is another standardized projective instrument (Rorschach, 1921). The child is shown 10 cards depicting abstract, non-representational designs. The child is instructed to report what he or she thinks the designs might look like. The most common method for interpreting the results is the use of the Exner (1986) scoring system.
 
Human Figure Drawing (HFD) This projective technique is described in Psychological Evaluation of Children’s Figure Drawings (Koppitz, 1968). The child is asked to draw a picture of a person. The drawing is interpreted as a reflection of the child’s sense of self, usually in a manner consistent with psychoanalytic theory.
Kinetic Family Drawing (KFD) This projective technique is described in Self-Growth in Families (Burns, 1982). The child is asked to draw a picture of a (or his or her) family doing something. The method for interpreting the resulting drawing is also described in the text.
 
Wechsler Intelligence Scale for Children-IV (WISC-IV) The original version of this standardized measure of intelligence was developed by David Wechsler in 1949. The WISC-IV was first published in 2003. The test requires the child to answer questions and/or complete tasks on five Verbal Comprehension subtests (Information, Similarities, Word Reasoning, Vocabulary, and Comprehension), four Perceptual Reasoning subtests (Block Design, Picture Concepts, Matrix Reasoning, and Picture Completion), three Working Memory subtests (Digit Span, Letter-Number Sequencing, and Arithmetic), and three Processing Speed subtests (Coding, Symbol Search, and Cancellation). The method for scoring and interpreting the test is described in the test manual (Wechsler, 2003). The average score is 100 with a standard deviation of 15.
 
The Developmental Teaching Objectives Rating Form—Revised (DTORF-R) “This is a developmental assessment. It consists of 171 hierarchically arranged, operationally defined objectives that encompass a developmental age span from birth to the age of 16. The rater simply begins at the earliest developmental level in each area (Behavior, Communication, Social, and Academic) to be rated. Each criterion behavior that is judged to be evident in the child’s repertoire at least 80 percent of the time is checked in sequence. The rater proceeds down the list until he or she reaches a behavior in which the child does not engage regularly; this behavior becomes a treatment goal” (O’Connor, 1991, p. 151). Data on Jason was obtained from interviews with Mary, Emilio, and Jason’s teacher.
Mary and Emilio each completed a Child Behavior Checklist (CBCL) (Achenbach and Edelbrock, 1982). The portion of that measure reported on here consists of a checklist of 118 items describing various behavior problems. Each item is rated as being between not true (0) and very true (2) of the child’s behavior over the past six months. The resulting scores are plotted on the revised Child Behavior Profile yielding nine scale scores: Schizoid/ Anxious, Depressed, Uncommunicative, Obsessive/Compulsive, Somatic Complaints, Social Withdrawal, Hyperactive, Aggressive, and Delinquent.
 
Test Results and Interpretation Emotionally, Jason appears to be struggling with issues of control. Many of his TAT stories revolved around power struggles with various authority figures. A typical example follows:
These two guys are lawyers. The old guy is the boss. He is always telling the younger lawyer what to do and how to do it. The younger guy gets really mad because he knows just as much as the older lawyer but isn’t given a chance. One day he goes to court and does the exact opposite of what the boss told him to do just because he is sick of being told what to do. The lady he was supposed to be defending got convicted. Now he doesn’t know what to do. He feels bad that he lost the case and afraid of what the boss will do. He really wants the boss to like him but he wants to be trusted more. (TAT, Card 7BM)
When power struggles were not the dominant theme, then themes of self-control loomed large, as in the following story:
This girl really doesn’t want to go to school, but she knows she has to if she is ever going to get an okay job when she grows up. She never even tells her mother or father how much she hates school, because they will just say that it is important for her to go. She tries to do her best, but it never seems to be good enough. Something is always going wrong and she gets in trouble. She wishes she could sneak off and do what she wants, but she knows she can’t. She just has to keep going to school no matter how much she hates it. (TAT, Card 2)
The Rorschach results indicated that Jason’s reality testing was generally intact, although his impulse control was rather limited. He gave 23 responses, most of which involved the use of pure Form (F). His X+% was 75. His F+% was 90. His Lambda score was .98. His D and Adjusted D scores were -1 and 1. He received no Special Scores.
Jason’s HFD was relatively meager given his IQ as measured by other tests. The drawing was first scored using the Goodenough (1926) system, resulting in an IQ score of 90. There was very little detail, and the overall drawing was very large, almost filling the paper. He drew a picture of a boy wearing jeans and a T-shirt and holding a football. The boy had a neutral facial expression and a rather stiff, full face-forward stance.
Jason included Mary, Emilio, Carla, and himself in his KFD. None of the family members were engaged in any activity, rather they stood in a row facing front. Mary was on the far left and was drawn first. Carla was drawn next just to the right of Mary. Jason drew himself next, somewhat separated from Carla. Emilio was drawn last next to Jason and to the far right of the page.