In this post Dave reflects on a case from his early career in child psychiatry, where he recounts his play therapy experience with a seven-year old autistic girl. He still winces when he remembers his therapeutic mistake, but remains grateful for his relationship with this young, silent girl, and what she taught him.
Dave: Somewhere along the line, probably premedical, I came to believe there was something magical, vital and influential in relationships. Looking back and framing it with what I know now, it was my awareness of an experiential place where we are peers. The place is the realm of imagination or subjective experience. I am the center of this universe and you are in orbit around me. But I am aware you are the center of a universe with me orbiting around you. However having such experiences requires a mindset about being in the world.
There is a spirit in me that does not age. The spirit exists outside of time. That something is the non-adaptive core of integrity. I know how to follow rules, I know how to be in a hierarchy, but I also know about this realm of subjective awareness outside of hierarchy
I came to believe that the something (spirit) in me makes contact with the something (spirit) in you, has contact through awareness. I invented a name for the relationship between spirits. I call this abstract energetic core of therapeutic relationships “therapeusis”. As an example I am going to review a clinical experience from early in my Psychiatric career, a moment of contact between an autistic girl and me. Ultimately the case was a failure, but I will use it as an illustration. The curious ironic fact is I have learned the most from failures.
Many years ago when I was a Child Psychiatrist-in-training one of my assignments was six-month rotation at a Behavioral Disability Center 1½ days a week; all day Tuesday and Thursday mornings. My assignment was to participate in the care of several autistic children. One of them was Tracy, a seven-year-old autistic girl. She had no speech, avoided eye contact as well as physical contact. I did play therapy with her two mornings a week. She would walk with me to the play room. She never interacted with me. I liked working with her, and though from the outside it would appear nothing of value, nothing purposeful was happening, I sensed a relationship emerging grounded in empathy and attention. This is the ineffable something I call ‘therapeusis’. She did not play ‘with’ me. She played on one side of the room with blocks and two small dolls. I played near her with my own blocks and dolls, imitating her play. I spoke to her but in a non-manipulative, reflective way. I described what she and I were doing. No questions. No interpretations. The sessions lasted 30-40 minutes.
Along one wall of the playroom there was a three door cabinet 30” high and 30” deep forming a room wide counter under a one-way vision mirror. To my knowledge no one observed the sessions, but anyone could. One morning, fifteen minutes into a session, Tracy interrupted her play with blocks, went over and opened a cabinet door. She bent down, looked inside, then stood and closed the door. She did that about three times, in silence. I commented on what she was doing without being intrusive or interpreting. “Tracy opened the door.” “Tracy closed the door”, etc. Then she went and got a doll. She opened the door put the doll inside then closed the door. She never looked directly at me. She paused a few moments, then opened the door looked inside then closed the door. She repeated this three-four times and removed the doll. Time was up, the session ended.
The next session she started with her customary play routine, then with ten minutes left in the session, went back to the cabinets. This time she crawled inside with the doll and closed the door. All was a quiet for 2-3 minutes, then the door opened and Tracy came out with the doll. She was intrigued by being in there with the doll, repeating that scenario a few more times. I was intrigued to know what she was learning from her research. Then it was time to end. I followed her back to the classroom.
When we returned to the play room for our regular session she played with the blocks and the small doll. After 15 minutes she went to the cabinet again, opened the door, put in her head examining the interior. I was seated on a small chair about 8 feet away. She came and took my hand. She had never touched me before. I felt a sense of deep appreciation. She led me to the cabinet, pulled me down, pushed me inside and maneuvered me onto my back. She closed the door. I was astonished by this. Then she opened the door, looked me over, put her head in for a more thorough examination, backed out and closed the door. She left me there for a short while, then repeated the process. After one more trial, she opened the door, crawled in, lay prone on top of me, and pulled the door closed. We lay there in the dark, silently. The top of her head reached my chin. Neither of us moved.
I was deeply touched by this very unusual experience, touched by her trust in me, her comfort with me. However, I was also mildly anxious, I feared someone might be behind the mirror. What would they think? But by that point in my medical life I had been in many critical situations and I knew how to turn off the anxiety and pay attention. I was relaxed motionless. Silent.
You might ask appropriately, what was I worried about? I was worried I might be unknowingly observed and assessed by some of the psychologists. They were steeped in purposeful behavioral therapy methods and always seemed implicitly judgmental and dismissive of my therapeutic ideas. I felt I was experiencing a small therapeutic miracle.
At this point, around ten in the morning, Tracy pooted. It was silent, thus not a fart, but one of those particularly fragrant pre-bowel movement poots. The fetid odor filled the closed space. A comedic version of me took over, and I did something I look back on as stupid. “Oh Tracy! That was a smelly one!” and as I said it my comic self pushed open the door and rolled her out. “Oh boy! Ooooowheeeepeeeyew!” I rolled out after her. She immediately retreated to her play space on the other side of the room, with the blocks and the dolls, her back to me. Although my rotation there, thus the play therapy went on for another month, she never interacted with me again. It was as though I had double-crossed her and could no longer be trusted. I felt absolutely stupid and chagrined. I do to this day.
I believe I had formed an abstract energetic therapeutic relationship outside of language with her, the curtain around her autistic self had parted. Something in me hoped this relationship would make for some small change. Mine was a non-manipulative form of caring. It was not based on hunger, not based on my need.
I have had variations of this experience in many clinical settings. The ideas that guide me is my strategy in working with any deeply disrupted person. “Don’t just do something. Stand there!” or better “Don’t just do something. Be there!”
I continued with the play therapy, but it remained parallel. There was some evidence of small changes in her classroom behavior. I have no longer term follow up. There was only that moment. It was a therapeutic experience for me. I have had similar moments with others. There is no physical contact. But there is a deep emotional contact, presence to presence. I have awareness of it, attend to it always. It is an experience that both transcends and includes language, transcends physical contact. Some describe it as “presence”.