Canadian Psychiatric Association Journal No.3
Ottawa, Canada, April 1975
Vol. 20
Symposium - Child Psychiatry LANGUAGE BEHAVIOUR AND CHILD PSYCHOTHERAPY*
EVA
Recent years have seen a proliferation of psychotherapies for children - therapists ranging widely from child psychiatrists to minimally trained paraprofessionals or untrained 'detached workers' have been using a whole new range of techniques. At the same time, the premises underlying child psychotherapies are becoming increasingly vague (14). Several of the newly developed techniques use non-verbal or paraverbal modes of interaction. Verbal interaction is either minimized Qr simply not considered as a basic component in the therapeutic process. These innovations and the creeping laissezfaire attitude raise several questions, a number of which cannot be fully answered by psychiatric or developmental givens alone. One basic question is the function of language in child psychotherapy, and related to this the theoretical justification of the non-verbal and paraverbal techniques. The question is opportune because the recent expansion in developmental linguistics permits a new understanding of the use of language by children. 'Manuscript received June, 1974. 'Director, Child and Adolescent Service, Allan Memorial Institute, Associate Professor, Dept. of Psychiatry, McGill University, Montreal. Can. Psychiatr. Assoc. J. Vol. 20 (1975)
P. LESTER, M.D.!
The original non-verbal technique introduced as play therapy by child analysts was based on the assumption that the young child who is not yet 'verbal' requires a non-verbal field of communication for psychotherapy. A corollary to this was that play, like the manifest content of a dream, is the perceptible expression of a rich latent fantasy activity, and from this play the child's conscious and unconscious mental activities may be inferred. A dichotomy was thus introduced between non-verbal or play therapies for the young child and verbal psychotherapy for older children and adolescents, a dichotomy that is still tacitly accepted (2). The recent introduction of the term 'paraverbal therapy' does not question the use of language in psychotherapy as such; it only denotes innovations in the non-verbal communicative interactions of the child and therapists (7). The above dichotomy seems questionable because verbal (lexical) representation begins early, probably in the second year of life (8). This means that the child already at this stage begins to organize information through the use of words, and words as acoustic signs become part of his thought processes. It is equally questionable whether, in the absence of certain communications expressed in verbal symbols,
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any type of interaction between therapist and child can be called psychotherapy. Language, at all ages and in all forms of syntactical and semantic complexity, constitutes the matrix which connects and makes coherent all interactive processes in psychotherapy. Language sharpens and specifies what is to be communicated in a way that no other mode of interaction does. In addition, as Luria (12) pointed out "Words impart to their reception a certain constant and generalizing element and thus guarantee constancy of their perception." It is therefore through the use of words that the therapist can highlight some of the child's diverse activities in the playroom, and confer to them a specific meaning intelligible to the child. However, in order to use language as an effective tool in psychotherapy the characteristics of the child's language behaviour through the various developmental stages should be considered. This paper attempts to relate some notions on the development of language to current concepts of child psychotherapy.
Stages in the Acquisition of Language Discussing the origins of language Lenneberg (11) states that the existing evidence suggests a biological predisposition for the development of language related to the various characteristics of the human brain. He states: "Man's cognitive apparatus apparently becomes a language receiver and transmitter, provided the growing organism is exposed to minimum and haphazard environmental events." Therefore, language as "an intimate part of cognition" should be understood, "not as a tool or a product of the mind but as an operation of the mind." The child does not learn the language by simple imitation - he does not only generalize from what he hears but searches, abstracts and stores the various regularities and relationships from the language he hears, and, then applies these to the language he gradually develops for himself (13). As in the acquisition of any other function the child uses his own activity as 'nutrient' to further his own linguistic growth.
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Linguistic growth is characterized by a fixed, gross developmental schedule as well as by a specific and universal sequence of acquisition. This and the remarkable correlation between language and motor development point again to the biological roots of language (11). At about a year old the child shows syllabic reduplication and indication of understanding a few words. By eighteen months he already has a small repertoire of words, and repeats sounds with intonation patterns that resemble discourse. This is the stage of the one word utterance or holophrase which, depending on intonation, may be given as an imperative, a declarative or an interrogative 'sentence'. At this point the word is not yet a clear lexical signal for the child but is one part of a complex stimulus of intonation, gesture, affective charge and a directive for action. As Piaget (16) puts it: "The first language consists almost solely of orders and expressions of desire. Denomination is not the simple attribution of a name, but the expression of a possible action. " Words are rooted in action, and the young child's verbal activity is at first an extension of his sensori-motor action structures. Luria (12), summarizing the work of several Soviet investigators, makes the point that the formation of the simplest function of the word - naming an object - is by no means a simple act of connecting the vocalization of the word with an image of the object, but a very complex and lengthy process of isolating an adequate signalling attribute, to which the verbal symbol is then connected. "This lengthy process can be broken down into a number of stages, during which the child's elementary orienting responses initially playa leading role. Later, visual cues are more important. Finally, the process is regulated by those practical manipulations with the object which synthesize the complex of object signs, and thus complete the formation of the nominative function of the word" (12). Around the age of two the child makes his first attempts to put words together and to use language as a true expression of relationships. The two-word phrase is a universal characteristic of all languages and it is a striking example that
April 1975
LANGUAGE AND CHILD PSYCHOTHERAPY
the child at this age grasps the importance of categories and hierarchies in the construction of language. Characteristically the first two-word sentence is not just a combination of any two words but a rule-bound association of a few pivotal words that come first, and others freely selected from the child's remaining vocabulary. The transition to more complex sentences continues as his auditory memory span increases and his need mounts to store and to express more intricate and more subtle experience. The learning of grammar and syntax, depending largely on biological givens, precedes the learning of the semantic function of words which relies to a great extent on the variety of experience in the child's life. It is not until the ages of four to fourand-a-half that the child achieves syntactic and grammatical competence, and he may now use explanatory or deductive conditional structures to form complex syntax. Linguists have established that the average normal child can repeat correctly only that which is formed by rules the child has already mastered. Furthermore, experimental evidence points to the fact that children will not respond to language forms more complex than those they can produce, although comprehension of such forms cannot be ruled out completely (19). In other words, a true discourse with the child before the age of four is rather questionable expression of desire, description of action and command for simple action is all that the syntactic structures of the child allows for. It is important to distinguish between the lexical acquisition which may proceed quite apart and at a faster rate from the development of syntactic structures which will enable the child to understand and express operational relationships. After the first five years, during which grammar and syntax are established, the seemingly fixed schedule of language acquisition shows two definite periods of significant acceleration: from 5 to 7 and from II to 13 (I8). These, of course, are also the periods when other aspects of cognitive organization accelerate and reach new levels of equilibration.
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Between five and seven the syntax and grammar of the child acquire flexibility and new coordinating forms which enable the speaker to express intricate interrelations verbally. In a parallel development the child's thought becomes operational - he no longer depends on the surface qualities of a situation but understands and makes use of the hidden, intrinsic and enduring relationships of the phenomena. Logical and causal links are grasped and incorporated in the manipulation of the external world. Thus, operational and linguistic structures show a parallel growth (17). Between I I and 13 years the human brain reaches its final maturation, as indicated by various neuroanatomical and neurophysiological data. This biological ceiling forms the substratum of critical cognitive and linguistic events at this age. In the area of general thought processes the child achieves what Piaget calls "formal thinking"- the ability to entertain, in thought, all eventualities, even those remote in time and space, before he finally settles for the possible. Hypothetical and deductive thinking replaces the pragmatic, locked largely in the 'here and now' thought of the school child. "Formal thinking is thinking about thought" as Flavel put it (5). Interrelated with this in the area of linguistic growth is the phenomenon described largely by Vygotsky (19) and Luria (12) that at this age the word becomes freed from direct impressions. Despite the child's total command of grammar and syntax between the ages of 6 to 10 and his ability to express verbally any possible combination of linguistic structures, his speech still shows what Russian investigators have called a 'sympracticaI' character - only in a concrete life situation do words acquire meaning. Thus at this age the child produces spontaneous speech only in relationship to a direct and proximate experience. Piaget (15) made similar observations, described in his earlier work as the "syncretism" of language of the school age child. According to Luria (12) gradual separation of the child's speech from practical action becomes the essential factor in the acceleration of speech comprehension, and
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the development of his active speech. This kind of active, spontaneous speech should be distinguished from earlier forms of spon- . taneous verbal behaviour which are in the interest of exercising newly acquired verbal forms. The processes occurring in preadolescence accelerate and finalize this separation. The child may now initiate language to communicate not only what is immediately present but also events past and events fantasized. Language finally becomes what Bruner called' 'the implement of thought" (1), and the child or adolescent is now able to freely use, combine or differentiate the various attributes contained in words or sentences and to express thoughts independently of immediate experience. The Use of Language in Psychotherapy The laissez-faire attitude mentioned above threatens the understanding of the psychotherapeutic process. The claim that psychotherapy should be defined by its aim alone is incorrect. A definition should not only include the aim but the process itself; otherwise it becomes of little use for all practical purposes. If in the formulation of psychotherapy, besides a basic corrective experience, an additional, specific, interpretative response by the therapist is included, then psychotherapy must be redefined as a process intrinsically bound to linguistic growth (4). With this stipulation (before the age of four) whatever field of interaction with the child is chosen - (play, dance, music, and so on) psychotherapy is limited by the child's inability to comprehend and respond to linguistic forms which denote a wide range of relationships. By definition an interpretation is the expression of relationships, and as such it is beyond the grasp of the preschooler. On the other hand, naming of the affect or identifying the wish or the fantasy belongs to the nominating and signaling type of syntactic structures which the child can respond to and understand. Affect naming, although not an interpretation proper, is probably the most rudimentary psychotherapeutic act. It is an intervention by the adult which produces a trans-
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formation in the mental organization of the child. For example, a child forms a family grouping with dolls and leaves one doll out. The therapist says "The boy is left out The boy is sad". Identifying and naming the affect (and the fantasy) allows the child a new option of behaviour, the verbal behaviour about the sad boy. The diffuse emotions of anger, frustration and fear which prompt the child to this piece of silent symbolic play may now be organized around a new word, a concept that connects experience in a systematic and economic fashion (9). For the young child play therapy consists mostly of direct action in the playroom situation, motivated largely by the child's fantasy activity. In this symbolic play the therapist often 'recognizes' intricate dynamic connections which he then offers to the child in the form of an interpretation. It is doubtful whether the child, who at this age lacks the mental organization to understand and express intricate relationships (as shown by the linguistic forms he can produce), is in any way aware or even responsible for these intricacies. It is also questionable whether he can comprehend and respond to a complicated interpretation even if the words are carefully chosen. However, this does not negate the role of verbal communication in the therapy of the young child and far from being a non-verbal form of interaction, this therapy, like all psychotherapy, depends upon language to sharpen and specify what is to be communi. cated. Furthermore it is mainly through language that new options and opportunities for further ego structuring are offered (3). Therefore language is an integral part of psychotherapy even at this level, but it should be restricted to linguistic forms to which the young child can respond. These forms limit the therapist's verbal behaviour to affect, wish or fantasy, naming, and the expression of his own acceptance of the child. After five years of age the child has completed his learning of syntax and grammar and now possesses an excellent tool for verbal communication, but the 'sympractical' character of his language
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still necessitates certain modifications of the adult model of psychotherapy. For the early school child, play techniques, besides providing a means for symbolic expression, create a situation where familiar concrete activity fuels the child's linguistic competence. In this situation then a sustained, spontaneous and meaningful verbal exchange with the child may take place. The content of this verbal activity depends on his central conflicts, the level of his mental organization, the expressive opportunities offered by the 'play' material and the interactive skill of the therapist. Mark, a gifted severi-year-old boy, showing since birth a high level of tension and hyperresponsivity to a variety of stimuli, instability of behavioural patterns and many diffuse fears, enters the playroom with hesitation and shows amused contempt for a toy telephone. When I say casually the telephones are there for people to talk to each other and I pick up one extension he responds by lifting the receiver of another. He begins gingerly, but gradually he becomes totally unselfconscious. He dials the fire department and tells me excitedly of his terror about fires (aroused at the time by a violent act of arson in the City). More talk about fires is generated when he moves to the toy fire engine, setting it up and expressing the wish to take it home. In subsequent interviews he again makes 'phone calls' to me to say that burglars broke in and that he is afraid he will be kidnapped. This leads to his fears of the bigger bullying boys in his class, immigrant children attending this middle-class school and dealing with their own tensions of social ostracism, by being tough and cruel to 'sissies' like delicate, sensitive Mark. Counteraggression fantasies of 'beheading' them, fears of loss of control, retaliation and punishment by his father are played out, drawn on the blackboard and at the same time expressed verbally.
Throughout' all this I listened, participated and interpreted. My interpretation eventually linked the above fears to Mark's early experience of the 'loss' of the mother with the arrival of each new sibling and the several moves of the family with the subsequent loss of his familiar environment and his strategies of coping. It is suggested here that the therapist's interpretation and the child's efforts to express diffuse feelings and loosely organized
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imagery through the structured and ordered syntactic forms of language, promotes secondary process thinking and ego differentiation. It is not playing as such or even expressing emotional 'content' through play, but rather the specific language behaviour stimulated by, among other factors, the play, which becomes the major element of psychotherapy at this age. From the multitude of shapeless thoughts, vague, unbound emotions, past fragmented memories and present fluid experience, the child selects and organizes into syntactical forms only a small fraction. This selected and systematized mental content becomes the nucleus around which present and past experiences are organized, disturbing affects are neutralized and cognitive dissonances are lifted (I8). As is commonly observed, children in late childhood lose interest in the playroom before they show any true inclination for spontaneous verbal exchange with the therapist. Since these children have already developed free speech, as is shown by their surprising ability to talk about themselves or others with their friends, it is suggested that their limited verbal behaviour in the interview situation is related to the person of the therapist. The reason for the inhibited verbal activity in the presence of adults may be the child's emerging awareness and sensitivity to the sociolinguistic asymmetry of the situation - big adult - small child. Sociolinguists have recently pointed out that the social symmetry in discourse determines the linguistic behaviour of subjects (I 0). It seems that latency age children are more sensitive to this variable than younger ones. This asymmetry becomes more pronounced by the older child's awareness of the social importance of the doctor. Therapists have always sensed this and have attempted to overcome it by becoming amicable and 'equals' to the child. More often than not this does not work, and other measures have been tried. Role playing and the use of distancing devices alter the asymmetrical sociolinguistic situation between child and therapist. A typical distancing device is the use of a tape recorder therapist and child record their thoughts and
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then play back the tape. The child may relate a dream or an experience and the therapist gives an interpretation. Or, as in Richard Gardner's (16) "Mutual Story Telling Technique", role playing complements the recording ("We are now on the air, you are going to tell our audience a story - any story you can think of except one you have read or have seen on T.V."). The tape recorder and/or role playing introduce a new field of communication between child and therapist in which the social relation of the two becomes more symmetrical. Lisa, a 13-year-old, was seen after a period of shoplifting. She lived alone with her mother, isolated from family and friends by the mother's own decision to divorce the husband and move to the other end of the country, severing all ties with her past. Her mother, depressed, resentful, envious and impulsive, worked hard but felt she was not getting anywhere. The child was treated with undisguised ambivalence - on the one hand the mother provided good clothes and excellent health care (Lisa suffered from celiac disease and was on a troublesome diet) and on the other she left the child alone at night, even at the age of five, to attend night courses. When angry she attacked the child physically and abused her verbally. Lisa grew into a tightly defended, secretive, guarded child not trusting anyone. However, at school she did very well. In the treatment sessions Lisa sat immobile with her coat on, never initiating any piece of verbal behaviour, but when I introduced the tape recorder she 'talked', if not fluently at least with some spontaneity. She did not produce any 'story' but instead talked of her dreams and about some of her activities at school. When she lost interest in the tape recorder I asked her to write me a letter for each session, which she did for several months. I then read the letters aloud and talked about them. Lisa rarely spoke directly to me but in her letters she was tender and personal.
The tape recorder and letter writing modified the inhibiting social situation and enabled Lisa to communicate some of her thoughts, feelings and memories. In adolescents free spontaneous speech is established and, coupled with the ability for formal thinking, it enables the adolescent to introspect and to speculate about himself. Psychotherapy of the adult model is therefore feasible and often takes place in the
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therapist's office. In those cases where a free flow of verbal exchange is lacking, the possibility that, besides transference resistance, social factors which may inhibit speech in the patient should be considered. This may be particularly so when a marked class gap separates therapist and patient. In these cases it might be necessary to use role playing, distancing devices or other techniques to alter the sociolinguistic factors involved, before moving on to interpret the resistance.
Summary The dichotomy between non-verbal or play therapy for the younger and verbal psychotherapy for the older child is questionable in view of the fact that lexical representation begins in the second year of life. It is equally doubtful whether, in the absence of certain communications expressed in verbal symbols, any type of interaction between therapist and child may be called psychotherapy. Language, in varying forms of syntactical and semantic complexity, constitutes the matrix which connects and makes coherent all interactive processes in psychotherapy. This paper attempts to relate some notions of language development to current concepts of child psychotherapy. Linguistic growth is characterized by a fixed gross developmental schedule as well as a specific and universal sequence of acquisition. For the preschooler, still lacking a flexible grammer and syntax to express intricate relationships of perceived events, the value of 'interpretations' is doubted; simple statements concerning expression of affect are seen as a rudimentary psychotherapeutic intervention. For the latency child the play situation, with its familiar concrete activity, fuels the child's linguistic competence. Not the play itself but the resulting language becomes the major element of psychotherapy. In late childhood distancing devices and role playing may correct the sociolinguistic asymmetry (adult-child) which inhibits verbal behaviour.
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LANGUAGE AND CHILD PSYCHOTHERAPY
References 1. Bruner, 1., Oliver, R. and Greenfield, P.: Studies in Cognitive Growth. New York, John Wiles. 1966. 2. Diatkine, R.: Preliminary remarks on the present state of psychoanalysis of children. Int. J. Psychoanal. 53: 141-151, 1972. 3. Edelheit, H.: Speech and psychic structure: The vocal-auditory organization of the Ego: J. Am. Psychoanal. Assoc. 17: 381-412, 1971. 4. Edelson, M.: Language and dreams: The interpretation of dreams revisited: Psychoanal. Study Child. 27: 263-283, 1972. 5. Flavel, J. F.: The Developmental Psychology of Jean Piaget. Princeton, D. van Nostrand Company, 1962. 6. Gardner, R.: The mutual storytelling technique: use in alleviating childhood oedipal problems. Contemp. Psychoanal. 4: 16, 1968. 7. Heimlich, E. P.: Paraverbal techniques in the therapy of childhood communication disorders. Int. J. Child. Psychoth. 1: 65-82, 1972. 8. Horowitz, M. J.: Modes of representation of thought. J. Am. Psychoanal. Assoc. 20: 793-820, 1972. 9. Katan, A.: Some thoughts about the role of verbalization in early childhood. Psychoanal. Study Child. 21: 184-189, 1961. 10. Labov, W.: Academic ignorance and black intelligence. The Atlantic, June 1972. II. Lenneberg, E. H.: On explaining language. Science. 164,635-643,1969. 12. Luria, A. R.: Speech development and the formation of mental processes. In a Handbook of Contemporary Soviet Psychology. Ed. Cole, M. and Maltzman, 1., New York. Basic Books Inc., 1969. 13. Menyuk, P.: The acquisition and development of language. The Prentice Hall Series in Developmental Psychology. Ed. Wright, J. D. Cliff, N.Y. Prentice Hall Inc., Englewood, 1971. 14. Nickerson, E. T.: Recent trends and innovations in play therapy. Int. J. Child Psychoth. 53-71, 1973. 15. Piaget, J.: Play, Dreams and Imitation in Childhood. New York, Norton, 1951. 16. Piaget, J.: The Language and Thought of the Child. Translated by: Marjorie Gabain. London, Kegan Paul, 1952. 17. Sinciair-de-Zwart, H.: Developmental psycholinguistics in: Studies in Cognitive Development - Essays in Honour of Jean Piaget. Ed. Elkind, D., Flavel, J. H. New
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York, Oxford University Press, 1969. 18. Steingart,L and Freedman, N.: A language construction approach for the examination of self-object representation in varying clinical states. Psychoanalysis and ContemporaryScience. 1: 132-181, 1972. 19. Vygotsky, L. S.: Thought and Language. Cambridge, M.LT. Press, 1962.
Resume Si l' on considere que la representation lexicale commence la seconde annee de la vie, il est alors moins sur qu'il y ait dichotomie entre therapie non verbale ou ludotherapie pour Ie jeune enfant et la psychotherapie verbale qui s' adresse a l' enfant plus age. On peut egalement se demander si, en l' absence de certaines communications exprimees en symboles verbaux, on peut qualifier de psychotherapie tout type d'interaction therapeute-enfant, La langue, sous des formes diverses de complexite syntaxique et semantique, constitue la matrice qui, en psychotherapie, relie et solidarise tous les processus d' interaction. Dans cet article, on voudrait rattacher quelques notions du developpernent du langage aux concepts actuels de la psychotherapie de l' enfant. La croissance linguistique repond a une echelle de developpement general determinee et correspond en meme temps a un ordre d' acquisition particulier et universel. S'agissant de l'enfant dage pre-scolaire, qui ne possede pas encore de grammaire et de syntaxe flexibles pour exprimer les relations complexes des evenements percus, la valeur des «interpretations» est fort incertaine; on peut considerer les formulations simples, relatives al'expression d'etats affectifs elementaires, comme une intervention psychotherapeutique rudimentaire. Chez l' enfant en periode de latence, la situation ludique, avec son activite concrete familiere , alimente la competence linguistique du sujet. L'elernent majeur de la psychotherapie devient done non Ie jeu Iui-meme, mais Ie langage qui en resulte. Dans la grande enfance, des techniques de distanciation et Ie jeu de role peuvent corriger l' asymetrie socio-linguistique (enfant adulte) qui, a cet age, inhibe Ie comportement verbal.
Ottawa, Canada, April 1975
Vol. 20
Symposium - Child Psychiatry LANGUAGE BEHAVIOUR AND CHILD PSYCHOTHERAPY*
EVA
Recent years have seen a proliferation of psychotherapies for children - therapists ranging widely from child psychiatrists to minimally trained paraprofessionals or untrained 'detached workers' have been using a whole new range of techniques. At the same time, the premises underlying child psychotherapies are becoming increasingly vague (14). Several of the newly developed techniques use non-verbal or paraverbal modes of interaction. Verbal interaction is either minimized Qr simply not considered as a basic component in the therapeutic process. These innovations and the creeping laissezfaire attitude raise several questions, a number of which cannot be fully answered by psychiatric or developmental givens alone. One basic question is the function of language in child psychotherapy, and related to this the theoretical justification of the non-verbal and paraverbal techniques. The question is opportune because the recent expansion in developmental linguistics permits a new understanding of the use of language by children. 'Manuscript received June, 1974. 'Director, Child and Adolescent Service, Allan Memorial Institute, Associate Professor, Dept. of Psychiatry, McGill University, Montreal. Can. Psychiatr. Assoc. J. Vol. 20 (1975)
P. LESTER, M.D.!
The original non-verbal technique introduced as play therapy by child analysts was based on the assumption that the young child who is not yet 'verbal' requires a non-verbal field of communication for psychotherapy. A corollary to this was that play, like the manifest content of a dream, is the perceptible expression of a rich latent fantasy activity, and from this play the child's conscious and unconscious mental activities may be inferred. A dichotomy was thus introduced between non-verbal or play therapies for the young child and verbal psychotherapy for older children and adolescents, a dichotomy that is still tacitly accepted (2). The recent introduction of the term 'paraverbal therapy' does not question the use of language in psychotherapy as such; it only denotes innovations in the non-verbal communicative interactions of the child and therapists (7). The above dichotomy seems questionable because verbal (lexical) representation begins early, probably in the second year of life (8). This means that the child already at this stage begins to organize information through the use of words, and words as acoustic signs become part of his thought processes. It is equally questionable whether, in the absence of certain communications expressed in verbal symbols,
175
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CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
any type of interaction between therapist and child can be called psychotherapy. Language, at all ages and in all forms of syntactical and semantic complexity, constitutes the matrix which connects and makes coherent all interactive processes in psychotherapy. Language sharpens and specifies what is to be communicated in a way that no other mode of interaction does. In addition, as Luria (12) pointed out "Words impart to their reception a certain constant and generalizing element and thus guarantee constancy of their perception." It is therefore through the use of words that the therapist can highlight some of the child's diverse activities in the playroom, and confer to them a specific meaning intelligible to the child. However, in order to use language as an effective tool in psychotherapy the characteristics of the child's language behaviour through the various developmental stages should be considered. This paper attempts to relate some notions on the development of language to current concepts of child psychotherapy.
Stages in the Acquisition of Language Discussing the origins of language Lenneberg (11) states that the existing evidence suggests a biological predisposition for the development of language related to the various characteristics of the human brain. He states: "Man's cognitive apparatus apparently becomes a language receiver and transmitter, provided the growing organism is exposed to minimum and haphazard environmental events." Therefore, language as "an intimate part of cognition" should be understood, "not as a tool or a product of the mind but as an operation of the mind." The child does not learn the language by simple imitation - he does not only generalize from what he hears but searches, abstracts and stores the various regularities and relationships from the language he hears, and, then applies these to the language he gradually develops for himself (13). As in the acquisition of any other function the child uses his own activity as 'nutrient' to further his own linguistic growth.
Vol. 20, No.3
Linguistic growth is characterized by a fixed, gross developmental schedule as well as by a specific and universal sequence of acquisition. This and the remarkable correlation between language and motor development point again to the biological roots of language (11). At about a year old the child shows syllabic reduplication and indication of understanding a few words. By eighteen months he already has a small repertoire of words, and repeats sounds with intonation patterns that resemble discourse. This is the stage of the one word utterance or holophrase which, depending on intonation, may be given as an imperative, a declarative or an interrogative 'sentence'. At this point the word is not yet a clear lexical signal for the child but is one part of a complex stimulus of intonation, gesture, affective charge and a directive for action. As Piaget (16) puts it: "The first language consists almost solely of orders and expressions of desire. Denomination is not the simple attribution of a name, but the expression of a possible action. " Words are rooted in action, and the young child's verbal activity is at first an extension of his sensori-motor action structures. Luria (12), summarizing the work of several Soviet investigators, makes the point that the formation of the simplest function of the word - naming an object - is by no means a simple act of connecting the vocalization of the word with an image of the object, but a very complex and lengthy process of isolating an adequate signalling attribute, to which the verbal symbol is then connected. "This lengthy process can be broken down into a number of stages, during which the child's elementary orienting responses initially playa leading role. Later, visual cues are more important. Finally, the process is regulated by those practical manipulations with the object which synthesize the complex of object signs, and thus complete the formation of the nominative function of the word" (12). Around the age of two the child makes his first attempts to put words together and to use language as a true expression of relationships. The two-word phrase is a universal characteristic of all languages and it is a striking example that
April 1975
LANGUAGE AND CHILD PSYCHOTHERAPY
the child at this age grasps the importance of categories and hierarchies in the construction of language. Characteristically the first two-word sentence is not just a combination of any two words but a rule-bound association of a few pivotal words that come first, and others freely selected from the child's remaining vocabulary. The transition to more complex sentences continues as his auditory memory span increases and his need mounts to store and to express more intricate and more subtle experience. The learning of grammar and syntax, depending largely on biological givens, precedes the learning of the semantic function of words which relies to a great extent on the variety of experience in the child's life. It is not until the ages of four to fourand-a-half that the child achieves syntactic and grammatical competence, and he may now use explanatory or deductive conditional structures to form complex syntax. Linguists have established that the average normal child can repeat correctly only that which is formed by rules the child has already mastered. Furthermore, experimental evidence points to the fact that children will not respond to language forms more complex than those they can produce, although comprehension of such forms cannot be ruled out completely (19). In other words, a true discourse with the child before the age of four is rather questionable expression of desire, description of action and command for simple action is all that the syntactic structures of the child allows for. It is important to distinguish between the lexical acquisition which may proceed quite apart and at a faster rate from the development of syntactic structures which will enable the child to understand and express operational relationships. After the first five years, during which grammar and syntax are established, the seemingly fixed schedule of language acquisition shows two definite periods of significant acceleration: from 5 to 7 and from II to 13 (I8). These, of course, are also the periods when other aspects of cognitive organization accelerate and reach new levels of equilibration.
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Between five and seven the syntax and grammar of the child acquire flexibility and new coordinating forms which enable the speaker to express intricate interrelations verbally. In a parallel development the child's thought becomes operational - he no longer depends on the surface qualities of a situation but understands and makes use of the hidden, intrinsic and enduring relationships of the phenomena. Logical and causal links are grasped and incorporated in the manipulation of the external world. Thus, operational and linguistic structures show a parallel growth (17). Between I I and 13 years the human brain reaches its final maturation, as indicated by various neuroanatomical and neurophysiological data. This biological ceiling forms the substratum of critical cognitive and linguistic events at this age. In the area of general thought processes the child achieves what Piaget calls "formal thinking"- the ability to entertain, in thought, all eventualities, even those remote in time and space, before he finally settles for the possible. Hypothetical and deductive thinking replaces the pragmatic, locked largely in the 'here and now' thought of the school child. "Formal thinking is thinking about thought" as Flavel put it (5). Interrelated with this in the area of linguistic growth is the phenomenon described largely by Vygotsky (19) and Luria (12) that at this age the word becomes freed from direct impressions. Despite the child's total command of grammar and syntax between the ages of 6 to 10 and his ability to express verbally any possible combination of linguistic structures, his speech still shows what Russian investigators have called a 'sympracticaI' character - only in a concrete life situation do words acquire meaning. Thus at this age the child produces spontaneous speech only in relationship to a direct and proximate experience. Piaget (15) made similar observations, described in his earlier work as the "syncretism" of language of the school age child. According to Luria (12) gradual separation of the child's speech from practical action becomes the essential factor in the acceleration of speech comprehension, and
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the development of his active speech. This kind of active, spontaneous speech should be distinguished from earlier forms of spon- . taneous verbal behaviour which are in the interest of exercising newly acquired verbal forms. The processes occurring in preadolescence accelerate and finalize this separation. The child may now initiate language to communicate not only what is immediately present but also events past and events fantasized. Language finally becomes what Bruner called' 'the implement of thought" (1), and the child or adolescent is now able to freely use, combine or differentiate the various attributes contained in words or sentences and to express thoughts independently of immediate experience. The Use of Language in Psychotherapy The laissez-faire attitude mentioned above threatens the understanding of the psychotherapeutic process. The claim that psychotherapy should be defined by its aim alone is incorrect. A definition should not only include the aim but the process itself; otherwise it becomes of little use for all practical purposes. If in the formulation of psychotherapy, besides a basic corrective experience, an additional, specific, interpretative response by the therapist is included, then psychotherapy must be redefined as a process intrinsically bound to linguistic growth (4). With this stipulation (before the age of four) whatever field of interaction with the child is chosen - (play, dance, music, and so on) psychotherapy is limited by the child's inability to comprehend and respond to linguistic forms which denote a wide range of relationships. By definition an interpretation is the expression of relationships, and as such it is beyond the grasp of the preschooler. On the other hand, naming of the affect or identifying the wish or the fantasy belongs to the nominating and signaling type of syntactic structures which the child can respond to and understand. Affect naming, although not an interpretation proper, is probably the most rudimentary psychotherapeutic act. It is an intervention by the adult which produces a trans-
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formation in the mental organization of the child. For example, a child forms a family grouping with dolls and leaves one doll out. The therapist says "The boy is left out The boy is sad". Identifying and naming the affect (and the fantasy) allows the child a new option of behaviour, the verbal behaviour about the sad boy. The diffuse emotions of anger, frustration and fear which prompt the child to this piece of silent symbolic play may now be organized around a new word, a concept that connects experience in a systematic and economic fashion (9). For the young child play therapy consists mostly of direct action in the playroom situation, motivated largely by the child's fantasy activity. In this symbolic play the therapist often 'recognizes' intricate dynamic connections which he then offers to the child in the form of an interpretation. It is doubtful whether the child, who at this age lacks the mental organization to understand and express intricate relationships (as shown by the linguistic forms he can produce), is in any way aware or even responsible for these intricacies. It is also questionable whether he can comprehend and respond to a complicated interpretation even if the words are carefully chosen. However, this does not negate the role of verbal communication in the therapy of the young child and far from being a non-verbal form of interaction, this therapy, like all psychotherapy, depends upon language to sharpen and specify what is to be communi. cated. Furthermore it is mainly through language that new options and opportunities for further ego structuring are offered (3). Therefore language is an integral part of psychotherapy even at this level, but it should be restricted to linguistic forms to which the young child can respond. These forms limit the therapist's verbal behaviour to affect, wish or fantasy, naming, and the expression of his own acceptance of the child. After five years of age the child has completed his learning of syntax and grammar and now possesses an excellent tool for verbal communication, but the 'sympractical' character of his language
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still necessitates certain modifications of the adult model of psychotherapy. For the early school child, play techniques, besides providing a means for symbolic expression, create a situation where familiar concrete activity fuels the child's linguistic competence. In this situation then a sustained, spontaneous and meaningful verbal exchange with the child may take place. The content of this verbal activity depends on his central conflicts, the level of his mental organization, the expressive opportunities offered by the 'play' material and the interactive skill of the therapist. Mark, a gifted severi-year-old boy, showing since birth a high level of tension and hyperresponsivity to a variety of stimuli, instability of behavioural patterns and many diffuse fears, enters the playroom with hesitation and shows amused contempt for a toy telephone. When I say casually the telephones are there for people to talk to each other and I pick up one extension he responds by lifting the receiver of another. He begins gingerly, but gradually he becomes totally unselfconscious. He dials the fire department and tells me excitedly of his terror about fires (aroused at the time by a violent act of arson in the City). More talk about fires is generated when he moves to the toy fire engine, setting it up and expressing the wish to take it home. In subsequent interviews he again makes 'phone calls' to me to say that burglars broke in and that he is afraid he will be kidnapped. This leads to his fears of the bigger bullying boys in his class, immigrant children attending this middle-class school and dealing with their own tensions of social ostracism, by being tough and cruel to 'sissies' like delicate, sensitive Mark. Counteraggression fantasies of 'beheading' them, fears of loss of control, retaliation and punishment by his father are played out, drawn on the blackboard and at the same time expressed verbally.
Throughout' all this I listened, participated and interpreted. My interpretation eventually linked the above fears to Mark's early experience of the 'loss' of the mother with the arrival of each new sibling and the several moves of the family with the subsequent loss of his familiar environment and his strategies of coping. It is suggested here that the therapist's interpretation and the child's efforts to express diffuse feelings and loosely organized
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imagery through the structured and ordered syntactic forms of language, promotes secondary process thinking and ego differentiation. It is not playing as such or even expressing emotional 'content' through play, but rather the specific language behaviour stimulated by, among other factors, the play, which becomes the major element of psychotherapy at this age. From the multitude of shapeless thoughts, vague, unbound emotions, past fragmented memories and present fluid experience, the child selects and organizes into syntactical forms only a small fraction. This selected and systematized mental content becomes the nucleus around which present and past experiences are organized, disturbing affects are neutralized and cognitive dissonances are lifted (I8). As is commonly observed, children in late childhood lose interest in the playroom before they show any true inclination for spontaneous verbal exchange with the therapist. Since these children have already developed free speech, as is shown by their surprising ability to talk about themselves or others with their friends, it is suggested that their limited verbal behaviour in the interview situation is related to the person of the therapist. The reason for the inhibited verbal activity in the presence of adults may be the child's emerging awareness and sensitivity to the sociolinguistic asymmetry of the situation - big adult - small child. Sociolinguists have recently pointed out that the social symmetry in discourse determines the linguistic behaviour of subjects (I 0). It seems that latency age children are more sensitive to this variable than younger ones. This asymmetry becomes more pronounced by the older child's awareness of the social importance of the doctor. Therapists have always sensed this and have attempted to overcome it by becoming amicable and 'equals' to the child. More often than not this does not work, and other measures have been tried. Role playing and the use of distancing devices alter the asymmetrical sociolinguistic situation between child and therapist. A typical distancing device is the use of a tape recorder therapist and child record their thoughts and
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then play back the tape. The child may relate a dream or an experience and the therapist gives an interpretation. Or, as in Richard Gardner's (16) "Mutual Story Telling Technique", role playing complements the recording ("We are now on the air, you are going to tell our audience a story - any story you can think of except one you have read or have seen on T.V."). The tape recorder and/or role playing introduce a new field of communication between child and therapist in which the social relation of the two becomes more symmetrical. Lisa, a 13-year-old, was seen after a period of shoplifting. She lived alone with her mother, isolated from family and friends by the mother's own decision to divorce the husband and move to the other end of the country, severing all ties with her past. Her mother, depressed, resentful, envious and impulsive, worked hard but felt she was not getting anywhere. The child was treated with undisguised ambivalence - on the one hand the mother provided good clothes and excellent health care (Lisa suffered from celiac disease and was on a troublesome diet) and on the other she left the child alone at night, even at the age of five, to attend night courses. When angry she attacked the child physically and abused her verbally. Lisa grew into a tightly defended, secretive, guarded child not trusting anyone. However, at school she did very well. In the treatment sessions Lisa sat immobile with her coat on, never initiating any piece of verbal behaviour, but when I introduced the tape recorder she 'talked', if not fluently at least with some spontaneity. She did not produce any 'story' but instead talked of her dreams and about some of her activities at school. When she lost interest in the tape recorder I asked her to write me a letter for each session, which she did for several months. I then read the letters aloud and talked about them. Lisa rarely spoke directly to me but in her letters she was tender and personal.
The tape recorder and letter writing modified the inhibiting social situation and enabled Lisa to communicate some of her thoughts, feelings and memories. In adolescents free spontaneous speech is established and, coupled with the ability for formal thinking, it enables the adolescent to introspect and to speculate about himself. Psychotherapy of the adult model is therefore feasible and often takes place in the
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therapist's office. In those cases where a free flow of verbal exchange is lacking, the possibility that, besides transference resistance, social factors which may inhibit speech in the patient should be considered. This may be particularly so when a marked class gap separates therapist and patient. In these cases it might be necessary to use role playing, distancing devices or other techniques to alter the sociolinguistic factors involved, before moving on to interpret the resistance.
Summary The dichotomy between non-verbal or play therapy for the younger and verbal psychotherapy for the older child is questionable in view of the fact that lexical representation begins in the second year of life. It is equally doubtful whether, in the absence of certain communications expressed in verbal symbols, any type of interaction between therapist and child may be called psychotherapy. Language, in varying forms of syntactical and semantic complexity, constitutes the matrix which connects and makes coherent all interactive processes in psychotherapy. This paper attempts to relate some notions of language development to current concepts of child psychotherapy. Linguistic growth is characterized by a fixed gross developmental schedule as well as a specific and universal sequence of acquisition. For the preschooler, still lacking a flexible grammer and syntax to express intricate relationships of perceived events, the value of 'interpretations' is doubted; simple statements concerning expression of affect are seen as a rudimentary psychotherapeutic intervention. For the latency child the play situation, with its familiar concrete activity, fuels the child's linguistic competence. Not the play itself but the resulting language becomes the major element of psychotherapy. In late childhood distancing devices and role playing may correct the sociolinguistic asymmetry (adult-child) which inhibits verbal behaviour.
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References 1. Bruner, 1., Oliver, R. and Greenfield, P.: Studies in Cognitive Growth. New York, John Wiles. 1966. 2. Diatkine, R.: Preliminary remarks on the present state of psychoanalysis of children. Int. J. Psychoanal. 53: 141-151, 1972. 3. Edelheit, H.: Speech and psychic structure: The vocal-auditory organization of the Ego: J. Am. Psychoanal. Assoc. 17: 381-412, 1971. 4. Edelson, M.: Language and dreams: The interpretation of dreams revisited: Psychoanal. Study Child. 27: 263-283, 1972. 5. Flavel, J. F.: The Developmental Psychology of Jean Piaget. Princeton, D. van Nostrand Company, 1962. 6. Gardner, R.: The mutual storytelling technique: use in alleviating childhood oedipal problems. Contemp. Psychoanal. 4: 16, 1968. 7. Heimlich, E. P.: Paraverbal techniques in the therapy of childhood communication disorders. Int. J. Child. Psychoth. 1: 65-82, 1972. 8. Horowitz, M. J.: Modes of representation of thought. J. Am. Psychoanal. Assoc. 20: 793-820, 1972. 9. Katan, A.: Some thoughts about the role of verbalization in early childhood. Psychoanal. Study Child. 21: 184-189, 1961. 10. Labov, W.: Academic ignorance and black intelligence. The Atlantic, June 1972. II. Lenneberg, E. H.: On explaining language. Science. 164,635-643,1969. 12. Luria, A. R.: Speech development and the formation of mental processes. In a Handbook of Contemporary Soviet Psychology. Ed. Cole, M. and Maltzman, 1., New York. Basic Books Inc., 1969. 13. Menyuk, P.: The acquisition and development of language. The Prentice Hall Series in Developmental Psychology. Ed. Wright, J. D. Cliff, N.Y. Prentice Hall Inc., Englewood, 1971. 14. Nickerson, E. T.: Recent trends and innovations in play therapy. Int. J. Child Psychoth. 53-71, 1973. 15. Piaget, J.: Play, Dreams and Imitation in Childhood. New York, Norton, 1951. 16. Piaget, J.: The Language and Thought of the Child. Translated by: Marjorie Gabain. London, Kegan Paul, 1952. 17. Sinciair-de-Zwart, H.: Developmental psycholinguistics in: Studies in Cognitive Development - Essays in Honour of Jean Piaget. Ed. Elkind, D., Flavel, J. H. New
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York, Oxford University Press, 1969. 18. Steingart,L and Freedman, N.: A language construction approach for the examination of self-object representation in varying clinical states. Psychoanalysis and ContemporaryScience. 1: 132-181, 1972. 19. Vygotsky, L. S.: Thought and Language. Cambridge, M.LT. Press, 1962.
Resume Si l' on considere que la representation lexicale commence la seconde annee de la vie, il est alors moins sur qu'il y ait dichotomie entre therapie non verbale ou ludotherapie pour Ie jeune enfant et la psychotherapie verbale qui s' adresse a l' enfant plus age. On peut egalement se demander si, en l' absence de certaines communications exprimees en symboles verbaux, on peut qualifier de psychotherapie tout type d'interaction therapeute-enfant, La langue, sous des formes diverses de complexite syntaxique et semantique, constitue la matrice qui, en psychotherapie, relie et solidarise tous les processus d' interaction. Dans cet article, on voudrait rattacher quelques notions du developpernent du langage aux concepts actuels de la psychotherapie de l' enfant. La croissance linguistique repond a une echelle de developpement general determinee et correspond en meme temps a un ordre d' acquisition particulier et universel. S'agissant de l'enfant dage pre-scolaire, qui ne possede pas encore de grammaire et de syntaxe flexibles pour exprimer les relations complexes des evenements percus, la valeur des «interpretations» est fort incertaine; on peut considerer les formulations simples, relatives al'expression d'etats affectifs elementaires, comme une intervention psychotherapeutique rudimentaire. Chez l' enfant en periode de latence, la situation ludique, avec son activite concrete familiere , alimente la competence linguistique du sujet. L'elernent majeur de la psychotherapie devient done non Ie jeu Iui-meme, mais Ie langage qui en resulte. Dans la grande enfance, des techniques de distanciation et Ie jeu de role peuvent corriger l' asymetrie socio-linguistique (enfant adulte) qui, a cet age, inhibe Ie comportement verbal.
