1. Introduction
Play is a habitual activity for children. Marzel [1], using the definition in the Le Robert dictionary, defines play as “a physical or mental activity whose essential purpose is the pleasure it gives”. The play has several dimensions, including that of education. By playing, children practise everyday actions that prepare them for adult life [1]. Moreover, through play, they can externalise their intrapsychic conflicts and free themselves from their inner tensions. Klein, Winnicott and Dolto developed theories on play to demonstrate its importance from a psychopathological point of view. As Bailly [2] points out, “M. Klein claimed to have established the technique of analysis through play and, by the same token, the technique of child analysis which consists of interpreting a child’s play as one would interpret a dream. She uses play as a therapeutic medium: a way of talking and associating freely. She sees it as a means of accessing the child’s internal, symbolic representations.” Thus, in the context of child psychiatry work, play has a dual function: it is as much a tool for assessing the child’s skills as it is a therapeutic medium.
In clinical examination, child psychiatrists regularly make playing equipment available for children, so that they can observe their motor, affective and cognitive skills. In this way, through projections, the play space, becomes a mean of communication, a stage that exposes the child’s intrapsychic problems and the conflicts to which he is confronted. In the child’s play experiences, there is an essential place for ‘pretend’ games or symbolic games. This type of play allows the child to mime everyday actions while assigning roles to invented objects and characters, out of context. For Marzel [1], playing with dolls, is the beginning of building one’s future as an adult. In that context, playing has, therefore, a dual function: it is both a tool for assessing the child’s skills and a therapeutic mediation. So, dolls’ game is a key element in the exploration of the female infantile psyche [3].
The play space becomes a potential and transitional space, as Winnicott taught. It is a space of possibility and of doing, a place of saying that enables the child to grow up and project himself into an adult future. For Marzel [1], the play has a particular characteristic as a child’s laboratory for future life. In the child’s experiences during play, there is an essential place for ‘pretend’ games or symbolic games. This type of play allows the child to mimic everyday actions while assigning roles to invented objects and characters, out of context. For this author, playing pretend, playing with dolls, is the beginning of building one’s future as an adult. From this stems, the importance and place of play in psychological care for children.
The medico-psychological follow-up of a sibling of anorexic girls and the play scenes opened up the possibility of analysing the impact of this play activity in the care of one of the girls.
In this way, the play of this girl, who had been monitored for anorexia for a year at the Child Guidance Centre of the National Institut of Public Health of Cote d’Ivoire, made it possible to expose, beyond the eating disorder, the disturbance in the attachment bond and the parental imagos in distress.
The clinical history of M. (3 years old) provides us with a framework for thinking about the contribution of play to care, and a psychodynamic reading of a play sequence sheds new light on this child’s problems. Faced with an ailing motherhood, masculinised girls and anorexia, what contribution can playing with dolls make to the psychodynamic work required for therapeutic care?
We hypothesised that playing with dolls, in the presence of the therapist and the mother, is a way of highlighting the relational distortions in the mother-daughter relationship, and that it could open up, for the child, the field of a possible future outside anorexia.
2. Clinical Case
The mother (aged 35) was also anorexic with a history of depression and suicide attempts. She had been treated for 5 years by a private psychiatrist when she was an adolescent. M’s pregnancy was marked by maternal mental health problems, with a persistent pattern of anxiety and angry feelings linked to early anorexia in the 1st child.
Marked by the anorexia of her first daughter (aged 5), the mother provided little maternal care for her second daughter to make her autonomous as quickly as possible, under the illusion that this would keep the specter of anorexia at bay. During the interviews, the mother acknowledged her lack of availability and the emotional deficiencies from which M. could have suffered, as she left her in the hands of the nannies to focus on her elder daughter or her work.
Despite the eating disorders, psychomotor development took place within the expected timeframe, and cognitive and academic skills were developing correctly.
Emotionally, M. had fits of anger that alternated with moments of tenderness. She has gone from being very aggressive towards her older sister to strongly identifying with her. In terms of socialization, she enjoyed dangerous games and had difficulty accepting what is forbidden. She played with other children and can be aggressive.
Physically, she was a skinny child with a shaved head and no earrings, with a masculine physique that gave her a masculine look. Her mood was sad and her play was generally appropriate for her age.
The maternal discourse set the framework and context for the problems that punctuated the lives of this mother and her daughters, as well as the parental couple. Psychodynamic analysis of the mother’s discourse revealed emotional immaturity with dependence and regressive attitudes. The mother had mental health problems, with anorexia that had been developing since she was an adolescent: “My husband, the father of our children, supports me; he encourages me to eat to set an example for the children. Sometimes he has to force me to eat. He spoon-feeds me in the marital bed, otherwise I find it hard to eat. I can’t eat with and in front of the children.”
Even though this mother was aware of her own problems, she was not seeking care. Her request was focused on her children.
3. Playing Means Talking to Repair
M has been under child psychiatric care for 7 months. At the beginning of the treatment, she was defensive and not very participative during the activities on offer. The improvement in eating behaviours that had been observed over time enabled the child’s ability to play to develop. In the presence of the child psychiatrist and the specialised educator, a play sequence was organised, during which the mother was invited to play with dolls with her daughter.
The game lasted about 30 minutes.
M. selected three dolls from the toys box and named them in turn: Mama R (doll 1), M (herself, doll 2) and L’heureux (“The Lucky”, doll 3 holding a feeding bottle) (Figure 1). The theme of her game is: “Making the dolls take a bath.”
Figure 1. The dolls chosen by M.
During the game, M asked her mum to give her a loincloth, then invited her to be the one to heat the water for her dolls’ baths.
M had set up all the accessories needed for a bath: a basin, a sponge, warm water, soap (here she used a banana) and a towel. Using the loincloth (it’s a pullover given to her by her mother), M put the “Mummy R” doll on the back.
She started the series of baths with the ‘M’ doll. She undressed “M”, put her in the basin, washed her and after drying her off, put her on the mat on a towel a few metres away from her.
Then it was Mama R’s turn to bath. She gently lowered her from her back, undressed her and then gave her her bath. At the end, it was the same process.
She ended the series of baths with ‘The Lucky’ and the same ritual. Note that M. did not dress any of the dolls again and she don’t take care of The Lucky, same as if he had the bottle, it’s enough for him. She turned away from them and was no longer interested.
Her mother’s congratulations on her play did not elicit any particular reaction.
Observation of this play sequence showed that, in addition to the eating disorder, there were other psychopathological issues that needed to be taken into account in order to continue to provide quality care for this child.
The interview at the end of the session allowed the mother and child to verbalise their emotions and the experience of the session. For the mother, it was an opportunity to become aware of the impact of her personal problems on her daughter’s psyche. For the daughter, the play time was a moment of intimacy with her mother, who took time for her. A bond seemed to develop during the session. Subsequent consultations showed a gradual improvement in the mother-daughter relationship.
4. Comments
This sequence of playing with dolls was an opportunity for the care team to investigate a little further the problems of a child who had been monitored for anorexia for several months at the Centre de Guidance Infantile.
Quoting Winnicott, Bailly [2] states that play is not only a reflection of the child’s internal representations but also bears witness to the impact of the environment on the child’s development. Similarly, Soulé [4] recalls Dolto’s work on doll play as a means of establishing contact with the young child. For him, playing with dolls is fundamental to the child’s psychological development, and is more than just a play activity; it is a game that involves the child and the whole family. For Brougère [3], “play involves a dialogue between the child and the doll. The child talks to the doll (scolds it, consoles it), more rarely makes it talk... The baby doll is seen above all as a being that needs to be cared for, hence the importance of imitation and stereotyped, repetitive situations. If the child projects itself into a role, it is that of the mother as modelled by her... Play develops in all areas of care: washing, dressing, changing, putting to bed, feeding, taking for a walk, but also in complementary activities that are essential to the previous ones: ironing clothes, preparing meals, shopping.”
In this way, play symbolises what is going on in the child’s reality, and the intrapsychic issues, for the duration of the play sequence, unfold on a visible stage... This is how we were able to see that playing with M’s doll revealed various problems, from her struggle with anorexia to her fight to be a child in her own right, existing and alive in her mother’s eyes. As a child who was emotionally abandoned and neglected by her mother from birth, M. seems to have fully understood the meaning and importance of food for her mother, and she shows this in her play. After bathing and feeding the baby dolls, she turns away, leaving them naked and unprotected. In anorexia, Vignalou and Guedeney [5] have described a model of mother-child relationships in which the mother’s relationship with her child is distant, cold and emotionally controlled. M solicits her mother’s gaze and care, but gets little. M’s handling of the dolls illustrates her demand for care and attention: body care, carrying, feeding (milk/food-food and milk/food-affect). This is what Bailly [2] points out when he writes that play appears both as a staging of the child’s psychic tensions and as a therapeutic means, within the framework of transference.
In addition, M. intuitively perceives her mother’s emotional needs, but she expresses an emotional quest for her mother and a need for interaction. M.’s requests are blocked because her mother has difficulty engaging in interaction. As Vignalou and Guedeney [5] point out, anorexic mothers are more emotionally disengaged and do not make positive assessments of either the taste of the food or the experience of eating, making it difficult for them to experience pleasure in interactions with their children. By playing make-believe, by pretending to be the mother of a trio of baby dolls, M dramatised her relationship difficulties and the pitfalls of her motherhood. After this session, the improvement in the mother-daughter relationship testifies to the therapeutic effect of play. Winnicott emphasised that play is not only a therapeutic means, with therapeutic virtues in itself, but also a content and a container. For him, “when the child plays, he enters an intermediate zone, where reality no longer intervenes as a constraint but is remodelled according to his internal needs, just as the infant, because of his immaturity, needed this illusion of “omnipotence.” The child can distinguish reality from its own desires, but play is a means of existing as a “self”, despite the constraints of reality to which it must adapt.” [2] [4]
We could say that for the child, play is existence. Children’s play is built on the reality around them and on the activities of adults [6]. By playing as being a mother, M. is acting out her mother’s maternity and parenthood.
Many authors have defined parenthood as all the psychological and emotional changes that enable adults to become parents. This maturative process enables them to meet their children’s needs (nurturing and physical care, emotional life and psychic life) [7]. In addition, the mother-child relationship bears witness to the bond forged between child and mother from the moment of conception. During the first few years of life, the child develops a special relationship with its mother. This relationship is the foundation on which the child’s personality is built. Food is the main vehicle for building this bond. The personal history of R., M.’s mother, has been marked by eating disorders since childhood, break-ups, a lack of bonding, abandonment, failure to resolve conflicts and depression. In the ante- and post-natal period, feeding and mothering one’s child is a maternal prerogative that enables women to build their maternal identity. It also contributes to the development of attachment figures. Attachment is an emotional bond between an individual and an attachment figure (usually a carer). When the bond is not created and life situations or disorders coexist, the attachment becomes insecure, anxious or disorganised.
George and Solomon [8] have shown that playing with dolls is a good way of investigating attachment in children. In their view, attachment theory postulates that models of internal representations of attachment are derived from actual experience with attachment figures. In addition, they demonstrated that playing with dolls ‘provides empirical validation of the clinical idea that such play is indeed a window on the child’s inner world and that it is indeed related to the observed quality of models of interaction with attachment figures. Secondly, it demonstrates that the quality of children’s attachment to their mothers provides the framework for the organization of this play. Psychodynamic analysis shows that this process is in difficulty with M’s mother.
The young child then takes care of his doll as if it were a real baby, responding to his needs, feeding him, changing his nappy, dressing him, putting him to bed to make him sleep, and so on [7]. In this way, unconsciously, children act out what they experience on a daily basis. Playing with dolls is a symbolic way of reproducing scenes of parenthood, allowing children to identify with the adult role of parent and re-enact family and emotional scenes. By playing with dolls, children reproduce and invest in the parental role [6] [9].
Playing with dolls has a number of virtues and meets children’s needs. It has a cathartic function: putting the baby on stage allows the child to re-enact his or her own experience and thus to evacuate any concerns. Adults can use this game to detect difficulties in the child. Dolls also encourage children to imitate everyday life, making it easier for them to understand. It also encourages language, imagination and creativity.
M.’s play with the doll highlights these issues: she shows that her mother needs to be carried and emotionally nourished at the same time: nourished by food-affect and food-food (milk) and to receive bodily care. In this way, M. expresses her desire to carry her mother. M’s play reveals a loss of identifications, a reshuffling of positions and a structuring of parenthood, exposing the pitfalls of the maternal. M’s need for security and support is not met, and we witness a role reversal. Vignalou and Guedeney [5] describe this reversal of roles: the child is “parentified”, she looks after her mother and her needs as a child are not taken into account.
This doll game shows how the suffering of a mother can impact the future of her children. However, play is also a therapeutic mediation and liquidator of the child’s mental suffering. The play of the doll has a cathartic function [6] [10]. Play with the doll allows the child not to directly express his active desires but to make a detour (making them tolerable). The doll is the outlet for this conflict [11]. Play is a “journey” or “spawning” for the drive [12].
As noted, many children use the symbolic game to understand and express their emotions. The use of the doll for therapeutic purposes allows the child to become a child again, during the session, and second, the symbolic play with dolls exposes the child to his fears of eating and becoming fat and has provided a forum for him to express the feelings associated with it [6] [9] [13].
5. Conclusions
Each person has a story, a unique feeding path that is born from the early and close relationship between the nurturing mother and her child.
This clinical vignette based on the analysis of a play sequence with dolls offered on the one hand, the possibility for a child to externalize his psychic problems centered on disturbances of the bond with the mother and, on the other hand, to show the place of a playful mediation as the doll to initiate a particular psychic work.
If anorexia was the primary reason for management, the favorable clinical evolution of this disorder allowed other issues to be addressed. The results of the support provided for the mother-child couple allow us to highlight the importance of doll play, as highlighted in the scientific literature. However, the place of the doll in the game of the African child has been little studied so this first work, in an Ivorian context, on this subject opens up research tracks on the place of the doll in the game of the African child. Lusardy [9] and De la Noë [14] have hypothesized that the symbolism of the doll in the game would not be the same for African girls. For these authors, the doll is not a practical tool for African girls to learn in adult life because they are very early on socially educated to take care of the little ones with whom they experience parenting.
Implementing care focused on therapeutic mediation with a doll for children with attachment disorders or anorexia should open up new possibilities to improve the mental health of children in Cote d’Ivoire.