This was the first time we’d seen Valerie show interest in any specific object external to herself. Doll play, as is widely known, has a long history in child psychotherapy, where it enables children to project thoughts and feelings too complex for their limited vocabularies. Observers have noted that doll play can provide sensory stimulation and comfort for older adults in dementia-care settings. We found no reports about the use of doll play with adult psychiatric inpatients. But we embraced the possibility that Valerie’s behavior might be key to some kind of activity which finally could engage her. After much deliberation, the team came to an agreement, and nurses mobilized. One of us bought in one of our children’s old dollhouses and a set of wooden furniture pieces. Another donated a miniature plastic “family” and an assortment of tiny household objects such as lamps, pillows, and blankets. We added a few small plush puppies and kittens and set up a table in an activity room.

The second week, rather than merely naming and identifying characters, Valerie started arranging plausible activity scenes in which characters were depicted as active agents. She organized the animals in a circle around a table, for example, and said “this is my birthday party.” She began accepting the human figurines and adding them to the arrangements. In the third and fourth weeks, her originally bizarre, seemingly haphazard piles of furniture gave way to increasingly visually orderly and logically coherent compositions. She aligned all the chairs in neat rows along the wall edges, for example, and separated out functionally plausible two- and three-item settings of tables with objects such as flowerpots, food bowls, and lamps. Her story lines expanded to include more than one sentence and more complex narrative structures. She saw a box of yellow plastic blocks in a corner of the activity room, for example, and stood up to fetch it. Arranging the blocks delicately in a yellow pile on one of the shelves, she described an ambulance rescue in which a puppy disappeared while she and her mother were saved from a house fire. (“The puppy dog sleeps when Anthony sleeps…The doggy got lost in a fire. I don’t know what happened to him”). She also identified a purported future husband (“This is Rocky. I am going to marry him”) and referenced a character, Susan, not represented by any object, who “drives the ambulance that saves mommy’s life and my life.” One day, after painstakingly sorting the furniture collection by size – large objects in one pile and small ones in another – she neatly balanced all the smaller pieces on top of the larger ones, forming a double-decker row. “I am old enough to take care of my own kids,” she said.

As the visual coherence and narrative complexity of her doll play increased over time, Valerie’s behavior on the unit also evolved. She no longer needed sedating medication or close staff monitoring; her physical and verbal aggression slowed and then stopped. Staff reported Valerie was attending most unit programming, sleeping in her regular bedroom, and joining other patients at mealtimes. She had begun initiating conversations, asking comprehensible questions about scheduling and snacks. She agreed to showers and began cooperating with phlebotomy and clinic appointments such as podiatry. She even gave one of us a “gift” of a small stuffed animal she had stored in her bedroom. “I want you to have this,” she said, revealing what seemed to us to be a new awareness of the feelings of others. “I think you might like it.” Valerie was stabilized on a new medication regimen at this time as well, and we marveled, as an interdisciplinary team, at the transformations which accompanied this convergence of pharmacological and non-medication-based therapeutic interventions. There was a brightness, an optimism, about the Valerie who had awakened before our eyes, and all of us were enjoying it, and enjoying her.

Around the eighth week, something changed abruptly. Valerie came to the activity room eagerly, as before. But one morning, she didn’t talk about the figurine arrangements or tell any of their stories. Rather, her configurations were purely decorative – ornamental rather than narrative: “That looks pretty,” she said, placing teddy bears in each corner of the dollhouse. “Nice.” Valerie had not described anything previously in this way, and we took it as a signal: I told Valerie I was going to put the dollhouse away for a while, and she agreed. Her schedule was full by then of other, more conventional group programs and therapies. For the first time since her admission, Valerie was permitted to leave the locked unit independently to visit the snack shop and go to the gym without staff supervision. It was not long afterward that she was finally able to leave the locked facility with confidence, dignity, and some measure of restored capacity for self-determination and self-care.

A century ago, the linguist Roman Jakobson noted links between geometry and grammar – between external shape structures and visual compositional forms, on one hand, and, on the other hand, the internal structures of speech and thought (Jakobson, 1987). It can be said that our nursing intervention exemplified this principle. Establishing a venue in which Valerie could assert control and decision-making, but with materials of interest to her, doll play provided an open-ended “dialect” by which she could disentangle, quite literally, some of the story elements of her life – assemble and arrange them, stand apart, observe, and consider them. The dollhouse, we might say, became an external grammar as its concrete shape offered an ad hoc structure for calling up and organizing meanings from the background noise of experience.

Our doll activity did not emerge from a manual of nursing interventions or list of formal objectives read off from a diagnostic chart. But it activated the patient’s capacity for observational and narrative agency during a period when conventional words were not available to her, even though, quite clearly, she had something significant to say. Doll play offered a transitional configuration which linked a complex internal mental experience to a simpler, more externally share-able structure for representing and exchanging meaning. Moreover, it illustrated the success which can result from intensive interdisciplinary collaboration. We hoped, as Valerie left, that she would be able to access consistent and reliable community supports and sustain a life for herself free from confinement and institutionalization, and that she would continue, when the feeling moved her, to play.