Karen brought Sophie to her first appointment. Sophie was a very cute girl with long brown hair which she kept twirling around her fingers. I asked her if she knew why she was here. She sighed a bit before she answered. "I suppose most kids that are eleven don't know why they have to go to therapy," (as she said the word therapy she stretched out the word, so it sounded like 'theeeeeeeerapy') "but I have been to soooooooo many other therapists that I could actually be a therapist. I went to play therapy, talk therapy, star therapy, chiropractor therapy and every kind of therapy." She stopped suddenly here and looked out the window. She said, "Look at that bird." Then she continued, "And I am here because my mom said if I didn't come, that I couldn't watch any TV for the rest of the year. Look-there's another bird! What was I talking about? Oh yeah, that's why I am here!" At the end of this recitation, she smiled at me, but the smile had a certain edginess to it. Her pattern of changing the subject mid-sentence was to continue throughout the session.
 
 

When I started to ask her what had worked and what hadn't worked with the therapy she had in the past, she fidgeted, then jumped up and went to the sandtray collection. When I went to join her by the collection, she said, "Wow! You have a lot of stuff. I have this same cat." She picked up a tall wooden cat with bright blue eyes. "Well, actually," she continued, "I don't have my cat anymore. I got mad one day and broke mine. My mom," here Sophie stopped to glare at Karen, "my mom said that I couldn't do something. I even forget what it was. And so I stomped on ALL my things that I had on my bureau. And I broke them all. Can I please have yours?" At this, Sophie smiled at me.
 
 

At this point, I felt like I was reeling. Sophie had been literally and figuratively jumping all over the place. I felt it was important to gain control of the session, but not in a heavy-handed way. I knew if the therapy was to work, that we would have to work together. I needed to meet her energetically, establish rapport, and set some boundaries.
 
 

I asked her about her cat. She said it was a present from her "real Dad's" mother, a grandmother she had never remembered meeting. In fact, Karen said that Daniel's mom had come for a visit once when Sophie was nine months old and had given her the wooden cat as well as other toys that were not safe for infants. The cat was the only toy that had survived Sophie's toddlerhood until its recent demise during a tantrum.
 
 

I felt like I was in a minefield. Here, only a few minutes into the session, Sophie has brought up all the therapists that had failed her, her missing grandmother (and, by association, her missing father), and something that was broken that couldn't be fixed.
 
 

I imagined that it was Sophie herself who felt so broken, who couldn't be fixed.
 
 

I was sensing how the ADHD diagnosis had been made, with Sophie barely sitting still. Yet, her underlying hopelessness and depression were also palpable. I was remembering the red flag warnings of grandiosity, suicidal gesture, irritability, decreased attention span, and racing thoughts. Sophie had all the bases covered!
 
 

I began to show her toys that had been broken which had been fixed. It was fortunate that the cat she was holding had, in fact, suffered a broken tail, which I had been able to fix it. I showed her the blue porcelain horses, many of whom over the years had either their legs or tails broken off and repaired. Together we looked at toys which had been fixed. I also showed her my 'toy hospital' where broken toys await repair. Finally, I turned to her, creating full eye contact, and said, "It's lucky isn't it...that sometimes things that you think are really broken can actually be fixed." She looked back into my eyes, nodded. Then said, "Mom, you can go now. I have some things to do here." Without looking at her mom as Karen left to go into the waiting room, Sophie began making a sandtray.
 
 

She quickly pushed the sand around, spilling some on the floor. "Whoops!" she said, "Whoops, Whoops, Whoops!" As I was to learn, sometimes she slipped into a vocal tic when she was stressed. This is what led to an earlier diagnosis of Tourette's Syndrome.
 
 

Sophie continued with her sandtray, adding many horses that were "running wild" she said. There were toys used that were typical of eleven year old girls: princesses, a castle, even a unicorn. She then placed a tiny girl in an indented area of sand, literally in a depression. The girl was in alignment with the wild horses. She could be run over. It seemed that she was symbolically expressing what had led to her suicide attempt. She was depressed and did not see a way out of being run over by a manic state.
 
 

Right at the end (after numerous warnings that our time was running out), she placed a carousel in the sandtray. It was askew and seemed like an afterthought. We had very little time to discuss what she had created. Her final comments were, "Do you know the song from the sixties? My mom used to play it. It says 'The painted ponies go up and down.' I know what that feels like."

Sophie was referring to the song "The Circle Game" which was sung by Joni Mitchell. With the wonders of cyberspace, you may click here The Circle Game to hear the song. (Be patient, as it may take a few minutes to load.) The lyrics that Sophie was singing are:

And the seasons, they go 'round and 'round,

And the painted ponies go up and down.

We're captive on the carousel of time.

We can't return, we can only look behind

From where we came,

And go 'round and 'round and 'round in the circle game.

Copyright 1966 Crazy Crow Music Ladies of the Canyon

Sophie did indeed know about the painted ponies going up and down. She aptly described the torment of having a bipolar diagnosis. Her moods would go up and down without rhyme or reason.
 

Please go to the website of Demitri Papalos, MD and Janice Papalos, authors of The Bipolar Child: the Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder. They have an extensive on-line questionnaire at http://www.bipolarchild.com/survey/bcq.html which they have graciously given me permission to use. They also have requested feedback on it. This is extremely helpful in the differential diagnosis of children and adolescents with bipolar disorder.
 

My job at the moment was to empathize with Sophie, assess her for suicide, and make contact with her psychiatrist. It would take a few more sessions to fully develop a treatment plan, but I knew at the outset that we would need to:
 

• confirm or rule out the diagnosis of bipolar disorder
• consult with her psychiatrist regarding her medication needs
• increase internal resources with regard to self-soothing behavior
• help empower her to accept more responsibility for her behavior
• contact the school to see how Sophie was doing and work with the teachers to address Sophie's needs.
• provide psychosocial support for issues with peers
• address family dynamics, working to give Karen and Ron support
• perhaps contact Daniel, Sophie's father, to assess if there is a genetic component to Sophie's behavior
• help Sophie understand bipolar illness, how it impacts her, and plant the seeds that she has a condition which will most likely necessitate her staying on medication for the rest of her life.

 

Questions have arisen as to the appropriateness of play therapy with children who have a diagnosis of bipolar disorder. Play therapy with a young child suspected of having a bipolar disorder is generally an appropriate intervention, as play is the first language of children. Often, through play, healing symbols, metaphors and stories will emerge that help a child master some of the difficulties of having BPD.  Play often helps the child learn how to be in the 'real' world, with fantasy play and metaphor setting the stage for learning new social skills, ways of communicating, etc.

In subsequent sessions, Sophie repeatedly played with a small 'Kelly' doll, who had no friends. In Sophie's play, the doll would turn into a werewolf every full moon, eating raw chickens and scaring all the other kids. In the initial play, the little doll had to locked up in a tower room to keep everyone safe from her. (Was this perhaps a comment on the numerous time-outs, with the door being locked, that Sophie had experienced?)

When Sophie was entering a manic phase, the quality of her play changed dramatically. The story line became very illogical, and Sophie's voice would get  so loud it would hurt my ears in the session. When the content of play becomes grandiose, and the child becomes hyperactive, and his or her voice gets louder and louder, it may indicate the approach of a manic episode.

When I tried to introduce a character in the play who was manic, it fell flat! It seemed that the metaphor works much better if it originates with the child. (Or adults; many of these techniques, such as sandplay, storytelling, play therapy can be equally effective with adults. For more on adult play therapy, please read the Introduction: The Healing Potential of Adults at Play (Dottie Ward-Wimmer).)from Play Therapy with Adults by Charles E. Schaefer (Editor)

Sometimes, when a child or adult is entering a manic phase, I move away from symbolic play, or limit the use of play materials in the session. Play therapy techniques that access unconscious content can be dangerous to a child, adolescent or adult in a manic phase, as the ego is already overwhelmed.

In time, Sophie's play began to shift. An old woman came to the little werewolf doll and mixed her some magic potions and herbs that helped her not become a werewolf every full moon. The doll, interesting enough, stayed a werewolf for life (much as an alcoholic says that he or she remains 'in recovery', rather  than being 'recovered') as long as she took the  magic potion given by the old woman (who might have been me!).

As Sophie's play progressed, the little werewolf doll stopped focusing on the transformation to werewolf as Sophie's bipolar disorder was better controlled with medication, and Sophie no longer feared being taken over by a wild part of her psyche. Sophie's play switched as her meds kicked in, and she began to trust that her hypomanic, manic and depressive episodes would be under better control. The play then dealt with social issues at school, with the little doll searching for a 'best friend'.

Play therapy and sandplay can be used to find out the child's emotional state and then use it constructively to guide the session. Starting from Sophie's werewolf metaphor, and staying in the metaphor, we played out ways in which the little doll could tell the other dolls what was wrong with her, and how come she was different. At first the doll was very reluctant to share her condition, but, over time, paralleling the psychoeducation that Sophie  and her family were getting, the play shifted, with the doll able to tell the other dolls about being a werewolf. Play seemed to assist Sophie in releasing her fear, frustration, and anger, while playing in the session modeling appropriate social relationships  to Sophie on two levels; one was in the content of the play itself, and one was in how we learned to play together.

Chapter 2

 

 

Painted Ponies

 

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