Groups for Abused and Traumatized Children

Trauma groups have multiplied since the early reports of Green (1978), Cunningham and Mathews (1982), and Mara and Winston (1990).
In 1994, Reichert reported on the use of play and animal-assisted therapy for sexually abused Appalachian children. The focus was on the use of play and fantasy for the children to reverse their role from victims to survivors. DeLuca et al, (1995) evaluated the effectiveness of brief (9 - 12 weeks) structured therapy groups with 35 girls, 7 to 12 years of age, with a history of sexual abuse, showing an increase in self esteem and a decrease in anxiety and behavior problems. Parents also felt that the treatment was helpful, at 9 - 12 month follow-up. Zamanian and Adams (1997) using a time-limited (16 week) psychotherapy group with 4 sexually abused boys, describe the loss of power, helplessness, and the defenses of identification with the aggressor, splitting, dissociation and so forth. The therapist?s conflictual and countertransference is discussed.

Streider et al. (1996) outline a comprehensive ego -enhancing program of 10 session psychotherapy groups for cumulatively and repetitively traumatized children. As part of an elementary school-based violence prevention/intervention program Murphy, et al. (1997) introduced trauma/grief focused psychotherapy groups for children exposed to intrafamilial and extrafamilial violence. The multimodal, interdisciplinary team?s goals were both psychological repair and social adjustment.
A comparison between a psychodrama group with young girls and a control group showed significant decreases in self-reported difficulties, withdrawn behavior, and anxiety/depression (Carbonell and Partelano-Barehmi, 1999).

Peled and Edelson (1992) reported on a 10-session group format for children of battered women. Children who are witnesses to violence and abuse of their mothers sustain significant trauma. The ability to speak about these events with their peers and therapists provides significant support in short-term, manually guided psychoeducational groups. Activity groups (Nisivoccia and Lynn, 1999) and play therapy (Gallo-Lopez, 2000), as well as a multimodal programs have been used with children who have witnessed abuse. Crockford et al. (1993) introduced an integrated program, ?Play Friendly and Safe?, in which there were separate and combined groups for children and abused parents, as well as the inclusion of a non-offending parent support group. A psychoeducational group for grandmothers raising inner city, abused, helpless, and depressed children, focused on practical issues of school, home maintenance, and daily problem solving. (Vardi and Bucholz, 1994).

Child victims of extra-familial sexual abuse have been treated in separate, combined, group, and family approaches (Grosz, et al. 1999). Group play therapy combined with psychoeducational techniques, drawing, and story telling have been used for family traumetized latency age children (Leavitt et al., 1997; de Ridder, 1999).
Children who were abused by a school employee were treated individually, in play groups, and with the family (Pelcovitz, 1999). Children and adolescents who have abused others have been treated in trauma-alleviating groups (Erooga and Masson, 1999).

Working with these abused children in all settings is difficult because they are fearful of divulging secrets about their abusive parents (Schacht et al., 1990). In residential settings, they are treated in homogeneous groups, whereas in outpatient clinics, and day centers they more frequently are seen in heterogeneous groups. Negative countertransferential feelings toward the parents must be faced. Often these abused children become the perpetrators, and tend to victimize weaker children. In play groups, several cotherapists often are necessary to control and moderate the acting out.

Learning Disorders, Underachievement:

Clinic- and School-Based Groups
Gaines (1986) outlines a variety of strategies helpful in the treatment of the retarded children and those with attention deficit disorders, including computer games, videotaping, and expressive arts. The use of structured, time-limited activities is critical with this group (Azima, 1986). Various group models for these underachievers have been used in various settings. Mishna (1996) used a psychodynamic interpersonal model stressing mutual recognition and trust in an outpatient setting. Slavin (1997) using a psychoanalysis-based approach in schools, addressed both academic and behavior problems.
Gupta et al. (1995), used a method of classification and diagnosis of school-aged children seen in clinic groups. Working with ego-impaired groups in a residential program, Winek and Faulkner (1995), used a psychoanalytic, insight-oriented group, conceptualized as a collective superego, to encourage maturation. In school settings, groups using art therapy (Prokoviev, 1999) and psychotherapy (Merydith, 1999) have been used with underacheiving students.
In an assessment of brief group therapy with low-achieving elementary school children, Shechtman (1996) examined 142 low achievers, in Grades 2-6, who were randomly divided into an experimental and a control group. In addition to receiving assistance with school work 4 to 6 hours per week, the experimental children participated in a weekly psychotherapy group. The results indicated significant gains for the psychotherapy group in both academic progress and social well-being, which increased over time period.

Montello and Coons (1998) compared the behavioral effects of an active, rhythm-based group music therapy with a passive, listening-based group music therapy with 11- to 14- year olds in special classes for emotional, learning, and behavioral disorders. The Achenbach?s Teacher Report Form showed that both music therapy interventions (not only the hypothesized active music groups) produced a lowering of scores on the aggression/hostility scale. It was suggested that music was a helpful modality for increasing creativity and self mastery.

Medical and Neurological Conditions

Increasingly, medical and neurologic conditions are being treated in groups for children, adolescents, and parents. Some of the following subgroups overlap with former ones in the review (e.g., learning disorders, school, trauma ). Hyperactive children were treated in a semistructured activity group to enhance self-esteem and social competence, diminish sense of shame, and work through unmet exhibitionistic needs (Gnaulati, 1999).
Group therapy with siblings of autistic children increased knowledge of the disorder and allowed the expression of thoughts and feelings related to despair, guilt, and alienation from society (Carmi, 1997). Children with Aspergers' syndrome have been treated in a social skills group for boys (Marriage et al. 1995), and in a 2-year interpersonal group stressing peer interaction (Mishna and Muskat, 1998).
A parents' psychoeducational and experiential group for developmentally disabled adolescents was integrated into a total treatment program (Lynn, 1994).
A structured group intervention for siblings of children with cancer was conducted for a younger (7 to 11 years of age) and an older (12 to 17 years of age). The 6-week program revealed statistical and clinical improvement on post treatment measures in interpersonal and intrapsychic problems, improved mood and communication, and greater cancer-related knowledge (Dolgin et al., 1997).

A 3-year play group for three hearing-impaired latency-age boys showed improvement in school, home, and community posttreatment and 2 years after termination (Troester, 1996). A social skills group for boys with Gilles de la Tourette's syndrome showed small improvements in self esteem and ability to voice social and academic problems with each other and families. Subsequently, a monthly support group was formed for parents and children (Lambert and Christie, 1998).

Habit reversal training for trichotillomania in a group format showed decreases in measures of global severity of obsessions and hair-pulling behavior at 1-month and 5- month follow-ups (Mouton and Stanley, 1996).

Epileptic adolescents were treated in psychoanalytically oriented group therapy for 2 years. The goals were a better understanding of the illness, and provision of information on questions such as the effects on sexuality, pregnancy, and work. The goals included psychological support, comprehension, acceptance, and coping with the disorder (Rossi et al., 1997). A cognitive-behavioral group for adolescents and adults with spinal cord injuries led to improved feelings of self-control compared with a control group at a 2- year follow up (Craig et al. 1998).

The results of these studies of various group models suggest important group applications to these long-standing, chronic medical and neurological illnesses.

Family Issues

Groups for children of divorce, are used in various formats, including psychoeducational, cognitive-behavioral, drawing, and story telling activities. Epstein and Bordium's game (1985). "Could This Happen" helps focus disclosures of anxiety about angry, "bad" parents.
Roseby and Johnston (1997) introduced a group treatment manual for school-age children dealing with violent separating families. The manual includes drawings, cartoons, and specified themes and activities.
A group intervention for children and separated families, revealed differences posttreatment and 6 weeks later. (Durkin and Mesie, (1994) suggest that children should not be regulated as to with whom they communicate with, or how, but rather that caution be used to allow children to make their own choices regarding visitation rights and the like.
Parents, family, and multifamily groups have used psychoeducational, psychotherapeutic, parallel, combined or integrated programs (Epstein, 1976; Hoffman et al., 1981; Paramenter 1976).

A comparison of multifamily group therapy (42 families) with traditional family therapy (39 families) in the treatment of abusive and neglectful caregivers, showed that the children in the multifamily therapy group became more assertive, had fewer behavior problems, and showed greater self confidence (Meezan and O?Keefe, 1998).

ADOLESCENT GROUP PSYCHOTHERAPY

Young Adolescent Group

The techniques used with the pubertal group (12 to 14 years of age) approximate those used with latency age children, namely, a combination of activities, play, drawing, psychodrama, and discussion periods. Most therapists tend to treat pubertal children in homogeneous groups with a same sex therapist. These adolescents often are gauche and active and have difficulty in verbalization, especially the more pathologic, who are hospitalized or live in residential care. This age group works best on structured themes related to dependency, attachment, separation, and competition among others. Sessions in general are a maximum of 45 to 50 minutes in length. Both short term and long term models are used. In the latter category, Gordon (1989) has reported a 2 year group with aggressive boys that used the model of working through symbiotic attachment and gradually working toward individuation. Interpretations were made to the group as a whole, dealing with ongoing interpersonal themes, rather than on the intrapsychic material of any one member. Videotaping, music, projective art techniques, and board games (Kraft, 1986) often are stimulating for children of this age, who often are too timid to talk openly about their sexual abuse, drug use, inferiority fears, and marked ambivalence to parents.

Middle and Late Adolescent Groups

The age group of 15 to 19 years is most amenable to verbal psychotherapy. Outpatient models usually group the 15 to 18 year olds. Increasingly, the adolescents referred for group psychotherapy are characterised by depressive reactions, suicidal attempts, and borderline symptomatology, in addition to the usual range of behavior disorders linked to delinquency, rebellion against parents, school dropout, and drug and alcohol use. The more severely disturbed adolescents are hospitalized and placed in residential and treatment centers. School groups focus on learning disorders, low motivation, disruptive behavior, and the like. Outpatient clinic groups treat the largest number of adolescents, whereas private practice groups tend to cluster in the more affluent areas.

The average psychotherapy group size ranges from six to eight and includes both sexes (with the exception of the pubertal group); where possible, heterogeneous composition is preferable. Acutely psychotic, autistic, or very handicapped borderline youngsters are suitable for outpatient groups but may be placed in modified group formats in hospital and residential settings (Speers and Lansing, 1965; Stengel, 1987). The inclusion of borderline and very fragile adolescents depends on the strength of the total membership, which acts as a type of absorption filter and control mechanism. Group sessions vary from 1 to 1 ? hours, at the rate of once or twice a week, and may be either short or long term.

THEORETICAL CONSTRUCTS

Identity Group Psychotherapy

Rachman (1989) proposes a theoretical model based on the resolution of the adolescent's identity crisis in the group context and uses a blend of creative introspection, free thought, verbal and fantasy experimentation, and active techniques. The latter include role play, psychodrama, and dream interpretation, as well as specially devised scenarios to permit adequate self disclosure and working through of problems.

Interactional Psychodynamic Adolescent Group Psychotherapy

It is proposed that confrontation, empathy, and interpretation are the therapeutic triad underlying this approach and that all three stem from a common source (Azima, 1989). Confrontation accentuates the verbal enunciation of thoughts and feelings, whereas empathy involves the experiential process incorporating the other person's feelings and thoughts. It is postulated that the peers in the group are representative of varying confrontational and empathic styles. Some personalities are in need of a more confrontational approach, whereas others need longer nurturance and silent understanding. Interpretation occurs at the point in the therapeutic process when there has been sufficient empathic confrontation and clarification to uncover and give meaning to the underlying unconscious conflicts, and it should occur in synchrony with the individual and the group process.

Case illustration

John was a 15 ? year old with marked narcissistic and grandiose features. For many sessions, he boasted that he could live on his own, that he did not want to be in school, and that he had many friends. The other five group members could hardly get a word in, as he pontificated and analysed everyone. Gradually, certain members began to confront and question him and to express their annoyance. He soon revealed that his mother had divorced his alcoholic, abusive father and later married an older, quiet man. This man could not tolerate the patient, and he was moved into a small apartment with one of his brothers, who soon left, and he continued there alone. As these facts and feelings came out, he was amazed to regain the empathy of many group members. The therapist in the early stages had assumed an empathic, understanding approach with John and only gradually began to confront the narcissistic defenses. Although the patient was willing to interpret everybody else's problems, he could not accept other people intruding into his inner life. Many sessions later, a pretty adolescent to whom John was clearly attracted told him in a direct, confronting manner that he would have a hard time making friends, especially with girls, because he was not truly interested in them, and that he was sure to make others very angry by his know it all manner. John was stunned, averted his gaze, bent over, and remained silent. He slowly lifted his head, and holding back his tears, he said, ``I think you are right, and that's what I am afraid of.''

Comment

It may be necessary to confront the silence of adolescent members very early, in an understanding way. The psychodynamic significances of the intrapsychic and interpersonal communications and interactions remains the cornerstone of the interactional psychodynamic group psychotherapy approach. As in all psychotherapies, the goal is for the adolescent to develop self understanding, independence, self esteem, and interpersonal competence.

The preceding clinical example was taken from an outpatient, open ended, heterogeneous group with an average patient attendance of 2 years. In this model, the goal is the development of autonomy and independence. Parents are seen only at intake and at the end of each year's group, with the adolescents' consent. Confidentiality is highly protected in this model, and this in turn promotes faster divulgence of material. This approach is facilitated in a country (such as Canada) that provides funds so that parents do not have to pay the bills. In addition, in the Canadian system of health care, any adolescent older than 14 years of age can request treatment without the parents' knowledge. Outpatient clinics and private practice group psychotherapy often involve a combination of psychopharmacology, combined individual and group therapy, and parallel or conjoint parent or family therapy. In long term treatment necessitated by regressions or traumatic events, a combined network approach has been used effectively (Richmond, 1989).