The Treatment of Child Abuse Play Therapy with a 4- Year-Old Child
Peter A. In, M.D. and John F. McDermott, Jr., M.D.
Abstract. There are few reports on the follow-up of child-abuse victims or indications that these children need an y special treatment beyond removal from the abusing situation . We suggest that indeed these children suffer many sequelae and are in need of individual psychotherapy. A case study of play therapy with a severel y regressed girl is presented. Typical issues that need to be resolved to prevent crystallization of a chronically disturbed and arrested character structure in these children are discussed .
In the past decade, a wealth of literature on the subject of child abuse has been published. Much of the work deals with the radiological diagnosis and the medical treatment of these cases. Emotional resistance to the idea that parents could mistreat their children seems to influence many of the studies (Helfer and Kempe, 1968) which focus on the psychodynamics of the battering parent and modes of therapeutic intervention with them. There has been little or no information available on the treatment and follow-up of the victims of child abuse. A few studies indicate that these children suffer residual damage. Elmer (1967), in a selected population with orthopedic injuries, reported that 90 percent showed aftereffects. Morse et al. (1970), in a more comprehensive sample of abused and neglected children, judged that 70 percent of the group studied were outside of the normal range by intellectual, emotional, social, and motor development parameters. While these articles point to serious sequelae among abused children , little has been written about psychiatric work with these children . Most of the articles describing case study treatment derive from the extensive work with burned children of all causes, and focus primarily on the problems of the child in the hospital; they delineate the role of the psychiatric worker in providing a liaison in helping the child cope with the Dr. III is a Frllou- ill Child P.'ychial')', and Dr. IHcDpnnal/ II Projessor and ChaiT77UlIl, Department of Psuhuurv, U"iwnity ofHau-au, School ol Medicine, Lrahi Hospital, Honolulu , HI 96816 , uiher« reprint s 11Uly lIP rrqursted from thr authors.
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emotional response to his burn treatment (Galdston, 1972; Bernstein et al., 1969; Bezzeg et al., 1972). The paucity of articles dealing with the treatment of abused children suggests another area of neglect. It is a commonly held belief by child workers that simple manipulation of the social environment (i.e., foster home placement) is enough to correct the psychological trauma of child abuse. Unfortunately, as the following case illustrates, removal of a child from an undesirable situation does not always mitigate his reaction to the abuse; moreover, it can create another problem and its sequelae, separation anxiety; removing a child from an abusing situation may not be the end of treatment, but merely the beginning. We feel that early psychiatric involvement in cases of child abuse is necessary in determining the child's role in producing the abuse and his reaction to it and in recommending appropriate comprehensive treatment for the child, including psychotherapy in many cases. Such early involvement can help prevent the situation in which children are shunted from one foster home to another because of continuing problems that the child presents. CASE HISTORY
Erica was an attractive, petite 3%-year-old blonde who was brought to the hospital by her distraught foster mother after 3 months of increasingly bizarre behavior. The precipitating incident was finding Erica in bed masturbating, digging her hand into her rectum, and smearing feces over herself and the bed. It was the third such incident; but when the foster mother returned to the room with a towel and found the girl smearing herself with blood from selfinflicted epistaxis, she decided that she could tolerate the situation no longer. During her 3-month foster home placement, Erica had also demonstrated difficulty getting along with the other children in the family. Stubborn behavior centered around getting up on time, using the toilet (she insisted on using the bathtub instead), and eating her food at mealtimes. She also was withholding urine and was having stress incontinence as a result. There were questions as to Erica's contact with reality; she would talk to herself at times and refer to imaginary playmates. Five months before Erica had been hospitalized in a general hospital for 60 days as an abused and neglected child. Her problems at that time were: (1) a large second and third degree burn covering most of her right buttock which had been sustained approximately
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I Y2 months prior to admission; (2) a large frontal hematoma reportedly secondary to head banging; and (3) seizurelike activity which included head banging, breath holding, shaking of the extremities, stiffening, growls and unresponsiveness to vocal commands. These episodes were also accompanied by fecal and bladder incontinence and had started around the time the patient received the burn. (4) Another symptom was alopecia: her hair began falling out 4 months prior to admission, at which time there was a diagnosis of fungal infection, and a month later she was bald (but hair was returning at the time of admission). (:1) There were multiple bruises about her body reportedly sustained from frequent falling, upper lip swelling and ulceration, said to have been obtained by the child stuffing food under the lip and leaving it there until it decomposed, and bilateral purulent otitis. Erica had been treated on a general pediatric ward, and all her problems responded to supportive medical treatment. She did not manifest any of the bizarre behavior reported prior to admission. A negative EEG made a seizure disorder unlikely. Plans were made to skin graft the extensive burn of her buttock, but were postponed when she developed chicken pox. By the time she had recovered from this, her burn had gl'anulated in with hypertrophic scar tis-
sue. During the hospitalization, a psychiatric consultation was obtained, and Erica's maternal grandparents were able to give a fairly extensive background history. They stated that from the time their daughter, Erica's mother, was 12, they had had problems with her. In early adolescence she met a young soldier and announced she wanted to get married. They opposed this, but she became pregnant and married at age 16. Erica's father was alleged to drink excessively and drive recklessly. There were marital difficulties, and the husband was frequently out of the house. Despite these problems, the union produced three daughters, a year apart, before it ended in divorce. Erica was the middle of these daughters. The pregnancy was marked by mononucleosis during the first trimester, but delivery was uncomplicated. As an infant, Erica was reported to be irritable, but had no feeding problem. Developmental milestones were within normal limits. Shortly after Erica's birth, the family moved away from their hometown. The grandparents were concerned for the children's welfare, for although they did not suspect that their daughter was physically abusing the children, they did know that at times she would emotionally and materially neglect them. Eventually, when Erica was around 2Y2 years old, they were successful in bringing their daughter and her three chil-
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dren back to their house. Erica was enrolled in a nursery school at this time and did well there. During this period, Erica's mother was frequently neglecting the children, which initiated the first report by an anonymous concerned neighbor to the Child Protective Service. Frequently, the children were left in the care of the grandparents. Finally, they became the custodians of the children when their mother became pregnant again and entered a home for unwed mothers. At the time of this separation, Erica was :~ Y:~ years old. She had been her mother's favorite and, in turn, was very attached to her mother. After her mother's departure, Erica's grandparents singled her out as being a "bad child" and identified her as being like her mother, a stubborn and willful youngster. They complained that she urinated and defecated on her sister's clothing and vomited up her food and ate the vomitus. She was also stuffing her mouth with food and retaining it there. At the start of treatment, Erica seemed to the casual observer a lively, attractive, curly-haired little girl. She had about her, however, the appealing precociousness that is often described of the abused. From her history, it was evident that she was the victim of significant abuse and neglect. It was apparent that neglect by her mother had been followed by abuse from the grandparents. Although they claimed that Erica had inflicted the burn herself by drawing hot water in a bathtub it was obvious that she could not have sat by herself in the tub without burning other parts of her body. In the hospital, E6ca still appeared to be confused about this episode of abuse. On direct questioning she was not able to elaborate how she had received her burn, other than "my grandfather did it." Further questions produced either "I don't know" or silence. We decided that there were still many unresolved conflicts in this little girl, and that play psychotherapy was indicated as a means of delineating those conflicts which were giving rise to regressive behavior and providing a means for her to gain mastery over them. The intensive portion of treatment of this severely regressed child took place during a month's hospitalization at the inpatient treatment facility of the University of Hawaii's Child Psychiatry program. It provided a structured milieu program with activity group therapy, occupational therapy, arts and crafts, and outdoor games. Ten individual psychotherapy sessions were held. Following discharge from the hospital, Erica had 10 more outpatient visits which led to the reunion with her mother. The intent of therapy was to explore the past and clarify it, to deal with whatever issues
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Peter A . In and John F. M clrermott, Jr.
were brought up. make an interpretation of those issues through pla y. and then pla y out more successful resolutions to the issues ' rai sed . The Play Therapy
Erica's initial resistance to therapy was overcome by the presence of attractive and relevant pla y materials. In this case. the most dramatic incident of abuse had re sulted in a burn. Galdston (1972) has po inted out that two thirds of ch ild re n are inside their homes when burned. the largest number in the kitchen. and the next in the livingroom, bathroom. and bedroom. in that order. The therapist's dollhouse therefore provided an opportunity and setting for Erica to play out her internalized conflict. The therapist was also able to elicit that in the hospital Erica continued to have terrifying nightmares. which had as their main feature "the sound of a stove in the night." Once this frightening disembodied sound was identified concretely. she excitedly wanted to tape up the "stove" in the dollhouse. This was accomplished with a Hourish of Scotch tape until the lid of the stove was taped sh ut and it was safe to put back into the dollhouse.
The taping exercise became the basis of an ongoing ritual. At the beginning of each new session. Erica would check to make sure the stove was still taped , and then would rigorously insist on taping it up again if it had become loo sened . This play activity seemed to provide several function s; it was a reparative act and also a means for her to gain mastery over the dangerous stove. The taping also provided a new theme of repair which was repeated in other session s with a small plastic bear which came to represent Erica. In one pla y sequence. Erica had the bear go to the hospital with a "burned butt." In the hospital room she surrounded the little bear with a collection of other dolls. When she was asked who they were, she replied, "They're the doctors." "What are they doing?" she was asked. "They're not doing nothing." This sequence seemed to replay her previous hospitalization when the doctors had to abandon their plans for skin grafting. Erica was able to provide some help herself by taping up the little bear's buttocks and also that of a father doll. This action was seen as repairing damage to the person to whom Erica had fantasized retaliation for her own burn. While this work was going on in play therapy. Erica's behavior on the ward was marked by none of the previous regressive symptoms she had demonstrated in the foster home. (This was similar to her previous hospitalization, except that weekends at home now
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were also marked by continued normal functioning.) Her main remaining behavioral problems on the ward were manipulative behavior, occasional temper tantrums when she could not get her own way, and minor difficulties with peers. The nightmares and "sound of a stove" resolved during the period of working through the trauma in therapy. Oppositional behavior was managed by the staff with firm limit setting and the careful use of seclusion. At the end of a month's hospitalization, we decided that further play therapy could be done on an outpatient basis. (There was a 3-week interruption in therapy, due to transportation problems, which coincided with a return of enuresis, but this also cleared up when therapy was reinstated.) In the ensuing weeks, Erica's need to gain mastery and to express the underlying rage over her abuse led her to use play materials which permitted displaced expression of her aggression. The use of play telephones nicely filled this function as it permitted a free expression of ideas, yet still was viewed as "play." (The telephone can also be seen as a very powerful instrument because in reality it gives the abused and neglected child a link with the outside world.) Ideas too could be safely stated over the telephone, with no danger of immediate physical harm (or things being "too hot"), and the option of hanging up if things were too threatening. The following demonstrates how Erica was able to use the play telephones in working out the past. Erica came in 30 minutes late because the volunteer transporting her had lost her way. She walked in a very ladylike and prim fashion and exasperatedly slumped into a bean-bag chair with her teddy bear, leaned over slightly, and sighed, "I'm tired. We drove all over today." T: Well, why don't you catch your breath first and then see what we can do today. We don't have too much time, but we do have about 15 minutes. E: Let's talk on the telephone. I'll call you up (ring ring). T: Hello, this is Dr. X speaking. Who is this? E: This is Erica's mother. T: Oh hello, is Erica there? E: No, she's in the hospital. T: Oh dear, what's happened? Why is she in the hospital? E: She's in the hospital because she got burned. T: Oh dear, that's terrible, where did she get burned? E: She got burned on her butt. T: She got burned on her butt! How did that happen? E: Her grandfather burned her.
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Peter A. In andjohn F. McDermott,jr.
T : Oh m y gosh, wh y did he do that? E: I don't know . T : So how is she doing in the hospital? E: I don't know. I haven't see n her. T : Oh , yo u haven't been to the hospital yet? E: I have to go now, T : Okay, please let me know how Erica is doing, Bye now. E: Bye (pause) , Let's cha nge phones (hand s the therapist her phone and takes his). T : Who shall I be now? Can I be the . .. grandfather? E: Okay. T: Hello, this is grandfather (in a somewhat slurred voice). E : This is Erica's sister. T: Where is Erica? Put her on. E: I can't. She's in the hospital. T : Oh? Why is she there? E: You know, you burned her (in angry tone)! T : What do you mean, I burned her? Where did I burn her? E : You burned her on her butt! T : I did not. An yway, how do yo u know? You weren 't there. E: I do, too. I heard it. T : Oh (still den ying)? Well, if' yo u're so smart, what did I burn her with? E: You burned her with the fr ying pan. This is Erica's nurse, and you were bad. (This was the first disclosure of the details of the abuse episode .) T: You don't know what yo u're talking about. E: I do, too. T : Did I pull down her panties? E: No, yo u burned her through her dress. Wh y did yo u do that ? T: Well, ma ybe I did burn her on her butt . But I didn't mean to hurt her. But I got ang" y and lost my temper because she didn't mind. E: Erica's not bad. She minds. T: Well, mostly she's a good girl, but sometimes she doesn't listen and is stubborn and I just lost my temper. E : (no comment). T: Yes, she got me mad. E: This is Erica's mother and you burned her (still angry voice)! T : Well, I'm sorry, but sometimes Erica doesn't mind. Anyway, you take care of Erica. E: Okay.
In this sequence the use of the telephone allowed the child to play out confronting the abuser. She used the character of various
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authority figures, first the sister, then the nurse, and finally the mother, to do so. That she was still able to identify with her mother as a caring figure seemed a good prognostic sign. Not only did she establish her grandfather as the abuser, but she sought to find out why she was abused. The therapist provided a reason which might be understandable and therefore more acceptable-namely, the grandfather's anger. The therapist thereby offered a rationalization for the terrible act. The therapist also apologized for the grandf~lther and then transferred responsibility for further care of Erica back to her mother in this phone conversation. Two sessions later, Erica played out with the therapist a scene in which she returned home from a trip to the supermarket. She said she was going to cook a steak for the family and asked the doctor to set the table. After making sure the stove was taped up, she proceeded to cook the steak but said the stove was too hot. When the therapist pointed out that the stove had to be hot in order to cook the steak, Erica paused and then said she would take off the tape. The therapist reassured her they would be careful of the stove when they cooked the steak. After this session, the theme of "stoves" and people getting burns disappeared from Erica's play. In subsequent sessions, she made direct reference to her burn, usually followed by a matter-of-fact inspection of the progress of its healing. The burn, although divested of much of its former ernotional charge, still held much significance for her. (At one point when asked if she had started preschool yet, Erica replied, "No, I still have my burn.") Once Erica was desensitized to her burn, other themes emerged in her play. During this period the therapy was complicated by the necessity to place Erica in another foster home, because the present foster family was leaving the state, and Erica, due to court order, could not leave with them. The therapist anticipated that this move would be interpreted as another rejection and abandonment, so he played out a structured dollhouse session of a girl going to live with a new foster family. Although Erica played along in this session mainly as a spectator, it allowed her to express later that she thought her foster parents had left because they did not like her. The theme of a mother leaving and the child having to go to a new home naturally reawakened concerns about her real mother. Two sessions after she had released the stove from its taped-up, immobilized state, she used the telephones again to play out a dialogue concerning her mother "being shot to death by the cops." In the play, the mother was shot in the kitchen and taken by the police to the hospital. The little girl on the phone also expressed
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Peter A. In andJohn F. McDermott, Jr.
concern that the police would kill her father too if he returned home. This theme of "what's happened to Mom?" gradually became elaborated during the next 3 sessions, along with the theme of "Erica's new Mom" as the real-life situation of her change in homes was dealt with in therapy. Exploring these issues in the play sessions happily corresponded to a smooth transition in foster families with none of the anticipated regressive behavior. The story of "Mom's killed by the cops" is probably best understood as an expression of the issue of separation and attachment. Bowlby (1969, 1973) has written extensively on the importance and strength of this developmental force. Indeed, it might be the case that Erica's initial regressive sphincter problem was related to the loss of her mother at the point when the latter left for the home for unwed mothers. The added insult of a burn to her buttock only further sensitized the child to this zone. Once it became clear through the play that loss of the mother was an important ongoing concern for Erica, plans were considered for reuniting the two. Fortunately, during the time of Erica's treatment, her mother was involved in individual and group psychotherapy. Six months after Erica's treatment had started, her mother had remarried and her situation seemed stable enough to permit maternal visits. These went so well that 15 months after they had been separated, mother and daughter were reunited. So far, there has been no return of symptoms. Erica's rapid recovery points to a fairly well-developed basic ego structure. These strengths point to a strong motherdaughter bond and indicate that in regard to Erica the mother had been able to give her adequate early nurturance. Perhaps it was precisely this close bond which made separation so traumatic. DISCUSSION AND CONCLUSIONS
In this case, as in so many cases of child abuse, simple environmental manipulation was not sufficient to prevent the recurrence of regressive phenomena. It is this lack of early psychotherapeutic intervention which can lead to the crystallization of a chronically disturbed and arrested character structure. For example, many have commented on the frequency with which abusing parents were themselves abused during childhood, i.e., an identification with the aggressor and inability to perform in the parenting role because they had never experienced an adequate model. The importance of psychotherapeutic intervention must be stressed in dealing with the behavioral problems found in abused children. Yet few, if any, guidelines seem to exist.
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In working out a dynamic formulation to understand this patient's symptoms, we did not believe it was enough simply to relate disturbed bowel functions and difficult behavior to the trauma (both emotional and physical) of experiencing a severe burn on the buttock. What seemed likely is a complex interplay between separation, regression, and abuse. The importance of Erica's attachment to her mother and separation anxiety clearly emerged as this theme was elaborated in therapy. Sequentially, it is likely that regression followed separation, which in turn led to abuse. Further separation compounded the regression. It is also important to consider the child's cognitive level of development which limits his ability to integrate all of these experiences into continued healthy functioning. In Erica's case, integration took place only after her life experiences were re-created in play, and mastery and control gained through that play. Once the abusing situation was mastered and its issues were no longer "too hot to handle," the developmental issue of the child's attachment to and the anxiety caused by separation from mother could emerge and be dealt with in therapy. True mastery, one must keep in mind, is not only being able to live with one's past but also with one's present. With Erica, attention was paid to facilitating the playing out of the ongoing stresses of changing foster parents and the final reunion with her natural mother. The ability to "forgive" the abusing parent through a psychotherapeutic experience is a powerful factor in releasing the child from seeking constant repetition of the abusing experience in childhood, and from later reversing roles as a parent in a series of futile attempts to rid himself of its effects. In similar cases of child abuse, play therapy might be designed to help resolve the child's ambivalent feelings toward an abusing parent: on the one hand, the fear and negative image of the parent based on reality issues, and on the other, the power of a positive image and attachment which is a developmental force to be reckoned with and balanced with the former. Working through the attachment issue in therapy requires that the therapist acknowledge the reality of these ties. Careful assessment of the strength of these ties and the exact role they play in symptom production is necessary in deciding the best course of action, i.e., separating or reuniting parent and child. It is hoped that this report of successful work with one young child will stimulate further research work into the special psychotherapeutic needs and approaches for children of abuse and neglect, children who have been far too long neglected by child
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therapists. The decision for removal or non removal from the home and for involving the parents in rehabilitative work is an insufficient package in many cases. It is paradoxical that the dramatic national concern for protection of these children has not been accompanied by an appropriate psychotherapeutic program aimed at restoring healthy development for their future lives.
REFERENCES BERNSTEIN, N. R., SANGt:R, S., & FRAs. I. (I !Ui9), The Iumtions of the child psychiatrist in the managemelll of severelv burned children. This [ournal, H:620-6:~6. Brzzz«. E. D .• FRATIANNt:, R. B., KARNASIEWICZ, S. Q.. & PLANK, E. N. (1972). The roll' of the child care worker in the treatment of sevetelv burned children. Pediatrics, 50:617-624. BOWLBY. j. (1969, 1973), Attachment and Lo.IJ, Vol. I & II. New YOI"k: Basic Books. ELMt:R, E. (1967), Children ill Jeopardy. Pittsburgh: U niv. Pittsburgh Press. GALDSTON. R. (1972). The burning and healin!{ of children. Psvchiatr», :~5:5 7 -66. HELFER. R. E. & KBIPE, C. H. (196H). The Battered Child. Chica!{o: Univ. Chicago Press. MORSE. C. W. SAIIU:R. O . .J., & FRIEnMAN, S. B. (1970). A three-year follow-up study of abused and neglected children. Amer.], Dis. Child.• 120:4:~9-446.
Peter A. In, M.D. and John F. McDermott, Jr., M.D.
Abstract. There are few reports on the follow-up of child-abuse victims or indications that these children need an y special treatment beyond removal from the abusing situation . We suggest that indeed these children suffer many sequelae and are in need of individual psychotherapy. A case study of play therapy with a severel y regressed girl is presented. Typical issues that need to be resolved to prevent crystallization of a chronically disturbed and arrested character structure in these children are discussed .
In the past decade, a wealth of literature on the subject of child abuse has been published. Much of the work deals with the radiological diagnosis and the medical treatment of these cases. Emotional resistance to the idea that parents could mistreat their children seems to influence many of the studies (Helfer and Kempe, 1968) which focus on the psychodynamics of the battering parent and modes of therapeutic intervention with them. There has been little or no information available on the treatment and follow-up of the victims of child abuse. A few studies indicate that these children suffer residual damage. Elmer (1967), in a selected population with orthopedic injuries, reported that 90 percent showed aftereffects. Morse et al. (1970), in a more comprehensive sample of abused and neglected children, judged that 70 percent of the group studied were outside of the normal range by intellectual, emotional, social, and motor development parameters. While these articles point to serious sequelae among abused children , little has been written about psychiatric work with these children . Most of the articles describing case study treatment derive from the extensive work with burned children of all causes, and focus primarily on the problems of the child in the hospital; they delineate the role of the psychiatric worker in providing a liaison in helping the child cope with the Dr. III is a Frllou- ill Child P.'ychial')', and Dr. IHcDpnnal/ II Projessor and ChaiT77UlIl, Department of Psuhuurv, U"iwnity ofHau-au, School ol Medicine, Lrahi Hospital, Honolulu , HI 96816 , uiher« reprint s 11Uly lIP rrqursted from thr authors.
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431
emotional response to his burn treatment (Galdston, 1972; Bernstein et al., 1969; Bezzeg et al., 1972). The paucity of articles dealing with the treatment of abused children suggests another area of neglect. It is a commonly held belief by child workers that simple manipulation of the social environment (i.e., foster home placement) is enough to correct the psychological trauma of child abuse. Unfortunately, as the following case illustrates, removal of a child from an undesirable situation does not always mitigate his reaction to the abuse; moreover, it can create another problem and its sequelae, separation anxiety; removing a child from an abusing situation may not be the end of treatment, but merely the beginning. We feel that early psychiatric involvement in cases of child abuse is necessary in determining the child's role in producing the abuse and his reaction to it and in recommending appropriate comprehensive treatment for the child, including psychotherapy in many cases. Such early involvement can help prevent the situation in which children are shunted from one foster home to another because of continuing problems that the child presents. CASE HISTORY
Erica was an attractive, petite 3%-year-old blonde who was brought to the hospital by her distraught foster mother after 3 months of increasingly bizarre behavior. The precipitating incident was finding Erica in bed masturbating, digging her hand into her rectum, and smearing feces over herself and the bed. It was the third such incident; but when the foster mother returned to the room with a towel and found the girl smearing herself with blood from selfinflicted epistaxis, she decided that she could tolerate the situation no longer. During her 3-month foster home placement, Erica had also demonstrated difficulty getting along with the other children in the family. Stubborn behavior centered around getting up on time, using the toilet (she insisted on using the bathtub instead), and eating her food at mealtimes. She also was withholding urine and was having stress incontinence as a result. There were questions as to Erica's contact with reality; she would talk to herself at times and refer to imaginary playmates. Five months before Erica had been hospitalized in a general hospital for 60 days as an abused and neglected child. Her problems at that time were: (1) a large second and third degree burn covering most of her right buttock which had been sustained approximately
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Peter A. In and john F. McDermott,jr.
I Y2 months prior to admission; (2) a large frontal hematoma reportedly secondary to head banging; and (3) seizurelike activity which included head banging, breath holding, shaking of the extremities, stiffening, growls and unresponsiveness to vocal commands. These episodes were also accompanied by fecal and bladder incontinence and had started around the time the patient received the burn. (4) Another symptom was alopecia: her hair began falling out 4 months prior to admission, at which time there was a diagnosis of fungal infection, and a month later she was bald (but hair was returning at the time of admission). (:1) There were multiple bruises about her body reportedly sustained from frequent falling, upper lip swelling and ulceration, said to have been obtained by the child stuffing food under the lip and leaving it there until it decomposed, and bilateral purulent otitis. Erica had been treated on a general pediatric ward, and all her problems responded to supportive medical treatment. She did not manifest any of the bizarre behavior reported prior to admission. A negative EEG made a seizure disorder unlikely. Plans were made to skin graft the extensive burn of her buttock, but were postponed when she developed chicken pox. By the time she had recovered from this, her burn had gl'anulated in with hypertrophic scar tis-
sue. During the hospitalization, a psychiatric consultation was obtained, and Erica's maternal grandparents were able to give a fairly extensive background history. They stated that from the time their daughter, Erica's mother, was 12, they had had problems with her. In early adolescence she met a young soldier and announced she wanted to get married. They opposed this, but she became pregnant and married at age 16. Erica's father was alleged to drink excessively and drive recklessly. There were marital difficulties, and the husband was frequently out of the house. Despite these problems, the union produced three daughters, a year apart, before it ended in divorce. Erica was the middle of these daughters. The pregnancy was marked by mononucleosis during the first trimester, but delivery was uncomplicated. As an infant, Erica was reported to be irritable, but had no feeding problem. Developmental milestones were within normal limits. Shortly after Erica's birth, the family moved away from their hometown. The grandparents were concerned for the children's welfare, for although they did not suspect that their daughter was physically abusing the children, they did know that at times she would emotionally and materially neglect them. Eventually, when Erica was around 2Y2 years old, they were successful in bringing their daughter and her three chil-
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dren back to their house. Erica was enrolled in a nursery school at this time and did well there. During this period, Erica's mother was frequently neglecting the children, which initiated the first report by an anonymous concerned neighbor to the Child Protective Service. Frequently, the children were left in the care of the grandparents. Finally, they became the custodians of the children when their mother became pregnant again and entered a home for unwed mothers. At the time of this separation, Erica was :~ Y:~ years old. She had been her mother's favorite and, in turn, was very attached to her mother. After her mother's departure, Erica's grandparents singled her out as being a "bad child" and identified her as being like her mother, a stubborn and willful youngster. They complained that she urinated and defecated on her sister's clothing and vomited up her food and ate the vomitus. She was also stuffing her mouth with food and retaining it there. At the start of treatment, Erica seemed to the casual observer a lively, attractive, curly-haired little girl. She had about her, however, the appealing precociousness that is often described of the abused. From her history, it was evident that she was the victim of significant abuse and neglect. It was apparent that neglect by her mother had been followed by abuse from the grandparents. Although they claimed that Erica had inflicted the burn herself by drawing hot water in a bathtub it was obvious that she could not have sat by herself in the tub without burning other parts of her body. In the hospital, E6ca still appeared to be confused about this episode of abuse. On direct questioning she was not able to elaborate how she had received her burn, other than "my grandfather did it." Further questions produced either "I don't know" or silence. We decided that there were still many unresolved conflicts in this little girl, and that play psychotherapy was indicated as a means of delineating those conflicts which were giving rise to regressive behavior and providing a means for her to gain mastery over them. The intensive portion of treatment of this severely regressed child took place during a month's hospitalization at the inpatient treatment facility of the University of Hawaii's Child Psychiatry program. It provided a structured milieu program with activity group therapy, occupational therapy, arts and crafts, and outdoor games. Ten individual psychotherapy sessions were held. Following discharge from the hospital, Erica had 10 more outpatient visits which led to the reunion with her mother. The intent of therapy was to explore the past and clarify it, to deal with whatever issues
434
Peter A . In and John F. M clrermott, Jr.
were brought up. make an interpretation of those issues through pla y. and then pla y out more successful resolutions to the issues ' rai sed . The Play Therapy
Erica's initial resistance to therapy was overcome by the presence of attractive and relevant pla y materials. In this case. the most dramatic incident of abuse had re sulted in a burn. Galdston (1972) has po inted out that two thirds of ch ild re n are inside their homes when burned. the largest number in the kitchen. and the next in the livingroom, bathroom. and bedroom. in that order. The therapist's dollhouse therefore provided an opportunity and setting for Erica to play out her internalized conflict. The therapist was also able to elicit that in the hospital Erica continued to have terrifying nightmares. which had as their main feature "the sound of a stove in the night." Once this frightening disembodied sound was identified concretely. she excitedly wanted to tape up the "stove" in the dollhouse. This was accomplished with a Hourish of Scotch tape until the lid of the stove was taped sh ut and it was safe to put back into the dollhouse.
The taping exercise became the basis of an ongoing ritual. At the beginning of each new session. Erica would check to make sure the stove was still taped , and then would rigorously insist on taping it up again if it had become loo sened . This play activity seemed to provide several function s; it was a reparative act and also a means for her to gain mastery over the dangerous stove. The taping also provided a new theme of repair which was repeated in other session s with a small plastic bear which came to represent Erica. In one pla y sequence. Erica had the bear go to the hospital with a "burned butt." In the hospital room she surrounded the little bear with a collection of other dolls. When she was asked who they were, she replied, "They're the doctors." "What are they doing?" she was asked. "They're not doing nothing." This sequence seemed to replay her previous hospitalization when the doctors had to abandon their plans for skin grafting. Erica was able to provide some help herself by taping up the little bear's buttocks and also that of a father doll. This action was seen as repairing damage to the person to whom Erica had fantasized retaliation for her own burn. While this work was going on in play therapy. Erica's behavior on the ward was marked by none of the previous regressive symptoms she had demonstrated in the foster home. (This was similar to her previous hospitalization, except that weekends at home now
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were also marked by continued normal functioning.) Her main remaining behavioral problems on the ward were manipulative behavior, occasional temper tantrums when she could not get her own way, and minor difficulties with peers. The nightmares and "sound of a stove" resolved during the period of working through the trauma in therapy. Oppositional behavior was managed by the staff with firm limit setting and the careful use of seclusion. At the end of a month's hospitalization, we decided that further play therapy could be done on an outpatient basis. (There was a 3-week interruption in therapy, due to transportation problems, which coincided with a return of enuresis, but this also cleared up when therapy was reinstated.) In the ensuing weeks, Erica's need to gain mastery and to express the underlying rage over her abuse led her to use play materials which permitted displaced expression of her aggression. The use of play telephones nicely filled this function as it permitted a free expression of ideas, yet still was viewed as "play." (The telephone can also be seen as a very powerful instrument because in reality it gives the abused and neglected child a link with the outside world.) Ideas too could be safely stated over the telephone, with no danger of immediate physical harm (or things being "too hot"), and the option of hanging up if things were too threatening. The following demonstrates how Erica was able to use the play telephones in working out the past. Erica came in 30 minutes late because the volunteer transporting her had lost her way. She walked in a very ladylike and prim fashion and exasperatedly slumped into a bean-bag chair with her teddy bear, leaned over slightly, and sighed, "I'm tired. We drove all over today." T: Well, why don't you catch your breath first and then see what we can do today. We don't have too much time, but we do have about 15 minutes. E: Let's talk on the telephone. I'll call you up (ring ring). T: Hello, this is Dr. X speaking. Who is this? E: This is Erica's mother. T: Oh hello, is Erica there? E: No, she's in the hospital. T: Oh dear, what's happened? Why is she in the hospital? E: She's in the hospital because she got burned. T: Oh dear, that's terrible, where did she get burned? E: She got burned on her butt. T: She got burned on her butt! How did that happen? E: Her grandfather burned her.
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T : Oh m y gosh, wh y did he do that? E: I don't know . T : So how is she doing in the hospital? E: I don't know. I haven't see n her. T : Oh , yo u haven't been to the hospital yet? E: I have to go now, T : Okay, please let me know how Erica is doing, Bye now. E: Bye (pause) , Let's cha nge phones (hand s the therapist her phone and takes his). T : Who shall I be now? Can I be the . .. grandfather? E: Okay. T: Hello, this is grandfather (in a somewhat slurred voice). E : This is Erica's sister. T: Where is Erica? Put her on. E: I can't. She's in the hospital. T : Oh? Why is she there? E: You know, you burned her (in angry tone)! T : What do you mean, I burned her? Where did I burn her? E : You burned her on her butt! T : I did not. An yway, how do yo u know? You weren 't there. E: I do, too. I heard it. T : Oh (still den ying)? Well, if' yo u're so smart, what did I burn her with? E: You burned her with the fr ying pan. This is Erica's nurse, and you were bad. (This was the first disclosure of the details of the abuse episode .) T: You don't know what yo u're talking about. E: I do, too. T : Did I pull down her panties? E: No, yo u burned her through her dress. Wh y did yo u do that ? T: Well, ma ybe I did burn her on her butt . But I didn't mean to hurt her. But I got ang" y and lost my temper because she didn't mind. E: Erica's not bad. She minds. T: Well, mostly she's a good girl, but sometimes she doesn't listen and is stubborn and I just lost my temper. E : (no comment). T: Yes, she got me mad. E: This is Erica's mother and you burned her (still angry voice)! T : Well, I'm sorry, but sometimes Erica doesn't mind. Anyway, you take care of Erica. E: Okay.
In this sequence the use of the telephone allowed the child to play out confronting the abuser. She used the character of various
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authority figures, first the sister, then the nurse, and finally the mother, to do so. That she was still able to identify with her mother as a caring figure seemed a good prognostic sign. Not only did she establish her grandfather as the abuser, but she sought to find out why she was abused. The therapist provided a reason which might be understandable and therefore more acceptable-namely, the grandfather's anger. The therapist thereby offered a rationalization for the terrible act. The therapist also apologized for the grandf~lther and then transferred responsibility for further care of Erica back to her mother in this phone conversation. Two sessions later, Erica played out with the therapist a scene in which she returned home from a trip to the supermarket. She said she was going to cook a steak for the family and asked the doctor to set the table. After making sure the stove was taped up, she proceeded to cook the steak but said the stove was too hot. When the therapist pointed out that the stove had to be hot in order to cook the steak, Erica paused and then said she would take off the tape. The therapist reassured her they would be careful of the stove when they cooked the steak. After this session, the theme of "stoves" and people getting burns disappeared from Erica's play. In subsequent sessions, she made direct reference to her burn, usually followed by a matter-of-fact inspection of the progress of its healing. The burn, although divested of much of its former ernotional charge, still held much significance for her. (At one point when asked if she had started preschool yet, Erica replied, "No, I still have my burn.") Once Erica was desensitized to her burn, other themes emerged in her play. During this period the therapy was complicated by the necessity to place Erica in another foster home, because the present foster family was leaving the state, and Erica, due to court order, could not leave with them. The therapist anticipated that this move would be interpreted as another rejection and abandonment, so he played out a structured dollhouse session of a girl going to live with a new foster family. Although Erica played along in this session mainly as a spectator, it allowed her to express later that she thought her foster parents had left because they did not like her. The theme of a mother leaving and the child having to go to a new home naturally reawakened concerns about her real mother. Two sessions after she had released the stove from its taped-up, immobilized state, she used the telephones again to play out a dialogue concerning her mother "being shot to death by the cops." In the play, the mother was shot in the kitchen and taken by the police to the hospital. The little girl on the phone also expressed
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concern that the police would kill her father too if he returned home. This theme of "what's happened to Mom?" gradually became elaborated during the next 3 sessions, along with the theme of "Erica's new Mom" as the real-life situation of her change in homes was dealt with in therapy. Exploring these issues in the play sessions happily corresponded to a smooth transition in foster families with none of the anticipated regressive behavior. The story of "Mom's killed by the cops" is probably best understood as an expression of the issue of separation and attachment. Bowlby (1969, 1973) has written extensively on the importance and strength of this developmental force. Indeed, it might be the case that Erica's initial regressive sphincter problem was related to the loss of her mother at the point when the latter left for the home for unwed mothers. The added insult of a burn to her buttock only further sensitized the child to this zone. Once it became clear through the play that loss of the mother was an important ongoing concern for Erica, plans were considered for reuniting the two. Fortunately, during the time of Erica's treatment, her mother was involved in individual and group psychotherapy. Six months after Erica's treatment had started, her mother had remarried and her situation seemed stable enough to permit maternal visits. These went so well that 15 months after they had been separated, mother and daughter were reunited. So far, there has been no return of symptoms. Erica's rapid recovery points to a fairly well-developed basic ego structure. These strengths point to a strong motherdaughter bond and indicate that in regard to Erica the mother had been able to give her adequate early nurturance. Perhaps it was precisely this close bond which made separation so traumatic. DISCUSSION AND CONCLUSIONS
In this case, as in so many cases of child abuse, simple environmental manipulation was not sufficient to prevent the recurrence of regressive phenomena. It is this lack of early psychotherapeutic intervention which can lead to the crystallization of a chronically disturbed and arrested character structure. For example, many have commented on the frequency with which abusing parents were themselves abused during childhood, i.e., an identification with the aggressor and inability to perform in the parenting role because they had never experienced an adequate model. The importance of psychotherapeutic intervention must be stressed in dealing with the behavioral problems found in abused children. Yet few, if any, guidelines seem to exist.
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In working out a dynamic formulation to understand this patient's symptoms, we did not believe it was enough simply to relate disturbed bowel functions and difficult behavior to the trauma (both emotional and physical) of experiencing a severe burn on the buttock. What seemed likely is a complex interplay between separation, regression, and abuse. The importance of Erica's attachment to her mother and separation anxiety clearly emerged as this theme was elaborated in therapy. Sequentially, it is likely that regression followed separation, which in turn led to abuse. Further separation compounded the regression. It is also important to consider the child's cognitive level of development which limits his ability to integrate all of these experiences into continued healthy functioning. In Erica's case, integration took place only after her life experiences were re-created in play, and mastery and control gained through that play. Once the abusing situation was mastered and its issues were no longer "too hot to handle," the developmental issue of the child's attachment to and the anxiety caused by separation from mother could emerge and be dealt with in therapy. True mastery, one must keep in mind, is not only being able to live with one's past but also with one's present. With Erica, attention was paid to facilitating the playing out of the ongoing stresses of changing foster parents and the final reunion with her natural mother. The ability to "forgive" the abusing parent through a psychotherapeutic experience is a powerful factor in releasing the child from seeking constant repetition of the abusing experience in childhood, and from later reversing roles as a parent in a series of futile attempts to rid himself of its effects. In similar cases of child abuse, play therapy might be designed to help resolve the child's ambivalent feelings toward an abusing parent: on the one hand, the fear and negative image of the parent based on reality issues, and on the other, the power of a positive image and attachment which is a developmental force to be reckoned with and balanced with the former. Working through the attachment issue in therapy requires that the therapist acknowledge the reality of these ties. Careful assessment of the strength of these ties and the exact role they play in symptom production is necessary in deciding the best course of action, i.e., separating or reuniting parent and child. It is hoped that this report of successful work with one young child will stimulate further research work into the special psychotherapeutic needs and approaches for children of abuse and neglect, children who have been far too long neglected by child
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therapists. The decision for removal or non removal from the home and for involving the parents in rehabilitative work is an insufficient package in many cases. It is paradoxical that the dramatic national concern for protection of these children has not been accompanied by an appropriate psychotherapeutic program aimed at restoring healthy development for their future lives.
REFERENCES BERNSTEIN, N. R., SANGt:R, S., & FRAs. I. (I !Ui9), The Iumtions of the child psychiatrist in the managemelll of severelv burned children. This [ournal, H:620-6:~6. Brzzz«. E. D .• FRATIANNt:, R. B., KARNASIEWICZ, S. Q.. & PLANK, E. N. (1972). The roll' of the child care worker in the treatment of sevetelv burned children. Pediatrics, 50:617-624. BOWLBY. j. (1969, 1973), Attachment and Lo.IJ, Vol. I & II. New YOI"k: Basic Books. ELMt:R, E. (1967), Children ill Jeopardy. Pittsburgh: U niv. Pittsburgh Press. GALDSTON. R. (1972). The burning and healin!{ of children. Psvchiatr», :~5:5 7 -66. HELFER. R. E. & KBIPE, C. H. (196H). The Battered Child. Chica!{o: Univ. Chicago Press. MORSE. C. W. SAIIU:R. O . .J., & FRIEnMAN, S. B. (1970). A three-year follow-up study of abused and neglected children. Amer.], Dis. Child.• 120:4:~9-446.
