GROUP

THERAPY
WITH CHILDREN
AND ADOLESCENTS
A Treatment Manual

Edited by
Barbara B. Siepker, A.M.
&
Christine S. Kandaras, A.M.

with contributions from

Laura H. Lewis, Ph.D. Anita K. Lampel, Ph.D. Charles
H. Hemdon, M.S. Margot Schnitzer de Neuhaus,
A.M.
Copyright © 1985 by Barbara B. Siepker, A.M. and
Christine S. Kandaras, A.M.

e-Book 2018 International Psychotherapy

Institute

All Rights Reserved

This e-book contains material protected under

International and Federal Copyright Laws and
Treaties. This e-book is intended for personal
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be used in any commercial manner without
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reproduced in any other format.

Created in the United States of America

 Table of Contents
PREFACE

1. RELATIONSHIP-ORIENTED GROUP PSYCHOTHERAPY WITH

CHILDREN AND ADOLESCENTS
Premises

Theoretical Components

Therapist Role, Function, and Training

Co-therapy

Consultation and Supervision

2. CHILDREN'S AND ADOLESCENTS' GROUP THERAPY

LITERATURE
Psychoanalytic Models

Short-term models

Comparisons

Stage Models of Group Development

Challenges

3. STAGE I: PREPARATION
Experiential Description

Dynamic Description

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 Special Issues

4. STAGE II: EXPLORATION

Experiential Description

Dynamic Description

Special Issues

5. STAGE III: ANXIETY

Experiential Description

Dynamic Description

Special Issues

6. STAGE IV: COHESION

Experiential Description

Dynamic Description

Special Issues

7. STAGE V: TERMINATION
Experiential Description

Dynamic Description

Special Issues

8. STAGE VI: CLOSURE

Experiential Description

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 Dynamic Description

Special Issues

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 DEDICATION
This book is dedicated to all those who have

survived and enjoyed group therapy with children

and adolescents; but most especially it is

dedicated, with love and respect, to all those

children who have borne with us while we learned

and in the process have shared themselves with

us. It would not have been possible, though,

without the love and sharing of those closest to us.

We thank you all for your patience, understanding,

and sharing.

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 PREFACE
This book emerged from the authors’ struggles

to develop a seminar on group psychotherapy

with children and adolescents for our colleagues

and trainees in the Division of Child Psychiatry at

The Children’s Memorial Hospital, a private,

nonprofit hospital on the north side of Chicago.

The hospital offers comprehensive medical,

surgical, and psychiatric services to children from

birth through sixteen years of age; additionally, it

is the pediatric training hospital for McGaw

Medical Center of Northwestern University. The

patient population is composed of a diverse

cultural and socioeconomic group. A large

multidisciplinary staff provides comprehensive

mental health care to children and their families.

The division’s approach is eclectic, and we

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 struggled to keep it that way in our presentation.

Pulling together our varied experiences,

training, theoretical orientations, and the

literature into a thorough, worthwhile

presentation for clinicians quickly impressed us

with the immensity of the undertaking. As we

progressed, we made several discoveries. The

literature available did not speak to the

difficulties, thoughts, and feelings experienced by

the therapist throughout his or her contact with a

group of emotionally disturbed children. We soon

saw that in order to answer the questions we

asked ourselves and were being asked we needed

to describe the observable experiences in the

group, explain them dynamically, and integrate the

two. Additionally, special issues and techniques
needed thorough discussion. Another discovery

was that the authors’ practical approaches to

group psychotherapy were very similar even

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 though we had a diversity of training and

professional backgrounds. Discussing our

experiences, we found that in addition there were

similarities both in the paths pursued by the

groups and in the affective experiences of the

children and the therapist. These discoveries

shaped our approach to our task and led naturally

into the structure and format of this book.

We would like gratefully to acknowledge the

inspiration and support of the teachers and

colleagues with whom we have worked during our

training, practice, and teaching. We appreciated

the many opportunities to share ideas and to listen
to valuable feedback, especially from our readers,

Dr. Jerome L. Schulman, head of the Division of

Child Psychiatry, and Dr. Mary Louise Somers,

Professor Emeritus, School of Social Service

Administration of the University of Chicago. The

first version was compiled under the direction of

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 Mrs. Roberta Woods of the division’s clerical

services. Chapter 2 was read by Dr. E. J. Anthony,

Margaret G. Frank, and Dr. Hyman L. Muslin.

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 Chapter 1

RELATIONSHIP-ORIENTED
GROUP PSYCHOTHERAPY
WITH CHILDREN AND
ADOLESCENTS

Barbara B. Siepker, Laura H. Lewis, Christine

S. Kandaras

This book proposes a developmental model of

group psychotherapy with children and

adolescents that emphasizes relationships in the

therapeutic process. Most group therapists share

an emphasis on the therapist’s acceptance of the

child, first named “social hunger” by Slavson

(1943). As relationships and identifications also

occur among the children, implicit to this book is

the assumption that behavioral and attitudinal

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 changes are made out of increased and continued
acceptance by the therapist and group. Most

traditional models do not highlight the equal

importance of the group’s acceptance.

An effort has been made to bridge the theory-

practice gap, to communicate the art of group

psychotherapy with children and adolescents. The

experiential intertwining of the relationships and

the dynamic parallel processes of individual and

group dynamics have a multidetermined and

multivaried impact on the group.

Premises

Underlying this relationship-oriented

conceptual framework and model are attitudinal

and operational premises relating to both theory

and practice. The process of conceptualizing these

premises resulted from the six authors’

agreement, influenced by their individual and

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 collective backgrounds, training, and experience.

The first of these premises is that normal

childhood contains several developmental stages

in the lifelong process of individual growth and

development. These developmental stages have

clearly recognizable goals, tasks, and milestones

that must be experienced before moving onto the
next stage. Given a proper amount of nurturance

and absence of trauma, a child moves through

these stages, even if conflictual, and attains the

next stage of development. In times of stress,

anxiety, and trauma, the child may regress to

earlier conflicts and behavior. A child’s progress

can be ascertained at any point by evaluating the

child’s behavioral and psychological phenomena

and comparing it with established criteria.

Individual differences and dynamics due to

environmental and genetic factors are evident in

the child’s movement in, through, and out of each

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 stage.

Preschool-age children are dealing with

separation-individuation issues (Mahler, Pine, &

Bergman, 1975). In groups we see them as

transferring trusting relationships outside of their

homes, learning and practicing social roles and

functions with peers. Latency-age children are

enmeshed in their struggles of establishing and

maintaining close friendships, cooperating and
sharing, learning the rules and consequences of

participation. There is a predilection for group

experiences at this age with a frequent preference

for nonverbal modes of communicating
(Scheidlinger, 1966). Adolescence is the second

chance at establishing themselves outside of the

home, transferring dependencies onto the group,

and forming intimate relationships. It is seen as a

second stage of individuation (Bios, 1979).

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 In line with developmental thinking, we view

children as children, not as diminutive adults.

Different expectations are held commensurate

with the children’s development of cognition,

judgment, language, symbolism, insight, impulse

control, intuition, observing ego, and ego
capabilities. Children become very knowledgeable

and sophisticated about themselves and

significant others around them, in relationship to

their feelings and dynamics at their own levels of

development. They can be expected to make age-

appropriate decisions and to assume

responsibilities for implementing and abiding by

their own decisions. Therapists must take care not

to expect or attempt to force a child to make

decisions at an adult level. Children, especially

disturbed ones, need support, instruction, and

guidance to develop their abilities in the

therapeutic growth process as well as to acquire

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 freedom to use them. Children are entitled to be

treated with respect, dignity, and consideration for

their being, worth, and feelings as persons.

Groupings, intense feelings, and relationships

develop naturally and spontaneously among

children, even at early ages. As children advance in

age, these groups grow sequentially in

organization, cohesiveness, and sophistication.

Mueller and Bergstrom (1982) found that the
equal nature of peer relations have three basic

positive personality aspects associated with them:

cooperativeness, playfulness, and friendliness (p.

192). “Early peer relations are shown to foster

both specific social skills and a general sense of
efficacy,” a source of competence (pp. 213-214).

Grunebaum and Solomon (1982) have advanced a

peer-oriented theory of group therapy. They have

formulated developmental stages of friendship

formation that they feel are autonomous,

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 sequential systems forming a unique form of “pair

bonding.” They are momentary physicalistic

playmates and an egocentric view (toddlerhood);

unilateral partners and one-way assistance

(preschoolers): bilateral partners and fair-

weather cooperation (middle childhood):

chumship and consensual exchange

(preadolescence); and intimate and mutually

shared friendship (adolescence) (Grunebaum &
Solomon, 1982, pp. 285-297).

Another premise is that therapy groups are

different from these natural groupings but take

into account and utilize understanding of these
dynamics and relationships. Therapy groups are

led by a qualified therapist who utilizes

therapeutic techniques grounded in theory. The

group of children are led in the process of

changing their behavior, personalities, and

emotional lives, which enables them to increase

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 their personal satisfactions and their interactions

with significant others. The defined population,

therapeutic goals, techniques employed,

theoretical underpinnings, and the qualifications

required of the therapist differentiate therapy

groups from other groups. The terms group

psychotherapy and group therapy are used

interchangeably in this volume and are utilized

with the knowledge of definitions of group
psychotherapy and social group work

(Scheidlinger, 1953; Slavson, 1974).

Group therapy is the treatment of choice for

some children following an evaluation. It is not a
panacea for every emotional disturbance affecting

children nor a method to be used simply because

all others have failed.

Children’s therapy groups are different from

adult therapy groups, a view firmly held by most

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 children’s group therapists. Developmental
differences in cognition, motility, reality testing,

ego organization, identifications, and impulse

control cause children to be more active in all

stages of group treatment. They act out openly

both in ego mastery and in testing the limits of

relationships, utilizing modes of expressing their

intense needs that are different from those used

by adults. As a consequence, they exhibit different

therapeutic needs from those of adults. Also,

therapists working with children’s therapy groups

differ from therapists who work with adults in

similar settings. This is in great part a result of the

differences in the expression of the needs of

children in therapy and in the required responses

to those needs.

A group process approach to children’s groups

is taken by the authors. In this book, the terms

group process and group dynamics are used

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 interchangeably. Groups have a group

atmosphere, moods, likes and dislikes, that change

and vary with activities or discussion. Groups

differ in their tolerance of difference and deviance

among members. Groups have levels of

manageability. At times they are resistant,

disorganized, and fragmented, with breakdowns

in controls; whereas at other times they are

cooperative, geared toward ego mastery, and
independent in carrying out activities and

discussion. Groups can be variously attributed

with having a group ego and superego and as

being transitional objects (Levin, 1982) and

“mother-group” (Scheidlinger, 1974).

Every children’s treatment group is viewed as

having a similar developing process. This process

differs only in sophistication of its form, the level

of awareness in the children and therapist, and

mode of expression due to developmental levels,

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 age, and pathology of the group. It begins before

the beginning of the group and continues beyond

the group’s end. The group dynamics can be used

as a vehicle of change when influenced by the

therapist and the group. Individual dynamics and

behavior also are recognized and observed for

both relevance to the individual and impact on the

group. The therapist observes, formulates, and

handles these multiple levels of relationships. In
children’s groups, these relationships extend

beyond the group itself and extend themselves to

parents, consultants, teachers, and agencies. The

process evolves in a parallel fashion at many

different levels, each affecting the other in varying

ways and degrees.

A group process approach encompasses the

conceptual gestalt that therapy groups are more

than the sum total of all their parts. This premise

holds that groups are an entity to which group

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 members relate and of which they are a part. The

fields of group dynamics and group psychotherapy

have developed largely in isolation from one

another. Their potential contributions to one

another were the subject of the 1957 and October

1963 issues of the International Journal of Group

Psychotherapy, a book by Durkin (1964), and an

article by Lieberman, Lakin, and Whitaker (1969).

Slavson gave recognition to group processes in

1946, indicating that group therapy had been

evaluated only in terms of its effects on the

individual and that there was a need for greater

understanding of what occurred within the group
to produce the therapeutic effect, the intragroup

process. He wrote, “Group therapy as a tool in

treatment will come into its own when the group

dynamics are understood” (Slavson, 1946, p. 669).

Later Slavson (1957) carefully distinguished

between group dynamics and interpersonal

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 interactions. He defined the common purpose of

the group as patients having the same purpose of

achieving individual relief of suffering and

personality deficiencies, rather than there being a

common group aim. He argued that although

group dynamics are present, they are not

permitted to operate and are “nipped in the bud”

(Slavson, 1957, p. 145). Slavson concluded that the

process of individuation prevented the
development of group cohesion.

In 1954 Scheidlinger observed that group

psychotherapy follows the dynamics of treatment

and that most group theoretical writings
concentrated on individual behavioral patterns

and phases of therapeutic process. “Group

psychological aspects which in all probability are

basically the same for all face-to-face groups have

been largely neglected” (Scheidlinger, 1954, p.

143). Attention that has been paid to them, he

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 adds, has largely been as they tend to interfere,

such as resistance, scapegoating, conflict between

cliques, and reactions to new members.

In 1957, Anthony (Foulkes & Anthony, 1973)

defined psychodynamics as including both

individual and group dynamics. He discusses

where to place the focus, whether on the

individual, the group as a whole, or the

interactions between the members (pp. 141–144).
The group analyst’s focus is not fixated but

flexible, constantly shifting from intraindividual to

interindividual depending on the events and

circumstances. This flexibility and need to
empathize with the group as a whole and with

each individual member creates heavy demands.

The therapist’s attention is oscillatory, the focus

being determined by the vicissitudes of the

therapy and his or her professional experience.

Experience develops this capacity for multiple

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 attention. Anthony’s analogy is to a spectator’s

ability to follow individual plays, team, and

partner interaction, and eventually to umpire

decisions in team tennis. “It would, in fact, be

difficult to maintain dichotomized interest since

both individual and group are vividly present all

the time” (Foulkes & Anthony, 1973, p. 143). A

further contribution to group psychotherapy

dynamics theory is Anthony’s group
phenomenology, including socialization, “mirror”

phenomena, “condenser” phenomena, “chain”

phenomena, resonance, and group ego. He

concludes that “there is no group therapy without

group dynamics, and group dynamics is essential

to the understanding of group therapy” (Foulkes &

Anthony, 1973, p. 182).

Day (1981) adds his perspective that “some of

the apparent controversy over individual versus

group dynamics … may be an expression of styles

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 congenial to particular therapists and not a matter

of dogma” (p. 156-157). He views individual and

group dynamics as “intermeshed in making group

therapy effective for its members” (p. 155).

Group psychotherapy books integrating group

process conceptualization have been on the

increase, thus creating more interest. This began

in 1954 with Bach, followed in 1957 by Foulkes

and Anthony, Whitaker and Lieberman in 1964,
Yalom in 1970, and Levine in 1979. There has not

been a book published on children’s group therapy

focusing on and integrating group process

conceptualization with group psychotherapy. Redl
and Wineman (1957) come close but cover

broader areas than group psychotherapy. Speers

and Lansing’s (1965) group process orientation is

limited because of their population of preschool

psychotics. Rose (1972) has integrated group

dynamics with behavior modification.

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 The manner in which the group process

progresses from the beginning to the ending of the

group is conceptualized in developmental stages

by the authors. This premise views every

children’s therapy group as having a similar,

ongoing, developing group process with
recognizable stages, each with goals, tasks, and

milestones that are observable and

understandable and that can be utilized to

accomplish individual and group treatment goals.

These accomplishments need completion before

moving on to the next stage. Passage through the

stages is influenced by the therapist’s actions, the

children’s dynamics, and the group’s balance and

dynamics. The group is vulnerable to stress,

trauma, and lack of nurturance, much like the

individual progressing through life’s

developmental stages. Because of these factors,

not all groups pass through all of the stages. Their

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 movement through the stages varies in ease,

fluidity, and speed. Some regress, some fixate, and

some have peaks and valleys, whereas others

move in a fairly steady progression. Therapeutic

benefits do occur simply with the passage through

each stage.

Within the group-development literature, the

theoretical issue arises whether these stages are

really as evident or as stratified as some propose
or whether progression is more linear or cyclical.

Whitaker and Lieberman (1964) indicate a cyclical

process of issues, dealt with at a different and

deeper level the next time around. Bach (1954)

utilizes a “wave” concept and proposes an
elaborate system of themes, communications,

resistances, and therapeutic functions. Feldman

and Wodarski (1975) assent that the progressive

phase concept is practical due to one or a cluster

of attributes predominating in one phase as

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 compared with others (p. 49). Yalom (1975)

prefers speaking of developmental tasks, as

groups rarely permanently graduate from one

phase. He sees the phases as having dim

boundaries, overlapping, and not being well

demarcated but feels a developmental sequence

concept is necessary so the therapist can maintain

“objectivity and to appreciate the course the group

pursues despite considerable yawing” (Yalom,
1975, p. 316).

Theoretical Components

The following developmental conceptual

framework and practice model has been utilized
with preschoolers, latency- aged, and adolescents

with varying degrees and types of disturbance. It

is an attempt to present a view narrow enough to

be considered a therapeutic model within a

conceptual framework broad enough to

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 encompass the use of existing models of group

therapy. Its basic components also may be applied

to existing group therapy frameworks and models.

It can be practiced in any clinical setting as long as

chosen composition, goals, and techniques are

consistent and its therapists are qualified.

Guidelines allow for variance based upon age,

disturbance, setting, and theoretical orientations.

In addition to premises underlying our model,

there are several essential theoretical components

necessary to explain and encompass its breadth,

depth, and flexibility. These components, arising

out of an eclectic theoretical and practice
background, basically represent a melding and

integration of several individual and group

psychotherapeutic methods and models. Because

of the nature of this framework and the way it

evolved, it is difficult to trace and give adequate

credit to all of our forebears. In retrospect, we

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 have chosen to identify the basic influences in the

literature by way of illustration, agreement,

comparison, and contrast.

There are six basic components to the authors’

framework and model. It includes a

developmental, psychodynamic orientation,

incorporating multiple levels of influence and

communication. It is a group process approach

that has a dual focus on individual dynamics and
group dynamics. Here-and-now and then-and-

there interpretations of behavior are utilized. A

multidimensional focus on the following group

relationships are present; therapist and child,
child and child, therapist and group, child and

group, therapist and therapist. Transference,

countertransference, and real-person aspects of

these relationships are experientially utilized as

indicated. The additional influence of outside

relationships with families, school, and agency

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 show themselves within the group.

Group dynamics or process theory is not

viewed by the authors as conflictual with

individual dynamics. Although aware of this

controversy, we view them as separate but

parallel developmental lines. The relevance and

importance of individual dynamics—the necessity

of utilizing, understanding, and interpreting them

—is not underestimated, overlooked, nor
exclusively focused on. The therapist utilizes

psychodynamic information to help individuals

recognize, understand, and influence their own

dynamics and to educate the group to its
importance and relevance to behavior. Individual

and group goals are formulated. Individual and

group explanations and interpretations are made

when individual behavior speaks for the group,

when it becomes central to the group’s conflicts,

and when it stimulates imitation, produces an

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 echo effect, or is highly contagious. Individual role

behavior at times becomes group role behavior

and is recognized and utilized therapeutically with

a focus on how one influences the other.

Subgroups form and often dissolve as quickly as

they form. Leadership takes varying forms and

formats. Sometimes pairings, cliques, clusters, and

collusions form more permanently. There is a

natural, easy interchange and flow between
individual and group behaviors, which is not

contradictory nor combative but is reflective of

the dynamics and nature of each particular group

and its membership. Each member and the

therapist influence or affect every other person

and the group by his or her action or lack of it, by

successes, failures, crises, comings, and goings.

These processes are more apparent during the

cohesive stage when parallel associations and

transferences are explored (Day, 1981, p. 169).

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 The therapist structures interpretations in the

simplest form, focusing first on the here-and-now,

observed defenses and behavior seen in the group.

He or she is always mindful of the timing and

simplicity. Schiffer (1977) utilizes the term

explanation as being more accurate than
interpretation because of the children’s limited

thought and ideational capacities (p. 383).

Understanding the nature, purpose, and intent of

these helps the child, therapist, and group to feel

more comfortable and safe and to learn alternative

modes of coping. With time and further

understanding, this may include identifying how

this environment is not a repetition of his or her

past, as may have been expected and anticipated.

Often simply experiencing strong emotional

expression in an accepting group environment is

sufficient. For children, resonance to earlier

experiences is not always in the distant past, as

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 they daily experience poor relationships with

parents, siblings, and peers. More often the

therapist works toward derivative insight,

acquired nonverbally over a period of time

through experience, rather than the more

complex, psychological insight. This derivative

insight is the child’s capacity to sense changes in

his behavior and within himself as a result of
therapy; “the child reflectively begins to see

himself in a new light” (Schiffer, 1977, p. 382).

This insight is “often a result rather than a cause of

improvement” (Ginott, 1975, p. 355). Because of

the “uncrystallized” nature of the children’s

personalities and character, “new, corrective

experiences in psychotherapy can be internalized”

(Schiffer, 1977, p. 382).

This framework has a multidimensional focus

on group relationships as acceptance and

closeness are sought and feared and accompanied

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 by anxiety. Object relations theory has been

utilized by Kosseff (1975) to develop the concept

of how the group serves the function of a

transitional object. This theoretical advance

demonstrates how the group serves both

intrapsychic and interpersonal functions at the

same time. The group serves as a bridge for

children trying to emancipate themselves from a

symbiotic tie to the therapist. It allows for a
healthy identification process with the group (pp.

233-235).

Due to the age, cognitive ability, and time

proximity of children to their normal
developmental and pathological crises and

conflicts, transference reactions are not always

clearly crystallized, developed, and evident.

Emotions may not be repressed, and the therapist

and/or children do not become a replacement

object. An expectation and emotional reaction is

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 strong and apparent but not always clearly

transferential. Grotjahn (1972) views group

therapy as the treatment of choice for adolescents,

as the “family neurosis” is transferred to the group

enabling it to be reenacted, reexperienced,

interpreted, and worked through (p. 173).

Therapist countertransference is especially

strong and evident in work with children and

adolescents. Evans (1965) indicates the
acknowledgment and use of it as a therapeutic tool

is a recent development. Children’s and

adolescents’ projective defenses, ambivalence, and

limited internal controls are normal, innate, and
intense. They easily become dependent on an

idealized parental figure. The therapist can just as

easily fall into wanting to rescue, protect, and

nurture. Evans views projective defenses as

enabling the adolescent to become disappointed

and detached, allowing him or her to become

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 independent (p. 269). Grotjahn (1972)

recommends the use of co-therapists to stimulate

further the family transference and to help

evaluate the therapist’s countertransferences.

Partly because of the strength of the projective

defenses, it is often a long, slow process for the

child or adolescent and the group to recognize and

appreciate the real-person aspects of the therapist.

Often not until the therapist is pushed to reveal his
or her real feelings of anger and hurt during stages

III and IV are the child and group finally able to

trust the therapist’s empathy, understanding, and

caring. The therapist’s acknowledgment and
sharing of these real-person aspects varies with

child and group but help lead to an internalization

of the therapist as a real person.

Not only are the intragroup and intergroup

relationships influential but so are the outside

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 relationships. Parents are dynamically
intertwined. Agency policy, support, and reaction

are present and felt both by the therapist and the

group. Schools likewise can exhibit influence on

the children and therapist, as can colleagues.

These relationships are evident in the group in a

parallel fashion. There is no literature found

outlining and discussing these parallel processes

so inherent, especially, in children’s groups. Only

Soo (1977) has an article correlating a process

between the child and parents in group treatment,

and Rosenthal (1958) has one on the therapist-

group-supervisor triad.

The theoretical approach and the therapeutic

model developed from our experiences seems to

be explained naturally by dividing the group

process into six stages. The beginning stage,

preparation, takes the therapist from the time of

initial commitment to doing a group to the point at

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 which the group is to begin, including the initial

contacts with the group candidates and their

parents. It deals with the trials and tribulations of

starting a group and beginning to form a

relationship between the therapist and the

individual children. Exploration begins with the

first session and continues until the group has a

labeled identity, Anxiety, a most difficult action

stage, ends when the children commit themselves
to the group process. Intense psychological

closeness is present during the cohesion stage.

Termination follows with the recognition of the

coming end of the group and finishes when the

door closes on the final session. Closure, the final

stage, takes the therapist from the final session

through implementation of the recommendations

for future care of the children to final resolution of

his or her feelings for the children and the group.

Each stage is further delineated by the

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 conceptualization of subphases.

Each stage chapter is organized into three

sections. The first, Experiential Description, is an

attempt to capture the essence of what is

observable in group process from an invisible

observer’s perspective. The clinical material is

reported in this manner in order to provide a

fuller picture than would one group’s process

recording. The clinical examples exemplify a
closed, older latency-age group, with exceptions in

process noted for younger and older children.

Dynamic Description is an explanation and

integration of the observable and experiential with

the dynamic and the theoretical. It is in this
section that the child, therapist, group, parent, and

agency are highlighted. Discussion and exploration

of clinical techniques and issues arising in each

stage requiring special attention are elaborated in

the Special Issues section of each chapter.

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 Therapist Role, Function, and Training

Theoretical, technical, and practical

considerations of a group therapy framework or

model would be incomplete without a discussion

of the therapist’s role, responsibility, training, and

supervision. The three major mental health

professions—psychiatry, psychology, and social
work—provide some of the training necessary to

conduct therapy groups with children and

adolescents. The same training, ethical, clinical,

and professional standards adhered to for

individual therapists within these professions are

assumed to apply also to group therapists. The

authors assume that no therapist following these

standards would undertake group psychotherapy

without some prior training, course work, or
supervision. In addition, a competent children’s

group therapist needs skill in both individual and

group psychotherapy.

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 Yalom (1975) and Levine (1979) outline

training criteria for group therapists. Yalom

includes four experiences: to observe experienced

group therapists at work, to have clinical

supervision of his or her early groups, to have a

personal group experience, and to have personal
psychotherapeutic or self-exploratory work (p.

504). Ginott (1961) also stresses that to work with

children a theoretical knowledge of psychosexual

development is necessary, as is supervised

experience in individual and group play therapy,

activity, and interview therapy. “Experience alone

cannot be a substitute for supervised training; ten

years of work may in reality add up to no more

than one year of error-full experience and nine

years of repetition” (Ginott, 1961, p. 125).

Any therapist involved with children needs

certain qualities, above and beyond the

professional qualifications, as the therapist’s

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 personality is of utmost importance in the success

of treatment. Among these are the following: that

he or she see children as special people needing

and responding to respect and courtesy; that he or

she genuinely like children; that he or she can

bridge the years and psychological gaps to be truly

empathetic with children. We agree with Ginott’s

statement that the therapist must like children but

must not have a strong need to be liked by them
(p. 127). He cautions that “every therapist should

have a clear appreciation of the particular

gratifications that he derives from working with

children” (Ginott, 1961, p. 133). An ability to

communicate verbally and nonverbally with

children on an effective level and a high degree of

frustration tolerance and resilience are important.

It helps to retain that special wonder of childhood

that triggers enthusiasm, spontaneity, curiosity,

and exploration, as does an appreciation of the

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 joys that only children can bring. Additionally, we

assume that the therapist can give and receive

affection, play comfortably, and get dirty, and that

he or she has both patience with and tolerance for

children’s expression through activity. The

therapist must be young enough in spirit or years
to still have “those irrational qualities of youth

that enable grownups to stand, withstand, and

understand children” (Ginott, 1961, p. 127). These

qualities apply equally to adolescent-group

therapists with variance according to the differing

tasks of adolescence. Some therapists are able to

work equally effectively with both age groups,

whereas others cannot.

The role of the group therapist with children

and adolescents is seen as being an active,

involved, responsive one, sensitized to the

psychosocial needs of the developmental age of

the group and to the manifestation of disturbance.

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 At all times, support and facilitation are

uppermost in the therapist’s mind and action,

even when utilizing the techniques of

confrontation, interpretation, clarification, and

intervention. The main role of the therapist is to

create a consistently predictable atmosphere that

motivates learning about oneself and others. This

necessitates providing enough security,

acceptance, limits, and respect, which varies with
the child and the group, to allow expression and

exploration of their innermost selves and

strivings. As the children experience the

therapist’s consistent, nonjudgmental attitude,

they are freed to reveal and face their feelings

more openly. As they experience the inherent

importance of boundaries and limits, free of the

therapist’s guilt and anxiety, they are freed to

individuate and develop self-identity. As they feel

accepted, respected, and appreciated, they are

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 able to feel a sense of self-worth. Only through this

all-accepting, consistently caring relationship, first

with the therapist and through him with the

group, will the children be able to counteract the

inconsistent, sometimes threatening manner in

which they were treated in the past. These real
aspects of the therapist, his reaction and response

to the child and his behavior, are of prime

consideration to the child.

The role of the therapist is partially defined by

its primary emphasis on the use of therapeutic

communication focusing on relationships. The

developing relationship follows the course of any

therapeutic relationship except that it is done in a
group. The therapist must be active in an open,

honest, and direct manner, consistently

communicating and establishing this through

word and action. This includes an understanding

of the parameters and limits of the room,

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 equipment, and relationships. Acceptance of

thoughts and feelings and their confidentiality are

issues needing explanation and repeated

assurance.

The manner in which the therapist accepts and

deals with anxiety, anger, aggression, testing,

acting-out, resistance, conflicts, leadership, rules,

and decision-making also conveys this therapeutic

role and stance. How the therapist is able to
demonstrate, simultaneously and consecutively,

his or her concern, caring, and developing

relationship with each child, the group, and a co-

therapist reinforces this emphasis on the
relationships within the group.

In order to accomplish this consistent

approach, the therapist must have theoretical

understanding and rationale to increase both the

ease of decision-making and his or her confidence.

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 As the therapist sees the structure and arena in
which these complex therapeutic relationships

and communications take place, he or she needs

the support of his or her convictions. The more

information and knowledge the therapist has of

individual psychodynamics, group dynamics,

developmental theory, object relations theory, ego

psychology, peer relations theory, and behavioral

theory, the more complete will be this

understanding and rationale. All is not apparent as

it meets the eye; it also must meet the mind and

connect with the body affect. The therapist must

also stay in touch with his or her intuition,

integrating mind and body theory.

What is seen and heard in the group of the

therapist’s own feelings and reactions relates to

the therapist’s awareness, comfort, and theoretical

support for their exposure. The therapist need not

reveal all he or she is aware of, nor hold back

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 when he or she judges it appropriate and

necessary to share. The stage of the group, the

core issues being dealt with, and the pathology of

the children, signal the timing, nature, and degree

of disclosure.

In their work on peer-oriented theory of group

therapy, Grunebaum and Solomon (1980) advise

the therapist to be a participant-facilitator,

responsive, open, accepting, and confident, and
most of all he or she should foster better peer

relationships and group formation (p. 42).

Anthony states that there is a “constant centripetal

centrifugal movement of the group as a whole in
relation to the therapist” (Foulkes & Anthony,

1973, p. 210). Slavson (1943) views the therapist’s

role in activity group therapy as an “ideal parent,”

giving unconditional acceptance. Sugar (1974)

views it not as being a better, gratifying parent but

as an interpreter and encourager of participation

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 with other children. Battegay (1975) sees the

leader’s role as being attentive to the group

process and individuals while at the same time

remaining in the background as a moderator and

facilitator. Helping the members find ways to

contribute, involves them in the three important

factors of analytic work, repeating, insight, and

social learning (p. 101).

Co-therapy

Whether or not to utilize a co-therapist with

children’s and adolescents’ treatment groups is

often a decision relating to agency structure and

expectations and/or therapists’ theoretical
expectations and orientation. Theoretical,

economic, and training issues are sometimes more

involved in the choice than therapeutic

considerations.

The use and effectiveness of co-therapists is a

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 relatively unexplored and unresearched area.
Although its use was often begun for training

purposes, it was soon discovered that certain

transferences and dynamics occurred

spontaneously due to the presence of two

therapists. This has opened up a new territory of

information. More has been written in relationship

to advantages and disadvantages of utilizing co-

therapists with adult groups (Levine, 1979;

Lundin & Aronov, 1969; Yalom, 1970, 1975). Two

therapists simulate a family environment and offer

two observations, perspectives, and expertise. Co-

therapy allows easy stimulation of transferences, a

splitting of ambivalence between the two, and

utilization of splitting techniques such as support

and confrontation. Two carefully chosen

therapists can complement each other’s strengths

and weaknesses. Their relationship can serve as a

successful role model for relationships for the

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 children and provide professional and personal

growth and learning for the therapists.

An advantage, especially unique and important

with some children’s groups, is a reduction of

anxiety surrounding controls. Limit setting can be

easier with an acting-out group; one therapist

deals with the group while the other deals with

the acting-out member. Due to their feelings of

helplessness and impotence, those members
exhibiting conflicts with authority often try to

undermine, intrude, and split the two therapists.

Use of co-therapists can allow for the therapeutic

splitting of the control function, which is especially

helpful with adolescents: One therapist can
become “one of the group” while the other can

remain in control (Grotjahn, 1972).

One disadvantage inherent in co-therapy is the

considerable time and effort required to

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 communicate about the individual members, the
group, and the co-therapy relationship. An

independent practitioner may feel uncomfortable

with the necessity of sharing decisions,

techniques, control, and personal reactions with

another therapist, as he or she may feel exposed

and vulnerable. A tremendous drawback occurs if

the co-therapists are unable to develop a good

relationship. A poor co-therapy relationship may

evolve into the group’s acting-out the therapists’

difficulties and may not provide adequate

modeling of relationships (Levine, 1979). Yalom

(1975) states the importance of equal status,

competence, and sensitivity, so as to decrease

tension and lack of clarity, and advises

establishing only a co-equal status between co-

therapists.

Heilfron (1969) focuses on what she feels is

the essence of co-therapy, the relationship

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 between the therapists, as an influential factor in

the outcome of the treatment. When they like and

respect each other, trust, and establish a bond,

they can possibly engage in a discovery of their

own interrelationship. A progression develops,

from separate individuals working together to a

sense of we-ness in partnership, which requires

deep personal investment and commitment.

Lundin and Aronov (1969) expand on the

simulated family experience with its unique

learning and broader dynamic areas. Patients

naturally respond to one therapist with a major

primary reaction of dependency, anger, seduction,
or ambivalence. This therapist is seen as more

aggressive or masculine, whereas the other

therapist is seen as assuming protective, feminine

qualities. One therapist tends to be feared, the

other idealized (p. 198).

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 Gallogly and Levine (Levine, 1979) clearly

elucidate the unique, differentiated role

techniques available for use with co-therapists

after they have achieved a degree of mutuality.

One co-therapist can help a patient connect or

respond to the other co-therapist, complete or
reinterpret an intervention begun by the other.

Support and confrontation can be split between

the two to help deal with resistance and rigidity in

the group. Ambivalence sometimes can be

resolved by each co-therapist supporting one side

of it. Gallogly and Levine identify five

developmental phases of the co-therapy

relationship that parallel the therapy group’s

crises and developmental stages (pp. 299-304).

Yalom (1970) feels that with co-therapists anger

and attack from a group member on one of the

therapists can easily be explored as an issue by the

other. The existence of the other also helps to

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 maintain objectivity in the face of “massive group

pressure” (p. 320).

There are several exceptions to a co-equal

status between the co-therapists. When utilized

for training purposes, an unequal status may be

accepted, but it has its own complex, inherent

conflicts, dynamics, and issues. Sometimes co-

therapy roles are split into practitioner and

observer. In his work with delinquent boys,
Kassoff (1958) felt that the co-therapy

interrelationship was important and effective with

a neophyte and an experienced therapist. Gallogly

and Levine (Levine, 1979) caution that a trainee

should have more than just the one co-therapy
relationship with his trainer in order not to have a

one-sided view. It may also be important to

experience sole leadership or another co-therapy

relationship concurrently. The authors advise all

novice and experienced therapists to have more

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 than one group running concurrently, in order to

maintain a perspective on one’s competence when

groups run into difficulties, and to appreciate the

uniqueness yet commonness of each group.

Consultation and Supervision

The necessity of supervision and consultation

is supported by Kadis, Krasner, Winick, and

Foulkes (1963) as they caution against some “wild

cat” therapists conveying “the idea that

supervision is not necessary” (p. 34). In areas

where adequate supervision is unavailable locally

they suggest hiring competent people to come in

weekly or semimonthly from another area. To
neglect supervision “in the practice of group

psychotherapy is as dangerous as it would be in

any other therapeutic endeavor” (Kadis et al. p.

34). “A supervised clinical experience is a sine qua

non in the education of the group therapist” and in

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 many ways is “more taxing than individual

therapy supervision” (Yalom, 1975, p. 506).

“Mastering the cast of characters is, in itself, a

formidable task,” in addition to the necessity of a

“highly selective focus” on the “abundance of data”

(p. 506).

It seems superfluous to note that the therapist

should trust and respect the consultant’s

judgment. The beginning relationship covers an
understanding of the type of therapy planned, the

nature of the children’s disturbances, what and

how much advice the therapist wishes, the

techniques the consultant uses, and how much, if
any, responsibility he or she will be asked to or is

willing to assume for the therapy.

As therapy progresses, the consultant tries to

maintain an objective view of what is happening to

the children and the therapist, what themes are

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 evident, and what the interactive effect is of the
following relationships: therapist and child,

therapist and group, co-therapists, therapist and

consultant, and consultant to group through the

therapist. There are also the relationships of child

and parent, therapist and parent, consultant and

parent through the therapist, and all of the above

with the agency. The therapist may need help in

relieving his or her own anxieties, fears, and

doubts in order to develop emotional insulation

against anxieties induced by the group (Rosenthal,

1968). It is the consultant’s role and responsibility

to convey his or her observations and assessments

of what is happening within the group including

the effect of the therapist’s role and actions to the

therapist in the least critical way possible in order

to be of assistance. Decision-making rests with the

therapist, as does determination of how he or she

may make the best use of the information.

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 The supervisor’s role, although similar to the

consultant’s, has a few distinct differences. In

general, the supervisor retains a great deal more

responsibility for the therapy than does a

consultant. He or she is usually also responsible

for the training and professional growth of the
trainee. Consequently, the supervisor will not only

assess the data, giving his or her opinion to the

therapist, but will define, label, and illustrate the

processes as they occur, while describing and

recommending techniques. This role should find a

balance between supporting, leading, and guiding,

yet promote enough independence in the trainee.

Throughout the process, the supervisor should

never lose sight of the fact that his or her first

responsibility must be to safeguard the well-being

of the children while guiding trainees in increasing

their therapeutic skills. Appreciating these

differences, in this volume the terms supervision

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 and consultation are mostly used generically and

interchangeably.

Joint supervision of co-therapists, also called

triadic supervision, should be held, with a triadic

focus on the development of the co-therapy

relationship and its effects on the group, as well as

the assessment of the group and its members. It is

both appropriate and helpful to work on some

aspects of the co-therapists’ egalitarian
relationship. Supervision can have a stabilizing

influence on both co-therapists over a period of

time and can examine the effect of the co-therapy

relationship on the group (McGee, 1974). Gallogly

and Levine (Levine, 1979) recommend that co-
therapists meet both alone and with a supervisor,

bringing to supervision those issues they are not

able to work out together.

The format for group consultation can follow a

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 more traditional individual method of supervision,
can be held in a group, or can have a group

workshop format. Such sessions can focus on

ongoing groups, group processes, and specific

problems. Use of process transcripts, tape

recordings, one-way screen observations, and

videotaping all have been found valuable.

If supervision of groups is impossible to obtain,

Kadis et al. (1963) suggest regular meetings of

those involved in group therapy, focusing on

continuous case presentation and/or discussion of

special problems. These meetings may offer

educational help as well as resolution of

difficulties. They observe that objective listeners

“may help to pick up and clarify disruptive

influences like countertransference factors

operating in the group” (Kadis et al., 1963, p. 34).

Our observation is that it helps to have

experienced clinicians present who are used to

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 observing transference and countertransference

phenomena, even if in individual settings, rather

than just a peer group of novice therapists.

References

Bach, G. S. (1954). Intensive group psychotherapy. New

York: Ronald Press.

Battegay, R. (1975). The leader and group structure.

In Z. A. Liff (Ed.), The leader in the group. New
York: Jason Aronson, pp. 95–103.

Blos, P. (1979). The adolescent passage. New York:

International Universities Press.

Day, M. (1981). Process in classical psychodynamic

groups. International Journal of Group
Psychotherapy, 31, 153-174.

Durkin, H. E. (1964). The group in depth. New York:

International Universities Press.

Evans, J. (1965). In-patient analytic group therapy of

neurotic and delinquent adolescents: some
specific problems associated with these groups.
Psychotherapy and Psychosomatics, 13, 265–270.

Feldman, R. A., & Wodarski, J. S. (1975). Contemporary

approaches to group treatment. San Francisco:

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 Jossey-Bass.

Foulkes, S. H., & Anthony, E. J. (1973). Group

psychotherapy: The psychoanalytic approach (rev.
2nd ed.). Baltimore: Penguin Books.

Ginott, H. G. (1961). Group psychotherapy with

children. New York: McGraw-Hill.

Ginott, H. G. (1975). Group therapy with children. In G.

M. Gazda (Ed.), Basic approaches to group
psychotherapy and group counseling (2nd ed.).
Springfield, IL: Charles C Thomas, pp. 272-294.

Grotjahn, M. (1972). The therapeutic dynamics of the

therapeutic group experience. In I. H. Berkovitz
(Ed.). Adolescents grow in groups. New York:
Brunner/Mazel. pp. 173–178.

Grunebaum, H., & & Solomon, L. (1980). Toward a

peer theory of group psychotherapy: 1. On the
developmental significance of peers and play.
International Journal of Group Psychotherapy, 30,
23-49.

Grunebaum, H., & Solomon, L. (1982). Toward a

theory of peer relationships: 2. On the stages of
social development and their relationship to
group psychotherapy. International Journal of
Group Psychotherapy, 32, 283–307.

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 Heilfron, M. (1969). Co-therapy: The relationship
between therapists. International Journal of
Group Psychotherapy, 19, 366–381.

Kadis, A. L., Krasner, J. D., Winick, C., & Foulkes, S. H.

(1963). A practicum of group psychotherapy. New
York: Harper & Row.

Kassoff, A. I. (1958). Advantages of multiple therapists

in a group of severely acting-out adolescent boys.
International Journal of Group Psychotherapy, 8,
70–75.

Kosseff, J. W. (1975). The leader using object-relations

theory. In Z. A. Liff (Ed.), The leader in the group.
New York: Jason Aronson, pp. 212-242.

Levin, S. (1982). The adolescent group as transitional

object. International Journal of Group
Psychotherapy, 32, 217–232.

Levine, B. (1979). Group psychotherapy practice and

development. Englewood Cliffs, NJ: Prentice-Hall.

Lieberman, M. A., Lakin, M., & Whitaker, D. S. (1969).

Problems and potential of psychoanalytic and
group-dynamic theories for group
psychotherapy. International Journal of Group
Psychotherapy, 19, 131-141.

Lundin, W. H., & Aronov, B. M. (1969). The use of co-

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 therapists in group psychotherapy. In H. M.
Ruitenbeck (Ed.), Group therapy today. New York:
Atherton Press, pp. 195–202.

Mahler, M. S., Pine, F., & Bergman, A. (1975). The

psychological birth of the human infant. New
York: Basic Books.

McGee, T. F. (1974). The triadic approach to

supervision in group psychotherapy.
International Journal of Group Psychotherapy, 24,
471-475.

Mueller, E., & Bergstrom, J. (1982). Fostering peer

relations in young normal and handicapped
children. In K. M. Borman (Ed.), The social life of
children in a changing society Hillsdale, NJ:
Lawrence Erlbaum. pp. 191–215.

Redl, F., & Wineman, D. (1957). The aggressive child.

New York: Free Press.

Rose, S. D. (1972). Treating children in groups: A

behavioral approach. San Francisco: Jossey-Bass.

Rosenthal, L. (1958). Some aspects of a triple relation.

In A. Esman (Ed.), New frontiers in child guidance.
New York: International Universities Press, pp.
78–89.

Scheidlinger, S. (1953). The concepts of social group

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 work and group psychotherapy. Social Casework,
34, 292–297.

Scheidlinger, S. (1954). Group psychotherapy.

American Journal of Orthopsychiatry, 24, 140—
145.

Scheidlinger, S. (1966). The concept of latency:

Implications for group treatment. Social
Casework, 47, 363-367.

Scheidlinger, S. (1974). On the concept of the

“mother-group.” International Journal of Group
Psychotherapy, 24, 417–428.

Schiffer, M. (1977). Activity-interview group

psychotherapy: Theory, principles, and practice.
International Journal of Group Psychotherapy, 27,
377–388.

Slavson, S. R. (1943). An introduction to group therapy.

New York: International Universities Press.

Slavson, S. R. (1946). Group psychotherapy. In E.

Spiegel (Ed.), Progress in neurology and
psychiatry. New York: Grune & Stratton, pp. 662–
680.

Slavson, S. R. (1957). Are there “group dynamics” in

therapy groups? International Journal of Group
Psychotherapy, 7, 131–154.

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 Slavson, S. R. (1974). Types of group psychotherapy
and their clinical applications. In S. DeSchill (Ed.),
The challenge for group psychotherapy. New York:
International Universities Press, pp. 49–119.

Soo, E. S. (1977). The impact of collaborative

treatment on premature termination in activity
group therapy. Group, 1, 222–234.

Speers, R. W., & Lansing, C. (1965). Group therapy in

childhood psychoses. Chapel Hill, NC: University of
North Carolina Press.

Sugar, M. (1974). Interpretive group psychotherapy

with latency children. Journal of the American
Academy of Child Psychiatry, 13, 648–666.

Whitaker, D. S., & Lieberman, M. A. (1964).

Psychotherapy through group process. New York:
Atherton.

Yalom, I. D. (1970). The theory and practice of group

psychotherapy. New York: Basic Books.

Yalom, I. D. (1975). The theory and practice of group

psychotherapy (rev. ed.). New York: Basic Books.

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 Chapter 2

CHILDREN'S AND
ADOLESCENTS' GROUP
THERAPY LITERATURE

Barbara B. Siepker

The paucity of literature available in the field

of children’s and adolescents’ group therapy is

readily observed. The books published in the past

25 years on children’s groups can be counted on

one hand and are reflective of very different

approaches: Ganter, Yeakel, and Polansky (1967),

Ginott (1961), Rose (1972), Schiffer (1969), and

Slavson and Schiffer (1975). Those on adolescents

represent similar numbers: Berkovitz (1972),

Brandes and Gardner (1973), MacLennan and

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 Felsenfeld (1968), Rachman (1975), and Sugar
(1975). Annual reviews of the group therapy

literature have made recurrent observations on

the paucity of this literature (Lubin & Lubin, 1973;

Lubin, Lubin, & Sargent, 1972; MacLennan & Levy

1967, 1968, 1969, 1970, 1971). In 1979 these

reviews combined both categories into one
paragraph.

As recently as 1970, MacLennan and Levy

observed some questioning of the usefulness of

treatment groups. There has also been a lack of

quality literature, especially regarding theoretical

and technical aspects of group treatment.

Rosenbaum and Kraft in 1975 similarly conclude

there is “a paucity of clear thinking concerning

therapy with children” (p. 601).

Psychoanalytic Models

Psychoanalytic models have been the prime

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 theoretical orientation of the group therapy
models for children and adolescents. The various

models differ in a matter of degree or emphasis

regarding the following theoretical issues: the

treatment of the individual in the group versus

through the group-as-a-whole; verbalization and

interpretation versus experiential learning; the

activity level of the therapist regarding

permissiveness and limit setting. These

differences most often relate to theoretical

orientation, population served, and setting.

Historical surveys of the development of group

therapy with children and adolescents clearly

attribute Slavson with its founding in the 1930s.

Appley and Winder (1973) summarize Slavson’s

impact as allowing activity to replace verbalization

of conflicts. Slavson’s activity group therapy

(1943) for latency-age children is an experiential

model for children with modifiable habit,

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 character, and behavior disorders. Strict

adherence to the model is required in group

composition and therapist’s activity. The therapist

provides an accepting atmosphere of unrestricted

and uninterpreted free play and activity. As a

neutral, uninvolved, noninterpretive observer, the

therapist assumes an “ideal” parental role of

unconditional acceptance and permissiveness

(although not sanction), thus allowing the child
over several years a “corrective experience.” This

model’s effectiveness is attributed to correct

selection and grouping to “psychologically”

establish and maintain a dynamic equilibrium and

balance of instigators, neutralizers, and neuters

(Slavson & Schiffer, 1975, p. 111). Once properly

composed, it is largely dependent on the “group

curative forces,” even though the focus remains

throughout on the individual dynamics.

A few years after activity group therapy was

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 developed it was recognized that it was not

suitable for all young children and preadolescents.

Two other models were then developed under

Slavson’s direction. The first model, play group

therapy, is essentially for children four to six years

old, involving the interpretation of the meanings

and feeling of the play and behavior. “Using libido-

evoking materials, the patients reveal through play

their life problems . . . and the attendant fears,
tensions, confusions, anxieties, anger and other

emotions” (Slavson & Schiffer, 1975, p. 355).

Information is provided and interpretations are

focused on the individual child, geared to his or

her understanding, and generally kept at a

behavioral level.

Ginott, in addition to growing out of the

Slavson tradition, was influenced by Axline’s

(1947) play group therapy for young children,

which utilized symbolic and fantasy play,

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 reflection of feelings, and interpretation. Ginott’s

model (1961) included latency-age children and

focused primary attention on the development

and ongoing therapeutic relationship with the

therapist. An emotionally active therapist’s role

requires structuring, therapeutic limit setting, and

redirecting undesirable acts, in addition to

permitting verbal and symbolic expression of

feelings. Permission is conveyed to the children to
express themselves freely through the medium of

play in their own time and way. The theory and

practice of limit setting is fully explored and

presented.

The second model, activity-interview group

therapy (Gabriel, 1939; Schiffer, 1977; Slavson

1945, 1947), was devised because more seriously

disturbed children with behavior disorders were

inaccessible to the “ego type treatment, either

because of over-intense fears and anxieties or

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 because their uncontrolled hyperactivity and

aggressions would prevent the therapeutic climate

essential for activity group therapy” (Slavson &

Schiffer, 1975, p. 297). A much more flexible

model than activity group therapy, it allows for

verbalization and interpretation of activity. The

therapist plays a more central role, structuring

“talking” and “working” parts of the meeting. Most

frequently, children are also in individual therapy
with the group therapist or another therapist.

Modifications of activity group therapy began

as early as the 1930s under Slavson’s direction.

This was followed in the 1940s by Scheidlinger’s
work with severely damaged and culturally

deprived children (1960, 1965). These children,

from families with severe social and economic

deprivation, experienced neglect, inconsistency,

and harsh physical punishment. Serious

disturbances in the children’s ego developments

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 and functioning resulted, including problems of

impulse control, oral fixation, poor reality testing,

distortions in perceiving others, poor self-image,

and confused identity. Necessary changes in group

therapy included active structuring of a consistent,

nurturant group climate, frequent therapist

activity in direct, emotional reactions, verbal

interventions in the form of confronting and

clarifying reality, and physical restraint in light of
uncontrollable impulsivity.

The 1960s focused on the inadequacies of

programs, children’s and adolescents’ group

therapy included, to deal with the numbers of
socially disadvantaged urban dwellers. Frank and

Zilbach (1968) voiced their concern that activity

group therapy had not kept pace due to lack of

proper training facilities, the need for a specific

physical setting, and greater comfort with talking

therapy. They called for continued solid footing

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 within the tradition of activity group therapy with

disturbance and setting modifications. MacLennan

(1977), sharing this concern, made an even

stronger, impassioned plea. In 1969 Schiffer

outlined changes in activity group therapy

necessary for a therapeutic play group in a school

setting with younger children, six to nine years

old. The therapist, although substantially

permissive and dynamically neutral, is more
involved due to the ages of the children, at times

intervening for safety. Consistent with activity

group therapy, interpretations are not made.

The 1970s brought a resurgence of suggested

modifications of activity group therapy, both

within and outside of the Slavson tradition, based

on population and setting differences and

demands. VanScoy (1971) suggested

modifications of activity group therapy based on

setting and population differences. Seriously

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 disturbed “cast-offs” and “rejects” in a residential

treatment setting were treated in small groups of

four to five, with co-therapists playing very active

roles, structuring activities, limits, and rewards.

Epstein and Altman (1972) described their

experiences in successfully converting an activity

group to verbal group therapy, as a permissive

free play atmosphere seemed to work “against ego

integration and toward encouragement of random,
regressive acting-out behavior” in these boys

evidencing power manipulations (p. 95). Similarly,

Strunk and Witkin (1974) describe changing a

girls’ activity group into a discussion group. These

girls with deficient inner controls also needed

clearly defined limits and expectations, which they

came to internalize, actively helping one another

to achieve self-control.

Frank (1976) has developed the dearest, most

detailed theoretical conceptualization of group

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 therapy with ego-impoverished children since

Scheidlinger. Reviewing activity group therapy,

she documents the different needs in the setting,

structure, and composition of the group and the

role of the therapist that is necessitated by these

children. In order to meet the therapeutic needs of

safety, acceptance, and nurturance, the therapist

must provide protective limits (as opposed to

punishment) when the children’s egos are
threatened and in danger of being overwhelmed,

and must simultaneously teach the children to

expand their ego capacities. The latter approaches

include teaching the use of talking as an ego

capacity to replace action in these children who

have not yet learned this secondary ego function,

and the use of the device of role playing to teach

ego perception. These children should be grouped

together, as they feel safer with others with

similar problems. The therapist, therefore, must

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 provide the balance in the missing ego resources

within the group.

Due to the far-reaching influence of Slavson’s

contributions, group therapy with children has

virtually been equated with activity group

therapy. One unfortunate result of this equation,

noted by Sands and Golub in 1974, has been that

not only has there been wholesale misapplication

to unintended populations and settings but
activity per se has become equated with

treatment. Charach (1983) observes that

therapists have “tried everything to improve on

the still influential paradigm of activity group

therapy”; those methods combining activity and
talking “often begin with an ‘apologia’ for any

method that deviates from activity group therapy”

(p. 349). The lack of sorting out the inherent

clinical and technical necessities of activity group

therapy and the psychoanalytic and child

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 developmental theoretical aspects of the model

has added to the confusion in the author’s opinion.

In addition, activity group therapy has been more

frequently highlighted than activity-interview

therapy, a model more similar to many models

currently practiced in clinics.

Several psychoanalytic group therapy models

have developed outside of the Slavson tradition. A

relationship therapy model conceived by Dr. John
Levy in the 1930s utilized children’s and

concurrent mothers’ groups in a child guidance

center (Durkin, 1939, Glatzer & Durkin, 1944,

Lowrey, 1944). The therapeutic relationship was
considered the essence of the treatment. The

therapist’s role in a permissive play atmosphere

was clearly defined to include the timing of

interpretations, stressing the necessity for

thorough training, experience, and judgment. This

model is not to be confused with the authors’,

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 which focuses not only on therapy in the group but

through and by the group.

Redl’s broad theoretical and practice

contributions have centered on translating

psychodynamic theory into everyday practice in

the fields of child development, education,

delinquency, and group therapy. Appley and

Winder (1973) attribute Redl with “translating

psychoanalytic concepts into the language of
group process” (p. 3). From the onset Redl differed

with Slavson regarding the issue of therapist

activity, questioning on a theoretical and clinical

basis the total permissiveness and
noninterference of the therapist (Redl & Wineman,

1957). The delinquent population Redl worked

with necessitated more active ego interventions to

maintain, replace, and strengthen ego functioning

under the pressures of group process. Redl and

Wineman’s model is representative of an

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 integrated psychoanalytic and group-process-

oriented model. Redl’s theoretical contributions in

the area of group process are unparalleled. They

include shock effect, group contagion (1949),

group composition, group resistances, and group

psychological roles (1966). Less well known are

the impact of group exposure on ego integrity, the

conflicting demands of group membership on the

individual personality, exculpation magic through
the initiatory act, spatial repetition compulsion,

and group intoxifying forces (1942).

Speers and Lansing (1965) described the

development of group process in a group of
preschool psychotic children and collateral groups

of mothers and fathers over a 4-year period.

Therapy began with the child needing to maintain

his symbiosis supported by massive denial and

psychotic fantasy. In the first 3 months of

treatment, wild panic reactions resulted from the

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 terrifying closeness of others as the child lost ego

boundaries, body image and identity, impulse and

affect control. Physical holding to ensure his safety

was necessary to help the child endure this phase.

These ego functions gradually developed through

a process of therapeutic symbiosis with the “group

ego” that had developed. Anthony (1973)

comments that this slow group development ends

where most neurotic groups begin, as the
authentic group processes beginning when

individuation is present (p. 231). Similar group

process was present with autistic and

schizophrenic children seen for only a year by

Gratton and Rizzo (1969).

Considerably more group process in groups of

schizophrenic children is reported by Lifton and

Smolen (1966). Their total approach, termed

relationship group psychotherapy, appears to be

close in nature to the approach of this book. It is

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 based on the theory that childhood schizophrenia

results from an original disturbance of

relationship, which leads to an inability to

establish a relationship to self, objects, and people.

All activities are utilized to develop and maintain a

relationship with the therapist and children,

including therapeutic utilization of resistances,

transferences, and countertransferences. Children

are treated both as unique individuals and as
members of a group. The therapist’s role is active

and involved; setting clear limits, protecting by

verbal and physical restraint, initiating breaking

down of autistic barriers, verbalizing and

interpreting behavior and feeling at a level that

can be understood and assimilated, sensitizing

children to each other’s problems, feelings, and

actions, aligning himself or herself with the child’s

ego, stopping and interpreting acting-out and self-

destructive behavior. It is Lifton and Smolen’s

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 belief that group therapy may be the treatment of

choice for schizophrenic children, as the group

process offers the most effective way to promote

socialization. The group forces recognition of

other children, provides the constancy, external

structure, control, and cohesiveness these children
need, and helps them establish increasing affective

contact with their surroundings without feeling

overwhelmed or threatened.

Anthony (1973) has elaborated three separate

group analytic psychotherapy models for children

and adolescents in a chapter of a book that

unfortunately has gone out of print. These group

analytic models, originally developed in England,
are both psychoanalytic and group process in

conceptualization, with all of the group’s

communications and relationships being brought

back to the group and the therapist for analysis.

All members play an active part, although the

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 therapist remains the primary transference figure.

The “small table” method, employed with four- to

six-year-olds, resembles play therapy with

symbolic play content and is held twice weekly.

The table setup structures five individual

territories and a common territory, with

individual sets of play equipment in separate

colors. The therapist plays a part, with his own

territory and equipment. Concrete and verbal
transactions occur, as does group development,

which begins with individual play, their parallel

play with “collective monologues,” and finally

“collective fantasies.” Anthony’s “small room”

method for latency-age children is a modification

of Slavson’s method, taking activity needs into

account. Originally a talking period was followed

by an activity period, but gradually this became

more verbal, analytic, and interpretive, with a

focus on the positive and negative aspects of the

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 group. Activity occurred spontaneously, becoming

a matter for discussion as it happened. The only

explicit rule is “no exit” from the room. For the

more acting out group the transformation to

verbalizing is difficult to handle and

uncomfortable for the therapist but absolutely
necessary for their treatment. Adolescents are

treated with a “small circle” technique. These

groups are characterized by fast-changing,

regressive-progressive movement and require a

high degree of therapist flexibility.

Interpretive group psychotherapy with

outpatient groups has been formulated for

latency-age children in an article by Sugar (1974).
It is designed for children exhibiting behavioral

and neurotic disorders, including psychosomatics,

who are able to verbalize. In a relatively

ungratifying playroom setting “designed to

facilitate the demonstration of conflicts, defenses,

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 and fantasies through verbalization and play”

(Sugar, 1974, p. 648), the therapist interprets the

child’s feelings. Maintaining a friendly, informal

role, the therapist encourages the child to

participate in play with other children, but does

not gratify the child directly or aim to be a “better

parent.” At times the play may need limiting when

it becomes disorganizing or destructive.

Schachter (1974, 1984) has formulated a

group therapy model for children who have

difficulties verbalizing their feelings and for

depressed children. Kinetic psychotherapy utilizes

children’s games as the medium of interaction,
serving as a catalyst for emotions. As emotions are

experienced and characteristic responses shown,

“a process called ‘stop the action’ is invoked by the

therapist” (1984, p. 85). Identification,

verbalization, feedback, and association are

encouraged as a part of the discussion.

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 Blotcky, Sheinbein, Wiggins, and Forgotson

(1980) describe a verbal, nondirective, insight-

oriented group technique for ego-defective

children in an inpatient setting. The therapist’s

role is permissive and interpreting. Blotcky et al.

present a review of latency, emphasizing that
older latency-age children possess sufficient

abstract and cognitive skills to verbalize present

and past experiences. They describe how verbal

therapy enhances internal structure and impulse

control in these children and how transference

reactions and group process can be put to

therapeutic use. They describe two group phases:

resistance, during which the expression of

thoughts, feelings and recreated previous

conflictual relationships leads to tumultuous

behavior with increasing anxiety and guilt; and the

treatment phase, which is cohesive, with the

children exhibiting increased internal controls.

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 The 1980s have brought new theoretical
developments. Trafimow and Pattak (1981, 1982)
offer a theoretical review of the developmental
line of object relations, applying it to group
process with very disturbed children exhibiting
serious ego deficits, developmental delays, and
primitive personality structures. They outline
three growth-inducing aspects of group process
that are offered within the group: other children
as objectal alternatives, group therapists as
auxiliary egos, and the group as symbiotic mother.
Levin (1982), also utilizing object relations theory,
focuses on the adolescent process of individuation.
By utilizing the group as a transitional object and
an instrument of change, the adolescents shed
their infantile dependencies on the therapist
through healthy identification processes with
peers.

Short-term models
Short-term models received some attention in

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 the 1960s and 1970s, particularly within clinics
and school settings, where the pressure for short-
term service is heavy. Therapy groups in the
schools vary in goals, structure, and length, from 6
to 12 sessions (Barcai & Robinson, 1969; Gratton
& Pope, 1972; Rhodes, 1973).

The length of treatment in outpatient clinics

varies from 6 sessions to 6 months. Karson (1965),
working with acting-out and neurotic boys,
structured concurrent children’s and mothers’
groups, each run by a therapist and an observer
for a period of 6 months. Ganter et al. (1967)
focused on an alternative 6-month intensive group
treatment experience for children suitable for
residential placement. Concrete goals were
accomplished through firm, consistent structure
and limits. Innovative therapeutic techniques
included refusing to become engaged in the
struggle, depersonalizing the sources of structure,

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 distracting-decompressing, isolating, insisting on

external demands, pacing expectations, avoiding

competition, giving freedom within the structure,

regrouping, and providing structural change

experiences. Pelosi and Friedman (1974) utilized a

structured athletic activity prior to refreshments

and discussion with early adolescents. Sands and

Golub (1974) developed a model that utilized

talking as the basic medium and group process as

the material of therapy and basic group

intervention during 16-week sessions. Lewis and

Weinstein (1978) specifically focused on learning

friendship skills with latency-age children for 5

weeks, meeting twice a week. Charach (1983)

experimented with a six-session interpretive

psychotherapy group.

Comparisons

Few efforts have been made to organize and

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 compare the different models of group therapy for
children and adolescents. MacLennan (1977)
describes limitations and adaptations of classical
activity group therapy due to population, setting,
and service differences, classifying other models of
group therapy accordingly. Schamess (1976)
attempts to clear the confusion by focusing on
differing diagnoses, including level of pathology
and ego organization, as the decisive factor in
treatment plan and group structure. He
categorized existing group therapy models into
four diagnostic groupings.

Stage Models of Group Development

Although there is an abundance of literature on

stage models of group development, these models
have largely been formulated with adult
populations. Three very different noteworthy

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 articles exist surveying, comparing, and classifying

this literature (Braaten, 1974/1975; Tuckman,

1965; Whittaker, 1970). This literature supports a

substantial consensus and inherent order

regarding developmental group-process models.

The models compared range from 2 to 13 phases,

with the larger numbers including subphasing and

transitional phases.

The Sarri and Galinsky model (1974), although

derived from research, is worthy of mention, as it

not only posits phases of development but outlines

a treatment sequence that includes therapist

techniques and interventions for concurrent
stages of treatment. During the origin phase, a

pregroup stage, the therapist does intake,

selection, and diagnosis. The therapist

concentrates on group formation during the

formative phase. The intermediate phase I finds

the therapist building a viable and cohesive group.

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 He or she maintains the group through the

revision phase and guides group process toward

treatment goals during the intermediate phase II.

The therapist maintains the group through the

maturation phase and terminates the group in the

termination phase.

The Garland, Jones, and Kolodny model (1973)

has been the only group developmental model

specifically conceived for and illustrated with
children’s groups. Developed under Bernstein at

the Boston School of Social Work, this model is

based on the assumptions that closeness is the

central theme in the process and development of
groups, that a frame of reference can be employed

for perception and behavior, and that this changes

as the character of the group changes. Formulating

a conceptual outline for the tasks, process, and

structure of the group helps provide a normative

structure of healthy, normal processes. This model

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 is felt to be most complete by Whittaker and has

many similarities with that of this book’s authors.

The worker focus and intervention material is

solid and excellent. The five-stage model begins

with preaffiliation and the early struggle of

approach-avoidance of initial closeness. Power

and control issues surface in the second stage,

forming largely on the worker-group relationship.

Stage three, intimacy, is characterized by more
intense involvement and openness of feelings.

Differentiation follows as members accept and

evaluate each other and the group experience as

unique and distinct. Group and individual identity

are heightened during this phase of cohesion. The

last stage, separation, brings with it regression

and recapitulation.

Children’s group psychotherapists, recognizing

and labeling group phases, but not proposing

stage theories, are Anthony, Karson, Schiffer, and

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 Sugar. Anthony (1973) distinguishes three phases

of treatment; the initial, intermediate, and

terminal. Karson (1965) also describes three

phases. The first, lasting six to nine sessions, is

spent testing limits and utilizing play to express

feelings. Phase two, lasting twice as long, consists

of working through or redirecting hostile impulses

into sublimatory channels. This is accomplished

through the medium of model construction. The
last phase includes encouragement to plan

activities and deal with termination.

Schiffer (1969) labels four psychodynamic

group process phases that are based on the
interaction between the children and the worker

and are evolutionary, following an “elastic

timetable.” During the preparatory phase, reaction

is largely to the worker’s permissiveness, learning

and testing its realities, which lasts approximately

six sessions. The longest in duration, the

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 therapeutic phase, sees the development of the

transference on multiple levels, including

regressions, aggressions, catharsis, and abatement

of anxiety and guilt. The reeducational phase

evidences increased frustration tolerance, the

capacity for delaying gratification, sublimation,

improved self-image, more reality-oriented

identifications, successful group interaction and

responsiveness, and more efficient group controls.
Separation anxiety causes temporary regression

prior to acceptance during the termination phase.

Sugar (1974) recognizes three phases of group

treatment. The initial phase, lasting 6 to 15
sessions, moves the child from a state of isolation

through anxiety, resistance, and avoidance to

some cohesion and stability in group dynamics.

The middle phase reveals the group emerging,

talking about problems with one another,

revealing more dependency, and showing

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 identification—functioning as a cohesive, working

group. This phase lasts from 3 months to 3 years,

after which the child’s functioning has improved

and he can relate well. The termination phase lasts

from 3 weeks to 3 months, with both the child and

the group sharing sadness and separation anxiety.

Challenges

Scheidlinger (1968) reflected that in the 1940s

children’s group therapy had been a “major sphere

of clinical practice” led by the “leading pioneers”

(p. 445). The field has heavily concentrated on

Slavson’s models and their modification, with

much restatement of original theory. Redl and
Anthony also have had an impact, focusing issues

of the therapist’s role and group process

orientation. The field has lost momentum and

some of its greats, even since the 1960s. Anthony,

Durkin, Redl, and Scheidlinger have not continued

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 to advance theoretical and clinical developments

in the field because of other pursuits. Slavson and

Ginott have passed away. In the 1970s and 1980s

new theoretical developments have been reflected

in children’s and adolescents’ group therapy.

These are in developmental psychology (Frank),

object relations theory (Trafimow, Levin), and

peer relations theory (Grunebaum & Solomon,

1980, 1982).

A challenge is evident because of the paucity of

literature in several areas. Reference is made to

inadequate or nonexistent training programs as an

aside, with none being presented directly or in
detail. This area is important, since it is clear that

the qualifications and kinds of demands are

different with children and adolescents and in

some cases greater than they are with adults.

Discussion of supervision, co-therapy, and

transference/countertransference issues are of

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 utmost importance yet almost nonexistent in the

children’s and adolescents’ literature. Group

dynamics and group developmental models also

are scarce. Little is available on the internal and

external processes the group therapist

experiences, the multidimensional relationships

inherent in these groups, and the parallel

processes. This volume is an attempt to address

these issues.

As it is most unlikely that any one theoretical

and clinical model will encompass all types of

children and adolescents in all settings, there is

room for models to be developed with varying
orientations, goals, and techniques. In 1971 Kraft

stated that a therapist “should be exposed to

several theories from which he can evolve both a

pragmatic self-fit for work and a vocabulary to

describe what transpires. From the theories and

from his supervised experiences, he produces an

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 individualized therapeutic style that enables him

to work well and comfortably with his patients” (p.

636).

Serious challenges still face the field. As Kaplan

and Sadock (1971) have observed, “few therapists

have been trained for or are willing to undertake

the group treatment of children and adolescents”

(p. 516). There are losses to the field every day of

both learners and leaders due to other priorities
or to the difficulty and unpopularity of these

groups. There is too often a lack of peer

understanding and support and a lack of training

and supervision. These are extremely important
because of the high personal and professional

demands on the therapist inherent in leading

these groups. Greater responsibility remains with

those continuing to teach and practice in the field.

More meetings need to be held in professional

organizations, with perhaps a group identification

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 and recognition of needs. Studies of group practice

with children and adolescents are needed, not just

from a historical perspective but including who,

where, and what models are being practiced,

where training exists, and why there is not more

publishing and advancement of theory.

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Appley, D. G., & Winder, A. E. (1973). T-groups and

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Axline, M. (1947). Play therapy. Boston: Houghton

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Barcai, A., & Robinson, E. H. (1969). Conventional

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 of Group Psychotherapy, 27, 85–96.

MacLennan, B. W., & Felsenfeld, N. (1968). Group

counseling and psychotherapy with adolescents.
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psychotherapy literature 1968. International
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MacLennan, B. W., & Levy, N. (1970). The group

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MacLennan, B. W., & Levy, N. (1971). The group

psychotherapy literature 1970. International
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Pelosi, A. A., & Friedman, H. (1974). The activity

period in group psychotherapy. Psychiatric
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 with adolescents. Springfield, IL: Charles C
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Redl, F. (1942). Group emotion and leadership.

Psychiatry, 5, 573–596.

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York: Free Press.

Redl, F., & Wineman, D. (1957). The aggressive child.

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Rhodes, S. L. (1973). Short-term groups of latency-age

children in a school setting. International Journal
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Rose, S. D. (1972). Treating children in groups: A

behavioral approach. San Francisco: Jossey-Bass.

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psychotherapy for children. In M. Rosenbaum &
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Sands, R. M., & Golub, S. (1974). Breaking the bonds of

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 tradition: A reassessment of group treatment of
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 International Journal of Group Psychotherapy, 15,
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 Whittaker, J. K. (1970). Models of group development.
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 Chapter 3

STAGE I: PREPARATION

Margot Schnitzer de Neuhaus

Experiential Description

Someone comes up with the idea of having a

group. As the word spreads throughout the
agency, staff members react with varying degrees

of interest, some secretly hoping it will turn out to

be a fantasy, while others are curious about the

possibilities and consequences of carrying out

such an idea. The secretaries speculate about the

number of letters, appointment slips, and calls the

group would entail, while the receptionist

anxiously anticipates a problem controlling a

group of “those kids” while they wait for the group

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 to begin. Administrators warn about disruption of
“the proper working atmosphere” and the degree

of property damage that a group of unruly and

noisy children could inflict, always cognizant of

the image portrayed to the Director or the Board.

There are clinical staff skeptical about the idea,

those strongly opposed often from individual

treatment orientations. “Just because group

therapy is different, everybody wants to try it. Are

we going to allow our staff to submit to the

pressures of treating more, faster, and less

frequently, in hopes of better results and/or

cutting costs? What has become of the traditional

treatment with proven effectiveness? Is there

anyone trained to conduct these groups who really

knows what they are doing? Who would
supervise? What about getting the appropriate

room and equipment? Coordinating all of that

seems impractical, expensive, and confusing! What

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 parent would want to entrust his child to an

agency that would only compound his problems

by putting him in a room full of others just like him

or worse? Just imagine the noise! What will

happen to the agency’s reputation?”

On the other hand, there are some clinical staff

members who have experienced the effectiveness

of groups. Among them are the family therapists

and the therapists with some group training or
group experience. These are the ones who

promote group therapy with considerably more

enthusiasm. “It’s about time! I have a number of

patients who could use group therapy, some who
could use it in addition to individual treatment.

Who will be the therapist? I’m not sure that I could

do it now, not with my tight schedule; though it

would be interesting to try. Maybe grouping some

of my patients together I could participate in some

real changes around here.” The first wave of vague

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 rumblings and rumors moves through the agency

and subsides when everyone is somewhat aware

of his colleagues’ thoughts on the issue. Beginning

at this point, a more vigorous second wave moves

toward the higher echelons with openly verbalized

questions: “Are we really going to have a group?”

“Who’s going to lead it?” “Can we hire a group

expert?” Finally, the response from the

administration; “Yes, we will have a group.” “Is
there a volunteer therapist?” There is mild panic, a

disorganized reorganization of attitudes.

Emerging from this confusion, a group therapist is

appointed or has somehow volunteered.

In his attempt to gather himself and his

material together, the newly identified group

therapist can be seen scurrying around the clerical

area. The secretaries, in turn, are seen frantically

shuffling papers in an attempt to accommodate his

seemingly endless requests for information. On his

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 way back to his office, he is stopped by his

colleague: “I hear you are running The Group." The

idea has become reality with a title. They either

offer help or express their condolences for his new

assignment, their remarks often providing a

moment of comic relief. It serves as a startling

reminder that he is in new territory, experiencing

mixed feelings, and sometimes fumbling for

words, not knowing quite how to verbalize his
goals for the group. The therapist tries to remain

calm, returns to his office, and calls his co-

therapist. He or they focus on what kind of a group

it will be, turning to the literature and a supervisor

to help find direction and ease anxiety.

After careful consideration, the therapist

emerges from his office, having formulated some

formal guidelines, and directs himself to the intake

worker and the rest of the staff to request

referrals. Reviewing the referrals, the therapist

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 selects cases that seem most appropriate. He calls

or writes to them, and if they show interest in

participating, he schedules an appointment. The

administration relinquishes a room, hoping that

the therapist keeps the children confined to it and

that he quickly instills in them respect for the

room and its contents and agency rules. As the

clerical procedures are completed and interviews

with prospective group members take place,
everyone begins to accept the group as part of the

agency’s program.

Parents who have been contacted also

experience confused and mixed thoughts and
feelings. “They said Mark might benefit from the

group. Does that mean he’s in really bad shape or

that he’s not so bad after all? I know he fights with

everyone, but does that mean he needs a group?

Who knows what kind of kids would come to the

group from that neighborhood? Boy, I’d like to see

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 the person who thinks he can handle my kid and

five others like him! The idea of putting all of them

in one room at the same time! They’d probably

come out worse. Maybe that therapist will turn my

child against me. Maybe this won’t be good for him

after all. But the school and our neighbor have said

it’s a good place and it can help. I guess I’ll go hear

what they have to say and then make up my mind.

Maybe Mark won’t feel so left out and different. It
actually makes more sense than seeing him alone,

as his problems only show up when he’s around

other kids.”

At the same time, the child may be thinking

and feeling: “Kids like me in a group, huh? I

haven’t seen anybody like me yet! I can’t just tell

anybody what’s on my mind; they’d probably not

understand and might even make fun of me. It’d

turn out like it always does; the kids would do

something rotten, I’d have to do something about

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 it, and then I’d get into trouble for it. I’m getting

tired of feeling so messed up. I’ve tried to forget

about it, but it just seems to be getting worse. I

have no friends and those grown-ups are

constantly on my back. Maybe I do need help. My

counselor in school thinks a group would be good

for me. I wonder if the group therapist will talk

straight like my counselor? If he finds out what I’m

really like, he just might get scared to death and
quit, or worse yet, decide he doesn’t like me.

Maybe they’ll have snacks and the boy next to me

will become my friend. Perhaps it would be easier

to talk with other kids who are like me and could

understand. Adults don’t really, and I’ve had

enough grown-ups’ answers. I want kids’ answers.

I’ll go see what he has to say.”

The idea of the existence of a group reaches a

startling concreteness as soon as the screening

interviews begin. Dealing with becoming a group

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 member, the child’s and parents’ feelings become

acute. After interviewing many potential group

members, the therapist reviews the names of

suitable candidates, coming up with a combination

that might be motivated and compatible. As he

selects the children he also takes into

consideration the degree of commitment to the

treatment process of the parents and of each child.

Now that the preliminary work is behind him, he
is relieved and eager to begin. “I wish I could start

right away. It seems like a nice bunch of kids. It’s

going to be interesting and fun. I’d better ask the

secretary to send the appointment slips for the

first meeting. I wish I had a two-week vacation

between now and then!”

Concurrently, the parents are nervous and

concerned about how their child will fare in the

group; the child may be thinking what he will wear

the first day. “I wonder who will be in the group

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 and if they will like me?”

The day of the first session has arrived. The

children, parents, and even the therapist did not

sleep well the night before, as they mulled over

their fantasies and fears about the new group.

They are nervous and impatient as they get ready

for their appearance at the agreed time and place.

Dynamic Description

The preparation stage is an integral and crucial

part of the process and outcome of group therapy.

Most stage theories in the literature usually begin

with the first session. A notable exception to this

in the practice literature is Sarri and Galinsky’s

(1974) model of group therapy. They include a

pregroup stage, origin phase, covering the period

of intake, selection, and diagnosis. Our stage

covers a similar period, beginning with the

inception of the idea of the group up until the first

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 session. Braaten (1974/1975) in his composite
model also included a pregroup phase.

Conceptualizing, screening, composing, and

balancing the group are the important tasks that

must be accomplished by the therapist during the

preparation stage. The stage conveniently divides

into three conceptual phases. The first
encompasses the preparatory efforts made by the

agency in establishing a group treatment program.

It begins with the inception of the idea of group

psychotherapy, including the decision-making

process, through the arrangement of

administrative and clerical details that precede the

functioning of the group, up to and including the

selection of the group therapist.

The second phase entails the therapist’s

preparatory efforts in becoming the group

therapist of this group. This preparation is

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 emotional as well as intellectual and practical.
First he establishes his position vis-a-vis the group

in terms of his capacities, preferences, objectives,

and treatment orientation; then he selects and

defines the composition of the group. He takes into

consideration his role and the agency needs and

expectations.

The third phase pertains to the child’s and the

parents’ preparatory efforts in becoming

participants in the group treatment program. It

includes the screening process to select the

appropriate candidates who would form a

working, well-balanced group. This phase also

includes an explanation by the therapist to the

parents and child of the conditions necessary for

group treatment to take place, including the

portion of the work to be done by each. It also

establishes the beginning of the trusting

relationship between the child, his parents, and

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 the therapist. This relationship serves as a bridge

for the child to the group and to all future

relationships within the group. The relationship

provides the parents with guidance and support in

allowing their child to undergo the treatment

process.

Clearly, the work accomplished during this

stage affects the readiness of the agency to have

groups, of the therapist to conduct group therapy,
of the group composition to be balanced yet

dynamic, of the group candidates to undergo the

group treatment, and of the parents to allow their

children to do so.

The Agency

Agencies providing clinical or psychiatric

services for children and adolescents at some

point consider the issues involved in including

group therapy as a treatment modality. This

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 consideration may be motivated by administrative
or clinical staff, internal service demands, a

decrease in staff and funding, and/or outside

community pressure. The agency’s characteristic

decision-making patterns in the establishment and

carrying out of procedures and programs will be

evident again in this process of considering and

forming groups. In addition to agency setting,

funding, and population served, agency theoretical

orientation, training commitments, staffing

structures, diagnostic and treatment services, and

physical facility influence the type of group,

composition, goals, duration, and staff hired.

Consideration involves pros and cons. Some

inconveniences result from a group of five to

seven children; noisier halls, greater risk of

property damage, difficulty with control,

additional clerical and staff time, special supplies,

equipment, and room. Often there is general

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 agency upheaval, and personnel with special skills

are necessary. On the other hand, some children’s

problems are better serviced through group

therapy, and it can augment other treatment

modalities. In addition, a more flexible,

comprehensive service can be provided. Often

shorter waits for service and favorable economic

conditions are achieved by running groups.

The agency is responsible for providing a

climate supportive of and conducive to successful

groups. This includes selecting and training the

group therapist; providing supportive backup

clinical services, such as diagnostic evaluation,
individual treatment, parental treatment, and staff

available to handle crises as necessary; supportive

clerical and maintenance staff; provision of

equipment, room, and house rules.

When the agency is physically and

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 psychologically prepared to tolerate the noise and
stress, the therapist and children are not placed

under as great a strain. In most settings it is

helpful to have a cooling-off place in the hall

and/or a time-out, quiet, or freedom room where

the child can safely regain control and then be able

to return to the room to continue therapeutic

work. Unless there are co-therapists, and even

sometimes when there are, another worker will

need to be trained and used to help man the hall or

quiet room. This may be a child care worker,

nurse’s aide, milieu worker, volunteer, or another

staff member who makes himself or herself

available during the group time. The person who

monitors the hall is responsible for watching the

child and not leaving him or her alone, but the

therapist must be involved in placing the child in

the room, along with dealing with the child’s

feelings and again with handling them once the

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 child has returned to the group room.

When a positive, accepting attitude toward

group psychotherapy is adopted by the agency

administration, it has a great impact on the

attitude of the rest of the staff. They feel supported

in their struggles with the changes necessary

when groups are formed. Adequate

communication, trust, and good will among

administrators, staff, and therapist help in the
understanding of the parallel processes that are

played out during the duration of the group as it

passes through various stages.

Sometimes in addition to the support the

agency supplies, the therapist must work

specifically with colleagues and ancillary staff,

listening to their fears and concerns, providing

enough understanding and support for them to be

able to carry out their portion of the

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 responsibilities to the group. Staff can be
interested in fulfilling their roles in getting the

group started or they can resist, procrastinate, and

even sabotage the therapist’s efforts. At times

colleagues may not make referrals or they may be

grossly inappropriate; appointment slips may not

be sent or equipment not ordered. Sometimes the

therapist must do as much education and

preparation of the staff as he does of the children

and parents to ensure a smooth and successful

beginning and progression of the group.

Kadis, Krasner, Winick, and Foulkes (1963)

also stress preparation of all personnel

responsible for and having a part in the

implementation of group therapy programs in

order to ensure initial and ongoing cooperation. In

institutional settings where a clear hierarchy

exists, “the group therapy program may do much

to dispel sources of staff conflict and tension. It

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 unites professionals of various backgrounds,...

facilitates communication … and may tend to

enhance mutual trust” (Kadis et al., 1963, p. 26).

When it offends or threatens certain staff, this can

often be “overcome with the passage of time and

education” (Kadis et al., p. 26).

Barcai and Robinson (1969) highlight the

importance of agency atmosphere and degree of

cooperation in their comparison study in two
different schools. In one school, where

administration appeared concerned with

discipline, frustrations and impediments were

repeatedly present, and it was felt that underlying
messages had been transmitted and had affected

the children’s response to therapy (p. 344).

The Therapist

Ambivalence is experienced by all group

therapists. The range and intensity of the

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 therapist’s affect varies according to character
structure, amount of experience, and motivation

for assuming the responsibility. Vacillating

between feelings of enthusiasm and expectation,

fear of personal or professional failure, anxiety

and varying degrees of panic, each therapist

utilizes defense mechanisms common to his or her

personality structure to deal with these intense

feelings. If the therapist has been coerced into

running the group, he or she must deal with any

anger or resentment present so that unresolved

feelings do not interfere with a successful

outcome.

While forming the group, the therapist has

several issues to consider and decisions to make.

These involve personal and professional interests

as well as characteristics specific to this group.

Personally, he or she may feel motivated to run a

group because of curiosity, challenge, growth

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 experience, and intellectual knowledge.

Professionally, the therapist may want to further

his or her experience by experimenting with

different group therapy models, types of

populations, groupings, goals, techniques, and/or

co-therapy. After considering these preferences,

the therapist must consider and choose a

theoretical orientation, treatment approach, group

composition, and treatment goals. Certain “given”
characteristics, such as agency population, as

defined by geographical location, economic, and

ethnic backgrounds, as well as severity and

manifestation of disturbance, must also be

considered. Other practical givens include the

agency’s clinical requirements, definition of the

therapist’s role, and availability of an appropriate

room.

Through self-searching and discussion with

colleagues, supervisor, and co-therapist, the

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 therapist balances these professional, personal,

and practical considerations. With an effort to

maintain consistency of theoretical framework,

technique, composition, and goals, the therapist

emerges with a set of guidelines. Prospective

group candidates are evaluated in terms of these

in order to choose children who would appear to

benefit most from this group.

The screening interviews are taxing due to

their dual purpose, assessing and educating the

prospective members. Considerable skill,

experience, and intuition is helpful in selecting,

composing, and balancing the group. Pressure is
felt to avoid making a wrong decision, which could

mean leaving out a child who should have been

included, or including one who would later prove

to be inappropriate. Such mistakes are made and

are reparable, but they also are painful for all of

those involved. In spite of the care and time taken

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 in choosing the group members, the therapist does

not “really know” how the child and group are

going to function until the group has begun to

meet. He or she often has to change goals and

guidelines, compromising original expectations

and hopes. The therapist must resolve his or her

feelings regarding these changes so that they do

not interfere with the treatment.

After selecting the children, choosing the room,

deciding on the inclusion or exclusion of

refreshments, toys, games, and activities, the

therapist completes the necessary administrative

and clerical details. Even if the therapist does not
have the full quota of children by the time the

group is scheduled to begin, he or she may choose

to begin, telling the children one or two may enter

the group later. At some point during this lengthy

process, his or her role as group therapist has

become accepted and internalized. He or she is

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 now The Group Therapist, the group is his (or her)

group, and he or she is ready to begin.

The Parents

The feelings parents experience as they contact

the agency depend on their motivation for seeking

treatment. Their feelings are affected by their level

of awareness of the problem, their desire and

capacity to change, and their ambivalence. Some

parents who appear motivated for their child to
get help may be merely projecting their own

problems onto the child. They may be. overly

identified with their child or cannot face their own

difficulties. These parents may lose interest in the

treatment or sabotage it once the child begins to

change. Ideally, these parents need a strong

therapeutic relationship for themselves from the
beginning of their child’s treatment for them to

allow their child to remain for the duration of the

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 group.

All parents are ambivalent at a conscious or

unconscious level of awareness, sincerely wanting

to do what is best for their child, at the same time

sensing that obtaining this necessitates change, a

feared unknown. Fearing change and

confrontation of painful hidden issues, their

patterns of denial further reinforce avoidance. The

therapist helps these parents confront their
ambivalence. If their child is selected for the

group, these parents may need some form of

therapy throughout the group’s duration to ensure

they do not sabotage the treatment.

Both at this early stage and throughout

treatment, common questions and reactions are:

What is the cause of the problem, what is the

therapeutic process, and what is the expected

outcome? This questioning is similar to that of

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 individual psychotherapy. Realizing the need for
more help than they have given, parents question

their effectiveness, wondering if they are to blame.

They see themselves as good parents, loving and

caring, having made repeated efforts to raise their

child “the right way.” They are guilty about all the

times they may have overreacted, hit when they

should not have, and yelled when they should have

understood. Confused and vacillating in their

reactions, they may fear an innate or acquired

“badness,” “meanness,” or “craziness” in

themselves and/or their child. They wonder, “Will

I recognize my child when it’s over? Will you turn

my child against me?” They want relief but fear

disharmony, loss, and even their inability to

change. This new experience needs guidelines and

ways to begin trusting, as they often fear rejection

and criticism. How successful the therapist is in

gaining their support and trust will profoundly

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 influence the entire treatment process. Parents at

this stage are equally as important as the children.

In spite of the therapist’s caution and

preparation, some parents get so confused and

overwhelmed that they are unable to hear

answers and accept emotional support. They resist

further involvement, dropping out because they

sense they are not ready or able to handle this

complex and difficult process. All parents resist
dealing with parts of the process at one time or

another. If only a few questions surface at this

stage, these and others need to be confronted later

in order to deal with resistances and to ensure the

parents’ continued cooperation. Parents need
differing amounts of help and emotional support.

The Child

Sometimes the child has not been told the

reasons for the screening interview and may have

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 just heard about the group. Regardless of what he
has been told, he feels anxiety and senses it in his

parents. The range of fantasies and feelings he

experiences may be distorted, due to nonverbal

and verbal messages and feelings he received from

his parents, peers, and community. His internal

concept of himself as possibly being “sick,” “bad,”

“mental,” or “crazy” is affecting him. As he is faced

with the reality of the interview, he may be

experiencing and may show any combination of

fear, anger, panic, frustration, denial, resistance,

embarrassment, shame, guilt, and relief.

Throughout the screening interview, shifts in

the child’s responsiveness may be evident as

intense ambivalent feelings and resistances

surface. The child handles these with defense

mechanisms characteristic of his or her

personality structure. A highly anxious child may

hear little of the interview. However, usually a

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 child is able to grasp at least the essence,

understanding that the group is being planned and

that he or she is being considered for it.

At this point a child may want nothing further

to do with becoming a member of the group. That

child may feel threatened and wish to flee or

simply may be not interested in a group but will

ask about the other treatment modalities. Another

child may want what the group seems to promise,
feeling relieved and calmed as he or she stays and

hears more. Such children will then attempt to

formulate the problems that they feel need help.

Children converting their difficulties into action
will need help in verbalization, as may children

who have had no previous treatment. At the end of

this interview the therapist informs the child and

parents whether the child would benefit from

group therapy. Whether or not he or she is

accepted for the group, the child will respond with

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 ambivalence. The child needs to understand the

reasons for the outcome and needs preparation

for whatever lies ahead.

Special Issues

The issues in this section are delicately and

intricately related. They are the first steps taken in

establishing the therapeutic communication and

relationship-oriented focus.

Group Selection and Composition

The selection of the group theory and model,

size and members, must follow a consistently

integrated pattern. It is first in the art of group

psychotherapy and relies heavily on intuition and

experience. Guidelines in the practice literature
are confusing, difficult to compare, and sometimes

contradictory. These two inextricable issues will

be handled together in an attempt to clarify and

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 highlight.

Ideally, the therapist has control over the type

of group chosen and the membership. Factors

contributing to this choice include the therapist’s

training and professional motivations. Much of the

format of the group is inherent in the choice of

theory and model. Goals, techniques, size,
composition, duration, frequency of sessions, and

room are integrally related to these theoretical

approaches and cannot be handled separately.

Yalom (1970) reviews the literature on

selection criteria in adult groups and comments on

the lack of consensus, highly individualized

terminology, contradictions, and scarcity of

guidelines. More exclusion (brain damage,

paranoia, extreme narcissism, hypochondriasis,

suicide, addiction, acute psychosis, sociopathism)

than inclusion criteria are presented. There is a

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 clinical consensus that exclusion should be on the
basis of the patient’s inability to participate in the

primary task of the group, that is, to relate to other

group members. Yalom’s study identified two

variables predicting success; a patient’s attraction

to the group and a patient’s general popularity in

the group, which seems related to his high degree

of self-disclosure and ability to introspect. The

therapist’s positive personal feelings toward the

patient also were determined to correlate with

success. Yalom further states that if change is to

occur, compatibility must exist between the

patient and the interpersonal need culture of the

group and that cohesiveness must be the primary

guideline utilized in selection. In other words,

individual selection should be based on the lowest

likelihood of premature termination, and the

group must be balanced for the greatest likelihood

of cohesion.

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 In the children’s group literature one finds

listings of clinical and characterological traits of

children that are indicated and contraindicated for

various types of group therapy (Ginott, 1961;

Slavson, 1955). Peck and Stewart’s (1964) survey

of playgroup therapy in child treatment facilities,
reported 77 percent of the responders had

exclusion criteria. Nearly all considered age and

sex as indispensable variables, 76 percent

considered intellectual level important, and 68

percent considered diagnostic classification and

dynamics as important. The most frequent

practice was heterogeneous grouping by

dynamics, “but the ability to interact with others

was considered to supercede this consideration”

(Peck & Stewart, 1964, p. 146).

Bertcher and Maple (1974) and Rose (1972)

are of the belief that behavioral attributes are

better predictors of individual behavior in groups

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 than are descriptive attributes such as age and sex.

The behavioral attributes are the ways a child acts

or is expected to act based on his or her past

performance. The critical attributes the group

therapist is looking for depends on the group

objectives and development. Rose ranks

behavioral assets and deficits on a scale from 1 to

10 and will place a child in a group only if another

is near him on most continua (pp. 23-24). Bertcher
and Maple have devised a more elaborate method

of ranking and charting these attributes on a linear

continuum, with plusses and minuses, allowing for

decisions regarding composition to be done

almost arithmetically. They find greater comfort is

experienced if descriptive attributes are similar.

Yet too much compatibility makes a group

ineffective, as does too much stress, inadequate

identification models, and negative subgroups.

Therefore, Bertcher and Maple present a way of

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 choosing two children from each cluster of

identified critical behavioral attributes as their

way of balancing for interaction, compatibility,

and mutual responsiveness.

Along these lines, Slavson (1955) states that

the chief requirement for including a child in

activity group therapy is the child’s desire to be a

part of the group and his ability to establish object

relationships. Additionally, “he must have
potential capacity to give up his undesirable

behavior in return for the acceptance by the

group” (p. 24), which Slavson terms social hunger.

He further states that there are only two

contraindications for placement in any type of
group: those that derive from inherent problems

of the patient and those that may have an adverse

effect on each other and the group. He further

states that placement considerations require

objectivity, training, and experience (p. 30). Redl

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 and Wineman (1957) also state that a clinical

group program must be in operation for many

years prior to the development of an adequate set

of criteria for selection. “Experimentation with

different problem intensities and types has first to

be done in order to begin to perceive clearly what

the particular design has to offer to the treatment

of different problem patterns found in various

children” (Redl & Wineman, 1957, p. 48).

Paradise and Daniels (1976) assert that taking

“needy” and “what-is-available” children will

produce groups whose outcome is as good on the

average as those more thoughtfully composed and
selected (p. 37). In addition, these authors avoid

utilizing diagnostic categories and caution that

there are no rules, do’s and don’ts, in the area of

group composition. From their experience they

identify 15 factors to be considered, the most

important of which are developmental level,

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 intelligence, skill, ego controls, tolerance of

behavior differences, ability to communicate,

ability to delay gratification, and a need to belong

to “this” group (p. 44).

Charach (1983) describes the “winnowing”

process occurring in clinics despite warnings as to

its inadvisability. This is the practice of seeing the

most promising, verbal candidates in individual

treatment and the least verbal, most physically
active children in group therapy. “One is far more

likely to find the three most disturbed or

otherwise unmanageable patients in a group than

to find the three most promising children in group
therapy at the same facility” (Charach, 1983, p.

351).

Only one empirical study was located that was

in a residential facility for acting-out children.

Johnson and Gold (1971) concluded that the

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 selection of group members was not the crucial
outcome variable but rather fitting treatment

techniques to the type of children selected for the

group and their behavior patterns.

The authors are in agreement with Paradise

and Daniels (1976) that “composition per se is but

one factor influencing the life of the group” (p. 37).
The number of children who can benefit from

groups is numerous and so intricately related to

goals and techniques that a list of inclusions and

exclusions is irrelevant and fails to provide

adequate guidelines on how the child will function

in the group and how these characteristics will be

expressed in a group. A child should not be

globally excluded from group therapy because of

inappropriateness, rather “this specific group or

model is inappropriate for this child for this

reason.” Thorough and careful placement is crucial

for the outcome of treatment along with matching

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 technique to selection to goal. Some children who

would be typically excluded from groups can

succeed if the group is properly selected and

balanced.

Although existing models may lack in

applicability and flexibility, the novice therapist is

not advised to change or modify design, selection,

and technique, nor to choose only partial theories

or models. The therapist’s strong preference for a
certain diagnostic category, technique, or group

structure may not be harmonious with a model he

chooses. Introducing simultaneous and unknown

variables affects the process, outcome, and ability
to sort out issues. As a therapist gains experience,

he may wish to change or modify slowly so that

the unknown variables are few and can be closely

observed. Many a new group has been doomed

from inception because of incongruities among

size, composition, theory, and technique. This

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 harmony should exist prior to the selection of

group members.

In children’s group therapy practice there is

considerable agreement regarding an optimal size

of five to seven children dependent on the group’s

composition. Factors influencing the number are

the age, degree of acting out, manifestation of

disturbance, and existence of co-therapists.

Usually a maximum of six with one therapist is
recommended (Karson, 1965; Levine, 1979; Sugar,

1974). Ginott (1961) limits this to five in play

group therapy with preschoolers. The authors are

in agreement with Sugar that if the children are
very anxious, active, aggressive, or hostile,

frequently four or five is a more ideal number.

Barcai and Robinson (1969) feel the larger the

number of aggressive children, the smaller the

group should be. If attendance problems are

extreme, eight or nine children may need to be

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 included to assure five or six being present.

Karson (1965) points out a need for 10 prospects

in order to select six appropriate candidates.

The two most important aspects in

determining the number of children are the

developmental level at which the children are

functioning and the mode of expression of the

children’s disturbances. Often the more severely

disturbed a child is found to be, the wider the
discrepancy between his or her developmental

level and that of his or her less disturbed

chronological age mates. If the mode of expression

is extremely aggressive, assaultive, hyperactive, or
bizarre, such children require more attention,

control, and care than those whose disturbance is

expressed less violently. Size is frequently

decreased by the therapist with younger children,

with more severely disturbed children, with a

group whose goals require specific, concentrated,

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 and time-limited work, with a small group room,

and with the therapist’s self-knowledge that he

feels more comfortable managing a smaller group.

In contrast, the size of the group is increased by

the therapist with the addition of a co-therapist,

with the need to improve the group’s balance, with

children who are relatively intact and have

internalized controls, with the necessity of

meeting the agency’s quota to cover expenses, and
with a group whose goals are broad and open-

ended.

Age spread in a group of younger children is

generally 1 (Ginott) to 2 years and for latency and
adolescents, up to 3 years. The span should be less

if games or activities require more even skill and

ability levels. Preschool can be mixed gender.

Sugar and Ginott prefer same-sex groups in

latency and adolescence to meet the differing

developmental and social needs. Mixed-gender

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 groups can be successfully accomplished in

latency and early adolescence. It has also been our

experience that strict chronological age

consideration is not as important as maturity,

social adjustment, school age, or developmental

levels. We are in agreement with Soble and Geller

(1964), that chronological age and diagnostic

classification are not as important as social and

emotional development of the child.

Screening

Considerable importance is placed on the

process of thoughtful screening and educating of

prospective group members. It is extremely

helpful if the child has had a thorough diagnostic

evaluation prior to the screening interview. It

gives information to the therapist on the
appropriateness of group therapy—that is, level of

object relationships, trust, quality of friendships

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 and peer relations, and the nature and degree of

psychological and social disturbance. When

dealing with a severely disturbed child, it is

frequently helpful if he or she has had previous

individual treatment. At times a full diagnostic

evaluation should precede a recommendation for

group therapy.

Without prior clinical observations and

formulations the therapist must assess whether
enough history and clinical material is available

through the screening process to be comfortable

accepting the child in a group or whether an

additional diagnostic appointment is indicated.
Consequently, after treatment begins, the

therapist must be prepared for possible dramatic

shifts in the predicted patterns of behaviors and

feelings.

The purposes of the screening interview are to

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 judge the child’s motivation and capacity to
engage in group treatment; to judge the parents’

ability to allow the child to undergo the treatment

process; to obtain a diagnostic impression of the

child; and to explain to the parents and the child

the function and responsibilities of the group,

child, parents, and himself or herself as group

therapist. The main purpose is to begin a

relationship with the child so that entry into the

group is easier for him or her.

The therapist begins the interview by asking

what concerns the patients have and what they

want of the agency, frequently asking the child

first. Their answers and further exploratory work

around the beginning and development of the

child’s problems provide the therapist with some

of the information he or she is seeking. Seeing the

child alone provides additional material and

privacy, which frequently allows children freedom

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 they might have lacked in their parents’ presence

to communicate their concerns, strengths, and

weaknesses.

The therapist uses all of his or her diagnostic

skills and experience in evaluating the child’s

appropriateness not only for group therapy but for

this particular group. The questions the therapist

is trying to answer are many: “Can this child see

his problems as others do? Can he see his role in
them? Can he identify with the feelings of others

and empathize? Is he open, motivated, appropriate

and willing to share of himself? Does he have

flexible defenses and energy available for change
and therapy? Can he delay gratifications enough to

tolerate the necessity of sharing in a group? Does

the child’s lack of anxiety and fluidity of speech

indicate few defenses or internalized controls, ego

weakness or boundary problems? Will such a child

out of self-preoccupation need to monopolize the

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 therapist or the group? Could this child serve as a

catalyst for the others? Will the child who is

mostly silent be more communicative in a group?”

Initial impressions need to be thought about and

discussed with others, such as the child’s

therapist, his teacher, and the group consultant.

On occasion the therapist feels a need to

schedule an additional interview before the group

begins. He or she may assess that a more
disturbed child needs extra time to establish a

minimal trusting relationship with the therapist.

He or she may need to see the parents again in

order to insure their cooperation or because a
more formal treatment contract needs to be

established. However, it must be stressed that the

need for these be carefully assessed with the

consultant in order to prevent

countertransference reactions and establishment

of an individual relationship with the therapist.

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 Experienced individual therapists but novice

group therapists must be especially warned of

this, which may relate to anxieties about doing

group therapy. Any additional interviews should

focus on preparing the child for group therapy.

The therapist’s need for more interviews may

indicate a need for a case review, staff conference,

or diagnostic evaluation before placement in a

group.

Diagnostic groups have been found helpful as a

part of the diagnostic process to gain peer-related

information not seen or available in individual

interviews (Churchill, 1965; Gratton & Pope, 1972;
Redl, 1944). Even though individual screening

interviews are more often utilized as predictors of

group behavior, they are not especially accurate

predictors of behavior exhibited in a group. This is

especially the case with children who translate

anxiety and issues into activity, both their own

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 and those picked up from others in the group.

Group observations can confirm or deepen other

staff observations and sometimes reveal children

behaving very differently in the presence of other

children or with children and an adult from the

way they behave when seen alone. Churchill

(1965) usually sees six children in four sessions

that are structured for exposure to specific

stresses and social and emotional tasks. Ganter
and Polansky (1964) utilize diagnostic groups to

predict a child’s accessibility to individual

treatment. Occasionally concurrent diagnostic

parent and child groups are held to gather

relevant diagnostic information in place of a team

diagnostic (Demsch & Brekelbaum, 1969).

The therapist is now ready to make his or her

final decisions on group selection based on the

results of the screening interviews. Those cases

chosen for the group consist of children who are

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 ready to work on their own problems and on the

common group goals, who fit in harmony with the

balancing needs of this group, and whose parents

are able to allow them to engage in the treatment

process.

Some groups are predetermined. If such is the

case, the therapist must focus on resolving his or

her own feelings about this lack of choice in order

to be prepared to assume the group therapist role.
If the group is inherited from a departing

therapist, he or she needs to resolve his or her

feelings about a group attached to and used to

another therapist’s style, as well as insecurities
regarding his or her ability to lead a group under

these circumstances. On the other hand, the

therapist may rejoice in not having to make the

difficult screening decisions.

Balancing

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 In addition to selecting and screening, the

concept of balancing is widely recognized as

extremely crucial in group composition. The

authors utilize the term balancing to refer to the

weighing and fitting of various physical,

emotional, psychological, socioeconomic, and
personality characteristics and attributes of

potential group candidates, so that a dynamic and

flexible equilibrium that includes tensions and

differences can be established and maintained

throughout the process of group therapy. To

balance is to ensure the flexibility and resiliency

that will enable and encourage healthy change,

intimacy, achievement of goals, and successful

treatment. Although abstract, balancing is all-

important to the dynamic process and group

growth. If a group is out of balance, it can become

stagnant and unable to move away from a

sometimes defensive or pathological position. A

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 stuck group cannot progress through further
stages of treatment unless membership changes or

the therapist can introduce enough of a shift in

structure, stimulation, or motivation to precipitate

the group’s movement. Group equilibrium is a

dynamic, ongoing process that ebbs and flows as

the group moves through the stages of group

treatment. The therapist chooses the membership
in an attempt to achieve this dynamic flow and

continues to keep it in mind throughout the

group’s existence. Sometimes in later stages the

therapist must introduce a change in structure or

membership to re-achieve this balance.

A balancing concept is referred to by other

descriptive labels by group therapists: Ginott

(1961) likens it to matchmaking; Schiffer (1969),

to checks and balances. Slavson (Slavson &

Schiffer, 1975) has established well the concept of

psychologically balanced activity groups that will

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 foster trust, relaxational security, empathy, and

achievement of a state of dynamic equilibrium. His

requires a balance of behavior patterns such as

positive and negative instigators, neutralizers, and

neuters. Schiffer (1969) interjects that it is not

enough simply to select an equal number of

aggressive and withdrawn children, as there are

initial qualitative differences in the nature of

passive and aggressive personalities and
modifications that evolve as a result of group

interaction. Due to the permissive role function of

the leader in this type of group, the appropriate

blend of children is absolutely necessary so as to

allow eventual neutralization of inappropriate

behavior through self-regulation. Ginott (1961)

strove for a harmonious combination that could

allow optimum tension yet be a haven from

persecution. He added that it should provide a

diversity of identification models yet exert a

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 corrective identification influence. Axline (1947)

allowed the child to invite playmates of his own

choice to make up the group. Paradise and Daniels

(1973) report an imbalance occurs when the

members are too similar. They seek to achieve a

dynamic balance in the following areas: passive–
aggressive; highly skilled-unskilled; other-

oriented–self-oriented; likable-unlikable; poor

reality testing–good reality testing; suggestive–

resistive to contagion (p. 42).

Both homogeneous and heterogeneous

groupings can be effective. With children’s groups

the concept of balancing has weighed heavily in

favor of the peer group membership balancing
itself naturally through composition. Traditionally,

this has been done by balancing active and passive

children. This is not possible when dealing with

homogeneous populations such as acting-out,

aggressive, delinquent, severely ego-impaired,

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 psychotic, and severely socially deprived. In these

groups, although some factors balance naturally,

others—such as limits and control, ego and

superego functions—remain the responsibility of

the therapist. By carefully structuring the group,

successful experiences can be provided for these

homogeneous groupings as demonstrated by

Frank (1976), Ganter, Yeakel, and Polansky

(1967), Lifton and Smolen (1966), Redl and
Wineman (1957), Scheidlinger (1960, 1965), and

Speers and Lansing (1965). A combination of

tightly structuring the format and group

interactions and the therapist’s lending his or her

ego, even at times taking over the group ego and

superego functioning, helps accomplish a

successful grouping with these populations

otherwise not suited for group therapy. Other

homogeneous groupings, such as underachieving,

school-phobic, or learning-disabled, may be more

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 loosely structured due to the presence of greater

ego controls in the children.

Homogeneous versus heterogeneous grouping

is really more of a pseudo- than an actual issue

(Johnson & Gold, 1971). More relevant issues are

which factors to balance or make homogeneous

(age, sex, race, diagnosis, problem, behavior, goal)

and how to use treatment techniques to work

effectively with the selected children in a group.
Heterogeneity in manifestation and degree of

disturbance, as well as in areas of strength and

weakness is important. In their work with adults,

Whitaker and Lieberman (1964) strove for a

maximum of heterogeneity in the patient conflict
area and pattern of coping and homogeneity in the

areas of tolerating anxiety and vulnerability.

An attempt should be made to try to ensure an

interesting, dynamic group that encourages

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 discussion, positive identifications, and growth at
many levels. It helps when children share some

common denominators, such as presenting

problems, goals, minority status, behavior,

personality patterns, and group roles. Often group

balance, understanding, and appreciation of others

is enhanced when children with reverse problems

or symptoms, such as withdrawn and acting out,

impulsive and inhibited, are included in the same

group, as long as some children are in between.

Successful balancing of composition rests on the

therapist’s theoretical orientation, experience,

intuition, and consultation, as to which

combination leads to the best working process to

reach the intended goals.

Goal Setting

Aims, purposes, and objectives are included in

the definition and discussion of goals. The

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 therapist’s goals and philosophical approaches are

influenced by the composition and model of group

therapy. Frequently reasons for referral develop

into treatment goals. These are long-range, short-

range or intermediate, general or specific, for the

group as a whole and for the individual child. All

are intimately related to the overall treatment

plan for the group and the child.

Individual goals are set by the child and the

therapist together. If the child has difficulty

formulating his or her own, the therapist

encourages and helps him or her to participate in

the process. The child’s parents may or may not be
present during this formulation. Adolescents

frequently set them alone with the therapist,

whereas preschoolers have them mainly set for

them by the parent and therapist in the child’s

presence. The goals depend on motivation and

capacity to work on them.

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 When group composition is known, the

therapist defines a tentative set of group goals;

these are more formally set by the therapist and

group together after the group begins. The group

goals often are established from individual goals

that may be common with other group members.
They further need to be realistic, not too difficult,

and obtainable. In addition to goal formulation,

Rose (1972) and Churchill (1959) advocate setting

individual and group objectives for every meeting.

Lowy (1976) states six principles relating to

the goal formulation process. Goals should stem

from diagnostic assessments, be stated in

behavioral terms with a desired outcome, refer to
improved functioning, be achievable, be ordered

according to priorities, and be a shared process

between members and workers (Lowy, p. 13).

The following is a sampling of possible

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 individual and group goals:
Learn social skills (getting along with others)
Learn to trust and be open
Learn how to become a friend
Learn how you feel about peers and siblings
Learn to share
Learn to observe how others handle conflicts
Learn alternative modes of looking at and responding to
situations
Learn to change patterns of relating, i.e., bully, cry baby,
know-it-all, mother’s helper
Learn to develop group membership and identification
Learn self-skills (who you are, what makes your self-system
work)
Learn to recognize, label, and talk about feelings
Learn to talk about yourself (what you want from yourself
and others)
Learn how to get feedback about your behavior and
personality characteristics
Learn about your defense mechanisms
Learn how you cope and handle stress
Learn new ways to soothe and comfort self
Get help seeing and maintaining reality contact
Develop a positive social self-concept
Learn to get along with adults

Learn how you feel about adults

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 Learn to trust and be open with adults
Work on individual contracts and/or concrete goals
Stay in the room for 10 minutes
Refrain from physically hurting anyone
Refrain from whining or hitting
Talk instead of hitting
Stop thumb sucking
Increase discussion time from 5 to 10 minutes

Structuring and Setting Up the Group

Decisions about the group’s structure are also

made during stage I and must meet the needs and

capacities of the children. The authors’ definition

of structure differs somewhat from common

usage. It includes format and method of

introducing the function, limitations, and

dimensions of the therapeutic relationship. It is

inherently related to the role and function of the

therapist and use of group time and activities.

A common structure for latency-age groups is

to divide the group’s time into an activity and a

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 discussion phase. Some hold the activity phase
first (Schachter, 1974; Schiffer, 1977), whereas

others hold it second (Anthony, 1973; Karson,

1965). Anthony utilizes the discussion phase to

choose an activity for the group during the activity

phase. Soble and Geller (1964) begin with

discussion followed by activity and end with a

closure phase of snacks. Frequently the verbal

portion begins with 10 minutes and is gradually

extended as the group’s capabilities for discussion

increase. Karson prefers meeting in a conference

room for the talking portion and in a playroom

with expressive toys for the activity time. Some

therapists divide time between play and

discussion flexibly. Activity group therapy

(Slavson and Schiffer, 1975) and play group

therapy (Ginott, 1961) are unstructured,

remaining in the activity room or playroom for the

entire session and not formally changing formats.

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 Room, equipment, and space requirements for

conducting group therapy vary, depending on the

model utilized and how activities are

incorporated. Although typically excluded from

group psychotherapy literature, social group

workers have done rather detailed program
analyses, matching activities to specific group

requirements, taking into account age needs,

space limitations, and developmental stages

(Churchill, 1959; Little & Konopka, 1947; Redl &

Wineman, 1957). Ganter et al. (1967) present an

example of utilizing repetitive limited activities to

provide necessary limits and boundaries that

seriously disturbed children can incorporate,

while also providing successful skills and learning

experiences. Although Whittaker (1974)

advocates the creative use of activities, he does so

only after exploring the “built-in” dimensions of

the activity and the individual and group variables.

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 After analyzing program activities along six

dimensions, he establishes an “ideal activity

profile” for each child in a group (pp. 244-257).

Anthony (1973) carefully structures territories

and color-codes toys for each child on a small

table. Slavson and Schiffer (1975) set rather

specific requirements for the room and its

contents in activity group therapy (pp. 55-85).
Ginott (1961) stresses the importance of room

size and contents (pp. 63-78) and provides a

rationale for toy selection in play group therapy

(pp. 51—62). Levine (1979) states that limits

should be built into the room and play materials to

reduce the destructive potential and to avoid

having the therapist set too many limits. Sugar

(1974) focuses on content that encourages

fantasy, discouraging weekly introduction of new

stimuli, crafts, and destructive or hazardous

materials (pp. 654-656).

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 When incorporating activities into the group,

close consideration should be paid to matching the

activities’ built-in dimensions with the specific

group composition and goals. These activities

influence the management and process of the

group, sometimes adversely. A room large enough
to contain comfortably six to eight children with

one or two adults is recommended. If

soundproofing is not available, the room should be

situated so that noise levels do not disturb

adjacent personnel. It should be free from

distractions while still maintaining a bright and

cheerful look. Everything in the room should be

childproof, and furniture should be sturdy, safe,

sized for children, and washable. If not enough

attention is placed on childproofing the room and

the equipment prior to beginning the group, the

therapist will spend much of his or her time

protecting agency equipment and worrying about

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 damage. The children should feel comfortable in

the room, knowing that for the time it belongs to

their group. One-way mirrors, tape recorders, or

audiovisual equipment may be present; however,

the therapy is for the children, and such

equipment should never be used without their

knowledge and permission.

Groups are either open-ended, able to add and

terminate members throughout their existence, or
closed, beginning and ending with essentially the

same children. Setting, academic, and training

needs tend to influence this structure. It is helpful

to view groups as closed in principle, with the

population remaining the same except for
replacing dropouts.

Snacks often are utilized with varying degrees

of emphasis by group therapists as part of the

therapy. They are of symbolic importance both to

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 the child and to the therapist, often being set out
in a nonthreatening manner. Some groups center

interaction around the snack time, with members

taking a progressively more active part in their

planning and disbursement. Although activity

group therapy utilizes snacks throughout the

group’s existence, Sugar (1974) mainly offers

them as a stimulus organizer in the beginning

stage of the group.

Establishing a Mutual Working Agreement or

Treatment Contract

Any treatment agreement must involve both

therapist and patient, and in the case of children,

their parents. The agreement, established during

the screening interview, includes mutually shared

and understood goals, obligations in

accomplishing these, and expected outcome.

Theoretical orientation, children’s needs, and

agency requirements influence whether this is

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 informal or a formalized signed contract. Rose

(1972) further differentiates between treatment

and behavioral contracts (pp. 95-105).

There have been recent advocates in the field,

often pressured by outside bodies responsible for

evaluation and funding, who believe the more

explicit the agreement, the easier it is to see and

measure results. The move in this direction has

challenged more traditional therapists to put their
purposes and intentions into clearer, measurable

goals.

The following issues are included in the

agreement or contract-making process: the
problems to be worked on; the desired goals; and

the therapist's, child’s, and parents’

responsibilities. The therapist is there to prepare

and help with difficulties encountered during the

treatment process. He or she informs the parents

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 that during certain periods the child’s behavior
might seem to worsen, that the child may feel

resistant and not want to come at times. The

therapist states the child’s and parents’ conditions

of the treatment: the child is expected to come to

every session on time, to stay for the whole

session, and to participate; the parents are

expected to assure the child’s attendance,

canceling only for good reasons, to communicate if

developments arise that may affect the child, to

adjust to temporary and long-term changes in

behavior as outlined and planned for, and to

engage in whatever treatment process has been

recommended for themselves. The younger or

more disturbed the child is, the greater is the

parental responsibility. Adolescents may take

considerable responsibility for arranging their

treatment, including making the initial contact

with the therapist. Contract making and signing

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 are frequently utilized with adolescents and help

to eliminate their use of denial and projection.

When financial arrangements are a part of the

therapist’s role definition, they are included at this

point.

Croxton (1974) views contract setting as a

gradual and complex sequence following these

phases; exploratory, negotiation, preliminary

contract, working agreement, secondary contracts
among group members, termination, and

evaluation.

Throughout this process the therapist helps

the parents and child identify, verbalize, and deal

with some of the unresolved feelings they may

have regarding their participation in the treatment

process. The degree of formality in the sealing of

this agreement may vary from an affirmative nod,

handshake, or verbalized statement to a written

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 and signed document. Once “sealed,” it enables the
therapist, the child, and the parents to proceed.

They agree on the date and time of the first group

meeting.

Length of Sessions, Duration of Group

Once setting, philosophy, therapeutic goals,

and age are established, the length of sessions and

duration of the group fall naturally into place. As a

rule of thumb, the more verbal, discussion-

oriented the group, the less time it can tolerate,

unless it’s very intact. Generally, groups can

handle 45 minutes. Groups having both activity

and discussion periods can be at least 60 minutes

in length with 30 minute periods or 20- to 40-

minute periods. Gradually, the talking time can be

increased to 30 to 40 minutes as the group

progresses through the year. A highly anxious

group may be able to begin with only 10 minutes

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 of discussion. Sugar (1974) feels that outpatient

preschool and early latency-age groups can handle

45 to 60 minutes weekly of interpretive therapy.

Play and activity groups often can handle

longer periods of time. Slavson’s activity group

therapy requires 1½ hours weekly for several

years. His activity-interview groups meet weekly

for 90 minutes to 2 hours.

Forty-five minutes often works well for

latency-age and young adolescents, while 60 to 90

minutes may be very appropriate for older

adolescents. Levine (1979) theorizes that “much of

the flagrant behavior reported in groups of
latency-aged school children stems from the threat

of too long a meeting” and that as much as 30 to

40 minutes of this behavior is largely to fend off

threatening discussions or experiences (p. 21).

Fifteen minutes two to three times a week may be

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 a good format.

Duration of groups also relates to setting,

philosophy, and staffing needs. Some settings

follow children’s school schedules or trainees’

schedules, which may last 6 to 9 months or 1 to 2

years. Longer-term psychoanalytic groups

frequently meet 1½ to 2 years. Some open-ended
groups go on rather indefinitely. Short-term

groups generally run from 3 to 6 months, and

diagnostic groups four sessions.

References

Anthony, E. J. (1973). Group-analytic psychotherapy

with children and adolescents. In S. H. Foulkes &
E. J. Anthony Group Psychotherapy: The
psychoanalytic approach (rev. 2nd ed.).
Baltimore: Penguin Books, pp. 186-232.

Axline, M. (1947). Play therapy. Boston: Houghton

Mifflin.

Barcai, A., & Robinson, E. H. (1969). Conventional

group therapy with preadolescent children.

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 International Journal of Group Psychotherapy, 19,
334-345.

Bertcher, H. J., & Maple, F. (1974). Elements and

issues in group composition. In R. Glasser, R.
Sarri, & R. Vinter (Eds.), Individual change
through small groups. New York: Free Press, pp.
186–208.

Braaten, L. E. (1974/1975). Developmental phases of

encounter groups and related intensive groups.
Interpersonal Development, 5, 112–129.

Charach, R. (1983). Brief interpretive group

psychotherapy with early latency-age children.
International Journal of Group Psychotherapy, 33,
349-364.

Churchill, S. R. (1959). Prestructuring group content.

Social Work, 4, 52-59.

Churchill, S. R. (1965). Social group work: A

diagnostic tool in child guidance. American
Journal of Orthopsychiatry, 35, 581–588.

Croxton, T. A. (1974). The therapeutic contract in

social treatment. In P. Glasser, R. Sarri, & R. Vinter
(Eds.), Individual change through small groups.
New York: Free Press, pp. 168–185.

Demsch, B., & Brekelbaum, B. (1969). Exceptionality-

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 change through the group. Journal of Pupil
Personnel Workers, 13, 137–141.

Frank, M. G. (1976). Modifications of activity group

therapy: Responses to ego-impoverished
children. Clinical Social Work Journal, 4, 102-109.

Ganter, G., & Polansky, N. A. (1964). Predicting a

child’s accessibility to individual treatment from
diagnostic groups. Social Work, 9, 56-63.

Ganter, G., Yeakel, M., & Polansky, N. A. (1967).

Retrieval from limbo: The intermediary group
treatment of inaccessible children. New York:
Child Welfare League.

Ginott, H. G. (1961). Group psychotherapy with

children. New York: McGraw-Hill.

Gratton, L., & Pope, L. (1972). Group diagnosis and

therapy for young school children. Hospital and
Community Psychiatry, 23, 180–200.

Johnson, D. L., & Gold, S. R. (1971). An empirical

approach to issues of selection and evaluation in
group therapy. International Journal of Group
Psychotherapy, 21, 321–339.

Kadis, A. L., Krasner, J. D., Winick, C., & Foulkes, S. H.

(1963). A practicum of group psychotherapy. New
York: Harper & Row.

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 Karson, S. (1965). Group psychotherapy with latency
age boys. International Journal of Group
Psychotherapy, 15, 81–89.

Levine, B. (1979). Group psychotherapy practice and

development, Englewood Cliffs, NJ: Prentice-Hall.

Lifton, N., & Smolen, E. M. (1966). Group

psychotherapy with schizophrenic children.
International Journal of Group Psychotherapy, 16,
23-41.

Little, H. M., & Konopka, G. (1947). Group therapy in a

child guidance center. American Journal of
Orthopsychiatry, 17, 303–311.

Lowy, L. (1976). Goal formulation in social work with

groups. In S. Bernstein (Ed.), Further explorations
in group work. Boston: Charles River Books, pp.
116–144.

Paradise, R., & Daniels, R. (1976). Group composition

as a treatment tool with children. In S. Bernstein
(Ed.), Further explorations in group work. Boston:
Charles River Books, pp. 34-35.

Peck, M. L., & Stewart, R. H. (1964). Current practices

in selection criteria for group play-therapy.
Journal of Clinical Psychology, 20, 146.

Redl, F. (1944). Diagnostic group work. American

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 Journal of Orthopsychiatry, 14, 53-67.

Redl, F., & Wineman, D. (1957). The aggressive child.

New York: Free Press.

Rose, S. D. (1972). Treating children in groups: A

behavioral approach. San Francisco: Jossey-Bass.

Sarri, R. C., & Galinsky, M. J. (1974). A conceptual

framework for group development. In P. Glasser,
R. Sarri, & R. Vinter (Eds.), Individual change
through small groups. New York: Free Press, pp.
71-88.

Schachter, R. S. (1974). Kinetic psychotherapy in the

treatment of children. American Journal of
Psychotherapy, 28, 430-437.

Scheidlinger, S. (1960). Experimental group treatment

of severely deprived latency age children.
American Journal of Orthopsychiatry, 30, 356-368.

Scheidlinger, S. (1965). Three approaches with

socially deprived latency age children.
International Journal of Group Psychotherapy, 15,
434-445.

Schiffer, M. (1969). Therapeutic play group. New York:

Grune & Stratton.

Schiffer, M. (1977). Activity-interview group

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 psychotherapy: Theory, principles, and practice.
International Journal of Group Psychotherapy, 27,
377-388.

Slavson, S. R. (1955). Criteria for selection and

rejection of patients for various types of group
psychotherapy. International Journal of Group
Psychotherapy, 5, 3—30.

Slavson, S. R., & Schiffer, M. (1975). Group

psychotherapies for children. New York:
International Universities Press.

Soble, D., & Geller, J. J. (1964). A type of group

psychotherapy in the children’s unit of a mental
hospital. Psychiatric Quarterly, 38, 262-270.

Speers, R. W., & Lansing, C. (1965). Group therapy in

childhood psychoses. Chapel Hill, NC: University of
North Carolina Press.

Sugar, M. (1974). Interpretive group psychotherapy

with latency children. Journal of the American
Academy of Child Psychiatry, 13, 648-666.

Whitaker, D. S., & Lieberman, M. A. (1964).

Psychotherapy through group process. New York:
Atherton Press.

Whittaker, J. K. (1974). Program activities: Their

selection and use in a therapeutic milieu. In P.

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 Glasser, R. Sarri, & R. Vinter (Eds.), Individual
change through small groups. New York: Free
Press, pp. 244-257.

Yalom, I. D. (1970). The theory and practice of group

psychotherapy. New York: Basic Books.

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 Chapter 4

STAGE II: EXPLORATION

Anita K. Lampel

Experiential Description

“Am I supposed to wait here? Who’s going to

come and get me?” While one child looks sullenly
or despondently at his shoes, another nervously

paces. Some try to guess who is in the group. The

children look at each other, as if at a birthday

party for someone they don’t know. They wait.

Then the therapist comes. His arrival decreases

the anxiety of children and parents, while others

wonder if “he’ll forget I’m here.” As feelings run

through the children’s minds, they focus on the

therapist. Almost inevitably, they are on their best

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 behavior as they walk toward the therapy room.

Two jostle for a place beside the therapist; it

seems safer there.

“So this is the therapy room. What’s in here? Is

it okay to look?” The children peel off each other

and the therapist. One tentatively explores the

room, wondering what the therapist will say.

Another looks at the other children, hoping for a

confirmation that this is in fact a place where

other children are like him and where he can find
a friend.

The birthday party feeling lingers for a while.

Children look gay, exchange pleasantries and

names. After all, no one’s mother is here, and the
kids don’t seem so bad after all. A quiet hum

settles over the room. There are signs that this is

not like anything the child has known before. The

children look at each other again, but differently.

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 Almost visible is the assessment each child makes.
Then they look back to the therapist for more

structure and understanding of the difference they

are beginning to feel.

One child tentatively reexplores the room,

wondering if he will touch some forbidden object;

another hovers near the therapist; still another
attempts to be “mother’s little helper”; while

another ignores the therapist in favor of his peers.

As they interact with each other, verbal and

nonverbal questions are directed to the therapist,

often disguised in behavior. Underneath, the child

wonders, “If I’m good maybe I can go,” “If I’m good

maybe I can stay,” or just “If ...” The therapist

moves in with quiet verbal and nonverbal answers

to the unspoken questions. Some therapists do

this with structure, formally stating the goals,

limits, and expectations. Others wait for questions

or for the situations to arise before introducing

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 these. Still others may step back but actively

initiate responses from the children about why

they are here and what they would like to do in

the group and get from it.

The room and children may be fairly calm for

several sessions. This period may be a

honeymoon, as the children gather their resources

to cope with the newness of the experience and

the anticipation of what is to come. Colleagues
who have run groups before discover that the

novice therapist is in their offices more than

previously. “Hey, this isn’t nearly as bad as you

said it was going to be” reflects the therapist’s
genial interest in his group’s psychodynamics at

this point. For those who have done groups before

or who find the concept exciting, much discussion

is generated.

Suddenly, the quasi-group feeling disappears

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 and discrete individuals reappear, each moving
emotionally and behaviorally. Each child is caught

up in this first expression of heightened anxiety.

“Maybe this is something I’m not supposed to do.”

“Let me try it.” “Boy, I’m going to get that kid.” “I’m

just going to sit here under the table.” “I’m going to

make this place just like every other place I’ve

known.” These messages buzz around on a

nonverbal level. The behaviors push and pull at

the children and the therapist. “What is he going to

do?” “What isn’t he going to do?” “How different is

this place really?” “Can he take it?”

For some children it is as if their senses are

now more acute, almost embattled. Others, also

anxious, are almost unaware of what is

transpiring, observing everything through a dense

fog. For one or two, anxiety arises around the

exploration of limits. For still others it is the mere

formalization of the group and the presence of the

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 other children that precipitates the anxiety. In one

or two children the anxiety rises quickly to a level

where it must be expressed. It’s catch as catch can

for the therapist as he hurriedly moves in to

express something to one child, only to have

another begin to do or say something that also

requires therapeutic intervention.

Then Chris begins to miss sessions. The

therapist calls to find out why. Mom says, “Well,
Chris just didn’t want to go and I didn’t feel I could

make him,” or “Baseball practice is on that day,” or

“He’s worse since he’s started,” or “I don’t know ...”

A 5-minute phone call easily stretches to 30
minutes while the therapist attempts to help the

parents reassess what Chris’s need for therapy is,

what Chris might or might not be trying to get out

of refusing to come, and what is going on in the

parents’ lives that might be influencing the refusal.

The therapist begins to realize this is not easily

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 straightened out over the telephone and decides to

talk to the parents’ group therapist or have the

parents come in to see him. What is the best way

to proceed in helping? The therapist experiences

anger and a drain on his time and energy. He has

struggled to get the group together, and already

it’s being disrupted. If this child does not return to

the group, he becomes the first dropout. As the

therapist moves to handle the necessary
arrangements, he feels pain and a hurt ego.

Sometimes, even this early, the therapist and

consultant realize a mistake has been made in the

selection of a child. Brad is tearing the room apart
despite all controls. The other children are afraid

of him and don’t want to come back. The therapist

grows increasingly uncomfortable with his

behavior with the other children, fearing for their

safety. When the therapist determines Brad isn’t

right and that the children can handle his being

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 dropped better than they can his continued

presence, he experiences a sense of relief. The

therapist calls the parents in for an interview.

Sometimes parents hear the statement with relief;

others react angrily to the implication that their

child cannot make it and reject any further

overtures.

Reparative work is necessary within the group

to help them understand why Brad had been
removed. The therapist repeats reassuringly, “We

will help Brad but in another way. I am not angry

at him. We will help all of you in the way it seems

best for you.” Even with this offered reassurance,
the therapist notes a sudden, even more acute rise

in anxiety. Those children in the group for whom

the group is beginning to work become

conspicuous by their behavior after the removal is

announced. They are fearful that they too may lose

that which is gaining in increased importance.

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 Such children require reassurance at a more

sophisticated level than those who accept the

disappearance with equanimity. To some children

the group has not yet gained such importance.

Some children have caught on to what is

supposed to happen. One child brings the events of

the day into therapy. Another mentions he had a

fight with his brother. Often his nascent comments

are lost or ignored by the others but are treasured
by the therapist. Another seems to have ceased a

particular mode of reacting to others, and the

therapist can see trust in himself and the group

deepening. Still another, though, seems caught in
the earliest sessions of the group, unable or

unwilling to move with the others. The child

repetitiously resists, acts out, or withdraws. The

therapist persistently repeats messages of

acceptance, understanding, and patience,

educating that this group is different from outside

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 experiences and relationships. The child still

comes and the therapist hopes that as the group

progresses, this child, even though moving slower

than the rest, will nonetheless make progress in

allowing these needed trusting relationships with

himself and the group to develop.

Outside the group therapy sessions, some

changes are beginning to occur. Parents and

school may be noting a change in the child’s
behavior. There may be less acting out at school or

less negativism at home, often a sign that the

child’s conflict is beginning to be brought to and

contained within the therapy group. Occasionally,
a parent will note that their child appears angrier

or sadder than usual.

The changes are seen too in the waiting room.

Johnny, whose maniacal behavior in the group

declared all to be his enemy, seeks out the

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 company of Bobby as he arrives. Together, they
peer anxiously out to see whoever is going to

come. The next child may be greeted with catcalls,

derision, or fisticuffs, in recognition of the child’s

status within the group as a sign that the group is

forming. The therapist arrives to find all of the

children in the group interacting in the waiting

room. His arrival acts as a catalyst and focal point

for communication within the group, as an

expectant air settles over the ongoing

communication, no matter how wild it may be.

Each child expects that the therapist will be there,

will do or say something, and that there is safety in

what happens.

Within the group, the key for the child is

“Where is my place?” Each child throws himself at

the therapist and at the other children. Even the

one who withdraws, seeming to ask for no place at

all, is testing whether that place will be allowed

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 him or if the therapist and the group will chase

him out. Much of the activity seems to have little to

do with limit testing but rather with: “Can you see

me? Can you hear me? Is it okay if I stay here?

Where do I fit in?” The search for alliances with

the therapist and individual members of the group

is more obvious now. Some children react with

delight to one another, behaving in perfectly

appropriate ways. An alliance that disappeared
within 10 minutes now lasts for 30. Occasionally

an immediate twosome will form.

Reacting to the activity and anxiety

surrounding the search for a place in the group,
the therapist increases the number of reassuring

and including remarks. “I know you are here. I

care about each of you. You are important to me.”

When each child finds his place, no matter how

low in status in the group that place may be, some

of the anxiety will diminish. A pecking order or

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 status and role emerges in which each child seems,

for a time, to be satisfied.

The therapist feels, from time to time, like a

ghost in the machine. His words can scarcely be

heard above the din of each child’s active

involvement with the others. But through it all the

child asks, “Where is my place with you?" The

therapist answers verbally, “It is here with me and

the group. He cannot show favoritism for one,
focus only on individual issues or only on group

issues. He is shared and has apparent concern for

all. His comments to one must be heard as a

comment to all. “You can trust me.” “I do
understand.” “It is hard.” “It’s okay to feel that way,

but not always to act that way.” “Feelings can be

talked about, shared, and understood.” The

therapist finds himself moving from child to child,

subgroup to subgroup, communicating to

individuals yet introducing the “we” essential to

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 group development. “Does anyone else feel that

way?” “Has that ever happened to you?” “Do you

understand what Mark is trying to say?” The

therapist experiences himself as both inside and

outside of the group. Outside because he cannot be

a part of the pecking order, inside because it is

from here that he is accepted and must establish a

safe, therapeutic climate. Trust in the therapist

must be marshaled against the testing to come.

One by one the children begin to hear and

believe that the therapist is there for one and for

all. Anxiety diminishes if only by just-noticeable

degrees. The fact of the group and the therapist’s
presence takes on importance in the child’s life.

Mother reports that Johnny was upset when the

teacher kept him after school.

The children begin labeling the group, one by

one, at home, school, and in the waiting room. “I

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 am here for my group,” one says to the
receptionist. “Where are the kids in my group?”

another says. “In my group . . .”

Dynamic Description

The exploration stage begins with the first

session and ends as individuals in the group have

invested enough in the group to personalize and

label it as “my group.” This may last anywhere

from several sessions up to several months,

partially depending on how reserved the group
tends to be and whether the group is long-term.

Groups of severely disturbed children may have as

their ultimate group goal merely to complete this

stage.

Stage II can be divided into three phases for

illustration of development and progression of

individual and group processes. In the First phase

the children check out various hypotheses about

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 the therapist and the other children. These
represent the growth of initial trust in the

therapist and the group, enough to bring them

back to a second and third session. The children

who pass through this phase are able to tolerate a

therapeutic environment, a therapist, and a group

of peers who do not conform entirely to

expectations. The ability to tolerate this rests

primarily on the child’s pathology and strength at

this point. The therapist uses his or her clinical

skills to help the children hear the message they

need to hear: “You are all right here.”

In the second phase, the children more actively

test the therapist’s tolerance for mildly disruptive

behavior. In this instance the children seem to be

asking, “Can you handle this minimal indication of

what I’m really like?” The minor infractions of

limits and house rules may seem like major

infractions to the novice therapist. The key is that

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 these are carried out in an air of expectancy by the

children. Again, the primary message on which the

therapist must concentrate is, “Yes, I see that and

still care about you. Yes, I can handle that.”

Finally, the children are ready to accept the

therapist and the presence of the other children.

They are not yet ready to accept the group as a

vehicle of behavioral and emotional change even

though such changes already may have occurred.
They are, however, ready to accept the therapist

as a trustworthy person, as a person who can

accept and deal with some of the behavior that has

been troublesome to them in the past. It may be
assumed that the other children exist, for the most

part, as the setting in which each child and the

therapist must form their private bond of trust.

This achieved step, the labeling identity of the

group, signals the end of Stage II: the child’s

acceptance of his or her place with the therapist,

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 among the other children, Other authors have

formulated an opening stage of group

psychotherapy with children (Rose, 1972; Sarri &

Galinsky, 1974; Sugar, 1974) and adolescents

(Bracklemanns & Berkovitz, 1972). Bracklemanns

and Berkovitz earmark this opening stage the

“Fragmented Stage,” with the group operating “in

a very chaotic, disjointed and disruptive fashion”

(p. 43). In a separate article Berkovitz (1972)
states that during the first four or five sessions the

status roles may be in the process of formation.

Slavson and Schiffer (1975) report that the

children initially experience a “shock effect” and

relate primarily to the activities available and

secondarily and minimally to the other persons.

Rose (1972) outlines techniques for the initial

phase to enable the children to move into the

therapy and to maintain attention and attendance.

Similarly, other behaviorally oriented therapists

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 address the issues of contract setting and

reinforcement of appropriate behavior beginning

with the initial setting. They seldom address early

relationships among group members or between

members and the therapist, except as defined

contractually, such as contracting for taking turns

during discussion.

Sugar (1974) isolates three phenomena that

characterize the initial phase: The children “are
learning to get along in the group”; the child shows

initial resistance “related to his realistic

disappointment in the anticipated functioning of

the therapist in the frustration of his transference
expectations”; “there are also the frequent, intense

dependency needs” (p. 656).

More variation is seen regarding the criteria

for the ending of this first stage. Bracklemanns and

Berkovitz (1972) state that the ending of the

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 “preworking stage” is heralded by a commitment
of the members to each other and a “unit-ness” of

the group. Sugar (1974) feels the end of the initial

phase is signaled by “a certain amount of relative

stability in the group dynamics and only relative

cohesion” (p. 656).

The Child

The children and the therapist are anxious

about the first group session. “This anxiety

ensures the success of the first meeting since, after

being together for a short while, everyone

discovers that his fears were unjustified. The relief

from the anticipatory anxiety is a great morale

raiser” (Sugar, 1974, p. 656).

First, there is “Who am I here?” The child’s

expectations and hopes for the group help to
determine what aspects of the information

available about the group characteristics are

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 assessed. Anxiety level also is a determining factor
in the initial analysis of data. The more anxious

child gathers reality data more slowly than the

less anxious child.

Then, “Who are you?” The only person the

child knows and has had interpersonal contact

with is the therapist. The therapist becomes the
buffer for anxiety. The child reacts to the therapist

according to the child’s dynamics, his or her ability

to trust, and whatever relationship he or she

developed with the therapist during stage I. The

child indicates, “Let’s you and me ...” to the

therapist; only to be answered, “Let’s you, me and

…”

Then the children move into a more active

phase determining the boundaries of the room,

therapist, and peers. Each child reacts

characterologically in a manner that is functional

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 and typical of him or her. Although the pattern has
pathological elements, the child struggles here in

stage II to keep these in check. Whatever ego

strengths he or she possesses are used to maintain

the balance between the emotional and

environmental press.

Each child experiences transference, which

becomes confused with the reality of the therapist

and the therapeutic climate. Relief may be felt by

one child who feared the therapist would be like

his or her angry mother or teacher. Another child,

though, with similar history, finds the therapist’s

approaches frightening and fights to maintain

status quo. The environment is different. The

permission to express emotional tensions is

different. The balance within the child begins to

shift.

During phase one, the child begins to form and

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 test various hypotheses. Predetermined fantasy
and expectations begin to confront reality as the

child sees it. Even such simple items as the room,

time, and structure of the group repeated ad

nauseam help to reduce the children’s anxieties.

They experience stability, predictability, and

support from therapist in testing their hypotheses.

As anxieties over forming new hypotheses

drop, anxieties over testing them rise, sometimes

precipitously, and the group enters phase two. The

child is propelled to reveal more pathology, which

asks of the therapist, “Can you handle this

beginning revelation of my innermost being?” The

upsurge in anxiety appears to be related to the

rigidity of the child’s defenses and pressure of

perceived unacceptable feelings and behavior. The

therapist’s response, “I see what you are showing

me and I can handle it and I still care about you,”

contributes to change. A change of hypotheses

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 means that new information has been processed

by the child. Each child is in the process of

assessing whether and how the group can function

for him or her.

By now the children are beginning to look

quite disturbed. The movement has been from

tentative exploration of environment to the

exploration of limits. From time to time a

subgroup is formed, but these alliances break off
and each child again operates on his or her own.

Another dyad forms and may indicate pathological

needs are partially met by this friendship.

The dropout and absenteeism rates can be high

during this stage. For one, there is the child who

cannot explore at the same pace as the others.

Perhaps his reality checking is too poor, his

anxiety too high, his inhibitions too great, or his

defenses too rigid. He is left behind as the others

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 stabilize their personal environment. One child
may by expression, posture, and verbalization

show this is not really what he wanted or

bargained for, and quickly reneges on his

therapeutic contract. Another, finds he “hates” the

therapist for his size, sex, or something. This is a

strong initial negative transference, and the

therapist may not have time within the group to

help the child work it through. The child,

therefore, is unable to depend on or use the

therapist as an anxiety buffer. On occasion this

child can be maintained through this stage

because of his strong alliance with another group

member, such as in a dyad.

There is also the child who feels he is hated by

the others. He is likely to be the one referred to as

“always picked on" or the “school bully.” He

operates so quickly to confirm his hypotheses that

the therapist, try as he may, has not seen how the

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 child sets it up. This child may decide he is once

again being scapegoated and will leave, or he may

linger long enough for the therapist to see the

setup and intervene.

Removing a child is painful for both the child

and therapist. Some children are angry and

defensive, experiencing rejection once again. Some

are sad and are able to express their hurt. Still

others feel relief because they too were aware that
this group or group psychotherapy did not feel

right.

By now the fact that Johnny is here means that

Mark will do or say certain things to Johnny. That
Melissa is here will mean that Elizabeth will seek

her out and that they will huddle together. One

child seems to make things happen, always his or

her own way. Even changes in dress, in physical

appearance, come to mean certain things to each

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 child, the group, and the therapist. Within the
group, the child is determining the strengths and

weaknesses of the others. Each child has placed

others in roles he or she finds most comfortable

and has found the most comfortable niche for

himself or herself. These roles are most likely

superficial, carry-overs from the past.

Throughout the group’s short existence, each

child leaves the group after each session having

had at least one question answered. Under these is

the unspoken one, “Can I trust enough to come

back again?” The child looks for reasons to come

back, and the therapist supports these; the child

looks for reasons not to and the therapist works to

mitigate those reasons. The exploration is at an

experiential level and the ground grows firmer.

The therapeutic work for the children began

on day 1. By the end of stage II, they have

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 accomplished a measurable amount. They have
assessed the therapeutic situation as different

from other situations. They have shown the

therapist and the other children something of who

they feel they really are, a preliminary statement

to be worked on for the remainder of group

therapy. They have begun to trust the therapist

and through this are beginning to hear the

therapeutic communication and respond

accordingly.

The Therapist

Therapeutic assessment, too, begins on day 1.

The children are in a new environment, a mode of

therapy chosen because it is most appropriate for

them. The therapist listens, observes, and

hypothesizes on similar questions about each

child. Does the child isolate himself or move

toward others? Does he attach himself in a

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 symbiotic way or can he be independent? Does he

accept or reject overtures from peers and

therapist? What is appropriate or inappropriate

about his behavior? Is he provocative or is he

withdrawn?

Things run very smoothly during the first

phase, so it often appears to the therapist that he

or she has chosen a normally reacting group of

children. This initial positive transference is
experienced because the therapist is seen as the

only source of expectation, authority, and

gratification in the group, a relationship begun

during the preparation stage. The child’s
dependency needs and disappointment at unmet

gratification of needs are less intense during this

stage than during the other stages of group

therapy. During this phase the novice therapist

may experience relief that group therapy does not

seem too difficult or demand too much;

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 bewilderment due to feeling unsure about what is

occurring and whether he or she should attempt

to do anything about it; overwhelmed by the

awesome responsibility of relating to so many

needs of so many children at one time.

As the anxiety begins to rise, the therapist

reconvinces himself or herself that the children

are disturbed. The novice therapist is beginning to

appreciate difficulties surrounding group therapy
with children. If the therapist has an eye for subtle

flashes of dynamics, he or she begins to store

these up. He or she continues making assessments

of what the group may do for each child; and may
also feel that he or she is gradually being torn

asunder by the effort to draw all the children, each

tugging away, into the semblance of a group. Some

therapists can relax a little in these opening

phases, while others wonder how a group will

ever be formed of these vying individuals.

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 By now, the therapist has begun assessing

underpinnings of behavior, noticing a quick

change of subject or appearance of inappropriate

behavior as the result of the theme being

expressed. The therapist notes the child who

approaches each situation stereotypically. He or
she has caught flashes of deep anger directed

against other children or against the therapist. He

or she notes the child who pushes limits

consistently. The therapist makes note of a dyad

forming and watches its development, knowing

that this can be destructive for a group and may

need to be split up. Or provided the dyad can

gradually allow others to share in its intimacy, it

may facilitate group cohesion. The therapist

functions much as a “radar system” (Berkovitz) as

he or she scans the scene looking for scenarios,

assessing them for plot, motive, and affective

valence.

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 Next, the therapist works on formulating some

plans for individualizing therapy; trying to match

technique with behavior to facilitate solidifying

the initial treatment contract. Sometimes these

contracts have to be reassessed and negotiated. As

he or she begins to intervene therapeutically, the
therapist realizes he or she has begun that which

is so unique and powerful in group therapy: to

conduct therapy during the actual behavioral

crisis rather than after it. Outside the group the

therapist spends considerable time with a

consultant, assessing children and treatment

techniques. Inside the group the therapist is seen

setting limits, communicating support, educating,

and clarifying.

As the children pass into phase three the

therapist realizes that the child is asking

something special of him or her. The therapist

continues to work hard at the message of trust,

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 strength, and inclusion. “You do have a place with

me and with the group.” Sensitized to the children

who are forming a bond of trust with him or her,

the therapist cements this and anticipates using

this nucleus to draw the others in. It is a judicious

blend of movement toward peers and movement

toward himself or herself that the therapist tries

to obtain. Moving from child to child, subgroup to

subgroup, the therapist communicates to
individuals yet uses the essential “we” in the

attempt to get the children to relate to each other

and to the concept of a group. The therapist

gradually expands the dependence on himself or

herself to dependence on the group, eventually to

open avenues of communication and

interdependence with the group members.

The Group

It is day 1. The group is more an administrative

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 definition than a group. Group formation and

development is just beginning, as is the therapy

within it. By the end of stage II the group is

embryonic. The children have jostled to find a
place with the other children. They have come to

recognize that the other children will be there

with them. Acceptance of peers within the therapy

time and space and the formation of brief
subgroups for many purposes is the initial stage of
group formation around the central figure of the

therapist. A birthday party is not a group for

therapy, nor are the individually anxious children,

nor are children cemented only to the therapist.
But as the children interact with one another, use

one another, like and dislike one another, group

formation has begun. The therapist has begun the
messages of “we-ness,” but the group has a long

way to go before it is cohesive.

The Parents

Many parents are optimistic about the course

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 of therapy and engage willingly in sessions around
their child’s behavior. They are often curious
about their child’s therapy group and can be aided
to turn this energy to working on issues within the
home. Some parents have concern about the
“excitement” or “wildness” they observe in the
waiting room before or after the group session
and worry that their children are getting over-
stimulated. Others have an emotional state
paralleling their child’s. “What are you doing to my
kid?” The message comes across to the therapist,
who may react with a sudden, brief flash of anger.
The therapist feels pulled into the family dynamics
again despite the fact that the contractual
arrangement and need for therapy had been
clearly understood by all parties.

Some parents may feel the need to collude

with the child as the child begins to push to be

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 absent or to drop the group. They begin to

realize what the contract really means in terms

of time and effort. They are unsure,

regretting their commitment, involvement, and

the pressure they exerted to get the child in the

group. Some may have a negative transference,

partially due to a buildup of resentments against

authority and the agencies who have previously

dealt with their child. Even the firmest of

contractual agreements does not guard totally

against family pathology. Reaffirming or

solidifying the therapeutic contractual

agreement requires more frequent contact with

the parents. The therapist may find himself or

herself engaged in direct work with the parents.

Disorganized families, families with a very

disturbed parent, and families without

socioeconomic resources, sometimes drop out

from therapy. It is during this stage or stage III

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 that this most frequently occurs.

The Agency

During consultation certain patterns begin to

emerge. The therapist arrives with a predominant
emotion, usually carried over from the group. A

blow-by-blow account of the group or a focus on

particular interactions reveals the generator for

the feelings. Emerging roles and patterns of

behavior are followed closely. A discussion of the
possible dynamics of the relationship, child or

status of the group leads into possible next steps

for the therapist. In addition to focusing on

beginning therapeutic communication, the

therapist is shown how to foster beginning group

development.

The agency is being called on to share with the

therapist. Potentially good therapists may be

turned from the use of group therapy at this point,

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 not by the group experience, which is going well,
but by the isolation from other therapists or the

agency during the early group therapy sessions.

The agency plays its most important role

during stage II with regard to “house rules.” In

house rules rest the needs of the agency to protect

the physical plant and to keep operations running
smoothly. The agency’s secondary role is

providing back-up and alternative resources for

children who drop or are dropped from groups.

Special Issues

Structured or Unstructured Groups

The therapist has considered his philosophy of

group treatment prior to the beginning of stage II.

The therapist’s chosen theory fits closest to his or

her own focus and training. Theories comment on
the opening phase, usually offering guidelines for

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 structuring the first sessions. These opening
sessions are used to establish the tenor of the

remaining therapeutic interactions and

interventions and the nature of the use of games

or activities.

Groups fall along a continuum of structured to

unstructured. In a structured group, the therapist
begins in a limit-setting manner to direct

interactions between all group members. An

obvious method of doing this is to present to the

children a contract for behavior during the group

that specifies the expected, approved, and

disapproved interactions. In some groups of older

children, the first few sessions can be devoted to a

discussion of their own ideas for the group’s

contract. The contingencies of behavior are then

considered. In some groups, a point system is

exchanged for privileges; in others, a point system

is valued for its competitive nature.

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 Sometimes activities and games are utilized to

force an external structure on the group’s

interactions. This technique is used frequently

with children who do not have sufficient ego

development, strength, and control to function

other than in a disintegrated, fragmented, or
overly aggressive manner in an open,

unstructured group setting. Some severely

disturbed children need the help provided by

simple structured games to learn interactional

skills.

Schacter (1974, 1984) utilizes specifically

structured yet noncompetitive games to facilitate

social interaction and mobilize feelings. “Stop the
action” is a command issued when the child

responds in a game with his characteristic and

pathological response to a feeling such as anger.

Because intervention occurs at the moment the

emotion is experienced, new alternatives can be

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 taught. Clifford and Cross (1980) describe utilizing

a “Stop and Go Rule” that gives group members, in

addition to the therapist, the power to prevent and

control unacceptable behavior.

Ganter, Yeakel and Polansky (1967) developed

very structured “standard operating procedures”

for working with severely disturbed children

lacking in “organizational unity” and “capacity for

self-observation” (pp. 49—54). They established a
strict, repetitive schedule of routine activities that

progressed from simple to more organized within

the activities themselves, within the session, and

from session to session.

The advantages of a highly structured system

are that the children are quickly led to an

identification of the issues to be worked on, in

terms they can grasp and manipulate verbally.

Limits of behavior within the group and the

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 applicability of such limits to behavior outside the
group are labeled, and realistic contingencies are

established. The therapist identifies himself, and

the adult population, as “in charge of

contingencies.” The children’s anxieties are

diminished because what is expected and what

will happen is immediately clarified.

Disadvantages are that children are placed in the

same relationship to authority that they encounter

in other situations. Children are possibly implicitly

informed that it is the behavior and not the

emotion that is important. Relationships are

initially controlled by material considerations and

contingencies, and not through more natural

consequences arising from the relationships and

behavior.

Some therapists carefully plan activities, rather

than allowing individual or group choice; others

allow group decision-making. More individually

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 oriented activities are planned during this initial

stage, with gradual movement toward group

orientation. Activities are planned with

therapeutic goals to enhance esteem through

completion, sharing of materials, and group

cooperation. Churchill (1959) describes planning

based on analysis of each child’s group roles,

happenings in the previous group session, and

anticipation of issues to arise during the following
session. Programming for ego support (Redl &

Wineman, 1957) is utilized to try to eliminate

anything “harmful to any child,” although it may

not be equally helpful to each member. Activities

are selected as needed for diagnostic usefulness or

for specific individual or group interaction.

Activity group therapy (Slavson and Schiffer,

1975) is an unstructured group, with freedom of

choice of available materials and activities and no

listing of rules and limits. The children’s behavior

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 is not dictated by the therapist. The therapist is a

low-key, nonintrusive, accepting participant-

observer. Activity group therapy is on the extreme

end of the continuum with other

psychoanalytically oriented therapy models

operating within the unstructured range. In these

groups the therapist steps back from direction of

the flow of the individual and group process. He or

she may then support or reinforce children who
appear to be taking appropriate steps toward

interaction. The therapist encourages symbolic

play and revelation of conflictual material which

he or she then clarifies and interprets.

The advantages of such a system are that the

children are not forced to related in any particular

manner, other than that which is

characterologically appropriate at the time. The

children are introduced to the therapist as a

nondemanding adult who offers support but does

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 not limit behavior and does not punish. The

therapist imparts to the children, through support,

a sense that their behavior is reasonable and

understandable and that their feelings are likewise

reasonable. For the therapist, such a group

provides an opportunity to allow relationships

and individual behaviors to occur naturally rather

than through the imposition of external limitations

and contingencies. Disadvantages accrue in this
model also. Lack of structure can immediately

increase the anxiety and decrease the intactness of

aggressive, delinquent, or ego-deficient children,

and of very disturbed children whose abilities to

interact with others and sustain group movement

are not well developed. This type of group is

sometimes painfully reminiscent of a child’s own

life situation, perhaps a highly disorganized,

undifferentiated family, and offers, at least

initially, less benefit than a more structured group

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 with its closer resemblance to reality

contingencies. These children need external

boundaries and expectations in relationships that

provide needed ego and object supports. This

approach works best in groups of several years’

duration.

In homogeneous groupings of aggressive and

severely acting-out children, when activities are

not able completely to channel and control their
impulses, the therapist must intervene and

provide appropriate channeling of expression. He

or she instructs, “We talk, not hit.” As necessary,

the therapist isolates, places a hand on the

shoulder, or temporarily removes a child to the
hall or a quiet room. Only if absolutely necessary

does the therapist restrain the child, preferably

after removal from the room.

Activities and structuring are utilized during

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 this initial stage to help establish a beginning
“groupness” and limit anxiety. As part of this

structuring, a therapist may wish to introduce

certain issues for discussion, and/or may allow

issues to introduce themselves from the activities.

Communication Within the Group

The initial task for the therapist is to open lines

of communication and to establish the expectation

that communication and relationships in the group

can be shared by all. The novice group therapist

discovers that these aspects of language differ

subtly from those found in individual therapy. At

the most obvious level, group therapy involves a

myriad of channels: between child and child,

between therapist and child, between therapist

and co-therapist, among therapist and two

children, ad infinitum. What channels are open

and between whom they are open, never mind

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 what is being transacted along the channels, may

be obscured or hidden in an active group of

children. In addition, the therapist feels “on stage,”

as his or her voice is raised and nonverbal

gestures are mildly exaggerated to catch and hold

the attention of the group. Communication may be

simplified and directed below the level the

therapist would use if he or she were doing

individual therapy. The “age level” of
communication needs to cushion, not challenge,

the abilities of the least able group member.

Clarification, or identification, is a flexible tool

that can be used to draw in other members of the
group. For example, the therapist may state, “I feel

you are angry at Mark. Does anyone else feel that

Mark is angry? How does he show it to you?”

Children of a variety of ages and pathology can

respond to the type of message that clarifies and

labels the behavioral components of the emotional

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 state. It can have both an educational and a group

development purpose. For younger children,

therapists may use doll or puppet play to illustrate

this type of communication. The children’s replies

are then used to help the others focus on similar

feelings in their own lives.

Support comments from the therapist often are

directed toward a particular child for a specific

behavior. “I know it’s hard for you to show me
that.” “You are really making progress in being

able to do that.” “You guys are sure beginning to

learn how to share.” “That’s great that we all came

and were able to participate.” This type of
communication is usually quite easy for the novice

therapist to provide. Nonverbal communication to

the child and group must be visibly explicit.

Control, on the other hand, is a difficult

communication to handle. To help the child

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 establish his or her own controls, the therapist
gives a message that the child is okay, but the

behavior is not because it is unacceptable.

Restrictions that are appropriate and not punitive

will be placed on the child to prevent the

occurrence or recurrence of the behavior. The

procedures utilized will become the prototype and

will establish an expectation for the group that

unacceptable behaviors will be handled in a

specific manner. The therapist must be prepared

and equipped to handle in a therapeutic fashion all

behaviors that occur. Clarification is not always

easily attained, because a group agitator, sending

messages of anxiety or anger, may in fact look as if

he is behaving appropriately while another child

acts out for him.

Interpretive comments in stage II may be

minimal, depending on the material presented.

Opportunity may arise for such comments as:

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 “When things go bad at home, kids are sometimes

angry enough to fight anyone.” “Maybe when

you’re being my assistant it keeps you from being

with the group.” Messages should be phrased,

whenever possible, so as not to increase anxiety to

a point of therapeutic immobilization. The

therapist can use these statements as

springboards for group discussion by asking for

reasons why a child might be behaving or feeling
as observed.

House Rules and Group Limits

Within stage II, a simple statement of house

rules and limits is made. House rules are for the

operational needs of the agency: tell the

receptionist you are here and wait in the waiting

room; we do not destroy property, run in the halls,
go in the stairways, play with the fire boxes,

elevators, or telephones. Group limits are imposed

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 by the therapist because of his or her philosophy,

needs, and tolerance level. All therapists have

limits to their endurance, learned quickly and

often uncomfortably, in anxiety-provoking

situations that children and adolescents elicit,

especially in groups.

Some basic group limits are “We do not hurt

other people or ourselves here; what happens in

the group is for the group’s information only.” One
therapist limits anything more than hand-

wrestling; another limits only if a child picks up a

scissors and starts running after another, or two

gang up on one. Hurt may be defined as hurt
feelings. Some therapists make swearing against

the rules; however, for many children the

therapist’s energy may be better spent. Further

limits can range from those stated in contracts—

for example, points are taken away for

interrupting another person—to those based on

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 idiosyncratic therapist need, for example,

“Because I don’t like to start groups late, all

children will come on time or not be admitted if

late.”

A statement about confidentiality usually

occurs within the groups during early sessions. No

matter how severe or bizarre the pathological

material a member shares with the group, it

should not be repeated at school, to the children’s
parents, or outside. Sometimes children are told

they can discuss the material with their parents or

individual therapist when they need to unload but

must not mention the name of the child. Children
must also be assured by the therapist that he or

she will not repeat confidential material to the

parents. Confidentiality is an easier concept for

older and better-functioning children to respect.

Refusal to respect this is viewed by some

therapists as reason for dismissal from the group.

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 If violations occur, feelings about it can be

discussed and handled as a group issue.

Rooms and equipment, often by their size,

nature, and arrangement, can set physical and

spatial controls. These can aid in self-control and

reduce adult-imposed limits (Churchill, 1959).

Selection of certain activities, such as finger

painting, is contraindicated when doing ego-

supportive treatment with other than inhibited
children unless the agency has a very supportive

maintenance crew.

Children's Initial Reactions

Initially, the therapist may assume that the

children are reacting to him or her and to the

other children in a pattern that is ego-syntonic for

them. The pattern has been functional for the child

and will probably occur in structured and

nonstructured groups. These patterns, often given

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 “game-playing” names, need individualized
appraisal.

“Mother’s helper” conveys “I am a good child

and I don’t need to be here,” or “I will make you

love me more than you love the others.” An

unwary therapist may find himself or herself with

a “teacher’s pet” or a “therapist’s assistant.”

The child whose behaviors seem to say, “I’m

not here,” plays a waiting game with the therapist.

The child may be anxious or passive-aggressive.
Anxiety requires consistent recognition and

support from the therapist: Passive-

aggressiveness often responds best to peers rather

than to the therapist, whose comments can be

interpreted as demands. With this child,

clarification and interpretation involving the

entire group may entice him or her from this

stance.

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 A child whose initial approach is “Let’s see you

handle this!” tests the therapist immediately. It is a

battle-cry from a child who perceives life as a

struggle of power and control over the monster

within him or her and those without. This child

can be a powerful catalyst for group interaction
because he or she precipitates expression of

feelings hidden in other children.

The child who seems to say, “I need you more

than those guys do,” is often the most regressed

member of the group. He or she allies himself with

the therapist or with peers and may display

jealousy when attention is paid to others.

The child who is involved in multiple-

therapeutic contacts often walks into the group

with more sophisticated expectations than the

others. He may be set to play out certain conflicts

over trust, power, and control that have developed

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 in his or her other treatment contacts. The issues
that arise necessitate clear communication about

this child among the professionals concerned. This

child may try to offend by describing how much

“better or more interesting Dr. X’s group was.”

This child is a valuable asset because he or she can

verbally model for the other children and is often

the most willing to begin communication.

Some children with rigid defenses approach

group therapy intending to maintain control by

behaving as if the situation were identical to home

or school. One of the manifestations of this is

semantic loading: This child is the last to give up

calling the therapist “teacher.” More subtly, he or

she reacts to situations with little flexibility and

accepts little support.

Goal Development

Individual goals become group goals as

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 members begin to verbalize their desire to change.
Levine (1979) points out that the individual must

feel that his goals can and will be incorporated

into the group goals (p. 111). Many children are

unable as yet to share verbally, so the therapist

may mention some children’s individual goals and

how they might become group goals. The

therapist’s goals are that the group can learn to

listen to each other, to take turns, and to share

their experiences. As members verbalize goals, the

therapist helps facilitate group goal development.

As these individual and group goals become the

focus of therapeutic work, they become the nuclei

of group decision-making and change. Mann

(1955) points out that the primary goal of any

group is group unity for the purpose of mutual

exploration and solution of problems.

References

Berkovitz, I. H. (1972). On growing a group: Some

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 thoughts on structure, process, and setting. In I.
H. Berkovitz (Ed.), Adolescents grow in groups,
New York: Brunner/Mazel. pp. 6—30.

Bracklemanns, W. E., & Berkovitz, I. H. (1972).

Younger adolescents in group psychotherapy: A
reparative superego experience. In I. H. Berkovitz
(Ed.), Adolescents grow in groups, New York:
Brunner/Mazel. pp. 37—48.

Churchill, S. R. (1959). Prestructuring group content.

Social Work, 4, 52-59.

Clifford, M., & Cross, T. (1980). Group therapy for

seriously disturbed boys in residential treatment.
Child Welfare, 59, 560—565.

Ganter, G., Yeakel, M., & Polansky, N. A. (1967).

Retrieval from limbo: The intermediary group
treatment of inaccessible children. New York:
Child Welfare League of America.

Levine, B. (1979). Group psychotherapy practice and

development. Englewood Cliffs, NJ: Prentice-Hall.

Mann, J. (1955). Some theoretic concepts of the group

process. International Journal of Group
Psychotherapy, 5, 235-241.

Redl, F., & Wineman, D. (1957) The aggressive child.

New York: Free Press.

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 Rose, S. D. (1972). Treating children in groups: A
behavioral approach. San Francisco: Jossey-Bass.

Sarri, R. C., & Galinsky, M. J. (1974). A conceptual

framework for group development. In P. Glasser,
R. Sarri, & R. Vinter (Eds.), Individual change
through small groups. New York: Free Press, pp.
71-88

Schachter, R. S. (1974). Kinetic psychotherapy in the

treatment of children. American Journal of
Psychotherapy, 28, 430-437.

Schacter, R. S. (1984). Kinetic psychotherapy in the

treatment of depression in latency age children.
International Journal of Group Psychotherapy, 34,
83—91.

Slavson, S. R., & Schiffer, M. (1975). Group

psychotherapies for children. New York:
International Universities Press.

Sugar, M. (1974). Interpretive group psychotherapy

with latency children. Journal of the American
Academy of Child Psychiatry, 13, 648-666.

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 Chapter 5

STAGE III: ANXIETY

Laura H. Lewis

Experiential Description

It is as though the group has been awaiting a

signal, and as soon as the stage II labeling identity
occurs, the group reacts singly, by pairs, or in

threesomes. The key words from here on are

activity and action. There seems to be constant

movement, both external and internal, and sound

in steadily increasing volume. Voices are shrill and

loud, but the sudden silences are equally loud.

There are frequent comings and goings into and

out of the group. A pair forms that closes everyone

out, quickly dissolves, only to reform in different

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 pairs. A child comes in close only to move his chair
away, while another turns his back and covers his

face. Still another opens expectantly and moves to

meet the warmth only to flee at any move to

approach him. The therapist moves from one to

two and back as though shepherding leaves in a

wind. He holds and works with one or two, only to
leave them to entice or rescue another. He sets

limits, only to wonder at the need with these

changelings and their mercurial natures. He now

appears “the therapist,” then seemingly

disappears in the group. There is little

resemblance to a group and group process, little

difference between patients and therapist.

Existing is just the sense of movement, sound, and

feeling, constantly moving to a crescendo.

The children seem to be continuously

questioning everyone without asking. “Do you

know I’m here? Where are the limits? Will you

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 control me? Are you strong enough? Do you care

enough? When or will you change?” It is a stage of

dramatic individuality but with each seeking

answers to similar questions with ever rising

anxiety. It is a bad scene for the therapist,

especially the initiate. It is filled with confusion

and bewilderment, often despair and flashes of

anger. The questions can be only fleetingly seen,

never fully revealed or comprehended, lost in the
swirl and flurry of activity and clouded by the

intense anxiety rampant in the room. The

therapist is now on trial, feels so, and often reacts

to this, further clouding the issues.

Early excursions and explosions are met by the

therapist’s peers and the agency jokingly, later

pointedly, “What kind of group are you running?”

“Can you do something about the noise?” Finally,

“Keep those kids in the room” comes from the

agency. While dealing with his own anxieties and

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 doubts, the therapist must endlessly respond to

the child and the group with “Yes, I care enough. I

am strong enough.” At the same moment he must

placate the scoffers and the authority while losing

none of his self-confidence. In despair he can only

ask, “Why do they not hear? Why will they not let

me in? Will the group ever jell? Can I do it?”

Slowly, almost imperceptibly, a pattern begins

to emerge unbeknownst to any of the combatants,
for the tempo, intensity, and sound often increase.

Asking the question, “Do you care enough?” or

hearing an answer even on a superficial level,

triggers even more intense anxiety necessitating
flight into either withdrawal, silence, physically

leaving, or wild acting out. The flight works.

Anxiety drops. A new anxiety rises as to whether

one has lost one’s place. This precipitates flight to

check it out. Then the whole sequence starts again

with ever higher anxiety aimed at the therapist,

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 building to a climax.

Somewhere in the kaleidoscope of movement

about the therapist the same procedure begins

between child and child or between child and

subgroup. Slowly the “Yes” answer is heard on a

deeper level. The children confine movement to

the therapy room and begin the testing of this new

truth. The anxiety never seems to drop.

Pathological defenses are universal; they break
often and easily under the constant stress.

Conflicts are raw and blatant, acting out is wild

and primitive, content is pathological and bizarre,

and regressive behaviors appear.

Now children react singly and as a group to

any changes. Absences of members are met with

exaggerated fear, worry, guilt, and blame. Changes

in time result in wild accusations and

recriminations hurled into the group space to

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 home in on the therapist. He feels it and reacts
intensely and very often with anger. He may try

new ways of conveying the answer, but finally in

desperation he shouts, “Yes, I am strong enough. I

am the therapist. I can control you and I will not

let anyone be hurt.” This is met with obvious relief

by all the children, although it is still being tested.

A subtle change has come. A group is in process of

becoming. At the moment, it is evidenced through

its growing importance to the child.

Through this time the universal question “Can

you handle me?” becomes “You can handle me.”

Questioning changes. Although still primarily for

the therapist, it is now also for the group. As

nonspecific group roles are tried and abandoned,

others are assumed or assigned. “How do I relate

to others?” Answers are being heard by one here

and another there. Although there is but little

perceptible drop in activity, group internalization

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 begins in a few children. They, in turn, begin

demanding that others change. This precipitates

wild anxiety as universally they demand, “How

much do I have to change to stay here?”

Gradually, as each question climaxes in an

answer, the child feels safe enough to feel slightly

more committed. He now trusts enough to ask,

“Can you help me?” but may not stay to hear the
answer. It is as though this child now sees and
feels dimly that he has a problem but has little real

acknowledgment of it or commitment to seek

change. The children reach this point singly and

with great variability in timing.

The therapist may feel the change but often

misses the inclusion of other group members in

the focus of questioning and testing, noting only

the speedup in questions needing answers. His

discouragement is most intense at this point. His

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 anxiety is increased from two external sources, for
not only has the agency become insistent on

control but the parents are being heard from.

“What is happening to my child?” Some parents

express delight over the child’s improved behavior

at home and suggest they’d like to withdraw.

Another parent irately insists that his child has

become much worse and is acting out at home and

in school. He too threatens to withdraw the child.

Still other parents insist on the therapist’s time for

their own anxieties, further burdening him.

The therapist wearies of handling both parents

and children and of placating the agency; fearing

he will never be heard, believed, and trusted, he

becomes discouraged with the seeming lack of

growth of group process. The fury still being

raised by the laggards overshadows the progress

of the few.

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 The advance guard in the group often adds to

the melee by anger at the therapist for not “doing

something about this mess.” Finally, out of sheer

desperation and with the sure feeling that it is

now or never, the therapist insists with little

finesse but with great finality, “This is enough. We
will calm down. You will stay with us. We will talk

about it. We will make some rules for our group.

Now!" One or two will now direct their anger at

the other members and demand, “Say, you guys,

let’s move on.” With relief the therapist moves to

help the process along.

Trust now appears openly and seems to grow

more quickly. Noise begins to abate. Anxiety
lessens. Warmth can creep in if it does so

unobtrusively and is tolerated for a moment or

two. Often in a flurry of activity and motion, the

acknowledgment “You can help me” is heard.

Rapidly, with obvious relief, the group becomes

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 our group, the therapist becomes our therapist.

The group slides into the next stage.

Dynamic Description

The goal for stage III is to move the children

into an awareness of group process to an

understanding of group therapy, and a beginning

internalization of the group. A successful passage

through this stage is a must for a successful

treatment process in a group. The anxiety stage is

the crucial stage in the life of group that marks the

point of no return. It can be resolved in only two

ways: either into the formation of a treatment

group or to dissolution. If stage III is examined
other than experientially, three phases emerge,

revealing differing individual and group foci and

goals.

Phase one begins with the initial surge of

anxiety and remains focused throughout by the

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 individual child on his or her relationship with the
therapist. The child’s goal is to interact with the

therapist and to exclude the other children. The

therapeutic goal for this phase is to help the child

form a more solid, trusting relationship with the

therapist.

Phase two begins when the child realizes that

to keep and solidify his relationship with his

important therapist, he must come to terms with

his rivals, the other children. He begins to form a

relationship with the others while continuing to

test the therapist by testing limits, seeking

strength and control, and revealing his pathology

to the therapist. Phase two ends as the child

attains a relationship with the other children and

begins to recognize a similar relationship between

the other children and the therapist.

In phase three the child is beginning to

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 internalize the group and recognize that this
group and membership in it are becoming

desirable. This forces an awareness that he or she

must change in order to maintain this

membership. Phase three and stage III end when

the child capitulates, accepts controls, and

commits himself to group membership.

The Child

Individuality is the keymark of phase one. This

individuality is different from seeing children as

individuals in the group as observed in stage II.

This individuality is glaring and constantly

accented as the child’s increasing anxiety and his

struggle to resolve his ambivalence strain the

coping mechanisms in his customary reaction

patterns. Each move the child makes toward the

therapist sends him flying one way or another.

Each reassurance he hears moves him nearer the

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 therapist into more anxiety. This rise in individual

anxiety is one of the surest signs that stage III has

begun.

This anxiety-producing process is revealed in

behavior that is provocative, manipulative,

possessive, demanding, rude, boisterous, active,

protective, polite, subservient, placating, testing,

or whining. The child may join another child to

ward off the therapist or his own feelings, may
collude with another child against a third, may

struggle for dominance and leadership, or may

scapegoat. The intent of the behavior is the same:

to escape, to dilute, or to destroy the closer
relationship with the therapist, to drive the other

children away from himself and the therapist, or

to join with them to exclude the therapist. Yet the

child is trapped in the situation by his or her own

needs. He or she needs, wants, and seeks the

affective nurturance offered. He or she fears,

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 avoids, and flees it because it means intimacy and

change. Fearing the loss of what he or she has

already attained, the child tried to relieve it by

running back to the therapist only to begin again.

A true approach-avoidance situation exists.

The data the child seeks are those that allow

him to explore, define, and test the emotional

boundaries of the therapist’s relationship to him.

With each new confirmed bit of information, the
child must re-form hypotheses and collect more

data. He asks again for control by testing the

strength of the therapist more actively. He is

relieved if an answer is quickly available, for at
best his knowledge is shaky, and he constantly

checks, refutes, accepts, and rechecks it all again.

Gradually, the child becomes more aware of his

worth to the therapist. At this point, he has gained

some relief from struggling to and from the

therapist, and the relationship has grown in

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 importance and comfort. Although the child’s

anxiety is still intense, it is less so when he is near

the therapist, so he struggles to stay in the room.

Staying usually decreases fear of loss.

Up to phase two, the child has amassed

considerable data about the other group members,

having progressed from seeing them as objects

who are different yet similar to learning that the

group and group time is shared with them.
Depending on the age, nature and degree of

disturbance, children vary in their ability to see

and relate to the other children as real objects.

Healthier children with latency development are
able to observe and relate to the others in dyads

and small groupings, viewing the other children as

need-satisfiers and identification models. At times

these peer relationships are an even more

important focus than their relationship with the

therapist. With younger and more severely

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 disturbed children, the other members have

remained relatively unimportant, largely accepted

as necessary to the setting in which the child

relates to the therapist. Now the child must begin

at a different level to deal with the others. A new

source of anxiety, rivalrous feelings, often emerges

full blast. Efforts to eliminate his or her rivals

brings information that this is not an acceptable

part of the game. The child realizes that he must
also find some way to live with these peers. This

process begins afresh, one at a time with his group

peers, at approximately the same relationship

level that he had with the therapist at the

beginning of stage III.

Phase two has begun, and the child’s anxiety

now never seems to abate. He begins to reveal

intentionally how bad the situation is within him

while also checking out his safety in a relationship

with his peers. His defense mechanisms are rarely

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 up to the strain, and the results depend

considerably on the nature, depth, and

pervasiveness of his pathology. Internal and

external conflicts are blatant. Content of speech

and behavior may by pathological and bizarre.

Rarely does a single child use all of these

behaviors, but he or she will use several within a

single session or from session to session. It can be

a confusing scene of wild acting out, noise,
confusion, and pressure as the child and his

fellows push the therapist for control and

strength. This is the group’s and the child’s most

difficult time to date, and the demands for support,
reassurance, caring, and control appear insatiable.

Support and reassurance are offered by the

therapist, followed by some of the peers.

Amazingly, with little external evidence, the child

uses it to the degree to which he or she is capable.

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 It is difficult to assess the actual progress of a

single child. Each of the children is following a

similar process. Several will be at the same point

at the same time. It is difficult to pinpoint when a

child accepts support from a peer or when he

offers it to another. Very subtly and slowly, the
child forms a relationship with another child.

Slowly he or she recognizes similar relationships

among the group, as these children have begun to

grow in worth to each other.

Overt signs of the beginning of phase three will

be hearing the use of group pronouns. First

appearing as labels, “our time,” “our room,” are

used outside of the group with the receptionist,
parents, or other children en route to the therapy

room. The individual child begins to react to

absences and changes in routine. As the group and

group members begin growing in importance to

the child, internalization of the group begins.

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 It has become evident that change must occur

in order to be group members. As this idea is

submitted to the same checking as every other

idea, the group process is well on its way in a

child. This new feeling is both attractive and

frightening, but it seems to offer a way of resolving
the conflict. As it is sought, impatience and anger

are directed at those impending its growth. It is

often a child or several children who demand

limits and strict rules to bring the group under

control. The tempo in the group has reached

almost unbearable heights.

When the therapist, with great resolve and

firmness, asserts control by restating the group
purpose, the child’s and group’s reactions are

immediate and observable. As the therapist shares

his desire that they all continue working toward

these goals, each joins openly, demanding all

conform. It is clear they all have shared this wish

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 and have each been involved in the need for

controls. As order emerges out of chaos, there is

delight in shared feelings—our therapist, our

group. The new group entity is explored with each

child prepared and committed to go on in the

discovery of group membership. The anxiety stage

ends.

The Therapist

The novice and the experienced therapist alike

move into stage III using their individual

relationship with the child to help form

relationships between the children, to foster the

group relationship, and to begin the group work.

They are chagrined and startled to discover the

children are not ready for all this and dismayed

with the wild rise in anxiety. Intuitively moving to
buffer and control the anxiety frequently results in

the therapist becoming fatigued and empty before

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 he or she realizes the children are not making use

of the help. The anxiety continues unabated and

the children begin acting it out.

The experienced therapist recognizes grimly

that the anxiety stage has begun and settles to

work it out. He works to solidify the relationship

of the individual child to him, using every

opportunity to explain the feelings and motives of

the children to each other. He plans his strategy
hoping he does not succumb to the anxiety or

become too drained to function effectively.

Building up his own support system he determines

this time to end this stage a little sooner.
Sometimes he is able to do so and sometimes not.

He has techniques with which he is comfortable

and skilled for handling the work during this

stage. However, he is still uneasy. With children,

interactions and relationships are on a very real,

intense level, necessitating honest, straight

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 nonverbal and verbal messages. It is tricky to build

trust with a disturbed child; the therapist must

“feel” through each interaction and relationship

himself as well as empathizing with the child. This

demands a great deal from the therapist as a

therapist and as a person.

No matter how many times a therapist lives

through stage III with a group, he or she is always

startled to re-live the feelings of the first time:
fatigue, despair, confusion, fear, anger, pain, and

much self-doubt. It is not a surprise that this stage

demands hard work and much investment, but the

intensity of the feelings is sometimes unnerving,
especially anger at the children individually and

collectively. Because of this intensity, the high

activity and noise level, and the blatant pathology,

it is nearly impossible to keep a clear picture of

what is occurring as it is happening. This leads to

self-doubt, because the therapist fears that his

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 timing or ability to read the children and their

progress is off the mark. Perhaps this will be the

group that he cannot help through this stage.

It is crucial that the therapist be aware of the

effect that pressure, from external sources and

from practical matters, can have on him and on his

feelings toward and about the group, and how

these pressures can change his handling of the

group.. Criticism is more prevalent from all these
sources during this stage. If job security and

pointed attacks on the therapist’s ability, clinical

judgment, and technique are added, his or her

confidence and ability can be badly shaken at a
time when both are in constant demand.

The first time a therapist encounters the

anxiety stage is an experience unlikely to be

forgotten. All of those things noted for the

experienced therapist are true for the initiate, only

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 more so. Even forewarned, it is not possible truly
to prepare for this stage. More than one therapist

has been “turned off” groups for some time, some

never to reexperience them. Bringing a group

through this stage can be a very rewarding

experience. Therapists can gain considerable self-

knowledge and demonstrate that they can help

and control a group, while feeling with the

children and using themselves therapeutically.

The emphasis and interpretation the therapist

gives the children and group vary, based on the

differing sources of anxiety in each phase. Phase

one messages are concerned with increasing trust

in the therapist, the child knowing that the

therapist sees and accepts him. “It’s okay to be

mad, but I see it frightens you.” The therapist

individualizes the messages, determining when

information is sought and needed and when

maneuvers are defensive.

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 In phase two these messages continue, often in

the face of wild acting out and testing of control.

The child will need reassurance about his

pathology, his “badness,” for he now lets it all hang

out and must know that the therapist sees this and
continues to accept him. As the phase progresses it
becomes necessary to step up the interpretations

of the feelings, intent, and wishes of the other

group members in order to foster relationships

between the children and to lead them toward

group commitment.

Phase three shows children exhibiting blatant

psychopathology, such as distortion of reality,

open fantasy, hallucinations, and other bizarre
behavior. Pathological rage or grief, the

destructive impulses and their intensity, which are

so often a part of the severely disturbed child’s

inner dynamics, arouse naked fear and anxiety in

the children and sometimes even in the therapist.

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 If the therapist is prepared to accept such

reactions in himself, he can more easily continue

to care for, accept, and control the disturbed child

while helping the other children handle it to their

therapeutic advantage.

The messages become more and more

centered on the group, group process, and group

feelings in the third phase, with the therapist

consciously dropping the singular personal
pronouns and stressing “we” and “us.” When

anxieties arise from the need to make a

commitment to the group, both therapist and

group members aid each child.

The Group

Group formation and group process is difficult

to see in stage II and the early phases of stage III,

but it becomes somewhat clearer as stage III

progresses. At the beginning of stage III the child’s

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 perception of the therapist is incomplete. As the
relationship with the therapist grows in

importance, the child’s awareness and perception

of him and of the other children undergo subtle

changes. The child becomes aware of the rivalry,

and early in phase two the interactions between

child and child are mostly negative. Both positive

communications and feedback between children

are filtered through the therapist. The children

begin to build a line of communication tentatively

but directly between one another, following the

lead of the therapist. Slowly, trust grows in the

group, the outward signs being their use of group

pronouns, reactions to absences, and concern for

each other.

Phase three has begun, as has internalization

of the group process. Considerable activity is being

seen between pairings and threesomes, with

changing in the groupings. Talking about our

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 group is heard, as solid relationships exist

between the children and the therapist. The

anxiety stage is coming to an end as trust is

becoming stronger.

The Parents

At the beginning of stage III, some parents

have reached an uneasy peace or a wait-and-see

attitude. Some, because of their own pathology,

symbiosis with their child, need for a family
scapegoat, or disagreement with their spouse, may

be waiting a more propitious time for making their

feelings and wishes known. It cannot be too

strongly stressed that anything that touches the

dynamic web uniting a family causes a reaction,

like a ripple, affecting each member. These ripples

increase in intensity and strength in stage III and
portend, with dramatic intensity, change within

the family. It is not possible to change any family

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 member dynamically without affecting every other

family member. As the child’s anxiety and changes

in behavior are dramatic in stage III, the flood

reaches the family, bringing about an anxiety

reaction. Even more dramatic is the recognition of

what is yet to come. The family and child begin to

experience changes in the family-dynamic

relationships and communication system.

Change that is already occurring in the child in

phase one often appears at home as a reversal of

the child’s customary patterns of behavior. The

very good child may now act out at home or

school. The acting-out youngster may confine his
or her acting out to the group setting and cease to

do so elsewhere. The very depressed child may

become hostile, argumentative, and irritable. The

overdependent, symbiotic child may begin subtly

resisting the symbiosis, making moves toward

independence. In any of these situations either a

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 conscious or intuitive recognition of these

occurrences triggers a rise in parental concern.

This rise is as sharp but possibly not as intense as

is the child’s rise in anxiety at the beginning of

stage III. Since parents lag somewhat behind the

child, phase one may be nearing its end before the

parents’ anxiety is elevated to the point that they

begin offering feedback to the therapist by seeking

him or her out more frequently.

Very often this feedback comes as positive

statements about the changes in the child that the

therapist may find unbelievable. In some instances

the parents are honestly quite pleased and may be
only seeking verification that their child is indeed

better. Some realize that the hostility or acting out

may be real progress, a move toward well-

rounded functioning. They then innocently inquire

as to how much longer therapy must continue.

Other parents are not sure they really want their

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 child like this; or they claim the child is well and

needs no more therapy, and they want to

withdraw.

Other parents report that their child has

become much worse, acting out at home and/or

school. He is moody, cries, is irritable, or any of the

dozen reactions the parents see as worse. There is

the frightened, concerned parent who asks,

“What’s happening? Will he stay this way? Was he
always this sick? Is he crazy?” The parent who

irately demands to know what the therapist is

doing for the child is worse; he or she threatens

immediate withdrawal. The pathological parent
who reports the same behavior and demands

something from the therapist is asking for help

with his or her own anxieties, demanding, caring

and attention from the therapist. Still other

disturbed parents carefully sabotage any

therapeutic effort to help their child while

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 continuing to keep the child in the group.

The need is the same. The parent must be

helped with his or her anxieties, helped to build

more trust, rapport, and commitment to the

therapist either directly with him or through his

agent. Parents must trust the therapist’s ability,

ethics, and techniques enough to allow their child

to continue with concomitant changes in the child,

the family, and the parents themselves. They need
to be taught about group process and progress.

They may now or later need direct counseling in

the changes necessary in themselves and their

handling of the child, and those needed in the
family to foster change in the child or to ensure

that it lasts. These approaches need to be offered

and the parents helped to accept them, whether

the child’s change is positive or negative, whether

the parents are disturbed or stable.

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 This is a crucial point in the group. The

parents’ needs, expectancies, and concerns are

real and of legitimate concern to the therapist. If

the parent cannot build a more solid relationship

with the therapist, making the transition through

stage III, then the child rarely can do so. The
parents must recommit themselves to change in

their child and must free the child to make this

change. On occasion it is possible for a child to be

motivated and strong enough to do so without

actually being freed by the parent and family. Late

latency-age children or adolescents can

occasionally do so, but it is an extremely rare

occurrence in younger children.

The Agency

The anxiety stage is the most difficult stage for

the agency, just as it is for the persons more
intimately involved with the group, with parallel

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 anxieties rising high. The therapist and the agency

authorities must keep this in mind and take care to

keep communication open. The therapist must be

well aware of the agency’s limits on destructive,

disruptive behavior and the contingencies set on

breaking these limits, and must operate within

them. It is often at the agency’s insistence that the

therapist acts to end this stage, optimally timed by

the progress of the children.

Special Issues

Handling Anxiety

The anxiety of stage III is individual and

unique, yet contagious and universal. This anxiety

and its containment, buffering, and channeling will

concern the therapist throughout the stage. The

therapist realizes that the child hears or

comprehends very little of what is conveyed to

him, either verbally or feelingly, when he is highly

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 anxious. Each therapist has his or her own special

way or handling anxiety but in general seeks to

lower it to a tolerable level and at the same time

turn his and the child’s attention to its source in an

effort to bring a resolution of the conflict that

underlies it. The same techniques for relieving

anxiety are used regardless of its source, but the

interpretative message the child needs varies with

the nature of the underlying conflict.

Nonverbally, the therapist needs to be open to

the child, aware of and concerned for him, yet

giving a feeling of strength, patience, and positive

acceptance. Verbally, the therapist acknowledges
the child’s fear and anxiety and offers him or her

support with the feelings. In addition, the therapist

reassures the child that he need not move more

rapidly than he can tolerate. The child needs to

know repeatedly that the therapist does

understand or will not stop until he does, and that

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 the therapist is certain that with help the child can

handle his problems.

Messages must be honest, succinct, and

phrased in language that the child can understand.

If too much verbiage or too sophisticated language

is used, it may increase the anxiety and interfere

with the child’s hearing the message. At first the

therapist can be reassuring. “I can help.” “You

don’t need to rush.” “You can calm down.” “It’s
okay to be afraid.” “I see how you feel.” “I do

understand.” “I won’t change.” Gradually, the

messages are changed, and therapist and child

enter the “Yes, but” period of the stage. The
message now goes something like this: “Yes, I

know you are afraid, but you can stay here.” “Yes, I
see that, but we can talk about it.”

Very often in stage III messages are ineffective,

for the child cannot use them. The therapist must

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 use reassurance, and help in times of increased
stress. The therapist learns as soon as possible to

recognize quickly the times when the child cannot

accept help of this kind. At these times, the

therapist may need simply to turn his own and the

group’s attention from this child to allow him the

time he needs to accept the messages. If the child’s

behavior is destructive to the group, the therapist

may suggest a “time out period for cooling off’ and

allow the child to withdraw to a corner of the

room. If this is ineffective or if the anxiety too high,

the child can be permitted to leave the room. If the

situation is adroitly handled, the child gains the

relief he needs and is able to return to the group.

In the use of such a measure, the therapist needs

to present it matter-of-factly and firmly, yet with

readily apparent acceptance of the child’s need for

help. A physically abusive child should be handled

immediately without courting the danger of

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 physical harm to another child or to himself.

The technique for use of the cooling-off period

outside of the room is as follows. A worker who

knows the children should be available and should

remain in the hall during this stage of the group.

When the need arises, the therapist communicates

to worker and child in this manner: “Eric has been

having a hard time and needs a chance to sit

quietly for a while. About two minutes will
probably do it, right, Eric? When things ease a

little, we’ll be glad to have you with us.” The child

remains with the worker or, as appropriate, with a

co-therapist in the hall. Any conversation should

be neutral and not about group work. The worker
helps and reinforces the child’s return to group. If

the timing is such that the child does not return

before the session ends, the therapist will spend

time with him, preferably while other members

are still around. When this occurs for the first

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 time, adequate explanation and reassurance need

to be made to the group and the resulting

reactions handled at once.

It cannot be mentioned too frequently that this

is a difficult and trying stage for the therapist. The

situation can become clouded and nearly

incomprehensible when there are four to eight

disturbed, intensely anxious children, all

clamoring for the therapist, his attention, and his
caring at the same time. If the therapist is anxious

or “catches” the children’s anxiety, the situation

may become nearly intolerable. If the therapist is

unaware of or loses sight of the fact that each
measure of help that lowers the child’s anxiety

moves the child closer to the source of the anxiety,

causing it to rise again, he may assume that he is

failing, that the children are too sick, that he lacks

the skill to pull it off, or that he is making the child

worse. However, if he can accept that anxiety,

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 fatigue, and despair are natural reactions to this

very difficult time, he may find his own anxiety

dropping and be better able to cope with the

situation.

Testing Limits and Acting-Out Behavior

Acting out and testing of limits are an ever-

present accompaniment to this action, noise-

oriented stage. These behaviors are seen

throughout but change somewhat from phase to
phase. It is important to differentiate between

acceptable and unacceptable activity, testing of

limits, struggles for control, and acting out of

feelings, impulses, fantasies, and conflicts.

Although the control measures needed may be

very similar, the interpretations and messages the

child or children need can be quite different.

Physical activity is an acceptable

accompaniment of childhood. To expect a child to

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 sit still and take part in a spontaneous discussion
without extraneous movement is a nonsensical

expectation. In general, children’s activity does not

interfere with concentration and participation if it

is suitably channeled for the situation and

providing the activity is an extraneous

accompaniment and not a project in itself. In the

therapy room, activity needs will be defined by the

chronological and developmental ages of children,

and the acceptable level of activity will be defined

by the tolerance levels of both therapist and group

members. Unacceptable activity is that which is

judged to be a hindrance to the child’s group

participation and an interference with his or

others’ concentration and participation, causing an

interference or disruption in group progress. It is

this unacceptable activity that is to be controlled.

Many children convert anxiety into activity,

and as anxiety increases in this stage, the tempo of

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 activity and noise picks up also. The children may

be unable to remain in chairs, continually roaming

the room; they may move in their chairs, make

noise, talk incessantly, play with fingers, chairs, or

clothing. If the activity is an expression of anxiety,

relieving the anxiety will usually help curtail the

activity and allow them to channel their activity in

group-acceptable ways.

Some of this apparently aimless activity can be

determined as more goal-oriented and less

expressive of anxiety. In some of the instances, it

may be a subtle testing of limits as a part of the

child’s data collection about the therapist, to
determine if the therapist is aware of the child, if

he or she will maintain limits, and how sharp the

therapist is. This tentative try at testing may be

the only attempt the child makes; however, in

many cases it is simply a warning of a real struggle

for control yet to come. Some children have a

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 pathological need to control every interaction they

encounter and in this way ward off close

relationships, frustrate the adult, and reject any

effort to help them.

Acting-out behavior refers to a loss of control

by the child and his conversion, of feeling—

anxiety, fear, anger, or depression—into action

expressed in such a way that it is emotionally or

physically harmful to himself, other children, or
the therapist. Acting out is to be expected and

anticipated in therapeutic groups of children. It is

this acting-out behavior for which control is

needed. This is an area in which many therapists
feel frustration and failure, as they believe they

“can’t control” the children. The goal is not to

stamp out the expression of the feeling but only to

channel the expression in such a way that it can be

worked with to therapeutic advantage. A balance

of control, limits, and allowing expression through

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 activity needs to be achieved. The therapist’s

personal and theoretical framework will

determine the limits he sets for the children in

both types of acting out.

Diligent work with a co-therapist and

consultant needs to be done in order to be

prepared for the steps of control necessary during

this stage. The therapist’s feelings, attitude, and

reactions to control and its institution in the group
are crucial elements in preparing for this stage.

Spontaneous grabbing, restraining, or ejecting a

child in the heat of a conflict could be disastrous

and might cost the child and group much time in
backtracking in order to reestablish trust. Well

planned and thought-out techniques and

progressive steps of control need to be understood

and available to the therapist. These steps also

need to be clearly discussed and understood by

the group before the necessity for instituting them

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 arises, or at least at the time the first need for

them arises.

These techniques for the control of acting-out

behavior are similar regardless of its source, but

the timing and the message the child needs varies

with the underlying dynamics and feelings. There

are points of no return where intervention is

needed and the therapist cannot hesitate to

institute controls. He will begin very often with an
effort to keep the child verbally, somewhat in this

manner: “I understand your feelings, but I cannot

allow you to do that”; “Stop it, Scott! You cannot do

that here.” If the child has been unable to do more
than partially respond, and verbal control is not

enough, a hand on the shoulder or arm can be

added. “You can talk it out and keep yourself from

hitting.” When mild restraint in addition to

positive, reassuring measures is ineffective, the

child may be placed to one side of the room to

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 regain control. Further progressive steps may

include taking him from the room for a cooling-off

period or removing him to a quiet room or

freedom room. Much reassurance and supportive

messages, indicating that it is okay to need such

help, are given to the child and to the group.

Exclusion from the group for the remainder of the

session is a final step.

In the use of any of these techniques, the child

must hear and be helped to feel that neither

therapist nor group rejects him or feels that he is

bad. They see and accept him apart from what he

does, yet he will be controlled and stopped from
hurting and totally disrupting the group.

Sometimes children like to set up rules during this

stage to help ensure enforcement and add clout.

By accepting control from the therapist and group,

gradually the child learns he can control himself. It

takes infinite patience and constant vigilance to

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 detect the problem, move at the right time, and

deliver the message so that the child can use it.

Some children and groups respond more

favorably to one or another of the methods,

depending on their dynamics and previous

experiences. Whether to allow more time, to

restrain, or to provide distance, as a means of

supporting the ego’s control mechanisms, is the

crucial decision. The therapist’s judgment and
theoretical orientation determine which and when

to implement. The child with little impulse control

cannot work with the same leeway others have.

There is also the child who initially needs slightly
longer to meet limits or the one who is so

inhibited that acting out may be encouraged. If the

group shows intolerance of these differences, the

therapist should reevaluate the situation to be

sure that his judgment is sound and that he has

not “been had.”

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 Care must be taken that the child does not go

beyond what is a therapeutic leeway or continue

beyond the actual need. Younger children and

latency-age children sometimes respond well to

being held in order to control aggressive attacks

on others or destructive attacks on property. But
specific care must be taken that children not feel

they need to act out to be held or to get other

attention. Acting out can be “catching,” with

children “following the leader” for some sort of

attention, trying it out for themselves before the

need to use it arises. One must be alert for cases of

one child or the entire group acting out for

another. As all of the children must share the

therapist, new methods need to be tried if any

single child requires holding a majority of the

time. Holding some children is not advisable, as it

can become too stimulating to the child and can be

experienced as a sexual or aggressive approach.

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 More often than not it is not experienced as

calming. Judgment, history, and experience help to

identify these children.

Some groups must be carefully structured from

the beginning. Controls and measures for

enforcing them are then spelled out carefully

before and in the first session. Examples of such

groups are aggressively acting-out adolescents

and older latency-age children and severely
disturbed children. These groups are prevented

from structuring their own controls because of the

expression of their pathology or developmental

task. Activities and games also can be utilized.

These groups may be more accepting of
consequences and controls if they were

incorporated into the initial contract. As

adolescence brings with it the developmental task

of resolving authority conflicts, a group can find

itself in the midst of a “no win” situation unless

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 these conflicts can be avoided from the beginning

by this careful structuring. A mutual and specific

contract, spelling out responsibilities, house rules,

and contingencies, may be made before the first

session. The therapist cannot choose for the child

or group but can only insist that the contingency

chosen be followed.

Children Presenting Special Difficulty

Not all children reach the zenith of the

accomplishments expected during this stage, but is

it imperative that each child make minimal

changes in order to commit himself or herself to

seek group membership and identity. Even the

children who lag far behind their group mates

must take these steps before they can end the

anxiety stage. Among these laggards are children
with intense resistances to change, those with

repeated negative and painful experiences with

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 relationships, and sometimes highly intelligent

children who use their intellects to avoid

relationships. Often seeming not to form any

relationships until the others are almost through

the stage, these children seem to profit greatly by

the experiences of the others, learning vicariously

by observing the relationship formation between

their peers and the therapist. Children fearing a

one-to-one relationship may be able to form the
relationships necessary in the group due to the

nature of the group setting. They experience the

risks and losses involved in a group relationship as

less intense than in a one-to-one and may utilize

the process of splitting dependency needs

between therapist and group or co-therapists.

Pressure from the advanced guard in the group is

often vociferous and helps to push them to take

the risks necessary. The therapist will often “feel”

the beginning relationship and find himself

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 supporting the child by saying, often to his own

amazement, “Tom is coming along; he’ll be with

us,” or some similar statement.

Seriously disturbed children who have untold

difficulties forming close relationships may lag far

behind their fellows in the intensity levels of their

relationship formation, sophistication of

internalization of the group, and active

participation in the group process. Such children
can become accepted members of the group, take

part in and use the group work to the degree they

are able, and not necessarily impede the progress

of the group. It is often noted that a relatively

intact group of children will tolerate, accept, and
help a seriously disturbed child while making

quite sophisticated progress of their own. This

child can make considerable progress with such a

group even when it may be obvious that long-term

individual therapy and additional group work are

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 needed. Some groups, though, are unable to

tolerate such a seriously disturbed child.

Regressive or bizarre behaviors may be too

threatening to them because they trigger their

developmental or pathological conflicts. In this

case, the child may need to be removed in order

for the group to progress. This decision should be

made only after it is clear that stage III is being

unnecessarily prolonged and all others appear
ready to move into stage IV.

Another type of child is found in those

instances in which one youngster forms a

collusion with another and uses this collusion
actively to oppose relationship formation, group

process, and progress. A collusion as it is used

here refers to a pathological relationship between

two children, maintained to obviate the need to

change. These relationships may be shown in

several ways: One of the pair may use the other for

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 working out or acting out his or her feelings while

seemingly remaining aloof; one may protect the

other, may ward off any closeness with others, or

may attempt to supply all dependency needs. Very

often these children have been involved in such

relationships with a parent or a sib and hence

attempt to perpetuate the model. These collusions

must be broken up, as these two children cannot

change in it and it is unlikely that they will allow
the remainder of the group to change. They need

to be separated to help them function individually.

Within the group, the children should be seated

away from each other, with the weaker being next

to the therapist. Then both should be encouraged

to be separate individuals. There should be open

discussion of their relationship as presenting a

problem to the progression of the group, to be

worked on in the group. Support, pressure, and

suggestions frequently come from the rest of the

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 group.

If separation and group pressure do not

succeed sufficiently, the following may take place

within the group, or outside, depending on the

therapist’s orientation. A thorough explanation

needs to take place, giving a clear message that the

relationship is harmful to the two and to the

group’s progress and that it cannot continue. Both

children need support and reassurance to choose
alternative ways of handling the situation,

agreeing to break the collusion. Cues should be

arranged to help the children see when they are

moving into the old pattern. When this approach

succeeds, there is clear evidence of it in the
immediate drop in group anxiety and therapeutic

movement in one or both of the two children. If

one or both of the children is unable or refuses to

break the pathological portion of the relationship,

he or she will either choose to leave the group or

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 be asked to do so by the therapist. If one leaves,

the other will continue to need considerable

support and guilt assuaging.

Dropouts

The attrition rate during stage III tends to be

lower than for the preceding stage. Children leave

spontaneously, fleeing from changing as much as

appears necessary for them to stay or judging the

cost of change too high. Their overwhelming
anxiety may be the precipitant to (light. Other

children who are not able to form the necessary

close relationships to complete this stage may not

drop out but instead need the therapist to make

this decision. When this is necessary, the timing is

important both to the individual child and to the

group. The most advantageous time would appear
to be before the end of phase two. It is unlikely

that the novice therapist will detect these cases

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 early enough to be prepared to handle them at this

time. The experienced therapist also may wish to

continue such children into phase three, hoping to

break through to them and help them into the

group. If this fails, these children must be dropped

before phase three can be brought to a close.

The therapist must convey the decision to the

group, immediately explaining simply and

honestly what has happened. He will help them
work through their anger, loss, and fear. Some

children will be guilty, accepting responsibility for

another child’s leaving; others may become

fearful, feeling that they may be next to go; and
still others may act out, testing again whether the

therapist can be trusted. The therapist must be

alert during this time to pick up cues to these

reactions in order to help the children. In some

cases the other children are very much aware of

the destructive aspects of the particular child’s

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 behavior; they may react to his or her

discontinuing with relief and move directly into

stage IV.

Making these decisions is usually quite difficult

for the therapist, especially the first time. He will

find himself experiencing many feelings about this,

including grief, anger, loss, failure, despair, and

relief. He may well spend some time reassessing

the situation, feeling that he should have done
something earlier or differently, to have enabled

the child to continue. If he has done his best with

the group, this is often a useless piece of self-

indulgence, and he may need help from a
consultant to resolve these feelings. He will then

be free to handle the further recommendations for

this child. The therapist may have to content

himself with the thought that if he helps the child

with this decision, the child may well be able to

seek professional help at a more propitious time.

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 Adding New Group Members

In order to insure steady progress in the group

it is better not to add new members after the

beginning of stage III. It is clear that therapeutic

progress is hampered and this stage unnecessarily

prolonged if additions are made. It is not

impossible to add a child at this time, if one is

practicing in an agency that insists that a certain

number be maintained for financial or political

reasons. There are also some situations where one

may decide for therapeutic reasons to add a new

member, such as when a group needs a specific

child to act as a catalyst for the group.

In preparing the group for a new member, the

therapist must succinctly but clearly explain the

reasons that necessitate such an addition.

Sufficient time must be taken to allow the children

individually and/or as a group to express and

work on their anger, fear, and frustration at such a

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 move. Adding the new child can become an

excellent opportunity for moving the children into

group decision-making and group action. If the

children are well into phase three, this can be

most profitable and also may help ensure only a

relatively slight degree of regression; however, if

the group is at the end of phase one or into phase

two, there will be little chance of keeping them

from regressing to the beginning of the stage. The
work already accomplished will not be lost,

although it will be hard to convince the novice

therapist of this. The children generally work

quickly through the steps already passed once the

new child is accepted.

The selection of a child to add to an ongoing

group is a tough one. A less disturbed, more intact

child, who has some ability at relationship

formation, would appear to have the strength

needed to join a group of children whom he knows

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 already know each other. One also should attempt

to choose a child who could fill a group need. One

must give careful attention to the child and his

parents, so that they understand and accept the

initial contract. The therapist also may feel the

need to add some specifics to the child’s contract

regarding acceptance of the rules and limits that

have been a product of the growth of the group to

date. The therapist also may wish to spend some
time building a relationship with the child slightly

beyond the point he or she reached with each of

the other members before beginning the group.

The group may be quite discouraged and

drained after the first session including the new

child. This will be especially so if the therapist is

unprepared for the regression the “older”

members may show. The therapist may feel

“caught in the middle,” trying to balance between

including, supporting, and protecting the new

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 member while reassuring, supporting, leading, and

controlling the others. However, patience, and

times are often all that are required for success.

Co-Therapists and Stage III

The anxiety stage accents very clearly and

quickly all the salient arguments both pro and con

for the use of co-therapists in group therapy with

children. This stage is at least as difficult for two

therapists as for one. Although all those factors
that cause the individual therapist such fatigue,

frustration, discouragement, and feelings of failure

are present for co-therapists, there is someone

with whom to share them. This sharing in itself

may cause the therapist much difficulty, since

many of the problems experienced by co-

therapists arise from the relationship between the
two and are intensified by stage III. Even co-

therapists who have worked together previously

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 can run into new difficulties during this stage.

One source of conflict can arise from a lack of

understanding of what such a relationship entails,

especially as to closeness, trust, openness, and

investment. This is especially true for novice

therapists. The pathology presented by the

children and their modes of relating with adults

puts an intense strain on the relationship between

the therapists. Still other sources of conflict can be
the differences in the individual tolerance for

acting out, noise, activity, and pathology. These

can lead to differences of opinion in any stage but

arouse intense feelings during this stage as to
what kinds of limits to set and when and how to

set them. Wide differences between the therapists’

tolerance levels for their own stress and anxiety

and their reaction to these feelings in themselves

can lead to difficulty.

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 Manipulative maneuvers aimed at dividing the

therapists, pitting one against another, or claiming

all of the attention of one are common behaviors

employed by children during this stage with co-

therapists. Sometimes this can reach scapegoating

proportions by projecting all negative
transference to one therapist, blaming him or her

for all interferences, and refusing to relate to him

or her. Occasionally the co-therapists have

unwittingly allowed this due to the confusions and

incomprehensibility of this stage at times. At other

times a child or the group may be acting out the

unconscious conflicts of the co-therapists.

One therapeutic technique can be utilized in

this stage by virtue of there being two therapists

present. This situation often occurs spontaneously

and is capitalized on by the therapists, but it also

may be fostered if indicated. A child differentially

uses the two therapists in resolving internal

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 conflicts by dividing the conflicted feelings

between the therapists. In this way, the child

avoids the confusion of two contrary feelings for

the same person. Examples of these conflicts are

the need for nurturance versus the fear of

closeness, a wish for closeness versus a fear of

abandonment, a wish to be good and accepted

versus rage at fear of rejection, and the oedipal

conflict. When the conflicted feelings are
understood, interpreted, and handled jointly by

the therapists, the child is helped to discover that

he can safely experience both positive and

negative feelings for the same person, or that he

can work on and resolve a conflict in a way he may

not have been able to before.

Consultation and Supervision

Consultation and supervision during stage III

are generally more active and challenging than in

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 other stages. As the therapist is experiencing

higher anxiety, frustration, fatigue, and despair,

more help is needed to relieve these. The therapist

needs support and encouragement during this

stage, not questioning and criticism. As it is easy

during this stage for the therapist to lose sight of

the overall group process and progress, the

consultant must be attentive to them, giving a

great deal of information and recommending
techniques.

The challenge and difficulty of consulting with

co-therapists can be great due to the complexity of

the parallel processes present and the propensity
for conflict in areas of control and acting out

during this stage. This stage brings out differences

in technique, style, and personality, and any

problem areas between the therapists will

intensify and will require time to work out.

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 Length of the Stage

Stage III can be relatively short, several

sessions, or several months. Important factors in

the length of this stage are the composition, and

core conflicts of the group and experience and skill

level of the therapist. An experienced therapist

recognizes quickly that this stage has begun and

moves to handle anxiety, control the children, and

teach them the steps of this stage, with confidence

and patience to wait it out.

Groups will be prolonged during this stage

when trust and control issues are central to the

children’s dynamics and reasons for initial
referral. Acting-out children and those with

authority conflicts will spend the majority of their

total group time in this stage.

Often this stage is somewhat shorter with

children who have had previous group or

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 individual therapy experience. One observed
phenomenon about inpatient groups and some

day hospital groups, even with very disturbed

children, is that the anxiety stage often does not

seem as violent or prolonged. One could speculate

that the overall level of control and the ability to

have one’s acting out dealt with therapeutically

during most of one’s day obviates much of it

within the group.

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 Chapter 6

STAGE IV: COHESION

Christine S. Kandaras

Experiential Description

The group, individually and collectively, slides

into stage IV with relief. Everyone and everything
is quieter now, even the room appears more

subdued. There is an awareness on everyone’s

part of this change in atmosphere. Frequent

comments are: “Now I can hear myself think”; “It’s

about time you guys quieted down”; or “I like it

better when everyone’s not fighting.” In this

absence of group tension a sense of anticipation

evolves—anticipation that now each child can be

heard and can begin to verbalize, looking for

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 solutions to their problems as a group. “Now we
can really talk and help each other.”

Anxiety is present but belongs to each child. It

is no longer diffuse, free floating, nor threatening

to disrupt the group. Each child struggles to bring

forward his or her painful, pressing experiences

for discussion and containment. Stories begin to

spill out about deserting fathers, erratic mothers,

violence, brothers who have died, and chaos that

has reigned. The air is often heavy with

depression. Gross exaggerations often appear in

the stories, as the child reexperiences what has

loomed inside so overpoweringly for so long. The

therapist helps by pointing out how small and

helpless the child must have felt at the time. He

helps another child by careful structuring and
reconstructing.

The other children are silent, sometimes deep

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 into their own experiences, which have been
triggered by the stories. The pervasive mood is felt

and shared even if the particulars are not heard, as

each child gets caught up with feelings inside. As

the need arises in others to unload their long-kept

stories, there is some jockeying for whose turn is

next. A sense of fairness is strong, and group

pressure grows to assure everyone’s turn.

Hesitant children are encouraged by the therapist

and each other to share their experience. The

therapist is more active in his role of relating

feelings and experiences to behavior and defenses.

An expectation develops that psychic pain will be

lessened through this process.

Many groups have a member who likes to

“grandstand” or perform. This child will tell

dreadful stories about his or her life while the

other children listen with horrid fascination.

These stories are often believed by the others and

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 can cause anxiety to rise enough to throw the

group momentarily back into the anxiety stage.

The therapist will try to catch this before it

happens, by pointing out to the group what is

happening. The performer usually stops when an

interpretation is made by the therapist or when

pressure is applied by the group.

Another member may be a stimulator for

group discussion. He understands, intuitively
perhaps, what is to come. To ensure himself a

special place with the therapist, or perhaps simply

because he is brighter or has had more therapy,

this child will initiate discussions in the group and
is ready to relate to other group members before

they are ready to relate as a group. Often the

others do not resent this but find it helpful. They

do resent it, however, if it becomes apparent that

this is a child who accurately pinpoints their

feelings but does not look at his own.

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 The children’s ability to verbalize their

problems depends directly on their verbal skills,

their ego intactness, their intellect, past therapy

experience, their personalities, and their social

backgrounds. Each child may repeat for himself

and the therapist why he or she is in the group but
is still somewhat embarrassed in front of the other

children. There is shyness about some symptoms,

such as bed-wetting, and boasting about others,

such as getting kicked out of school. Yet this pride

does not sound the same as it did the first time it

was reported. There is no longer the need to look

around the room and see how everyone is

responding. There is beginning comprehension as

to how feelings affect behavior. The consequences

of behavior have consciously become more

painful.

Hostile accusations directed at each other and

focused on behavior or physical characteristics are

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 less frequent. If it happens, the attacking group

member is no longer admired but often receives

censure. When one child becomes upset, the group

shares the upset. Their caring is usually shown in

primitive attempts to console or comfort. Calls of

“crybaby” are rarely heard. The group feels some

of each child’s hurt, perhaps more as it relates to

themselves rather than as it does to the upset

child. The group turns to the therapist, watching
how he or she physically and verbally comforts the

upset child. Noting the effect this has on the child,

they learn a new way to handle upsets, with

empathy and compassion.

The children are beginning to realize that

alternatives of behavior exist and can be chosen.

The observing ego that has been developing in

previous stages is now being used. Instead of

simply repeating old cycles, they are getting

different responses, and this feedback helps them

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 to control their behavior. Time out is needed

infrequently, but when it is needed, good use is

made of the time given to the child to help regain

self-control. Seldom does a child need to be

forcefully removed from the room or need

physical controlling; when this does happen, it is

more upsetting to the group than previously. The

therapist should discuss this situation with the

group and expect the children to be angry with
him. Part of this anger may arise from the feeling

that the therapist may have been unfair to a group

member, but the bulk of it relates to each child’s

own anxiety that he too might need to be removed

or leave the group that is so important to him. In

spite of criticism and group pressure, the therapist

often attempts an explanation even if he feels no

one is listening.

The children are growing stronger in their

feelings for each other. The child who has

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 previously perceived his problems with peers as

outside himself has only minimally used the group

but now is beginning to see that the problem may

be inside himself. This needs to be interpreted and

supported. The therapist does everything in his

power to help laggards reach this point.

The children begin actually to hear each other,

comfortably sharing stories and feelings. They

now can more actively support each other with
statements such as “I know what you mean, my

mom’s the same way” and “What a drag that must

be.” The children are reaching out to each other in

the form of a playful punch, an arm around the
shoulder, or a stroke on the head. If the therapist

and children stopped to think about it, it is

apparent that a change has taken place. A feeling

of groupness and cohesiveness is present. “You’re

my friends; I never had any before.”

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 Children and therapist eagerly anticipate the

group. Everyone feels close, and the atmosphere is

quiet, warm, and caring. Children arrive early and

have difficulty leaving when the sessions end. The

therapist too finds himself ready for the group

earlier than he was previously. The children hurry
to enter the group room, sitting down immediately

and expectantly. If someone is late, the group

demands an explanation as he enters. He is

forgiven if he has a good excuse. Tardiness of the

therapist will be met with anger, and the children

will demand that he make amends.

Discussion is intense and group-focused. Even

confrontations are done in a supportive manner,
rarely provoking fights or angry feelings. The

children deal with issues and respond

appropriately. The therapist rarely initiates group

interaction; he may have to force himself to be

quiet. Problems brought by each child become

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 group problems. No one is alone and everyone is

aware of this. Empathy, suggestions, and

interpretation flow freely from child to child.

Subgroups are less rigid and are used for the

benefit of group process.

In most groups affection is now openly shared.

The therapist’s words and actions have

demonstrated his views about physical affection. If

he has been demonstrative throughout the group
life, the children will follow his example. The

children will touch each other, offer tissues, or

shake hands and may actually hug each other.

Children who are not as comfortable with physical
contact may bring food for the entire group, or

their favorite game, symbolically sharing of

themselves.

Play is cooperative and activities are problem-

focused. The children may avoid activities and

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 spend the entire session in discussion. When the
therapist moves from the discussion before the

children are ready, the group forces him back to

the issue. Anger flares when he tries to make light

of a situation. An interruption is viewed very

negatively now. Group pressure is operating at its

height, and it may be used to control a group

member. It does not take Jimmy long to realize no

one appreciates his imitating a dog while the

group is trying to work. Jimmy is told to “stop it!”

and amazingly he stops. The group has taken over

responsibility for control, and any member

disagreeing is brought to terms immediately by

the group.

Anger may flare, but it is more often over

appropriate issues and is marked by an

undercurrent of warmth and caring. With

increased group sophistication the children may

be able to tell each other about it. If they cannot

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 discuss this anger, it must be worked out

physically; the children might suggest they Indian-

wrestle. Usually not hostile or attacking, the anger

more frequently arises out a child’s feeling of

being hurt or slighted, not by who won the last

game or whose cookie was the largest but by the

notion that their feelings are not being taken

seriously. The children may even get angry at the

therapist, if they feel he or she is being unfair or
too hard on one child. It is anger more easily

resolved, with each taking more responsibility for

his or her part in it.

There are more frequent quiet times, not due

to anxiety but rather out of respect for the child

who is talking, crying, or hurting. The group

intuitively knows that sometimes the best way to

help is to be quietly with one. Although there is a

wish to go on sharing forever, this intensity cannot

be maintained.

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 Group sessions are still eagerly sought and
hung onto. The children and therapist are
interested in each other. The content of discussion
moves almost imperceptibly from a group back to
an individual focus. Sharing, practice, and
reinforcement are still going on, about everyday
incidents and happenings. Awareness is increasing
regarding feelings, changes, and ability to handle
what could not be handled before. The children
like themselves and how they are alike and
different from the other group members. They feel
great inside. Most things are seen in this positive
light, confidence is building, and the children are
beginning to feel anxious to see if they can
function as well independently. Time and practice
provide satisfaction, reassurance, and confidence
in these changes. Great joy fills the child’s world.
Nothing can stop him now.

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 Dynamic Description
The cohesion stage is a time of intense
psychological closeness. Earlier stages have set the

groundwork by establishing basic trust, labeling

feelings, and lessening anxiety. Although not

exactly sure what to expect, the child and group

already feel relief and closer, having shared and

survived the anxiety stage. The goals for stage IV

are to accomplish individual and group problem
solving; to work through original referral

problems; and to reap the maximum benefit from

group identification, cohesion, and differentiation.

With further analysis three phases become

apparent. Phase one begins with the

reintroduction of an individual child’s problem.
The therapist actively prepares the child and

group for the process of problem solving and

change. Individual commitments are made.

Individual problems become as much a part of

group focus as group problems. Phase two finds

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 the group experiencing and living through the

intense groupness characterized as warm, caring,

and cooperative. Group commitments are made

and discussion and sharing pervades each session.

As phase three begins, the group is a functioning

unit, practicing and reinforcing individual and

group gains. Members are differentiated, and

group identification and internalization are well in

process.

The Child

The first phase opens with “I think you’re able

to help me. I’m now willing to look at myself.” The

child has stayed in the group because there was a

promise of something better for him. Moving into

this process slowly and cautiously because he is

committed to and wants to work on changing, he
begins to look at his own behavior. For one child

the realization that his behavior and method of

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 relating has consequences is a strong signal that

he is preparing himself to do something about this

behavior. For another it is the quiet admission that

the whole world is not against him. For the child

who believes he is totally bad, it is the beginning

feeling that there is hope; someone does like and

care about him and maybe others will too. The

therapist’s understanding and reinforcement of

the child’s positive behavior have given the child
proof that things can be better.

With each child’s commitment to look within

himself, his anxiety changes. Remaining intense, it

is no longer a vague, overwhelming feeling that
something is terribly wrong. He is able to identify

some of his own problems, and to hear, perhaps

for the first time, what the therapist and other

children are telling him. Denial has a different

flavor to it and is not accompanied by wild acting-

out behavior but rather by a pout followed by

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 quiet and thoughtful demeanor. The sometimes

feeble attempts to talk about his problems have

helped him realize his problems are very

important to him. Nothing else seems as important

to him now as he feels the pain. It is the only thing

the child can feel, touch, hear, and see. The feelings

sometimes become so intense that he has to have

help with them.

Each child’s pain has many origins and

individualized meanings. It may be the realization

that his not getting along with other children may

be a result of his own behavior, that he is not just

the “innocent victim.” It may be believing that his
father left home because he was a bad child. It may

be learning and understanding that he might still

be lovable even though his biological parents gave

him up for adoption. Perhaps it is the realization

that his mother is too overwhelmed by her own

problems to care for him adequately; rather than

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 believing he is causing his mother’s problems. It

might be one of the thousands of problems that

emotionally disturbed children must resolve in

their psychotherapeutic process.

The commitment the child makes in phase one

is an individual one to change himself, done in the

presence of and made to the therapist and group.

The therapist is watchful that these changes are

realistic and possible to attain. They can be in the
areas of openness and sharing of feelings, changes

in attitudes, and accepting alternative behavior

responses. A latency-age child may choose to list

verbally what he would like to change about
himself, or he and the therapist may choose to

write these down, signing them, and distributing

copies to the child, therapist, group, and parents.

Frequently just the process of identifying and

focusing on specific problems is organizing and

motivating enough to begin real problem solving

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 and change. Nonverbal agreements are sufficient

in younger, less disturbed, and less acting-out

children, who are participating in more play or

activity-oriented therapy than verbal, discussion-

oriented therapy.

As phase two begins, each child has a real and

vital place in the group, important both to the

therapist and other members. The group is very

important to him and he feels very committed to
it. It is a place where he can talk, be heard and

understood, and where his hurt is made less. He

no longer needs to act out to keep from

acknowledging other children’s problems. He
allows them to talk because he likes them and

feels his problems may be similar and that he can

learn from them. His anxiety has been lessened by

talking about his feelings and getting some relief.

He begins to understand on some level how

talking and sharing help. Initially the child had

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 looked mostly to the therapist, but he has learned

that the other children have helpful ideas and say

things to show they understand too. Some of them

have exactly the same problems—their mother is

always yelling at them, or they are not allowed

back in school either. The child listens intently to

what other children have to say; it is important to

him that they try to be honest and open. Each child

is extremely vulnerable. They sense this in each
other and become protective to avoid hurting each

other.

The child’s functioning is beginning to improve

inside the group. With this awareness he begins to
feel more intact and relates his changes to the

group, frequently believing that without the group

he would have been the same or perhaps worse.

He has practiced appropriate behaviors in the

group, and they do work. He attributes these

changes to the group and thinks if it were to go on

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 forever his functioning would certainly improve.

He does not understand how he could possibly live

without the group and may even wish the

therapist could be his parent and each member a

brother or sister. He arrives earlier each session

and has difficulty leaving the room when the

session is over.

The child’s commitment to the group is total.

He understands how children can and do help
each other. Able to help and make someone else

feel better, he learns he does have something to

give. These children who only a few weeks ago

were poking him, teasing him, and calling him
names, do understand him and do listen to him.

This week Johnny put his arm on his shoulder and

Jerry shook his hand. Maybe he is still being

poked, but the poke now has an affectionate touch

to it. He is liked by the others. They have made

their commitment to group goals and changes and

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 are working on these together. The motivating

factor for the child now is for some relief from the

pain that remains and the proven promise that

things can be better. His observing ego has been

watching for some time. He is dropping old

defenses and behaviors and developing new, more

acceptable ones. He tries these first in the group.

These changes become more consistent as the

child finds the other group members respond to
him more positively. The child is in the process of

internalizing the therapist and group members

and is beginning a solid group identification.

Children with very disturbed parents may have

accepted the fact that their parents are disturbed

and different. They are learning that they are

separate from them and that they can improve

their own functioning. They also may be learning

that their parents are not changing concurrently

and that sometimes things are worse for them

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 now that they have changed through treatment.

They feel the group gives them strength to cope

with their home environment. In order for the

children to have accomplished this separation

from their parents, they have substituted a

symbiotic-type relationship with the therapist and

group, which gradually dissolves as they begin

their steps of improved functioning within and

outside the group. They return as needed to the
group for necessary nurturance and support. New

relationships with friends or new dimensions in

relationships with family and friends are

beginning to gain in importance. They, along with

the children from less disturbed or destructive

home environments, slowly begin to feel that the

changes they have made are a part of them, not

only as group members but as individuals.

The process of internalizing the group and

therapist is solidifying. The child may surprise

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 himself to hear words and expressions the

therapist has used come out of his own mouth,

while another child has little awareness that his

movements resemble those of the therapist.

Another child stops to think before he responds to

some provocation, remembering what had

transpired in the past when the therapist and/or

group used to intervene to get him to observe

what had happened. Improvement begins to take
place outside the group. It may take reporting an

incident to the group for the child to realize how

much better he is handling situations. With time,

practice, and positive reinforcement, these new

ways of handling himself become stronger, more

automatic, and less conscious. Internalization is

difficult to assess externally and varies according

to the age of the child, stage of object relations,

and degree of pathology.

The second phase of stage IV begins as the

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 child feels more intact individually, differentiated

from the rest of the group. Each child is able to

look at himself, realistically evaluating the ways he

has changed. In addition to internalized control, he

has some awareness of what he cannot control.

The child from an exceptionally bad environment,

or the physically handicapped child, has begun

this acceptance and is learning to compensate. He

has gained strength and insight from the therapist
and other group members. He is taking these gains

with him. He feels great inside, different from, yet

a part of, the group. Although the group is still

extremely important, the investment and energy

required is different. It functions almost on its

own, to be there as it’s needed. It is no longer the

sole occupant of the children’s thoughts and

energies.

The child’s energies and commitments begin to

be directed toward the outside world, where he is

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 beginning to be convinced he can function

independently. He knows he is changed, feels okay

inside, and is anxious to continue his growth

outside the group. Anticipation and great joy fill

his world. While this “high” will not last forever,

the child enjoys it immensely now.

The Therapist

The therapist enters stage IV with great relief.

Finally he is beginning to see the fruits of his
labors. He lived through stage III but does not

believe he could ever do it again. He finds it hard

to believe that these are the same children who 3

weeks ago had him convinced that he was in the

wrong field. Now his attitude has changed to

believing once again he can work with groups of

children and even enjoy them! He no longer has to
raise his voice and feel like a policeman spending

his entire time setting limits. The children respond

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 when asked and, amazingly enough, are beginning

to set limits for one another. The therapist finds

that his attempts at affection and positive

reinforcement are no longer rebuffed. Children

who previously screamed “Don’t touch me” are

now asking for a pat on the back or for their hair

to be tousled. The therapist is amazed that these

children, who 2 weeks ago denied they had any

problems, are now talking openly and honestly
about things that upset them, are beginning to

look at themselves, and are taking more

responsibility for their behavior. This is very

rewarding for the therapist. He realizes that he

must have done something right, but it can also

feel like an awesome responsibility. The novice

therapist begins to wonder how he will handle all

of these gruesome stories. “Eric keeps bringing up

his father, how is Jimmy going to handle this since

his father died last year?”

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 How the therapist deals with the material an

individual child brings up is crucial for the group

and depends a great deal on his theoretical

orientation. Of prime importance in this model is

that both individual and group foci exist side by

side. Phase one finds the therapist reiterating and
clarifying individual and group goals, looking for

children ready to make individual commitments.

The first child daring to remention his problem is

helped by gentle questioning to enhance

clarification and understanding. The therapist

encourages group members to participate in this

process and to relate it to their own feelings and

experiences. His activity level has increased as he

encourages hesitant children to speak, asks for

group validation of feelings and experiences, and

interprets behaviors as relating to feelings. These

individual commitments usually precede group

ones.

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 The therapist’s influence over the expression

and solution of problems is of the utmost during

this stage. If he becomes overwhelmed by a

problem or an individual child’s pain, the child and

group will become immobilized. Unless

temporary, this condition can result in a
depressed group or blocked group that cannot

enter into the most intimate phase of the group’s

life. Each child’s pain is so intense in phase one

that the therapist, especially the novice, literally

can feel his body ache for each child. This triggers

feelings of wanting to rescue the child, take him

home, or at least take his pain away. The therapist

soon realizes he cannot make it his own, allow it to

overwhelm him, or falsely reassure the child. He

deals with his countertransference issues, hoping

to demonstrate to the child and group that he does

not feel as helpless, hopeless, and immobilized as

the child does.

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 The therapist has learned to offer support,

understanding, and advice while at the same time

demonstrating that pain can be a motivating,

mobilizing factor. He also has learned that some

children need to be stopped from exposing too

much to the group before he or they are ready to
handle it, or that a psychotic child needs

controlling of his bizarre verbiage. This may be

structured by allowing discussion of one problem

at a time or by gently but firmly silencing the child.

Therapeutic skill is tested here much the same as

in individual treatment except for the added

dynamics of a therapy group. It is a constant

process of understanding words and behaviors

and interpreting them accurately and

compassionately to the child and the entire group.

The therapist is very busy with his job of helping

the children to integrate cognitively and

emotionally their life experiences as they relate to

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 their behaviors. He now can relish doing “what a

therapist is supposed to be doing in therapy.”

Most of what the therapist says is heard and

not denied or defended against in phase three.

Children also are hearing each other. They have

begun to take over functions of the therapist in an

identification with him. The therapist feels

pleasure and sometimes amusement as he hears

the children using the same language and
interpretations, spoken with meaning as if they

were the children’s own words. The therapist is

filled with warm feelings for the group, looks

forward to group meetings, and hates to see them

end. He feels successful and understands the
marvels of group process. He is known to brag

about how great group therapy can be.

There are only two uncomfortable adjustments

during the second phase for the therapist to

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 contend with. Close, intense sessions often are
followed by sessions where little seems to be

accomplished and there is much vacillation.

Experience shows that some distance is needed to

integrate, requiring the children to maintain a

plateau or status quo before returning to a

cohesive group. The other adjustment is dealing

with no longer being the central person in the

group. He must deal with his feelings of being

excluded and not being as powerful and

important. As the group begins taking over for

itself, the therapist must allow this, no longer

being as active in facilitating and interpreting so

that the children learn to differentiate and become

independent.

The therapist realizes that the goals of the

group have largely been accomplished and stage

IV is coming to an end. He almost hates the

thought of it, as the group is running so smoothly

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 now. The therapist knows the gains are strong and

internalized and that he and the group have

served their purpose. Yet the therapist, like the

children is ambivalent. While he helps the child

with his mixed feelings by reinforcing the changes,

he also deals with his own. Although there are

some goals left unaccomplished, he realizes the

children are ready to enter stage V.

The Group

This stage is a period of calm after the storm.

The group is less physically active, but is a group.

The first positive group feeling was participating

in asserting controls and sharing in the relief of

having completed the anxiety stage. If a group

member was lost at the end of that stage, now the

group is able to mourn its loss. During phase one
the therapist is still looked to as the major

authority and nurturing figure. The child is

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 preoccupied with himself and his problems and is

not aware if this has an impact on or is shared by

other group members. As individual goals and

commitments are redefined, the therapist

facilitates some of these becoming group goals.

Group goals set in stages I and II are restated,

clarified, dropped, or modified in phase two. An

original goal, that the children talk about feelings

instead of acting them out, is still agreed on, but
different expectations may be set for different

members. One may need a label for his feeling

before he can talk about it, while another may

need assistance separating his feelings from those
of other members. A commitment has been made

to the group by each child: to allow the other

group members to work on their problems and to

actively help and support them while working on

his own. Group commitment differs from

individual commitment in that group wishes and

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 goals are equal to or take priority over individual

ones. The group begins to jell as these group

commitments and contracts are made.

Fairness and equality are prominent in the

group. In stage III the therapist had to be fair

because each child was frightened that the others

might get more than he would. They have made

significant changes in the area of sibling rivalry by

this time, and the benefits are seen in phase two.
The children are secure that they all have an

equally special place with the therapist. Even

though the children feel equal, differing roles are

present. The child who earlier set himself up as a
scapegoat may still be scapegoated but with an

understanding of why he does it and what he gets

out of it. He and the group are aware of their

respective roles, point them out, and often laugh

about them. It is no longer a destructive attack, but

representative of their problems in life and their

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 newly learned acceptance and understanding.

Dyads and subgroups are no longer separate from

the group but are nuclei around which closeness is

expressed. Disagreements and differences are

expressed comfortably and are not disruptive to

the group’s well-being.

Closeness expressed in this stage is both

physical and emotional. The children pull their

chairs together. The therapist is included, no
longer standing apart as the most important group

member. The give and take of the children is

significant, and they respond openly and warmly.

Group cohesion and identification contribute to
the group’s feeling of confidence and power.

Outside attacks, if any, are warded off and

viciously fought against. The group entity exists

with strong positive valences, made possible as a

result of the processes of internalization and

group identification.

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 Phase three begins slowly as the group revels

in its intimacy. Members’ accomplishments and

achievements click off as they expand their

relationships. There develops a realization that the

group’s goals have been achieved and its members

have changed. Sometimes slowly, sometimes
quickly, the group looks again at its goals.

Vacillation between knowing and fearing that the

group really has accomplished its purposes is

present.

The Parents

Parents rarely complain during this stage and

may wonder why their child is still in treatment.

Most parents are thrilled with the improvement

and take pleasure in the gains. Although some

parents may wish their child had improved more

quickly, they are still proud. They may start
noticing symptoms in another child and suggest to

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 the therapist that Eric’s brother now needs help.

The Agency

The agency is seldom heard from in stage IV

except for a remark that individual children or the
group seem better, calmer. If a child is sent out of

the group room, he usually can be counted on to

stay where he is put and to be in fairly good

control of himself. The therapist may hear from

the receptionist and from his colleagues that the
group is not disrupting them anymore. Other

therapists, in a joking manner, will ask the group

therapist, “What did you do, crack the whip?”

The group therapist may now brag about how

well his group is doing. To his friends he will say

that the group is really into it and may get

suggestions on how to handle certain issues. The

peace and satisfaction the group therapist feels

will permeate to the rest of the agency.

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 Special Issues

Handling Content and Feelings

Stage IV finds the child, group, and therapist

experiencing intense feelings of both psychic pain

and closeness. Together, they are called on to

handle these difficult feelings, sometimes

requiring great empathy, strength, and therapeutic
expertise.

The anxiety manifest in this stage is more

focused and contained and is more individually
related to a child’s conflictual issues. As the child is

ready, the therapist encourages him to talk about

his own anxiety and pain, letting him know that he

is there to help and support. When necessary, this

encouragement includes labeling for the child

what if feels like when upset and how the child

uses various behaviors to protect himself from his

pain. The therapist uses his clinical skills in

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 assessing the child’s, the group’s, and his own
reaction to the latent content and underlying

anxiety in the child’s message and behavior, to

gain more information regarding the source of the

anxiety.

Children vary greatly in how much they can

and should open up. Some very disturbed children
do not have enough ego boundaries to help keep

from “spilling all.” Revealing too much is not

helpful to these children or to the group, as it only

causes increased anxiety. These children need

careful structuring and containment of their

verbal content. Although it rarely occurs, if a child

reveals too much, “falling apart” during the group,

it is most helpful for the child and group if the

reconstruction can be done during the same group

session, even if it means a longer meeting time.

Some children dealing with difficult issues

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 become anxious and have difficulty feeling the
presence and support of the therapist without

physical touching. Frequently all that is needed to

calm down the child and enable him to work on

resolving an issue is for the therapist to put his

hand on the child’s arm, knee, or back to reassure

him of the therapist’s presence and caring. The

therapist should acknowledge to the child that

even though he knows how difficult it is for him to

talk about such things, he is happy and proud that

he is gradually able to.

Phase two brings with it a change in the

therapist’s typical role of facilitator, clarifier,

teacher, interpreter, and authority figure. As each

member reaches equanimity and group cohesion

is at its height, the therapist adjusts to a

temporary, more passive experiencing position.

Group members deal with him much as they do

any of their peer group members. They are now

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 identified with him, having incorporated his

caring, attitudes, and techniques. They now wish

to know more about him as a person and about his

relationships, as their central issue is now dealing

with relationships. They also are doing this with

one another. This is one of their last steps in the

process of identification. The content of their

exploration usually surrounds how the therapist’s

spends his time, personally and professionally.
Similarly, they want to know what their peers do

too. In this necessary process of identification they

are open and available for taking in as much as

possible from therapist and all group members in

this safe practice arena. Each session brings with it

concrete examples of solid and stable growth

inside the group.

Phase three is in process as each makes strides

to expand and continue this growth outside the

group, taking with him all of his accomplishments

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 and new sense of self. This individual sense of self

has been bolstered by all of the growth that has

been reinforced through the process of group

identification. A process of differentiation from the

group is beginning. The therapist recognizes,

supports, and appreciates the child’s discussion of

how he is different and separate from the group

and the other members. The therapist can step

back and revel in the mysteries and wonders of
the internal processes of identification and

differentiation.

Co-Therapists

The co-therapy relationship is a smoother

functioning unit; each complements the other,

picking up where the other ends or with what the

other misses. The group has reached this point in
the group life partially as a result of the co-

therapist team. The children have observed and

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 experienced how they talk, work, and relate to one

another.

By the end of phase one, disagreements over

the meaning or interpretation of behavior were

discussed openly in front of the children, thus

allowing the children to see two sides of a problem

and demonstrating that adults can reach

resolutions, not necessarily agreements, without

yelling and screaming. Sometimes the group’s
opinion had been sought. The co-therapists are a

team, experiencing the same intense closeness the

children are, with themselves and the group. They

are openly available as models of identification.

The children are now curious about the

relationship between therapists and will question

it. The children, observing closeness in the co-

therapy relationship, are confused about the

nature and meaning of close adult relationships. If

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 the therapists are of opposite sexes, the children
will frequently ask if they are in love or having

sexual intercourse. If they are the same sex, the

children will want to know if they are friends and

do things together. They want to know if they get

together and discuss the children and group.

Statements that men and women can be friends

and care about each other without having sexual

relationships may be helpful. Co-therapy during

stage IV can be a rewarding, fulfilling experience,

enabling staff to become close to each other and to

know each other in a way that might otherwise

have been impossible.

Confidentiality

Whatever the relationship between the

parents and therapist, the child must understand

that the therapist and group belong to him, not his

parents. The group also is informed of their

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 responsibility regarding confidential information

—that they not mention names when relating

incidents nor pass on information to friends or

family. If this message of confidentiality is not

repeated or clearly understood by the group, they

may not be able to reveal intimate and disturbing

feelings and information.

Occasionally parents will try to elicit specific

information from the therapist. “What did Johnny
say? Did he tell you about the fight in school?” If

the child wishes to discuss it with his parents, it is

the child’s decision. Parents are best advised to

give their child openings to talk to them if he
wishes to do so, but they should not push the

issue.

In situations where the child has done

something the therapist judges dangerous, the

therapist must deal with his doubts about

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 breaking his confidentiality pledge. These
situations are rare and should be considered

individually. After it is clear that the child is not

exaggerating or confabulating, the situation is

weighed with previous experiences. If the incident

is judged sufficiently dangerous, the therapist

should tell the child and the group that he feels the
child is in danger and that he, the therapist, must

talk to the child’s parents. The child should be

allowed to express his feeling about this and have

the opportunity to inform his parents if he wishes.

Absences and Changes in Membership

Absences are even more upsetting in the

cohesion stage. Each child is very invested in the

group, attached to other members, and will try to

attend at all costs. Although absences rarely occur,

the group should be encouraged to discuss them

thoroughly. If possible, the therapist tries to elicit

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 the children’s fantasies about why a member is

missing. In that way he or she can reassure them it

was not because of something they said or did.

Whatever the reason for the child’s absence, the

therapist should expect the group to miss the

member and to react with feelings of sorrow,

anger, and denial. This abbreviated mourning also

will reflect the child’s place and status in the

group.

This is the last stage in which members are

removed, and this occurs only when a child is

destroying the progress of the group. Such

children have been closely monitored through
stage III and dropped as indicated. Occasionally

the therapist has delayed the decision until phase

one of stage IV, hoping the child might still change.

However, if a child is incapable of

individualization by this time, if he has very poor

behavioral controls, cannot tolerate change, and

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 actively moves to prevent others’ change, he will

have to be dismissed from the group. This task is

the therapist’s, as rarely do children this disturbed

remove themselves. Sometimes in fairly well-

functioning groups, the other group members help

to force the issue. It is best done as rapidly as

possible, after being discussed with the child and

the remaining group members and having been

made clear that it was the therapist’s decision.
Generally, children no longer fear the same will

happen to them, but they still experience a sense

of relief. This relief may or may not be

accompanied by guilt.

Given the therapist’s preference, children are

rarely added to close-ended groups during this

stage. In a short, time-limited group a child would

not be added. If exceptions are made, the group

should be carefully prepared, and the new

member might spend a few sessions with the

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 therapist. The child should be relatively intact,

able to verbalize, and ready to work on his

problems. It is helpful if the child has had some

therapy previously. The child should be prepared

for some anger from the other children and

comparison to the old member.

Adding a new child during this stage need not

be destructive to the group. Provided they have

been allowed to ventilate their mixed feelings
prior to his or her arrival, they might help orient

the new child to how they function and to what

has happened in earlier sessions. The new child

should be able to make an adjustment without a
great deal of difficulty. Depending on the group,

ages, and pathology, the children should be back

into this working stage after a few sessions of

regression. There will be some testing and

hesitancy to deal with their problem in front of the

new child until they feel he or she can be trusted.

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 The other children in the group are so invested in

the treatment process and are in such pain that it

takes more than a new member to stop them at

this point.

In an open-ended group, new children

constantly enter into this intimate phase. The

group soon learns this procedure and, along with

the therapist, learns the quickest way to help the

new child enter.

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 Chapter 7

STAGE V: TERMINATION

Charles H. Herndon

Experiential Description

Individual members of the group are

comfortable with each other, and group discussion
flows easily. There is a strong sense of

“groupness,” and the therapist is rarely needed for

limit setting. Discussions about outside activities

and new friends increase. Beginning talk is heard

about plans for the future, sometimes with other

members of the group. Last week Jason mentioned

he was bored with the group because all they did

was talk about things they have been doing, and he

would rather be playing baseball.

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 The therapist finds himself muddling over

whether he should introduce the fact there are

only eight sessions left. By the time he feels ready,

two more sessions have passed, and Mark is the

one who brings the issue to a head by asking,

“How much longer do we go on?” Another
therapist, with only five more sessions remaining,

may have resolved enough of his or her own

feelings to bring up the subject, before a child

questions it.

The group’s reaction is puzzling. Some

members react with surprise—“Oh, no.” Others

show no apparent reaction. Although one may say,

“It’s about time!” his behavior demonstrates this is
not so. The calm that was present is clearly

beginning to crumble. Poignant silences appear, as

if a favorite balloon had been broken. The

therapist finds himself talking to fill these by

enumerating the gains they all have made. He

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 begins to feel himself “grandstanding,” calmly

trying to lower the anxiety that has crept into and

taken over the room. Almost as if to reassure

himself, he says, “There is plenty of time left, five

sessions, to do what we need to do.”

At this point Andy and Mark get into a fight,

and Jenny puts her hand over the therapist’s

mouth. The novice therapist is struck with anxiety.

He wonders if the group is really ready to end. The
anger and denial confronting him is reminiscent of

earlier onslaughts. The group no longer has the

feeling of groupness. He feels overwhelmed and

wonders if it all has been worth the effort, as
achieved gains seem so quickly to disappear. He

gently removes Jenny’s hand and tells the group

again that it makes him sad but the group is going

to end. Some members express their anger by

saying they hated “the dumb group” anyway.

Limits are rechecked for the trillionth time; as

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 always, the children are looking for caring from

the therapist.

Almost immediately after the announcement of

the final date, regression is noted both in the

group and in individual members. The therapist

talks about this with the group. “You don’t need

that kind of behavior anymore.” “I know when I

feel sad or like something is being taken away

from me, I sometimes act in ways that I know I no
longer need or that are not helpful to me.”

“Leaving is hard, scary, and sad.” Sometimes all the

therapist is able to fit in is a staccato message, “Cut

that out.” “No, you don’t need to do that.” “Stop
that.” Anxiety and anger trigger quick tempers.

“What’s happened to the group?”

The group may begin spontaneously to

recapitulate earlier events, or the therapist may

initiate this process. “Do you remember when

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 Mark hit Andy and they both started screaming?”
Laughter follows. “Do you remember that boy who

left the group?” Earlier losses may be talked about

with a different focus and meaning as the group

tries to prepare for separation. This process helps

to return the group equilibrium and feeling.

Jason protests, though, with “I still fight with

my brother, and my parents still yell at me.”

Others join him in talking about goals not quite

accomplished or expectations unfulfilled. Some of

the children comment on their changes but fear

they will lose all gains if they do not have the

group to support them. The therapist tries to

explain how the changes are now inside them, and

although it may be harder for them, they will be

able to continue their improved functioning. They

have “learned skills that will help them do this.”

The therapist helps the group begin to evaluate

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 itself by asking members what they have gotten
out of the group. Adolescents may be able to

evaluate the group and their experiences very

accurately. The therapist talks about how each

child has progressed. He asks for ideas about

future recommendations and discusses what he

had in mind for each one. Some children can

discuss their plans and seek support and others’

opinions. As much as they are able to, together

they make plans.

Allison begins to talk more openly about the

abuse she suffered earlier in her life. Several

children seem to work harder during these last

few sessions than they have previously. They seem

to want to say everything that is on their minds.

Sometimes the fact that the group is ending also

makes revealing material less threatening.

During the final sessions some of the group

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 members are able to talk about their sadness at
the loss of the group. One child says to the

therapist, “I will miss you. You are my best friend.”

The children may exchange telephone numbers

and vow to meet again. There is a fantasy that the

group can continue on as it has been. “If you care,

how can you let us go?” Some children come

earlier and stay later to spend every last minute

with the therapist and group. Other children try to

avoid the termination by coming late or not at all.

The therapist talks about his sadness at the loss of

this group and how this group is special and

different from all others.

Although some groups are not functioning very

cohesively, a child or the therapist may suggest a

closing party, a kind of “graduation party.” The

therapist may wish to give it, symbolically wishing

to give more of himself, or a group may wish to

share in the plans and preparations. Most enjoy

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 the celebration and are proud of their

accomplishments, and it can sometimes help pull

together a group that has really pulled apart

during the termination stage.

There is discomfort expressed by all during the

final session, reminiscent of the opening session.

But usually there is more happiness than sadness.

As the children begin their goodbyes, a child may

hug the therapist or shake his hand. The therapist
says good-bye to each child and usually sees them

out of the group room so as not to feel the pain of

an empty room. Some children make a point to say

good-bye to everyone in the agency, especially if
they are terminating all treatment. As the last child

leaves, the therapist may blink back a tear.

Dynamic Description

The goal of this stage is for the children and the

group to separate as successfully and as

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 completely as possible while maintaining and
utilizing the gains they have made throughout

therapy. “Ideally, the termination phase

represents a point where the member and/or

group have completed their major goals for

therapy and begin to move out of the group”

(Levine, 1979, p. 77).

The importance of this stage is a somewhat

debated issue in the literature. Braaten’s

(1974/1975) review of group development

models revealed that only 5 out of 14 had

termination stages. Slavson and Schiffer (1975) do

not deal with a group-as- a-whole terminating.

They suggest termination be handled by the

parents and make only a few references to it in

their entire volume. They terminate children as

they are ready and stop a group at the end of a

school year, shifting those not ready to

“transitional groups.” On the other hand, Garland,

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 Jones, and Kolodny (1976) stress that “when we

fail to recognize the impact that the group

experience and its attendant relationships have on

individuals, we tend to minimize and deny feelings

of loss that the members and we ourselves have

when it is time to part” (p. 64).

What earmarks the beginning of this

termination process also differs in the literature.

Rose (1972) introduces the fact of termination
during the first group session and feels it should

become a regular item on the agenda for at least 2

months before the end (p. 187). Levine (1979)

views the termination phase as beginning with the
“final separation crisis,” which is initiated “by the

therapist’s or member’s recognizing that the end is

in sight” (pp. 241-242).

The authors view termination as an important

stage that begins prior to the first statement by the

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 therapist or question by a member regarding the
group’s end. Either, and more often both, the

group members or the therapist had been aware

that the group’s end was imminent but had been

denying and avoiding the fact because of the wish

to continue the cohesive group feelings so

prominent during stage IV. The statement of

termination evokes differing but equally strong

separation reactions and coping devices. These

emotional reactions contain denial, anger,

regression, hostility, acting out, grief, relief, joy,

and pride. Various group members may express

these simultaneously, in tandem, or in

juxtaposition. All may be evident in flashes during

one session or may cluster more sequentially in

different sessions.

Regardless of the length of the group, a

minimum of three sessions is necessary for

termination. A group that has met for 9 months

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 more than once a week may need six to eight

sessions to terminate. Groups of hospitalized

children may need only three group sessions to

terminate group therapy, as they will be dealing

with termination throughout their days. If the

termination is too long, the group may suffer

dropouts; if it is too short, the therapist may have

visitors for weeks after the last session.

On closer examination the termination stage

divides into three conceptual phases. During phase

one the group has begun to introduce and discuss

happenings outside the group. The therapist

begins in earnest his or her evaluation of the
group and the individuals in it. The formal

statement of the termination date initiates phase

two. This precipitates anxiety and a separation

crisis. Separation reactions and coping devices are

the processes in evidence during phases two and

three. Their expression is not the same in all

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 groups and is very dependent on earlier group

experiences and sequence in handling emotional

issues in earlier stages. This is especially true of

the way a group may have progressed through

stage II and its characteristic mode of dealing with

crises, especially previous separation crises, which

may have arisen around dropouts or losses.

Garland et al. (1976) also have observed this

phenomena of an unorderly progression relating
to separation.

The third phase is a time of recapitulation,

reminiscing, and reviewing that is done by the

entire group. Resharing of the group’s previous
feelings and experiences as it passed through

stages I through IV, helps consolidate growth.

There are many memories to recapture. The

children have increased feelings of self-esteem

and have been successful in making and keeping

friendships, increasing their skills and levels of

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 mastery. This internalization of the group and

therapist, and this acquisition of new ego

strengths and functioning, has been gradually

taking place throughout the entire group life.

Termination offers each member a chance to

further solidify this process and to let go of one

another. The manner in which the child is able to

accomplish this greatly affects the total success of

his or her group treatment. The group has
progressed from desperate individuals to

combatants to cohesive buddies to integrated,

individuated beings.

Termination in children’s and adolescent

groups offers golden opportunities to work on

developmental tasks and separation issues.

Separation-individuation is often faulty or

incomplete and may be an underlying reason for

referral. Sometimes a child’s behavior or

personality disorder is found to be wholly or in

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 part caused by loss that has not been adaptively

coped with. The large numbers of children seen in

clinics with divorce, desertion, and death in their

case histories tends to attest to this. Adolescence

has as one of its main tasks the separation from

parents. Careful consideration and planning is

needed to provide an atmosphere to help the child

and the group rework some earlier losses while

also dealing with the group’s end. The process of

separation brings up these earlier losses. The fact

that these current and earlier separation

phenomena occur and are shared in the group

adds the supportive experience that the child is

not alone with his losses and that others have

them too. Successful experience with separation

helps the child in his development. Each success

adds a progressive step from “diffuse” to

“differentiation” to “integration” (Pine, 1971).

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 The Child
During phase one topics of conversation,
questions, and feelings about outside things begin

appearing. At First these are sporadic and often

not paid much attention to, but as they gain in

importance and meaning to the child, they begin to

be more intently listened to by therapist and

group. More information and support for their

importance is given, laying the groundwork for
termination. Outside increasingly becomes a part

of the member’s experience in the group. New

friends, peer groups, conflicting time schedules,

and changes at home make their appearance. The
therapist interprets why these things are

becoming more important, always reconfirming

the caring and support. Originally unaware of this

subtle shift, each child enjoys it, liking to share his

mastery. The recognition and reinforcement the
child feels from the group, the therapist, and often

his parents and the school help solidify his or her

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 improved ego functioning and integration.

This progressive growth scenario does not

always exhibit itself in practice, especially during

phase two. Whereas one group of children may

enter the termination stage in this manner,

another, which all along has had difficulty dealing

with losses, may enter it quite differently. The

group that had an explosive and difficult anxiety

stage will most likely repeat many of these
patterns during termination. The number of and

diversity of coping devices and defensive reactions

to termination are reminiscent of patterns seen in

stages II, III, and IV. Ambivalence during

termination is seen in a kind of tug of war: wishing
to avoid and regress while also wishing to master

and move on. At any given moment the stronger

pull is seen and expressed systematically in bits

and pieces or in flashes and clusters.

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 It may be the more anxious or put-together

child who heralds the beginning of phase two by

raising the question “How many more sessions are

there?” Even though the therapist may have said

during the first session that the group would end

when school let out, it now becomes the focal
issue. The next session’s comments reflect

ambivalence and the natural process of

separation: “I’m glad this group is ending, so I can

play with my friends.” “Anyway, we don’t have fun

anymore in this group.” “Remember the good

times and trouble we used to get into?” “What am I

going to do when the group ends?” “After summer

we can meet again and have a good time.” “This

group hasn’t helped anyway; I still get into

trouble.” “Let’s plan a big bash our last day.” “I’m

never coming back!” “I never did like coming and

talking anyway.” “Let’s get together and go to the

movies.” “Maybe I don’t need this group anymore;

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 I get along at school and my parents don’t bug me.”

Children prepare themselves in different ways

and in different sequences for functioning without

the group. Most children deny feelings of anger

and pain. Some will be able to grieve, cry, or

express their fears, while others talk about what

the group has meant to them. Fond memories are

sprinkled with shared chuckling, embarrassment,

and bravado. What they share in common is an
accepting therapeutic group atmosphere that

provides support, caring, and nurturance. Some

children, due to the fact that termination is

imminent, begin verbalizing in a way not

previously shown. One may reveal hidden feelings
or experiences; another may integrate and

consolidate gains.

The major portion of the therapeutic work

during termination is reminiscing, reconfirming in

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 the present, and looking forward to the future.
During phase three each child learns that he has

changed, now having something new and lasting

inside that is just his. The child can easily

distinguish himself from the problems and feelings

of the others, making his boundaries stronger and

clearer.

During the group separation process the child

continues internalizing and strengthening gains he

has made. Even though a child may be acutely

aware of his identification with and dependence

on the group, he still believes he has changed. This

comprehension aids the child and enables him to

say good-bye without overwhelming loss or

devastation. This is a highly individualized process

dependent on the child’s psychic structure and

previous separation-individuation experiences.

The child may additionally benefit from seeing

other children cope with their losses in different

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 ways. For the child for whom separation has been

experienced as a loss of a part of himself,

observation of others not fragmenting may be

beneficial.

There are children who cannot cope with the

termination and take flight, not returning to

sessions. Attempts to get them back are generally

unsuccessful. The group may experience this as a

rejection and utilize it to project their own feelings
of anger and loss. Focusing on how others deal

with their good-byes can help the remaining

children deal with their own feelings of loss.

Not all groups are able to discuss termination

in helpful, rational ways and can simply be

described as chaotic and fragmentary. The

therapist tries to lessen anxiety by returning to

structured activities and trying to rebuild

cohesion. He may organize an ending party. The

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 group goal becomes to remain together through
the Final session.

The Therapist

The therapist enters stage V as a member of

the group. He monitors, guides, listens, and

interprets only as necessary. Much of the group

material arising spontaneously is handled by the

group itself. He listens intently to the increase in

discussion of activities outside of the group. His

stance has changed regarding the expression of

this material. In previous sessions, when he felt it

was defensive, he might have limited the group

discussion to what occurred within the group. By

phase one if outside material does not come up

spontaneously; the therapist encourages it. With

children undergoing their first successful group

experience, he must increase the attractiveness of

outside groups. Rose (1972) explains how to help

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 accomplish this: increase outside friendships,

increase attractiveness of outside activities, and

decrease the attractiveness of the therapist, (p.

188).

Early in phase one, while the group is still

functioning smoothly, the therapist is advised to

evaluate each member’s and the group’s

functioning. This work is crucial now in order to

have a realistic assessment prior to the First
announcement of termination. The presenting

complaint, the change in the individual child, and

his or her developmental level are all considered

in relationship to the child’s environment. The
group’s cohesiveness, ability to allow

differentiation, and support of emotional growth

are reviewed: “Will this group be able to continue

its empathetic bond during the process of

separation and allow both sides of the

ambivalence to be expressed?” “How is the

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 separation process likely to proceed for these

individuals and group?”

Phase two begins as the therapist gently

expresses what has been covertly felt but

consistently avoided: “Yes, the group will end in

six sessions, but we have plenty of time left to do

what we need to.” The therapist then must be

prepared for an onslaught of responses.

Some respond with anger or regress and

return to behaviors exhibited in stage III. The

therapist handles this increased anxiety

reassuringly. This is easier as the lines of

communication and trust are firmly established.
He remains consistent in his focus and caring. “The

rules remain the same.” “No, you don’t need to do

that.” “I know you are angry and that’s okay.” “I

feel sad too.” “I know you don’t want the group to

end, but you will be able to function without me

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 and the group.” Others react as if nothing has been
said. The therapist repeats himself. “If avoidance is

extreme . . . the therapist must confront the group

with their behavior” (Yalom, 1970, p. 281). He has

had to return to a more active, directive role,

interpreting as indicated the connections with

earlier losses. Little or no time is left to enjoy the

feeling of being a group member or of being able

to assess accurately the progress of the group or

individuals. The therapist who did not evaluate in

phase one finds himself almost hopelessly

immersed in the process. He or she experiences

doubts about individual and group growth.

Group reminiscing, recapitulation, and

evaluation occur during phase three. Although not

all groups are equally able to experience this

process, as they are able they remember what it

used to be like. Previously enjoyable and

traumatic events invade with a feeling of shared

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 amusement and accomplishment. Together they

may be able to look at the group’s and each

member’s present level of ability, strength, and

growth. The therapist must buttress recently

learned behavior to help integrate and consolidate

gains. Expectations for the future are shared.

Further recommendations and plans are discussed

in the group as appropriate and as time allows.

Some may be done in individual conferences. The
separation process is assisted by the therapist’s

sharing each child’s and the group’s special

meaning.

Each therapist handles termination in his or

her characteristic manner, at times avoiding the

fact that the group is ready for and may already

have begun termination. Perhaps this avoidance is

due to a need to prolong the fantasy that the group

will go on meeting everyone’s needs forever or to

avoid the children’s anger. It is common for a

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 therapist to focus almost exclusively on getting the

group to deal with their termination issues, while

denying or ignoring his own. Some, who are more

in touch with their feelings, grieve first; others get

angry. Some withdraw, separating emotionally

from the group.

The authors of this book agree with Levine

(1979) and Yalom (1970) about the importance of

looking at the therapist’s own feelings about the
termination process, including difficult self-

awareness and countertransference issues.

“Saying goodbye to some patients is saying

goodbye to a part of ourselves” (Yalom, 1970, p.
280). This is especially true with children, which

the authors highlight by adding a final stage,

closure. The therapist’s “ideal parent” role,

protective fantasies, and realistic concern about

the child’s welfare and environment all surface

during the process of letting go of children.

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 The Group

The group begins stage V functioning well and

feeling a strong sense of groupness. There is a

comfortable predictability in group interactions,

and the members rather easily discuss one

another’s feelings and problems. There is

confidence in themselves and their decisions and a

substantial change can be noted.

Manner of progression through the

termination stage varies greatly and is colored by

experiences in stages II, III, and IV. The sessions

immediately following the statement of

termination often are chaotic, but the anxiety is
usually not as intense, nor does it last as long. The

therapist focuses on group discussion of

separation issues, evaluations, and

recommendations. Group pressure may be exerted

to keep behavior in line and to keep a member

coming, but usually not with quite the same

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 degree of tolerance and empathy as exhibited

during the cohesive stage. Prior group events,

happy and traumatic, will be relived during

termination. Any losses of a member or a therapist

will be reexperienced, focusing on separation

issues.

The Parents

As soon as the termination statement is made

in the group, the therapist can begin contacting the
parents. Sometimes a parents’ group meeting is

scheduled to review the group’s progress. The

agenda will be a review of accomplishments in the

group and what to expect during the separation

process. Individual appointments may follow for

private discussion and to convey

recommendations.

The parent-therapist contact and relationship

has been consistent and must also have its closure.

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 Parents’ feelings, concerns, and questions need to
be considered as recommendations are being

made. Agencies, names, telephone numbers, dates,

and financial matters are covered. Sometimes a

letter reviewing the conference is sent to help

ensure implementation of recommendation.

The Agency

Although groups vary, the agency in the first

phase of stage V is barely aware of a group

functioning in the clinic. The children come and go

happy and content. Except for illnesses,

attendance is perfect. In phase two the agency may

not become aware of the regression, anger, and

sadness, and complaints are rare.

The agency may experience increased

telephone calls to set appointments and search
resources, as well as increased paperwork as

follow-up plans are made. Treatment staffings,

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 consultations, and referrals also are taking place.
Children make their rounds to say special good-

byes to those staff important to them. If there is a

party, the people acquainted with the children and

those having played some role in the group’s life

are invited.

Special Issues

Terminations, difficult for everyone, are

especially so for children, because the major

developmental task of childhood is separation and
individuation. Children who may be struggling to

discover and maintain boundaries in their

relationships at home also have had to do so in the

group. Now they must separate from the group.

The intense familial feelings and identifications

inherent in groups had led to conceptualization by

Scheidlinger (1974) that the group is like a

mother. Trafimow and Pattak (1981) have

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 supported this concept in their work with groups

of disturbed children.

Children who have not successfully completed

Mahler’s (1968) stage’s of separation-

individuation will have a difficult time with

termination because they feel they are losing a

part of themselves. Although unable to

conceptualize or verbalize this, they may

experience a body feeling of being torn apart. This
experience produces anxiety and, in some, panic

and fragmentation. They may fear that they are

not complete and cannot function without the

group.

Denial

Denial is frequently the first defense used by

children to deal with termination, because the

reality of the impending separation may be too

painful or anxiety-producing to face. Denial results

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 in a variety of observed behaviors. The group may
react as if they never heard the announcement of

termination, continuing their play or discussion.

They may become “super cohesive” or

demonstrate a renewed dependence on the

therapist (Johnson, 1974). When the therapist

interprets to the group how painful the ending is,

how unfair it seems, the children ignore him, tell

him to “shut up,” or cover their ears or his mouth.

A child may “forget,” insisting he had never been

told anything about the group’s ending.

Few therapists use denial about the group’s

ending, but they avoid introducing it, “forgetting”

to announce the date for one or two sessions,

delaying the process and not giving adequate time

to work through separation. They may deny the

group’s or children’s meaning to themselves,

short-circuiting their own grieving by focusing

exclusively on the children’s grieving. Some

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 therapists who avoid dealing with separation

problems of their own unconsciously convey that

these feelings are too painful to handle. This

results in the group and the therapist being denied

the opportunity of working on separation issues.

Regression

Regression is an adaptive defense mechanism

used almost universally by children trying to face

separation from a group that has become a
meaningful part of the their lives. Like most

behaviors the kind and extent of the regression

needs to be considered. Some believe regression is

an essential, integral part of termination.

Garland et al. (1976) identify two types of

regression at the group’s end. First is “simple

disorganized regression,” which “is a sliding

backward in ability to cope with interpersonal and

organizational tasks, usually accompanied by

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 outbursts of anger toward one another and the
worker and toward the idea of the club ending” (p.

58). The “regressive fugue” is when members

behave in “a manner dramatically reminiscent of

earlier developmental stages. This condition ...

reflects a desire to ‘begin all over again’ and

involves a phantasy-like detachment from the here

and now of the group” (pp. 58-59).

Regression occurs both with the group and

within the children. The group most often

regresses to earlier forms of behavior exhibited

during stages II and III. The therapist will

interpret this, helping the group verbalize and

begin the process of reminiscing. Earlier behaviors

are recognizable, but often, as a result of the

intervening internal changes and increased ego

functioning, the quality in individual children is

less primitive and pathological. The regression

sometimes surprises and frightens the children,

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 parents, and even the therapist. The therapist

interprets in light of the previous therapeutic

work and the separation process.

Anger

Anger may precede, follow, be mingled with, or

used in the service of denial, regression, and grief.

It frequently first appears when termination is

mentioned and the final date set. It is expressed

toward the therapist, the group, the agency, and
toward other group members in varying degrees.

Anger is often expressed toward absent members.

However, regardless of the initial and apparent

direction in which the anger is focused, it is always

focused at some level on the therapist who is

ending this wonderful experience.

Anger at termination is normal. The therapist

accepts it and interprets it to the child and group,

also expressing his own anger. When anger’s

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 expression is prohibited, it is often
inappropriately expressed or displaced toward
other group members, clinic, or property. When
anger is not expressed, interpersonal conflicts in
the group increase (Levine, 1967). When the
expression of the anger becomes rage, the
therapist employs techniques for control found
useful during earlier stages. Anger also is used to
test again if the rules are still the same and if the
therapist understands that the grief has to be
warded off. The child wants to know if rejection
and termination are synonymous. Some children
may be able to verbalize comfortably their anger
at termination and are proud of this achievement.
They have been taught to express appropriately all
of their mixed feelings, making the shift from
action to talking.

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 Grief
Grief, or profound sadness, occurs in addition

to denial, regression, and anger. It is hesitant at

first, briefly stated, then often denied or rebuffed.

As the group’s end is acknowledged, a quiet

blanket covers the group. Some less defended

groups may express their sadness quite openly,
with each member stating it plainly, in analogy or

metaphor. A well-functioning group may have

experienced grief earlier, dealing with it together

over the loss of a member or a therapist. It will be

brought up as a focal issue again during stage V in

a second effort to deal with the pain. In another

group a member expresses it while talking about

his life, the existential pain of abuse,

abandonment, or divorce. Its expression is

accompanied almost with a sigh of relief, as it can

now be a shared group issue.

Often groups would like to gloss over the

feeling and expression of grief. If this is allowed to

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 happen it will be displaced of left unresolved. Only

by sharing sadness in the group, by obtaining

confirmation, reassurance, and caring from each

other will there be comfort felt. The letting go of,
resolution of, and healing of grief occurs with this

group comforting.

Grief shown during the final session is

somewhat different, more ambivalent. It is brief,
juxtaposed with happiness, and is more
situationally focused. For those denying

termination up until the final sessions or for those

who have dropped out early, the expression and

resolution is most difficult, as it cannot be done in
one session and will therefore have to be done

alone without feedback and group support. Group

fellowship, support, and reality testing is

important in working through grief.

Recapitulation

Recapitulation, the process of reenacting,

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 reminiscing, and reviewing, is also a necessary
ingredient in the separation process. Garland et al.
(1976) also identify two types of recapitulation.
The first is “reenactment … where earlier modes of
interaction, developmental crises, and program
events are relived” (p. 60). There may be requests
for exact reenactments of previous group activities
or merely discussion of significant events in the
group’s history. “Review” is the second type of
recapitulation and “is a more conscious process of
reminiscing” (p. 60) about group life and events.
Evaluation is seen as being closely tied to
reenactment and “reflects a more rationalized and
organized experience” (p. 61). Although begun
during stage V, review and evaluation often
continue beyond the group’s end and are therefore
highlighted in stage VI.

After a group has shared in their expression of

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 anger and grief, there is a certain freedom to

reminisce with both laughter and tears. As

glimpses of the “good old group” pass by, the

changes are evident. The group is no longer

necessary.

Dropouts

According to Yalom (1970) who works with

adults, dropouts are rare in this stage. This has not

been our experience with children, perhaps
because separation issues and tasks are so

developmentally current and conflictual. A variety

of factors may be at work when members drop out

of the group before the announced termination

date. One member finds separation too painful, so

he or she runs from it. This child may have shown

an outburst of temper or a rage attack directed at
the therapist, group, or clinic. Another way to

recognize this child is that he may cancel sessions

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 for reasons that would not have kept him away

during stage IV, or he may just not show. If a

member has missed more than a session or two,

the therapist may not be able to get him to return.

He may have missed so much group work that it

will be difficult for him to return or the group to

accept him back. The group may be angry and hurt

by this behavior, feeling rejected.

The member having separation difficulties

should be brought back into the group if possible

so that separation can be dealt with as a group

issue. If this is not possible, a special meeting

should be arranged with the child and his parents.
This child needs an explanation of separation

issues and an interpretation of his behavior. The

therapist points out that these feelings are normal

and are felt by all the group members. Sharing

goodbyes in the group will help free him to begin

new relationships.

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 Another potential dropout is the peripheral

group member who has minimally participated

and whose pathology greatly differs from the rest

of the group. This member may not be ready to

terminate or is no longer accepted by the group

because he cannot express and manage his
feelings at the same level of appropriateness as the

group or because he is unable to make similar

commitments. It may be important to maintain

more disturbed children in the group, so that the

others may terminate with them and so as not to

be too disruptive to group process.

Yalom (1970) also notes that there are

members who make abrupt departures from the
group because they find it difficult to express

gratitude and positive feelings (p. 279). Although

Yalom was referring to adults, this also holds true

for some children.

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 Recommendations

There are numerous avenues open for children

following group therapy. The directions chosen

will depend on factors such as the goals of the

group, the pathology of the children, their ages,

and the facilities available in the community. The

preschool child who has learned parallel play may

now be able to participate in a day nursery

program and continue his or her emotional

development. The psychotic inpatient may now be

able to participate in a day hospital program or

special school placement. Another may be able to

tolerate a one-to-one relationship and can enter

individual psychotherapy. The behavior-

disordered child may be able to focus his energy

toward scouting, “Y” activities, or sports. Those

slow to grow in the group process may have

another group experience recommended.

Recommendations are formulated as a result

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 of the therapist’s evaluation, and the consultant’s

and/or treatment staffing’s recommendations.

Part of the group’s termination is talking together

about what each may need when the group has

ended. Group members are asked their opinions

and often have helpful suggestions and knowledge

of community resources. Careful thought is given

to the child’s progress, his comfort and use of the

group, and the family’s functioning. “Will this child
be able to maintain his gains within the family

system?” “Is a different school setting or class

desirable?”

Whatever the recommendation, it needs to be

discussed thoroughly with both the child and his

parents in a joint meeting. If the child has been in

concurrent therapy, that therapist also may want

to be present. Most children, even the very young,

can recognize what further help is needed. Some

parents have a general understanding by this time

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 of the needs of the child and eagerly await the

therapist’s recommendations. This is probably one

of the most open and gratifying meetings the

therapist has with the family, as it is used to

discuss gains and recommendations. The child is

given approval, sometimes furthering his insight

into his accomplishments, which helps him

anticipate future expectations. This eliminates

some of the pain of separation and starts the joyful
expectations that make termination also a happy

experience. It also helps reestablish a supportive,

empathetic relationship between the child and his

parents. Contact should continue to assure that

recommendations are implemented. The more

complicated they are and the more disturbed the

parents, the more frequent the contact.

References

Braaten, L.E. 1974/1975 Developmental phases of

encounter groups and related intensive groups.

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 Interpersonal Development, 5, 112-129.

Garland, J. A., Jones, H. E., & Kolodny, R. L. (1976). A

model for stages of development in social work
groups. In S. Bernstein (Ed.), Explorations in
group work: Essays in theory and practice. Boston:
Charles River Books, pp. 17-71.

Johnson, C. (1974). Planning for termination of the

group. In P. Glasser, R. Sarri, & R. Vinter (Eds.),
Individual change through small groups. New
York: Free Press, pp. 258—265.

Levine, B. (1967). Fundamentals of group treatment.

Chicago: Whitehall.

Levine, B. (1979). Group psychotherapy practice and

development. Englewood Cliffs, NJ: Prentice-Hall.

Mahler, M. S. (1968). On human symbiosis and the

vicissitudes of individuation. New York:
International Universities Press.

Pine, F. (1971). On the separation process: Universal

trends and individual differences. In J. B.
McDevitt & C. T. Settlage (Eds.), Separation-
individuation. New York: International
Universities Press, pp. 113–130.

Rose, S. D. (1972). Treating children in groups: A

behavioral approach. San Francisco: Jossey-Bass.

www.freepsychotherapybooks.org 421
 Scheidlinger, S. (1974). On the concept of the
“mother-group.” International Journal of Group
Psychotherapy, 24, 417–428.

Slavson, S. R., & Schiffer, M. (1975). Group

psychotherapies for children. New York:
International Universities Press.

Trafimow, E., & Pattak, S. I. (1981). Group

psychotherapy and objectal development in
children. International Journal of Group
Psychotherapy, 31, 193-204.

Yalom, I. D. (1970). The theory and practice of group

psychotherapy. New York: Basic Books.

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 Chapter 8

STAGE VI: CLOSURE

Barbara B. Siepker

Experiential Description

With the closing of the doors and the final

good-byes of the last session a hollow echo begins
to resound in the halls. The children have

departed and gone their separate ways. Some have

been wildly demonstrative with promises of

calling or writing; others have slipped away

virtually unnoticed. The therapist moves alone

from room to room, mingling with people in an

attempt to escape the internal emptiness. It has

indeed ended. That which was so tumultuous and

elusive has slipped away, leaving its impression on

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 all. The children and therapist are similarly
affected. At times it feels as if a burdensome load

has been lifted, as if everyone involved is elated to

have more time, new beginnings, and new joys.

Underneath there is an emptiness and profound

awareness of the necessity to deal with this alone

—the pain of losing one another and all that has
been shared. Present is an aura of quiet

individuality, sparked with an added strength that

aids in handling these feelings. It is as if someone

out there understands how hard it is to “go it

alone.”

Friends and relatives seem intuitively to sense

this emptiness and offer caring and support. The

life of the group goes on in memory. Some need to

deny its importance, whereas others lose
themselves in almost manic, obsessive behaviors.

Still others show open sadness, grieving, and

depression. This is a period of memories and

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 reveries about experiences, together with

nostalgia about the day and hour the group

occurred. There is a need to fill the time,

substituting something pleasant to help fill the

emptiness. Everyone involved is changed; what

has happened will always retain its impression.

For the children there is the excitement and

anticipation of being able to manage on one’s own

with new friendships and experiences. “What will I
be doing a year from now?” “It’s fun and exciting.”

The therapist, most readily available for

observation, now takes his turn at withdrawing

and mulling over his experiences. This is his time
to finish his good-bye to the group in his own way.

He has been unable to complete his separation

partially because of his concerns with everyone

else’s feelings and needs. Now that it is his chance,

he periodically indulges himself in memories,

searching for answers. “Will they be able to

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 maintain their gains?” “What changes really did

occur and why?” “Do they miss the group?” “Will

their families allow them to maintain their gains?”

“What do their teachers need to know in order to

accept and manage them?” “What will become of

them when they grow up?” “Will they have

memories of the group?” “What is the real impact

of this experience on us all?” The therapist is

surprised to find himself experiencing intense
feelings of pain and loss. “I have trouble

concentrating.” “I am absent-minded and have

managed to misplace my keys.” “I was

embarrassed when I choked as I started to talk

about the group.” He sometimes finds himself

dreaming about the group or individual children.

It sometimes takes a long time to complete his

postconference, follow-ups, reports, and final

closures.

Less is known directly from the child

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 concerning his experiences and feelings now that

the group has ended. Usually extremes of behavior

tend to come to the therapist’s attention. A parent

calls because he does not know how to handle a

child’s worsening behavior, or a school checks to

find out what happened in the group because “he’s

a different child,” or “he’s worse than he ever was.”

As the final sessions ends, the child has thoroughly

checked out whether it is okay to call, write, or
visit the therapist for social or for more pressing

reasons. Frequently, pleasant associations are

made by the child as he recognizes familiar

landmarks enroute to the agency, takes the same

bus, passes by the agency, or hears it mentioned

on TV or by friends. Pleasant memories remain,

and the child may speak with pride about when he

was “in that group at the clinic.” For some children

the experience is largely forgotten except for a

positive feeling that groups and agencies can be

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 helpful. For still others there is repression

regarding ever having been in a group.

Children are very frequently heard from

directly or by word of mouth. For older, more

mobile children, there is “dropping by to visit”

with the receptionist, secretary, or therapist, or

“accidentally bumping into” them on the street.

Cards, letters, and phone calls may be received,

but more often news arrives via the grapevine.
Occasionally the children themselves will arrange

meetings with one another, especially when they

have had previous contact outside of the group or

when their parents have had contact with one

another during the course of the group.

Concurrently, the parents are having mixed

feelings accepting back the complete

responsibility regarding their child’s actions. They

have depended on the therapist’s help and

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 frequently fear the child will begin to exhibit old
symptoms that will trigger a chain of regressions.

They almost panic when an old behavior occurs,

questioning, “Is it all right for him to do this?”

“What does it mean?” “Will he lose all of his

gains?” “Will he be able to talk to me about it and

will I be able to handle it alone?” “If we have to

come back, does that mean he’s been a failure?”

“Maybe I should get him enrolled in a community

group as suggested.” There is a thrill or pride in

their child’s accomplishments and relief that their

lives no longer need to be planned around the

group’s time. They look forward to increasingly

satisfying relationships with their child and for

him with other children. Some having seen the

child’s success, desire it for themselves and plan to

enter treatment to achieve it.

The agency returns to old routines. No more

friendly, jovial faces arrive an hour early to share

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 their stories with the receptionist. It is almost as if

the group has been forgotten except for references

and comparisons to that “good old group”

creeping into conversations. “There never was a

group like that one!” “They would run through the

halls and crawl under the furniture.” “Remember

when two of them ran out of the group room and

locked themselves in the bathroom? Their

pursuing therapist, returning empty-handed,
turned purple when he found the group room

locked!” “Finger painting was a disaster that day it

became accidentally smudged all over the

furniture, floors and walls and took two hours to

clean up. The director really put his foot down

then!” “Somehow we all survived.” “It wasn’t so

bad after all.” “I wonder when we’ll have another

one?” “Who will run this one?”

New groups reflect remnants of the old,

echoing how it happened then and what changes

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 should occur. The “old group therapist” becomes

“expert consultant” and is looked to formally or

informally for advice and support. Children

contacted for new groups refer to their old groups.

“My group therapist was really nice.” “You mean

we’ll get to play where before we only talked?”

Parents wonder why this group leader seems to

advocate less freedom and more responsibilities.

“How does this activity group compare to the
other treatment group?” “Who will be in this

group?” And so, gradually, everyone becomes

immersed in the plans and recruiting for “the new

group.”

Dynamic Description

Although the closure stage is not recognized or

conceptualized in the field as a stage of group

treatment, it is an integral stage of treatment,

especially with children and adolescents.

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 Frequently due to this lack of recognition, stage VI

is not expected or adequately prepared for by

therapists. For some of the same reasons our stage

model began before the First session it is extended

beyond the last. Relationships, with their

associated affects and memories, continue a life of

their own within the human mind. Literature does

not address itself beyond the last group session to

the issues of terminating the relationships that
have developed during the course of treatment.

Garland, Jones, and Kolodny (1976) alert

practitioners to the fact that intense feelings have

developed in group relationships and that

recognition needs to be given to their seriousness

and how this affects termination. They note the

phenomenon of children returning following

groups and the possible need for continuing

support as a part of the group worker’s

commitment.

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 The beginning of stage VI is the ending of the

last session, lasts a few weeks to a number of

months, and is largely influenced by the internal

needs of the individual therapist to complete his

or her work and the external demands of the

agency. In another sense the reevaluation and
memories of the group live on indefinitely. The

stage formally ends with the inception of the idea

of running a new group.

On closer examination the processes can be

divided into three phases, which may vary slightly

depending on idiosyncratic methods of handling

separations. These phases are “letting go” of the

group, “letting go” of the individuals, and
reevaluation and preparation for a new group—

the first two being rather abstract theoretical

concepts recognized by and perhaps more useful

to the introspective, conceptual-oriented

therapist.

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 As the group in actuality no longer exists,

phase one is letting go of the psychic construct of

“the group” and its attendant meanings and

feelings to the therapist, child, parent, and agency.

This letting go incurs a process of separation and

mourning for the total gestalt and phenomena of
the group, involving global affects and

identifications that are not unlike those made with

familial, cultural, and societal groupings. These

evolve with the passage of time. There is an

acceptance of and comfort with this internalized

identification with the therapy group that occurs

in reminiscence and is accompanied by affects that

resemble paternal, maternal, fraternal, and

nationalistic feelings.

Phase two is a letting go of the individual

children, parents, and therapist, necessitating a

different level of separation, loss, and mourning.

The “narcissistic tentacles” of intense

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 interpersonal relationships must necessarily be

removed from one another and returned to the

individuals to allow separation and growth. For

the child, the process results in identifications

with and internalizations of the lost therapist and

children. For the parent, the process includes

identification with and trust in the therapist’s

conviction that the child is ready for termination

and, it is hoped, an internalization of the
therapist’s ability to handle the anxiety and

problems of the child. For the therapist, a personal

loss of the children and his investments in them

resolves itself through a process of identifying

with the strengths, successes, and

accomplishments of the child and parent. As the

therapist has accepted that the children are ready

for independent functioning, the dependent

therapeutic relationship therefore is no longer

necessary. The therapist receives satisfaction,

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 gratification, and pride in a “job well done.” This

process is similar to a parent’s healthy ability to

allow the child to grow up, away and beyond them,

yet remain comfortable in the knowledge they

have contributed significantly and successfully to

the child’s development. They can allow the child
to take credit for his own accomplishment and

growth but remain available if needed.

Delays in the process of letting go of individual

children occur when children need additional

treatment or management following the group.

Children are either referred or are seen by the

group therapist. In either case the therapist will

need to let go, in relationship to the group
treatment aspects, and new therapeutic contracts

will need to be negotiated. There is closure on the

group portion of the relationship. Adequate

completion of these feelings can allow the child,

parent, and therapist to move beyond the group

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 into new experiences. This process is generally

considered completed when post-conferences,

follow-ups, reports, and agency requirements are

completed.

The ongoing process of reevaluation, putting

into perspective the whole experience of group

therapy as exemplified by “this group,” and

preparation for new groups, are the highlights of

phase three. This is largely the task of the
therapist, although frequently agencies assist in

this by planning evaluation conferences. Another

level of conceptualization and cognitive

understanding takes place gradually through
retrospective thinking, discussion, presentation,

reading, and consultation around this group

experience and group therapy more generally. As

this process progresses, the therapist becomes

aware of a growing, nagging desire to try another

group in order to have more comparisons,

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 challenges, and experiences. Conceptualizations

begin to occur about this new group in which new

ideas and techniques will be applied and further

tested.

The Child

The child’s separation was largely completed

during the termination stage. Information

regarding what happens to the child following the

last session is most often incomplete and
conjectured. A child’s response to separation

varies widely, depending on the child’s ego

functioning, ability to verbalize internal processes,

personality patterns in handling feelings, the

quality of parent-child relationship, progress

within the group, and previous reactions to losses.

Most of these responses were clearly
demonstrated in stage V. Significant therapeutic

gains during the group allowed the child to

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 achieve an appropriate developmental stage. It is

assumed the child adequately handles any

remaining feelings and issues with his or her

parents and friends. What significant influences

the therapist and group continue to have on the

child lies within the theoretical realm of

identifications and internalizations. These cannot

be measured or observed directly, even if the child

were more available for comment.

Children who from all indications have

terminated successfully will sometimes return as a

matter of checking in with the therapist to receive

recognition and acceptance for his or her new
accomplishments. These contacts are best handled

neutrally, in a friendly, relatively nontherapeutic

manner, rather than encouraging a reinvestment

or reestablishment of a prior intense relationship.

The child needs to know the therapist enjoys

seeing him, remembers him, and continues to

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 remain available at the agency. These contacts are

best made at the child’s initiation. The therapist

can appropriately initiate contact regarding the

child by checking on the child and his progress

through contacting parents, schools, and agencies,

rather than directly with the child.

Children who experienced greater difficulty

terminating and progressing through the stages

will sometimes need direct contact with the
therapist in addition to their parents, school or

community. In most cases these are the children

who have a history of separation problems. These

children can be identified by their increase in
symptoms, parents’ and teacher’s alarm, which

may occur within days of the final session. Unable

to complete their separations, these children are

still dependent on the therapist for understanding

and interpretation. Other children also suppress

closing off in terms of the group experience,

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 especially the pain of separation, and may

withdraw and cut themselves off from their

feelings. Children having transitional difficulties

will need more support from their environment in

order to use this stage to complete their

termination. These children need to see the

therapist a few times, to assure his or her

continued availability. A relationship may need to

continue until the child is able to let go and be
transferred to another group or individual

therapist.

The Therapist

The process of separation can be studied and

observed most directly in the therapist. As much

as he feels he recognized and handled his feelings

during the termination stage, he was busy
“holding the group together” through dissolution

and did not have a great deal of time, energy, or

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 distance with which to handle his own. The novice

therapist is sometimes unpleasantly surprised and

unprepared for dealing with the intensity and

impact of his feelings during the closure stage. He

had expected all to be over with the last session,

even though he secretly feared all would return

the following week with the same problems. He

questions whether he should have such strong

feelings. Even experienced therapists are
sometimes surprised at their intensity. The

therapist has invested a great deal of himself,

received a lot in return, and needs to feel the

treatment has been successful. He would like to

protect his investment by “turning the child over

to capable and loving hands,” the ideal solution, or

at least find a reasonable compromise. He is wary

of turning over “his group of children” to

insensitive but well-meaning, or sensitive but

sabotaging, parents or teachers. He would like to

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 ensure that accomplished gains will be maintained

and that continued growth is possible.

Recognizing and handling his own separation

process involves the therapist’s accepting the

finality that the child is no longer externally

influenced by the therapist. The responsibility for

the therapy has ended, and only an administrative,

semitherapeutic one remains for transfer,

disposition, and closure. To separate emotionally
necessitates balancing his feelings of power,

authority, omnipotence, and grandiosity with

worthlessness, self-depreciation, powerlessness,

and helplessness. Experiencing a mixture, he

eventually ends up feeling somewhere in the
middle. “Significant progress was made in these

specific areas, but not these for the following

reasons …” “A combination of these factors

resulted in this change ...”

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 The natural course of the passage of time is a

crucial factor in the separation process. The

separation from “the group” as an entity requires

that the therapist come to terms with the mixed

feelings encompassed in and resulting from the

overall group experience. Although the stages
have been discussed with clarity as they

progressed, the impact of their entirety at times

seems overwhelming. As each group varies so

much in overall flow and intensity, certain stages

stand out dramatically. Certain of these may loom

out of proportion, taking on almost living

characterizations. Most likely these are shared

good-naturedly with a colleague or consultant.

Sometimes they are experienced more seriously

within, revolving around conflictual issues for the

therapist. Sometimes denied or ignored, they wait

and may nag for a chance at restitution. Optimally,

the therapist has help emerging from this scenario

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 with resolution or at very least with motivation

and goals to try it again with certain differences

and modifications. For some groups, the fact they

made it through all or even some of the stages

intact is indeed an accomplishment worthy of

appreciation. Each group has its own set of

accompanying memories, living on in the thoughts

of the therapist, children, parents, and agency.

At group’s end the therapist’s investment is

still active in regard to each child. Contracts, goals,

and therapeutic progress is reevaluated for each

child. The therapist’s goal and work is to ensure

successful transition to home, school, and

community. Because of this he finds himself
wanting to reassure significant others that the

child is really sensitive, bright, perceptive, and

caring even though the child may defend against

this, show the opposite, or have trouble expressing

himself well. The therapist often is reassuring

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 himself and alleviating anxiety regarding the

child’s improvement. There also will be warnings

regarding the child’s behavior, such as when

anxious or angry he will need distance or a chance

to withdraw temporarily. There is the nagging

impression of unfinished business until he assures

himself that each child made a successful bridge

from the group and himself back to the outside

world.

Concurrent reevaluation has been occurring,

determining whether goals have been

accomplished. This process becomes final with

post-conferences, follow-ups, treatment
summaries, and agency reports and can take

weeks or months to complete. The manner and

time in which these are completed reflect both the

idiosyncrasies of the therapist and the state of his

resolving the separation. In the process the

therapist separates from the children first

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 singularly and then collectively. In his memory

they remain individualized and the group

distinctive.

The final step is to conceptualize and integrate

this group’s process and stages as compared with

other groups the therapist has knowledge of or

led. This includes recognition and acceptance of

the feelings generated by this group. The therapist

evaluates his professional and personal standing
as affected by this group.

Therapists should continue to consult with

their supervisors for a session or more past the

group’s termination to help put the experience
into perspective. The consultative relationship

must be brought to closure to facilitate their

moving into a similar relationship with a new

group or moving into a co-therapy or colleague

role.

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 When co-therapists exist, this phase involves

letting go of their reciprocal group relationship.

Putting closure on this group’s experiences will

allow their relationship to enter into a new

dimension, which might include co-therapy with

another group.

For the therapist who has been able to

understand, accept, and put these intense feelings

into perspective, comes professional contentment.
With more time and less external bombardment,

considerable retrospective assessment can be

accomplished. Ironically, much of the

conceptualizing and understanding of the group

and the individual process occurs in retrospect,
especially for the novice therapist. He may often

search the group literature for further

understanding. He has not always been pleased by

his feelings and reactions. He has come to know

the primitive feelings and anxieties aroused by the

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 group, of the internal and external boundaries of

his anger, anxiety, caring, and sensitivity, and is

more sure about those he can handle easily and

those causing him anxiety and difficulty. Putting

closure on the group allows him to think about a

future group and the changes he will make.

The Parents

Parents, for many of their own reasons, are not

always able to or do not wish to carry through on
recommendations given during the termination

stage. This is a frustrating experience for an

invested therapist, even though these cases are

usually predictable. When the parent fails to carry

through on recommendations or refuses

treatment for his or her child the therapist has few

and often inconclusive options. He can attempt to
mobilize the parent to follow through by

scheduling appointments with him or her to

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 review the progress, stressing the importance of

further care for the child, and by informing the

referring source of the family’s failure to follow

through so that further persuasion may be

applied. If these approaches do not bring the

results hoped for, there are only two remaining

choices. He can give up and allow the parent the

autonomy of his decision, coming to peace with

the fact that as much outside therapeutic influence
as is possible has been provided currently for

child. If it is a case of extreme, provable neglect—

not providing necessary psychiatric care, or abuse

—the only choice is to report to the proper

authority or attempt a legal suit to get the

indicated care or placement for the child. The

latter cases are few but worth the effort when

one’s ethical and professional motivations are

sufficiently aroused regarding the child’s welfare

and future.

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 The Agency

During stage VI most agencies set a structure,

at best also supportive, for the therapist to work

through his or her separation following the

group’s ending. By expecting treatment

summaries the agency is providing the necessity

and the vehicle through which the therapist can

utilize his or her intellectual capacities to pull

together and evaluate the progress a child and the

group have made. Useful conceptualization takes

place through review, helping put the experience

into perspective and one step away from the

experiential.

Deadlines for report writing and case closures

are often instigated by the agency not only to meet

their deadlines but to help the therapist mobilize

himself around the work of separation. In a sense

these deadlines are self-imposed limits set by

administrators who have been through this before

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 and found them helpful. Therapists react to

deadlines with varying patterns of compliance,

rebellion, compulsivity, avoidance, and

procrastination, all of which are frequently

accompanied by anger and guilt for not having

done the work earlier.

Clinical treatment summaries are crucial

means of communicating to agencies and schools.

These cover the areas of strengths, weaknesses,
changes a child has made, further work needed,

and useful techniques in handling the child,

especially his or her difficult behaviors. The

clinical summary often begins, stimulates, or ends
the therapist’s process of reevaluation. This

process, as already stated, is crucial to the

therapist’s handling of his feelings of separation. It

allows the therapist the necessary distancing from

his clinical experience with the child and group

and continues to pave the way for a more

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 objective perspective of observing rather than

directly experiencing. This is accomplished

because the therapist must look back at what has

been experienced, compare with prior symptoms,

behavior, and age-appropriate cultural norms, and

draw certain impressions and conclusions as to

the child’s current functioning. The therapist is

then further pushed by this process to speculate

why the changes occurred and the function and
nature of the improvements. The reevaluative

process is taking place, which is a healthy part of

allowing a therapist to gain emotional distance.

Treatment summaries are often followed by

treatment staffings to present an overview of the

treatment progression and to formalize decisions,

recommendations, and dispositions.

In addition to clinical reporting therapists

often are encouraged by their agencies to

formulate the broader implications of their

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 experiences with the group as a whole in the form

of group process treatment staffings, conferences,

didactics, and seminars, which often have the goal

of evaluating a group’s experience and providing a

teaching experience. This provides a chance to

make statements about group treatment and for

the agency staff to familiarize themselves further

with group process and stages of treatment. It is

hoped that all of these will culminate in the happy
conclusion that psychotherapeutic groups with

children can be survived and enjoyed.

Special Issues

Handling Separation

Looking again at the entire stage, it is clear that

for all parties involved the overriding process

begun in stage V is an internal one of experiencing

separation and mourning. The individual’s

handling of this phenomenon is clinically,

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 experientially, and theoretically accepted and

understood to be influenced and patterned after

all previous separations and losses. Separation is

usually experienced as a complex, difficult process

involving intense feelings that arise and quickly

are covered over and defended against because of

discomfort, pain, and a fear of being overwhelmed.

Experienced are sadness, anger, and emptiness.

Separation and mourning are universal

phenomena that can resolve themselves in

healthy, active ways or more pathological ways. By

the closure stage, the process is already fully

begun, with healthy resolution hinging on
acceptance, a necessity of time, and letting it

proceed along its natural course. The internal

processes brought to play more frequently in

healthy resolution are identifying with aspects of

the lost object, sharing feelings with the lost

object, or projecting their mutuality onto the lost

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 object, and discussing with others in an effort to

share, reminisce, and gain an intellectual and

conceptual perspective. Observable is a movement

and dynamic interplay between loss of the object

and pleasure of therapeutic gain. There is typically

no need for contact or intervention during this

healthy process.

It is sometimes difficult to imagine how an

adult can allow a child to separate and proceed
with the lifelong process of growing into

adulthood. The joys and gratifications an adult

receives vicariously by reliving childhood through

children has many satisfactions. There is always
present the wishful, magical thinking that allows

the therapist, parent, and child to feel “this can and

should go on forever.” It is easy to find a need and

a reason to continue treatment and hard to find a

reason to terminate, especially when the child is

from a chaotic, rejecting, or pathological home. To

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 help a child with the realities of life, to let him or

her face the world alone, not yet totally prepared,

indeed feels at times cruel and unnecessary. There

never is an “ideal” time, solution, or place to refer

a child. There remains for the adult an unfulfilled

wish to see the child through the completion of

childhood with all of its incumbent tasks and

gratifications. If therapy has been working well for

this child, there’s a wish to prolong and enjoy it. If
a child is moving slowly or not at all, there is both

a wish to quit and a need to continue in hopes of

treatment accelerating. The therapist must come

to grips with the group’s being but “for a moment”

in this child’s life and learn to be comfortable

letting the child go on to experience the many

relationships, tasks, joys, and hardships remaining

in that fluid state called childhood. This

necessitates trusting that the child has

internalized something useful to him and that

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 future adults will look on the child favorably,

offering support as needed.

Theory remains inconclusive as to the degree

and influence of mourning in the young child. The

type and extent of a loss experience may be

quantitatively and qualitatively different from that

of an adult as well as perhaps being less lengthy or

elaborate. Age, ego functioning, and dynamics of

disturbance are factors in this process. The
younger the child, or the less able he or she is to

conceptualize and function with an observing ego,

the more difficulty he will have in understanding

and handling the separation. For those who have

not reached the stage of separation-individuation,
the experience of loss may be more for lost parts

of self. Some experience an actual loss of an object;

others will experience a loss of love from a

significant object. For an older child who also

possesses stronger ego functioning and more

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 independence, the experience can result in a solid

identification with and internalization of

functioning gained through the therapist and the

group. Identifications begun during the group

continue and often expand in fantasy. The loss

experience for this child may be more of losing

former aspects of himself such as his symptomatic

behavior patterns.

The more unusual and exceptional cases of

incomplete, unresolved, or acute mourning are

more blatant and in need of special attention. The

therapist must intervene and work with the child

or parent around the block or inhibition to the
normal processes of mourning. Unresolved

mourning is evident when the following continue

past interpretation: the fantasy wish to “remain

together forever,” anxiety or obsession regarding

the transfer arrangements, denial of the continued

existence of problems through an omnipotent

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 incorporation, or a global regression to earlier,

more regressed, symptomatic functioning. An aura

of fixity and rigidity prevails, indicative of

unresolved, sealed-over conflicts. Acute suffering

and pain indicate an inability to accept the loss,

possibly due to previous unaccepted losses. When

evidence is not present of active mourning, one is

alerted to the probability of suppressed,

unresolved mourning.

The technique or manner in which the

therapist intervenes is largely dependent on the

child’s or parents’ prior patterns and the

therapist’s orientation. In one case, the therapist
may be supportive, accepting, and understanding

of the intense, endless pain and help the child

recognize its genetic and dynamic roots, or in

another case the therapist may help the child

make a decision to “give up” the inappropriateness

of the feelings and the endless, overwhelming

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 burden these create. The important common

denominator is to confront the separation

problem by focusing attention on it, discussing it

with and interpreting it to the child and/or his

family, and working with them until some

resolution can be achieved so that the child can be

free to move on to investing in new relationships.

Children do frequently return to the therapist’s

attention in one way or another for visits or
follow-up care. Their return does not necessarily

reflect on the validity or integrity of group

therapy, the therapist’s skill or

countertransference, or resolution of the child’s
problems. Termination is often conceptualized in

child therapy more as an interruption in treatment

rather than completion, as in an adult model. Often

child treatment has as its goal to return or bring

the child up to an age- appropriate stage of

development. The tasks and conflicts of later

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 stages of development are still ahead for the child

and may cause him or her future difficulties

necessitating additional support or treatment.

Not all therapists are equally successful in

handling their separation feelings. Some exhibit

depression, obsession, or manic behavior, whereas

others withdraw and rely on previously confirmed

attitudes about themselves as therapists. These

may be extreme, rigidly held conceptualizations.
Some therapists overestimate their effectiveness

and importance, which frequently covers

underlying issues of self-doubt. They have trouble

accepting that someone else can love and handle a
child as well as they can, which results in their

remaining overinvolved, unable to allow

separation. Therapist inadequacy and insecurity

also may be evident in criticism of his role in the

group or depreciation of the contributions of

home, school, and community in the changes a

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 child has experienced. Anxiety surrounding his

professional or therapeutic contribution may

cause him to be excessively concerned regarding

the expertise and professionalism of the help or

treatment that is to follow. For some therapists

this is a trying stage, sometimes never completed.

Parcels of feelings, loss, overinvolvement, and

failure are carried around. These do not allow him

to have another group because of vulnerability
and inability to work these feelings through.

Ideally, therapists with difficulties in resolving

their mourning will be picked up by supervisors

and consultants in discussion, staffings, or group

presentations, or will be self-identified. Mourning

needs to progress in order for the therapist to

remove his or her investment in the children and

to allow a final separation. Only then can the child

be free to invest elsewhere and the therapist free

to consider undertaking other group therapy

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 experiences.

Signs of Successful Treatment

Successes in treatment are largely seen and

judged through the eyes of the “beholder.” The

therapist who formulated goals for the child feels

successful if these have been achieved. Children,
their parents, and teachers have also set goals they

hoped would be accomplished. The parent or

teacher who was irritated by a certain symptom is

relieved when this has disappeared and annoyed if

it remains. The parent who wants happiness for

his child will be pleased when he no longer seems

driven with behavior and conflict and seems to

enjoy life. The rewards of successful treatment are

often fed back to the therapist through pleased

children, parents, and teachers in the form of

thanks, visits, praise, or more referrals.

Handling Terminations and Transfers

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 When the child transfers to another therapist

within the agency or to another agency, any

contact with the therapist should support the

child’s new treatment. When the child is

ambivalent regarding the transfer and uses this to

try to engage the group therapist into siding with
his negative feelings, the therapist must be wary

and hold a consistent, neutral position regarding

their relationship while encouraging the child to

bring his feelings to his current therapist to work

them out. The therapist can support this by

reviewing with the child their beginning

relationship, when the child felt similarly toward

him but ended up feeling very positively. The

therapist shows his caring through demonstration

that he wants the child to get something from his

new treatment relationship. This is not the time or

place for strong, mixed feelings the therapist may

have regarding the new therapist or agency. These

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 ambivalent feelings should have been handled
prior to making the transfer. The child must be set

free to form a new therapeutic alliance. Although

transfers in treatment are indeed difficult and

often less than ideal, they are virtually impossible

when the ambivalent therapist is unable to allow

and help the child to separate from him.

Dropouts that have occurred much earlier in

the group life are handled much better at the time
they occur so that appropriate dispositions can be

made. If this was not done at that time and the

child returns after the group’s termination, an

assessment needs to be made to determine what

service the child and his family are seeking and
ready to invest in, as well as what is

therapeutically indicated at this time. It is

preferable for this assessment to be done by the

group therapist if he has the time and experience

necessary. If not, a referral should be made.

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 There are definable limits to the therapist’s

responsibility regarding transfer and disposition

of cases. Given the inherent limitations of ideal

therapeutic milieus in which to transfer a child,

the therapist must make the most educated,

realistic, yet therapeutic decision regarding
disposition. At the same time he needs to come to

grips with his own narcissism and grandiosity that

he is the best or only person who can really

understand and help this child. Once he has been

able to recognize and accept the limitations in

choosing an ideal situation and has come to

internal peace regarding his helpfulness and

effectiveness with a child, he will be able gradually

to decrease his investments and allow successful

separation of the children. Not until this is

complete and the therapist is finally satisfied that

every child in his group has been “properly

transferred” can he complete his mourning.

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 Reference

Garland, J. A., Jones, H. E., & Kolodny, R. L. (1976). A

model of development in social work groups. In S.
Bernstein (Ed.), Explorations in group work:
Essays in theory and practice. Boston: Charles
River Books, pp. 17-71.

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