The importance of inner transformation in the activity process

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Occupational Therapy International, 2, 36-47, 1995 © Whun Publishers Ltd 
The importance of inner 
transformation in the activity 
process 
JULIE CUNNINGHAM PIERGROSSI AND CAROLINA GIBERTONI 
Il Vivaio, Centra di psicologia dell'età evolutiva, Milan, Italy 
ABSTRACT The importance of the inner world of t/ie patients in occupational 
therapy has not been studied in recent occupational therapy literature. The activity 
process in this paper is seen as a complex mixture of internal and external transfor­
mations which occur as part of the panent's rehtionship with the therapist. Pertinent 
psychoanalytic theories are reviewed and their usefulness to occupational therapy is 
described. Specific sequences of therapy sessions in two case examples are presented 
to illustrate the dynamics of the rehtionship of patient, therapist and activity, and to 
start to identify inner transformations during activity participation. The authors con-
sider basic research on the meaning of activity as a fundamental part of the profes­
sion. 
Key words: activity, relationship, transformation, psychoanalysis, inner world. 
INTRODUCTION 
Activity is the basic component of the occupational therapy experience. 
What exactly happens in the patient and in the therapist during activity par­
ticipation is a question that the authors of this article have pondered for many 
years. They will describe their observations about the inner significance of 
action (doing) in their patients and in themselves, which they link to a 
process of inner transformation that evolves together with the external action 
(doing) of activities. 
In this process, as patients choose, for example, to hammer a nail or play 
the flute or mix flour and egg, they start to tell the story of themselves and to 
construct the story of their therapy experience. As they transform (or fail to 
transform) the wood into a box, the sounds into harmony, and the flour and 
egg into pasta, inside themselves many things can be happening. The smell of 
Importance of inner transformation in doing 
the egg may be stirring old memories, the squeak of the flute may cause feel­
ings of inadequacy, the noise of the hammer may frighten. These clinical frag­
ments, which contain both doing and feeling, become part of the relationship 
with occupational therapists who in their way of being and doing with the 
patient will allow and favour the start of a process of transformation. 
The present article examines the emotional, inner significance of activity 
through careful study of the relationship of patient, therapist and activity in 
actual case descriptions. 
The area of inner functioning has been neglected in recent occupational 
therapy research as explained by Susan Fine ( 1993, p. 2): 
Therapists appear to give less credibility to, or invest less effort in, the inner life of the 
patient. We most often focus on the product (what a person can do) and the process 
(how he or she does it and what his or her level of competency is). 
In the 1950s and 1960s, on the contrary, many authors wrote about occu­
pational therapy with a psychodynamic orientation and therefore had an 
interest in the inner, subconscious life of their patients (Azima & Azima, 
1959; West, 1959; Fidler & Fidler, 1963). In their book entitled Occupational 
Therapy, A Communication Process in Psychiatry the Fidlers describe one of the 
main functions of activity as being the communication of inner dynamics in 
the patients. In those years an important contribution was made regarding the 
specific characteristics of the activities themselves as well the role of the ther­
apist, and an area of research was initiated which then remained largely dor­
mant in the occupational therapy literature where other interests have 
prevailed. In the intervening 30 years many changes in society and in pro­
gramme funding have influenced a decisive move towards a functional 
approach to activities which tends to require less time and is more concretely 
definable. The more recent literature rarely refers to the inner lives of the 
patients as if function and inner world were two unconnected concepts. One 
exception seems to be in the evaluation process with psychiatric patients 
where psychodynamic aspects are still taken into consideration and are linked 
with performance (Hemphill, 1982). 
Many authors have been concerned with the importance of the therapeu­
tic relationship, which touches on the inner, emotional world particularly in 
connection with the therapist's use of self (Mosey, 1986; Nahmias & 
Froehlich, 1993), with the link between cognition and affect (Dickerson, 
1992) and with the concept of caring (Baum, 1980; Gilfoyle, 1980; King, 
1980; Yerxa, 1980; Peloquin, 1990). These authors, however, tend to describe 
the relationship without necessarily putting it together with the activity 
process. 
In the authors' treatment model as presented in this paper, activities are 
seen as vehicles for emotional movement. The emotional movement enriches 
the functional dimension and the two are seen as moving together in an 
intrapsychic as well as an interpersonal process (Gibertoni, 1993). 
Cunningham Piergrossi and Gibertoni 
The authors describe an area of research which was developed in Italy 
where the cultural and professional influences, together with their own partic­
ular interests in this area, have provided the arena and the possibility of inves­
tigating this specific aspect of occupational therapy (Piergrossi & Gibertoni, 
1982, 1986). A growing interest also seems to exist in this direction on an 
international level where a Psychodynamic Occupational Therapy Newsletter 
(edited by the Derby School of Occupational Therapy, Derby, England) was 
recently founded. Therapists in Montréal have also recently published a paper 
linking psychoanalysis and occupational therapy (Saint-Jean &. Desrosiers, 
1993). 
PSYCHOANALYTIC THEORIES 
The rich psychoanalytic literature seems to be little known to most occupa­
tional therapists who often seem sceptical and critical about a field that has 
much to offer in understanding the inner significance of doing. The concepts 
of inner self, therapeutic relationship and emotional movement as presented 
here are part of a psychoanalytic theory base the amplitude of which does not 
permit a thorough study in this paper. The present review will be limited to 
presenting parts of a few psychoanalytic theories which seem particularly rele­
vant. The only link between these theories at the present time is their com­
mon contribution to understanding the doing process. 
An important general trend in the field of psychoanalysis, which has influ­
enced the kind of clinical work carried out by the authors, is that of the rela­
tional model extensively described by Greenberg and Mitchell (1983) and by 
Mitchell ( 1988). The relational model views the individual as having a funda-
, mental need and desire for human relationships. As far as therapeutic inter­
vention is concerned this model differs from the drive structure model in that 
it views the quality of the analytic relationship as fundamentally therapeutic, 
whereas in the drive model the therapeutic action lies in enhancing the power 
of the patient's ego by increasing its knowledge of the unconscious drives. In 
the relational model, through interaction with the patient, the therapist 
enters a previously closed world of faulty, crippling ways of relating and opens 
the patient to new relational possibilities. 
As far as activities are concerned, psychoanalysts have not specifically 
studied the doing process because it has no place in their clinical work. 
Although most child psychotherapists use play and toys as part of their thera­
peutic tools for facilitating the production of symbolic content, in their theo­
retical orientation the real aspects of doing are notpart of the therapeutic 
action. The objects serve as a means of communication in patients whose lan­
guage skills are not fully developed and are not studied as therapeutic in their 
own right (Tustin, 1981). 
Harold Searles (1960), with his book The Nonhuman Environment, intro­
duced a new way of viewing non-human objects and surroundings. In so doing 
Importance of inner transformation in doing 
he explored an aspect of the individuation process which had never before 
been examined by psychoanalysts. For occupational therapists who deal with 
materials that are part of the non-human environment, his book opened a fas­
cinating field of enquiry. Searles, however, although thoroughly describing the 
influence of the non-human environment both on normal development and 
in pathological states, never described the use of the non-human environ­
ment in specific therapy. 
Donald Winnicott (1971) was an English psychoanalyst who studied the 
role of the transitional object in child development. His theories are pertinent 
to occupational therapy because he puts together the relationship between 
mother and baby with an inanimate object, much as occupational therapists 
put together the relationship of therapist, patient and activity. According to 
Winnicott, play begins with the transitional object. It enters into the baby's 
life when he or she is starting to distinguish mother as a separate entity. At 
birth the babies believe themselves omnipotent - they are hungry and find 
their mothers' breasts ready to feed them as if they themselves had invented 
the breast. At this stage the baby and mother are one and the same entity. To 
start to separate and individuate they discover their own particular use of the 
transitional object - it might be a piece of cloth, a stuffed animal, the corner 
of a blanket. The baby sucks it, rubs it, touches it to the face, etc. The object 
represents the mother but is not really a symbol. It is both me and not-me for 
the baby and maintains the illusion of omnipotence. It is part of the real 
world but it is also part of the inner world of the child; it paradoxically per­
mits distance from the mother and at the same time is a tie to the mother. 
Winnicott calls this space between mother and child, between real and un­
real, the intermediate area, a space that allows and favours play, that connects 
the real world with the world of fantasy, the outer world with the inner world. 
The creativeness that exists in the intermediate area is an expression of the 
self. The use of this intermediate area, initiated with the transitional object, 
continues for all of life and in the adult finds its expression in the artistic, 
spiritual or cultural experience. 
The theories of Wilfred Bion (1962), another English psychoanalyst, have 
been particularly useful for understanding the link of sensory input, emotions 
and thought, all of which are potent components of the occupational therapy 
experience. Bion gave much importance in his writings to very early sensory 
experiences in the baby's relationship with his mother. He speaks of an alpha 
function in every individual which converts raw sensory data into memory 
traces, permitting them to become part of both conscious and unconscious 
thought patterns and therefore able to be used by the individual. Without the 
alpha function sensory impressions remain 'beta elements' - raw, immediately 
evacuated and not transformed into inner richness. 
At the start of life the mother constitutes the alpha function for her child: 
she gives meaning to the primitive emotional and sensory elements which the 
baby transmits by restituting the baby's emotional and sensory signals trans-
Οηηχάηφαχη Piergrossi and Gibertoni 
formed into something that can be digested and that will become a kind of 
proto-image. Only later on, when the baby will have a sense of self that is more 
autonomous, will he or she be able to make the transformation activity his or 
her own. The mother's alpha function will have created the alpha function in 
the baby and he or she will start to store away his or her own internal images. 
PSYCHOANALYSIS AND OCCUPATIONAL THERAPY 
Perhaps the greatest contribution of psychoanalytic theories and practice to 
the authors' clinical work has been that of transmitting a different way of 
being with the patients. In this way of being together the therapist proposes 
less, is less active, and gives importance to aspects of the therapy situation 
which were not evident in a more functional approach. 
Each therapy session is seen as a new occasion which is part of a gradually 
evolving process where the therapist is alert and ready to intervene but only if 
and when the moment is right. The setting provides maximum space for 
choice and activities are many. Materials are flexible and available for realistic 
as well as bizarre use. The materials are always real but what the patient does 
with them may not be. Limits as part of the real world are precise and stated 
clearly and refer to breakage, hurting other people and time of the sessions 
(Piergrossi, 1990, 1991). 
Referring to Winnicott's theories (1971), the occupational therapy experi­
ence can be understood as taking place in an intermediate area where activi­
ties in a meaningful relationship form a kind of link between the real world 
and the inner world of the patient. The activities that inhabit the intermedi­
ate space together with the therapist and the patient acquire new meaning 
and new potential. At times they form a tie to the real world, and at times to 
another world of the patient's making (Piergrossi, 1992). 
The therapeutic setting is a meeting of two people, patient and therapist, 
who interact together with an activity. Bion's theories have been helpful for 
considering the therapist as one who contains rather than as one who acti­
vates. In fact the occupational therapy experience will be transformed into 
symbol and thought, and assume significance only if the therapist is capable of 
using his or her own transforming functions for communicating with the 
patient (Gibertoni, 1991a). If all of this happens there will be a transforma­
tion of the experience into two kinds of products: real, material ones and 
thought as a product. Thought must be considered to be made up of inner 
images of the experience which will become part of the inner world of the 
patient and which will be able to be used for enriching his or her interperson­
al relationships. If the therapist's own transforming function is lacking, the 
activity experience will remain superficial, isolated from inner emotions and 
unable to be transformed into thought that can be put to use. 
In occupational therapy the presence of the activity requires many differ­
ent kinds of relationships with the patients which create issues of fundamental 
Importance of inner transformation in doing 
importance. These have to do with gratification, dependency, acting out, all 
of which need to be recognised and used by the therapist to help the patient 
experiment new ways of being with a meaningful person, in much the same 
way as the relational analysts describe the action of their therapy. The activity 
helps to create the scenario. 
What the patient does with the activity is observed and accepted and pos­
sibly interpreted either with words or with actions (Piergrossi & Gibertoni, 
1992). Actions take the place of words especially in the treatment of primi­
tive sensory and emotional disturbances where simple sensory materials act 
both as a support and as a substitute for verbal interpretations. Colours, 
odours, sounds and tastes help create internal rough drafts, fragments of inter­
nal images in the patients (Gibertoni, 1991b). 
The occupational therapist is not a blank presence; she or he is a partici­
pant in much the way that the relational analystsdescribe their participation 
or Winnicott talks about the 'play' of the analyst. The therapist is especially 
careful to recognise and, in certain situations, to verbalise the patient's feel­
ings about doing (fear, pride, pleasure, greed, shame, etc.) and about the ther­
apist's part in the doing process (dependency needs, anger, jealousy, etc.). 
By exploring and experimenting interaction with both objects and people 
the patient slowly develops functional skills which will have both external 
and internal bases, and will therefore have the potential of becoming an inte­
grated part of the self. 
CASE EXAMPLES 
The two case examples that follow have been chosen to illustrate the rich 
contribution of activity to the therapy of the patients. Specific details of the 
interchange among therapist, patient and activity have been provided to illus­
trate the concepts presented above. 
Pasqualino 
The first case is that of Pasqualino, a 10-year-old autistic boy. At the begin­
ning of his therapy Pasqualino filled the therapy room with sounds. His only 
way of staying in the room was by searching for ways of producing sounds 
which helped him to create barriers between himself and the therapist. The 
toy instruments present in the room were ignored: he used his fingernails for 
scratching different surfaces. With a small wooden spoon he would tap the 
doors, walls, table and, with his ear cupped, would listen to the sound pro­
duced. He never looked at the therapist and after 10 minutes would leave the 
room, take up his jacket and depart. This went on for months. At the begin­
ning the therapist limited her verbalisations to telling him that sometimes 
children are so filled with fear that making sounds is the only way to create a 
safe place for themselves. She also reminded him that she was there and that 
Cunningham Piergrossi and Gibertani 
he could try to give his sounds and his fear to her. She also introduced some 
sounds of her own, for example, those of a triangle which she would strike, let­
ting the sound slowly die out before reproducing it again and perhaps record­
ing this sound together with those of Pasquatino. He would stop and seem to 
listen, but just for an instant, only to wander around the room again, far away 
with his tapping sounds. 
In the meantime time passed - the therapy sessions were always very short 
and the therapist began to deal with her sense of omnipotence, her ideal as a 
therapist. And with memory and with expectations (Bion suggests meeting 
each therapy session without memory and without expectations) she began to 
introduce new elements such as play with water, flour, the smell of popcorn, 
the shapes and reflections of soap bubbles. The results were even more frus­
trating: Pasqualino came close, seemed to look, wandered away, twirled 
around tapping, opened the door and disappeared, as if he wanted to tell the 
therapist that she had not understood anything about him. And she realised 
that it was true. The sensory play that she had been introducing turned out to 
be extraneous for Pasqualino: she had been covering up what he had wanted 
to communicate with his sounds. The therapist's attempts had the same signif­
icance as the patient's actions: both were producing beta elements, raw, to be 
evacuated and, instead of emotional nearness, both were searching for a refuge 
from pain, getting farther and farther apart from each other. 
The therapist decided to return to the sensory materials that Pasqualino 
had always used: his sounds. She realised that she had to activate her own 
alpha function to be able to mitigate his sentiments of terror, anger, panic and 
to be able to give them a significance, to transform them into something that 
Pasqualino would be able to take in, make into memory, a kind of rough draft 
of an internal image. But the profound sense of solitude which belonged to 
Pasqualino had become that of the therapist and she had to search for inner 
and outer resources both within herself and among the materials in the thera­
py room which might give her a hand. A string of Christmas tree lights helped 
her to define the limits of a space defined as a house in a corner of the room 
(the entire room seemed too large). And there in the house, she stayed, seated 
on the floor on a large cushion, this time 'without memory and without 
expectations'. She had with her the triangle, a kitchen ladle, a tape recorder, 
her voice. Pasqualino tapped with his spoon against the wall and she 
answered, tapping her ladle against the wall and singing. She sang his panic 
and his anger; she sang his solitude and his terror. She sang his difficulty in 
taking into himself the things of the therapy room. She sang and played with 
sounds, with the noises of the kitchen utensils, hers and his, and sometimes 
she recorded them to be able to listen to them together. Pasqualino came near 
and then ran away again but with an attention time that was gradually 
increasing. He would open his eyes wide while listening to the recording of 
the therapist's song accompanied by the tapping of the spoons and the sound 
of the triangle. He seemed to like a nursery rhyme that she recited while 
Importance of inner transformation in doing 
gently pinching the fingers of one of her own hands one by one. In this rhyme 
the adult usually uses the child's hand, but Pasqualino wouldn't have accepted 
that. The rhyme went like this: 'Pizzi, pizzi trangolo . . . la morte di Sandran-
golo . . .'. Pasqualino used strange manoeuvres, twirling, moving his fingers as 
he came near, ran away, returned; it was clear that he was curious maybe even 
beginning to have fun. And then one day Pasqualino ran charging into the 
therapy room all bundled up, came close to the therapist and without looking 
at her placed his hands on the table, fingers widespread clearly waiting to 
have his own fingers pinched one by one, and said: 'pizzi, pizzi . . . pizzi, pizzi'. 
His mother on the way out related that in the last few days Pasqualino had 
been pulling on her skirts, trying to get her attention and had even pulled 
away from her as he ran to the bus that brings them to Milan shouting: 'Car­
olina pizzi pizzi. . . Carolina pizzi pizzi.' 
These simple verbal expressions, 'pizzi, pizzi' and 'Carolina', had become 
fragments of inner images which Pasqualino managed to store away and use. 
At the start of his therapy experience the room, the therapist, the sounds, the 
materials, the words were surrounded by sentiments of panic and terror, and 
remained primitive and immediate experiences - depersonalised, taken in, 
introjected only to be immediately evacuated. Only when the therapist was 
able to contain and transform these experiences was Pasqualino able to con­
tain them in his own mind in the form of memories which he was then able to 
use in a moment of need. The defensive modality used by the patient was 
transformed from something rough, unrefined and inanimate (the sounds) 
into an object (singing, rhymes) invested with significance, ready to be intro­
jected and to become memory. Pasqualino's noises, from autistic defensive 
manoeuvres, became instruments of interchange and of sensory and emotional 
communication. In this case the sense of hearing, capable of uncovering 
buried images, this time created internal images. 
Dario 
Dario is a 16-year-old psychotic boy who on the first day of his therapy dis­
covered the bin filled with old clothes for dressing up and fashioned himself a 
king's costume (Piergrossi, 1994). His name was 'Re Spaccatutto' (King 
Break-Everything). At the beginning of every therapy session for 3 years he 
dressed himself as king in a very elaborate way with robes, vests, scarves and a 
crown. He claimed to be all-powerful, rich and self-contained. He was always 
cheerful and smiling even if referring to death or violently breakingan object. 
He completely denied any problems in the real world although at school he 
had difficulty in learning and he was without friends; he had some bizarre 
behaviours and occasional rocking stereotypes. 
After three and a half years of therapy he no longer presents himself as an 
all-powerful king and is beginning to have some moments of real communica­
tion. One particular episode illustrates the rich combination of activity, 
Cunningham Piergrossi and Gibertoni 
relationship and strong emotions that characterise his therapy programme. 
Dario had recently begun to play out a new interest in the movie 'Nuovo 
Cinema Paradiso', with which he was passionately involved during therapy 
sessions. He projected slides drawn by himself and decorated the room with 
pieces of the cinema as he conceived of it with notice signs about shows, etc. 
He identified with the man in the film who ran the projector, and was fasci­
nated with the fire which eventually destroys the place before it is then recon­
structed. 
The session to be described occurred on the day the therapist told him she 
would be gone for almost 3 weeks. He became very disoriented and threw 
chairs and other objects to the floor, saying that Cinema Paradiso was being 
destroyed. She talked to him about how angry and lost he was feeling about 
her going away and he denied this saying it had nothing to do with that. He 
was just playing Cinema Paradiso. He was far away, very much alone and com­
municated a sense of desperation. The therapist reminded him about King 
Break-Everything. Maybe he had come back to help Dario to feel strong and 
powerful in difficult moments like this and not sad and fragile, which were 
feelings he would like not to have. He stopped his aggressive behaviour and 
started to listen, but with the very grandiose idea of reconstructing the Cine­
ma Paradiso by completely redecorating the therapy room, as if he were again 
trying to return to the omnipotent defence of believing himself all-powerful 
and the only member of the therapist's domain. 
At this point the therapist's suggestion was to construct a wooden model of 
the Cinema Paradiso, and Dario 's immediate acceptance of the idea was a very 
important moment of his therapy. In the sessions that followed, as he mea­
sured and cut the wood he began to talk about his worries connected with the 
therapist's absence, to count the days on the calendar, to reassure himself 
about her return. 
Referring to Winnicott's theories the activity of constructing the model 
with wood was a kind of transitional phenomenon which served as a link 
between Dario's real world of making things, of being able and his inner world 
filled with fear and chaos. At this point, however, other knowledge more spe­
cific to the occupational therapy experience can be added about the actual 
doing phenomena. It can be hypothesised that Dario, far from forgetting his 
worries as he worked with the wood, was finally able to face them, because the 
activity was helping him to construct an inner structure in a manner parallel 
to the evolution of the outer wooden model. The model for the Nuovo Cine­
ma Paradiso had an intricate façade which he worked hard to replicate, but it 
was also a box-like container. By constructing it he was able to control the 
wood and watch the form evolve as he let his emotions be contained and 
transformed into thought which he could use to grow. This young man was 
not able through words alone to make connections, to use thought processes. 
Words were used by him for fanciful descriptions, for flight into unreal situa­
tions, but not for thinking in Bion's way of understanding it and not for real 
Importance of inner transformation in doing 
communication with others. With activities, on the other hand, he was able 
to experiment feelings that were available to him because of the relationship 
with the therapist. On this occasion he was able to realise that her absence 
would be painful for him. He was finally able to 'see' her in much the same 
way that Pasqualino formed the inner image of his therapist, Carolina. The 
therapist's participation and containment (suggesting the constructing of the 
model cinema) helped Dario to transform apparently meaningless action into 
thought. It was important that he accept his strong feelings of danger and 
destruction at the idea of being abandoned as belonging to himself and not as 
displaced onto the story of Cinema Paradiso. 
Dario's occupational therapy programme had started by accompanying him 
in the illusion of omnipotence (the all-powerful king) and had gradually 
helped him to risk living and interacting without the illusion of being 
omnipotent. The occupational therapy space permitted the beginning of an 
inner transformation from omnipotence to the acceptance of dependence. His 
alternative is unfortunately always his ready flight into psychosis which he 
communicates with his use of objects and materials. 
CONCLUSIONS 
In this paper, through case studies the authors have attempted to demonstrate 
what they mean by inner transformation in the activity process. The case 
examples have shown that perceptual, cognitive and language skills grow and 
develop together with the complex relationship with the therapist during 
activity participation. Psychoanalytic theory has contributed an awareness of 
intrapsychic and relational processes to the myriad happenings in the activity 
experience. Careful detailed study of the sequences of therapy sessions has 
helped to identify signals and indicators of internal as well as external trans­
formation in the two boys described. 
Future research should continue to focus on activities; the authors see 
activities and doing as representing the unique contribution of the profession 
and occupational therapists as the persons most prepared for this kind of 
research. 
Research on the inner significance of activities should not be limited to 
the psychiatric field. In the authors' supervisory work with occupational ther­
apy students and colleagues, the therapeutic use of activity as described in this 
paper has been applied and observed in geriatrics, brain trauma, neurological 
disabilities in both adults and children, adult psychiatry and with oncology 
patients (Piergrossi & Gibertoni, 1987, 1990). More systematic observation of 
the sequences of therapy sessions with different kinds of disability, both indi­
vidually and in groups, would further advance the kinds of knowledge that the 
authors have started to examine about a person's inner world. 
The limits of this kind of research lie in the subjective nature of the indi­
vidual's inner life and in the impossibility of really knowing what is happening 
Cunningjuxm Pkrgrossi and Gibertoni 
in another person. On the other hand, perhaps, it is important for the profes­
sion of occupational therapy to realise and to accept the fact that it will never 
be possible to quantify and standardise certain areas of our work which are the 
very parts that make it most interesting. 
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Address for correspondence: Julie Cunningham Piergrossi, Il Vivàio, Centro di psicologia 
dell'età evolutiva, via Quadrio 11, 20154 Milan, Italy.