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Interpretive Group Psychotherapy with Latency Children
Interpretive Group Psychotherapy with Latency Children Max Sugar, M.D.
The focus in this paper is on interpretive therapy in outpatient groups, not upon paratherapy or action groups or activity therapy groups. Interpretive group therapy takes place in a specific, constant, and stable setting-the usual playroom-which is designed to facilitate the demonstration of conflicts, defenses, and fantasies through verbalization and play. The therapist's activity is interpretive in a relatively nongratifying group setting where it is possible for the child's feelings to be understood through observing symbolic or representational behavior in the playroom. An appreciation of the specific aspects of latency children's type of thinking, psychosexual level, and typical defenses, as well as experience with individual child therapy, is necessary before embarking on group psychotherapy with children. Many mothers arrange play groups for their children wherein the children have a rotational scheme of playing with the same group of age-mates in different homes. While it may be a growth-promoting experience for the child, in that he learns to socialize with other children and other adults, it is unreliable and indirect as a therapy. Other types of play action groups in many communities include settlement houses, community centers, neighborhood parks, city recreation departments, clubs, Brownies, and Cub Scouts. Activity group therapy requires an extra large room with many crafts and hobby type of materials (Slavson, 1952; Schiffer, 1969). Schleidlinger (1965) described group work with socially deprived children, but he did not indicate if any of them required or received interpretive therapy. Karson (1965) used a six-month limit for children in group therapy, providing a corrective emotional experience by accepting and gratifying some dependency needs and allowing symbolic instead of direct gratification of hostile impulses. Dr. Sugar is Clinical Professor of Psychiatry, Louisiana State University Medical Center, New Orleans, Louisiana. Reprints may be requestedfrom the author at 17 Rosa Park, New Orleans, La, 70115.
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INTERPRETIVE GROUP PSYCHOTHERAPY
Interpretive group therapy may benefit many youngsters of latency age who have behavioral or neurotic disturbances. I have treated a wide variety of children with varying degrees of success through this modality. Their difficulties have ranged from ulcers, asthma, transvestite tendencies, and psychotic symptomatology to learning and behavioral disorders, and anxiety and phobic reactions. The children have come from intact and broken homes, institutions, and deprived backgrounds. The therapist in interpretive therapy remains friendly and informal, but he does not aim to be a better parent to the children or to gratify them directly. Instead, he encourages them to seek the participation of the other children in play. The child eventually feels free to express himself in play and words with fantasy material so that his defenses can be seen, understood, and interpreted. Everything that the child demonstrates need not be interpreted, and what is interpreted should be determined on the basis of the important unconscious themes. Attention should always be given first to the most superficial levels of resistance, and what is conscious and troublesome should be managed before proceeding to unconscious matters. Transference reactions are not as intense or clearcut in children in latency and preschool years, as the children are dependent on the parents or guardians with whom they live. A clear-cut transference neurosis does not develop, but intense transference reactions are regularly present and should eventually be interpreted when appropriate. Indications for Group Therapy for Children
Often in guidance clinics or community mental health centers, because of the many patients waiting to be seen and the inordinately long waiting list, groups are hastily formed without adequate attention to the individual patient's needs, or the training, experience, and readiness of the therapist to utilize group work with children. The same often happens in residential institutions so as to ease the burden of guilt about not having individual therapy time with each child. In private practice, the problem is often the reverse, with a practitioner having to wait a while for a number of suitable children to start a group; or if several children leave, wondering if he should terminate the whole group or wait to see if perhaps another child or two will come along who will be suitable for the group.
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Although characterizations have been made (Slavson, 1950, 1952; Schiffer, 1969; Ginott, 1958) about the type of child who is suitable for group therapy, none has been entirely satisfactory. Ginott's (1958) list indicates a wide variety without any exclusions, since he feels that group therapy is the proper approach for every child. Slavson (1950, 1952) and Schiffer (1969) advise that only the psychotic, the antisocial, or the aggressive child need be excluded from their groups. Depending upon the type of therapy offered, these writers may be correct, since if the focus is activity or action, the children may enjoy a great deal in this setting. However, for the purposes of interpretive group therapy with children, somewhat more specific indications would be helpful. The child who is deaf, or blind, or who has a serious neurologic or orthopedic disorder may be quite handicapped in such a setting, unless in a homogeneous group with a specially trained therapist. The child with a marked degree of intellectual retardation, the autistic, or the one who panics whenever he is close to other children similarly might be unsuitable for such a group. Perhaps an approach to considering the types of children who could be seen and treated in a group should revolve around the individual's need and the type of group he is to be offered. In an interpretive therapy group, the child has to be able to use play or language to express his conflicts and fantasies, and to be able to profit from interpretations being made to him. He would therefore need at least a low-average intelligence and would need to be responsive to verbalizations to some degree. The child who is deprived or severely antisocial should not be in a group with neurotic or borderline psychotic children for interpretive therapy. Such children profit more from activity groups, clubs, or individual therapy to help make up for some of their deprivation. The child who is totally action-oriented and does not use words will need a preparatory period of individual therapy rather than to be put into a group where play of a symbolic or representational nature and verbalizations are used. The child with a severely disorganized ego cannot attend to or concentrate on many stimuli, and he would be in a difficult position in a group with other children. The child who has marked anaclitic or symbiotic needs would not function well in a group unless the group were homogeneous and had multiple therapists (Speers and Lansing, 1965). Lifton and Smolen (1966) rarely allowed "free" play for their groups of schizophrenic children because it promoted confusion or withdrawal. After a lengthy preliminary period of intensive individual therapy with such children, however, some of them may
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be suitable for inclusion in a heterogeneous group with neurotic or borderline children . I have treated some psychotic youngsters in a therapy group, who had previously had one to three years of individual therapy and who continued in combined or group therapy with moderate improvement interpersonally and intrapsychically. One youngster who was at the educable, retardate level intellectually was treated individually for about two and a half years to help him with his borderline state, and then placed in a therapy group. The most suitable child for a group is the one who has a behavior disorder that is in the neurotic range or who has a psychosomatic disorder, neurotic symptoms, inhibitions, or sexual problems that are treatable and responsive to verbalizations. One child whom I saw might have been a suitable candidate for interpretive group therapy, but because of his needs and his diagnosis, he was treated individually instead. This youngster had had a number of losses over several years preceding the evaluation, and at that time he was neurotically depressed. The major themes involved in his depression were connected with losses and sibling rivalry. Individual treatment seemed more appropriate than subjecting him to another loss, that of the individual relationship he had established with the therapist. This would have been a reproduction, to some extent, of the famil y situation, and would not have worked successfull y at that time. The child who has done a good deal of work individually and has settled many of his conflicts, but who still has problems about peers as well as severe sibling rivalry, ma y be placed in an interpretive therapy group at such time to deal with these particular conflicts. Of course, this conflict will be connected with other areas of his psychic life that are unsettled , and combined therapy might be considered for such a child. I use this approach frequently with children who are having intrapsychic conflicts and problems with peers, with severe social withdrawal, inhibitions, hyperactivity, or anxiety. A preliminary period of individual therapy is necessary; otherwise, the child may turn down an offer of group therapy because of intense anxiety about the embarrassment he will experience. Interpretation at that point may not be useful, and if he is put in a group, it may not be successful. If, however, the child is seen individually for as long as needed to deal with some of the conflicts, then he may later be put in a group and seen in combined therapy; both types of therapy may then contribute to his further development and the resolution of his conflicts. Combined therapy brings up special complications and resistance for the group ther-
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apy, such as the child's feeling special and not talking much in the group, saving material for the individual sessions, or the reverse. Composition of Group
Ginott's (1958) suggestion that children in play therapy should be of the same age may be impractical, especially in private practice. In my own experience, preschool children in a therapy group may be with other children within a year or two of their age. In the latency age, the children may have a three-year age spread. Besides age, the level of maturity, the social adjustment, and the achieved school grade are considerations in group composition. A child of 10 who is in the educable, retarded range, and extremely deficient socially, would probably be out of place in a late-latency or pubescent group, but might be comfortable and work satisfactorily in a group with 6- to 8-year-old children. Although some people advocate mixed-sex groups for children, I believe that this overlooks the child's needs and developmental lines. The child of school age seems to do better in the same gender group. Boys in latency do not particularly wish to associate with girls, because they are making serious efforts to become identified with male figures. Girls at that age are having difficulties giving up their attachment to father, identifying with mother, and resolving their castration complex. For these reasons, it would be difficult to work interpretively with such children in a mixed-sex group. Members of a girls' latency group will talk about secrets or about household and baby things, whereas they might be embarrassed or fearful of ridicule if they discussed such things in the presence of boys. The maximum number for such a group should be 6. If there are too many active, anxious, hostile, or hyperactive children, it may be wiser to limit the number to 4 or 5. Below this number, the group does not have enough of a spread for interstimulation and identification with other behavioral patterns as well as interdictions that one member may espouse against another. The Parents As Part of the Setting
Once the child has been evaluated, an explanation is due him and his parents of the type and rationale of therapy. Before the child is ever seen for evaluation, the parents need to explain the reason for the visit. The therapist may connect data from the evaluation with the behavior or symptoms to the child and parents. An explanation should be given of how the child might be helped by therapy. A
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visit to the playroom before embarking on therapy may be useful for both parents and the child. The parents also need to be informed about the duration of therapy, the arrangements for the sessions, and the fees. Because the latency child usually gets fatigued after 45 to 60 minutes, a 45minute session is sufficient at the early latency level and preschool level. At a later age, a 60-minute session works satisfactorily. If possible, the session should interfere as little as possible with the child's playtime. In one group which had its sessions scheduled at 4:00 P.M. on a Friday, the resistance became apparent after a month or so of irregular attendance; Friday afternoon after school was a sacred time devoted to the children's special pleasurable pursuits. When the session was shifted to the morning, the work in the group continued satisfactorily, since it also decreased schooltime slightly. From time to time the therapist needs to see the parents to deal with their current concerns in managing the child, or with related data that they recall about the earlier years. The child and parents need to be informed that their data will be used in the therapy as indicated, although the child's material is confidential. But general statements about the child's progress may be made to the parents, and questions may be asked by the therapist. Group Arrangements
The arrangements are such that the group is open-ended within the limits of age, sex, and diagnosis mentioned earlier. In a clinic or residency training program, this is often difficult, as the group starts at the beginning of the academic year and ends according to the trainee's availability. In a community mental health center or guidance clinic setting, there is usually a long waiting list, and patients may have group therapy for one year, or some other arbitrary period, so that the people on the waiting list can be treated. Such groups may function satisfactorily with these time limits because of the pressure on the therapist as well as the patients to move on rapidly. In private practice, there is not usually a large waiting list of children within a specific age range, and a group might not be able to function if it were kept closed. By keeping it open-ended, children may come in as they have a need for group therapy, and leave when their needs are met. Since it takes time for youngsters to adapt to being in a group and dealing with their fears of exposure, shame, sharing, and with feelings of rivalry, a youngster is not taken into the interpretive therapy group when brief treatment is considered optimal for his
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condition. The patients for such a group have chronic problems which require lengthy work for a satisfactory effect, and the child is accepted for the group on the basis of being in it for a minimum of six months, although the treatment may be somewhat shorter or longer. The arrangements for confidentiality are clarified to each child and his parents so they understand that the members of the group do not reveal matters of group content or identity to people outside the group, including parents, and they do not socialize while they are group members. Frequently, a child is brimful of excited or anxious feelings after a session and, having a need to discharge them, immediately starts blurting out some material from the group when he gets into the car with his parents. The parents are told that this may happen, and when it does, they should not chide the child, but should try to understand the anxious or excited state which precipitated it. They may then remind the child of the need for confidentiality, and to bring up his feelings in the next group session, or the parents may call for an extra individual appointment. The Playroom and the Opening Sessions
By contrast with activity group therapy, which requires a large room with many toys, tools, craft materials, and the like, the playroom required for interpretive group work with children is of ordinary size and need not be filled with extra toys, crafts, or anything unusual. The playroom, with toys, a play table for a dollhouse and doll figures, need encompass only about 8 by 14 feet to be quite comfortable. Frequently an interpretation is required to relieve the initial anxiety that is connected with the expectation of having treatment here similar to that done by the pediatrician. An explanation is also due the child about why he is here and what the process consists of. Once this is done and the child is brought in to the playroom, he is in a setting in which production of fantasy is encouraged without promotion of guilt, anxiety, or embarrassment. The playroom should lend itself to the production of fantasies, questions, the playing out or speaking of various conflicts, rather than be involved with reality intrusions. The playroom for a group of children should not invite destruction, contain crafts or numerous new stimuli week-to-week, or be hazardous. Food need not be regularly available, but may be needed as an organizer or stimulus, especially in the initial phase. Toys are required for interviews so the children can use them (1) as a means of (nonverbal) communication; (2) in the enactment of
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scenes which they cannot describe but need to externalize; (3) for the expression of instinctual drives and for direct or substitute gratifications. Toys may be of the smallest practical size, of an indeterminate shape, and malleable. The following items seem useful: several open shelves with toys; a table with four to six small chairs; a doll house and table for it; a blackboard; a full-length wall mirror; lighting and windows that are protected or recessed; running water and a sink; play-dough; a sandbox (if possible) ; a doll family-man, woman, child , baby (relative sizes are important)-that may be malleable or not; some dollhouse furniture with a play tea set; a bathroom furniture set; puppets; costumes and clothes for the children to dress up in (Marcus, 1966); checkers; chess; various card games (like Old Maid); drawing materials (crayons, chalk, pencils, paper, fingerpaints); string; round-ended scissors; animal figures (one wild set and one tame set); cars, trucks, and airplanes (in specific or symbolic form); rubber knives and guns (that do not shoot anything); and a play nurs- . ing bottle. There should be a comfortable chair for the therapist, so that he may sit off to one side and observe the whole group without intruding, but be available for interpretive or supportive efforts. The room should be soundproofed so that parents in the waiting room will not become excited by the children's words or sounds during the group session. A radio playing in the waiting room provides good masking; double doors are useful, as are extra thicknesses of soundproof material on the doors and in the walls. Some five to ten minutes before the end of the session, the children should be notified that the session is about to end. This device helps children (in individual or group therapy) to wind down from the level of excitement or the high level of anxiety that they ma y have reached through some play. It gives them some warning that the play-pretend time is about to be over, and they can start harnessing their ego functions to leave the therapy session and go out into the real world again. This gives them time enough to regroup emotionally and to avoid the feeling that they have been abruptly cut off from some treasured activity. During this time, I begin to pick up and put toys away. I do not invite the children to assist, nor do I refuse their assistance if they offer it. THE INITIAL PHASE IN LATENcy-AGE GROUP THERAPY
The you ngster in a latency group relates to his therapist and to his peers. When the patient first enters the group, he is an isolate un-
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known to the others, and they, similarly, are not known to him. Each is concerned with his own problems and how this strange situation is going to be gratifying or useful to him. By the end of the initial phase, the group has developed a certain amount of relative stability in group dynamics and only relative cohesion. This amount of progress is a prerequisite for learning about themselves and their interactions for their therapy in the group. During this initial phase, they are learning how to get along in the group. They may be standoffish initially, playa game repetitiously, or surreptitiously look over the other members of the group, but rarely ask anything about them or even be ordinarily assertive. Certain resistances on the part of new members in the initial phase are a reflection of the patient's adjustment to a novel and unstructured situation, his anticipatory anxiety, expectation of being directed by another authority, and other attitudes related to displacement. The therapist can help the group work through this phase ifhe fully observes the patient's troubles and the sources of anxiety which are typically present in every phase of group life. Every patient and every therapist is anxious about the first meeting of a new group or a new member in a group. 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. The child's initial resistance is related to his realistic disappointment in the anticipated functioning of the therapist in the frustration of his transference expectations. No specific goals are set for the patient and each one is groping along still uncharted pathways. There are also the frequent, intense dependency needs. The dependency needs, the realistic disappointments, and frustrations peak in the first few sessions, at which time there is often a desire to drop out of the group or a fear that the group is going to drop him, caused by the patient's fear of rejection, his isolation, and unfulfilled needs. In brief psychotherapy groups, the intial anxiety is usually relieved, and if a group extends for only 6 to 15 sessions, not much may be achieved beyond this. Such a group then maintains the illusion of being directed by the therapist, who seems to function as a directive leader in the patient's mind, or the illusion may be that the group therapy sessions are really a class given by the therapist. Only if the therapist avoids falling into the role of directive leader or teacher, can the group move beyond the initial resistances. Otherwise, he will function in a nontherapeutic way by becoming active, directive, and authoritative, and the group will become leader-
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centered instead of group-centered. Such groups do little in the way of the interpretation of the child's conflicts and helping him understand his emotional difficulties. The therapist's use of the defaulting technique, on the other hand, and his refusal to assume an authoritative, directive role will make the group members turn to each other and begin interacting, showing each other and the therapist some of their conflicts. During this initial state the sessions may be dull, with long silences, feelings of embarrassment, or continued repetitious, obsessive play, isolation, and avoidance of one another as well as the therapist. The number of variations in the observable phenomena is immense and reflects the imaginativeness and uniqueness of the patients in each group. The dependency on the therapist is manifested early by the youngsters' looking to him for suggestions as to what to do, how to function, where to go, where to sit, and what games to play. When the therapist suggests that they might want to play with one of the other youngsters instead of with him, they appear hurt at being rejected and become sullen, putting up the toys or the game and sitting quietly for a while. Transference phenomena are at times less well concealed than in adult groups. This may induce the therapist's countertransference behavior to be more open as well, and at times to be more destructive to the grou p, especially if he has significant unresolved conflicts from his own latency age. Youngsters may look to the therapist as a father or favorite uncle, expecting him to behave as such a relative does . By knowing the history of the patient, the therapist is aware of the source of the displacement and can simply observe it, without interpreting initially or playing out the role of the transference figure that the patient wishes. Some transference reactions occur between patients, who may react to one another as if they were siblings. Sibling rivalry and oedipal rivalry are open, although often nonverbal, and are usually . expressed in fights or in picking at each other to obtain the "prize" seat or the best toy. The displacements and projections usually involve teachers or their friends who are not in the group, or their siblings at home. Pairing is often reflected in the same two or three members of the latency group seating themselves in the same situation or playing the same game several weeks in a row; thus they exclude the others in the group as well as the therapist. Sometimes pairing occurs between a patient and the therapist, the patient repeatedly trying to involve the therapist in helping him with his project or secluding him by talking only to the therapist, or sitting or standing near the therapist.
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Fight phenomena are very open; actual fighting may occur among several members of the group, or they may begin throwing things at each other, which somehow are not well aimed and seem to land on or near the therapist. Occasionally, a patient may discontinue visits after having sworn allegiance to the group forever the week before. This decision is usually imparted by a phone call from the parents, and at this point it is vital to explain the phenomenon to them and enlist their help in having the patient return to deal with this reaction more appropriately in the group sessions. The group members may manifest cohesion in a variety of ways, such as their involvement in building something, learning how to draw or play chess and exclude verbal interaction or exploration of emotions; or they may isolate the therapist from them-in a sense, a negative cohesion. The "nobody can help me" type of patient in a latency group will wonder aloud what he is doing there, since working on things with other boys is not helping him. Or he may bring marbles to play with the others or try to turn the group into a class in construction work. By any of these or other devices, he completely avoids the issue of therapy, while complaining about the fact that he is not getting any. Avoidance and rejection of help may occur, as it did when one patient retreated into a shelf containing toys and hid from the rest of the group. Monopolizing may occur through various devices, such as requesting continual help from the therapist, shutting off the others from any interaction with the therapist as well as themselves. The monopolizer may shut out the others by continually repeating his problems, his difficulties in his timetable, and so forth. In a latency group there is often an auxiliary leader, comparable to the assistant doctor of adult groups, who will engage in hostile exchanges with the therapist, make attempts to take over the group, and threaten to fight. The bully in the group will try to control all games or behavior, and in a sense is an auxiliary leader, but is also monopolizing. The group as a whole may show reaction to a focal conflict by a tremendous increase in the amount of noise they make with verbal exchanges, insults, singing, dancing, playing pseudodrums, or throwing toys about. Patients may use the differences in age, education, and position between them and the therapist to provoke and exaggerate their problems with authority. In this type of resistance, the whole group may join with the bully or the auxiliary leader. They may voice their feelings about this: "I came here to get out of school. Let's play baseball instead of sitting around here. You don't understand me, but the other guys here will because they are my age." The initial phase may last from 6 to 15 sessions.
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THE MIDDLE PHASE
The end of the initial phase is not a specific, titratable point, but it can be observed, and the transition to the middle phase can be tabulated by a variety of factors. One of these is that the group arrives at the recognition that the therapist will not direct them, teach them arithmetic, give advice, teach chess or poker; most members will discontinue turning to the therapist when they speak; all heads are turned to the patient speaking rather than to the therapist. The patients ask personal details about one another and recall them appropriately in subsequent sessions. They begin talking about problems that have been troubling them, and may even set up a peer court, asking the opinions of the other members (Sugar, 1967). The change will also be marked by changes in behavior, such as reduction in physical contact, verbal insults, and throwing things. Members will engage in a more playful technique in their hostile exchanges. Some of their verbal or physical exchange will also be an expression of some interest in or negative feeling about members of the opposite sex; they may tend to work together on something more constructive but involving a majority of the group throughout most of the session. The middle phase may last three months to three years and is the period of maximum distortion. Most of the work in therapy occurs in the middle phase. The children are now very dependent on the group, and there are fewer absences for minor events like "a cold" or "a dental appointment." They identify more with each other and compare notes more readily about their parents, teacher, siblings, and symptoms. They now consider the likes and dislikes of the group members and bring along specific items of interest, such as baseball and football cards, because of .rhe greater identification with each other. If the therapist focuses on one child, the others feel as if the whole group is attacked. The children now discuss their nightmares and dreams. They are encouraged to respond to the dream by sharing their feelings and experiences about the content, to clarify real from magic happenings, and to interpret the dream. When dreams are brought in, it also indicates a decrease in resistance, and if the group members work on it, it is a sign of a cohesive working group in the middle phase. It is especially helpful if the therapist can make some positive remark to the individual and the group about the dream. There are now some glimpses or clear-cut evidence of multiple transferences. The therapist can facilitate the therapy in this phase by promoting pairing by dynamics and defenses, reducing guilt, "going around," and universalizing the child's experience or feel-
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ings. Interpretations based on the group feeling may activate an individual to respond, and interpretations may be made to the individual or to the group, based on individual or group behavior. THE TERMINATION PHASE
This phase may last three to six months. The child is now able to give more, to play cooperatively, not defensively as in the past. He has now improved in relations to all group members, so that even those whom he dislikes he does not go out of his way to provoke, and he has come to see some good qualities about each of the members as well as the therapist. His transferences are less troublesome as they have been worked on. He is more realistically oriented, shows improved functioning as well as a decrease in symptoms and often a change in defenses. In this phase, the child no longer needs the group, but the group profits from his attendance since he is now more fair and easier to be with. The child may voice something about this, but he still attends regularly and does not look for ways to skip. When termination and a date for it are discussed, the youngster and the group members usually have some sadness and separation anxiety. But they often also have a feeling of envy and gladness that he "made it" and that someone is winding up. SOME GENERAL OBSERVATIONS
The youngsters are told at the beginning of the therapy that they may play with any of the toys in the room, but may not hurt anyone or destroy things in the room, or become involved physically with one another. Nevertheless, the therapist may occasionally have to separate two youngsters who are about to become engaged in fisticuffs. If they get involved in fighting or sexual play, such as hugging or kissing, then silent observation, a reminder of the arrangements, or an interpretation may be suitable. Should this continue, and group excitement grow, the therapist may need to intervene physically: first, by standing next to them silently; then, if necessary, by separating them. Some youngsters like to bring in some of their toys (their treasured possessions), and these are welcomed as communication about themselves, and then used therapeutically as much as possible. Occasionally, youngsters may bring in candies or other edibles as a treat or bribe for the therapist or the other youngsters. The therapist thanks the youngster for his thoughtfulness, gives
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him and the others permission to enjoy the treat, but does not accept the food himself if there is bribery involved. Turning the group room into an arena for baseball or football games is not allowed. Occasionally, limits have to be altered according to new developments. For instance , in one group session the you ngsters were making paper airplanes, which they were Hying across the room. Various feelings were being expressed through this behavior, and some of these were being interpreted: one you ngster flew an airplane upward in the high-ceilinged room; this was viewed by the others as showing great competence, both as a pilot and as a manufacturer of airplanes . However, when the paper airplane landed on the fluorescent tube at the juncture of the tube insertion into the socket and blew the lights out, it became apparent that this play activity was not safe, and limits had to be imposed on the direction of flying the airplanes. Further efforts to fly them in a curve, forcing the airplane upward, with a hope of landing it on the fluorescent tube and blowing out the lights again, led to disqualification of thi s activity altogether. Youngsters who are seeing the therapist individually ma y tr y to get him involved in games in the group session and exclude the others; or if they cannot manage the rivalry situation with another youngster, they may tr y to get the therapist on their side through the medium of a game or having him involved in their play. The therapist should tr y not to become centrall y involved in the pla y and games in the group, since he then loses his perspective as an observer beyond the one child and ma y arouse sibling rivalry. He can suggest th at th ere are others in the room with whom the yo u ngster ma y pla y this game, and if the child complains that no one will pla y with him, the therapist brings up the topic for everyone to explore. When two youngsters play a game of cards or checkers, and one of them seems unable to use his intelligence, I have interpreted the situation as it developed and wondered about his various plays or moves in a particular game in this connection. This may also aid in identification with the the rapist and in learning to share. One youngster complained bitterly that I was intervening on the other youngster's behalf in the checker game , and that it was unfair. I agreed that I was trying to help the second yo u ngste r learn to think better generally, to be able to pla y a better game with him . The first you ngste r was having a marked siblin g rivalry transference relationship to the seco nd boy and a hostile maternal transference reaction to me . I pointed out to th e first you n gster that he
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could think, but that he used his thinking to oppose parents and others in a defiant fashion; further, that he could even think of the consequences of his acts, but he did things to see if he could get away with them because he was so angry at his parents about unfulfilled things; that he used his thinking to control others. A third youngster in the group stopped what he was doing, intrigued by this, and curious about how it applied to himself. I told him that he too could think, but when he felt hopeless, he became jumbled up in his behavior and thinking. At such times, this youngster often became boldly deceptive, and he was aware that he was now prevaricating less. A fourth youngster came over then and said, "What about me?"-indicating that he wanted to know what I thought about him and his thinking abilities. I mentioned that he seemed to be afraid to think, and therefore he acted as the entertainer to get people to like him; in that way he avoided the fear of being hurt, as he did not have to think thoughts that might make him afraid. Excited or Disorganized States
Sexual and aggressive themes usually surface more quickly in group therapy than in individual therapy with children. When the particular play or toy is too exciting and seems to foster a child's becoming disorganized or destructive, the therapist may have to go from being a silent observer to commenting, confronting, interpreting, moving near the child, or limiting the child's activity. The latter may be done by removing the child from the specific play materials or by having him sit by the therapist for a while. If the child or group members ask why, the response should include a comment about the child's inability to control himself very well at the moment as he seems so excited and uncomfortable, and about the therapist's interest in helping him to be more in control. More specific interpretations may be made as the situation indicates. Later, the child may be allowed to resume the play if he feels he can control himself better. Restrictions usually involve water, clay, play-dough, fingerpaints, or similar materials, but the materials are left out for other children to play with. This contrasts with the approach used by Lifton and Smolen (1966) and Gratton and Rizzo (1969) with groups of schizophrenic children, wherein there are no play things and the children have to relate to one another or the therapist. When group contagion and excitement are about to go beyond the limits of safety or to be injurious to anyone, the materials may be removed and only verbal interchanges allowed until better individual and group control is
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regained. It is not always necessary to intervene when a certain amount of excitement or disorganization occurs, but it should be carefully observed as to quality, degree, and direction. Transference R eactions
Many varieties of transference reactions are evident throughout the group sessions. Whether they are 'inter p reted , and how, depends on the level, the timing, and the readiness of the patient particularly involved, as well as that of the group. Interpretations may be to the individual or to the group as a whole. Some examples follow of particular situations in different states of development in group therapy with children. I was going on a two-week vacation after a particular session to which a number of the group members (ages 8 and 9) were late in arriving. Each one asked about the absentees when he arrived. They did not seem to be interested in participating with one another, as they had been doing for some months previously; when they did use some of the toys, they did not interact or play with each other as they had . Instead , they engaged in the parallel play of preschool children. When I commented on this, one child responded as if he had been attacked , and countered with a hostile barrage. When I pointed this out, he responded: "You said we could do whatever we want and we were doing it." In turn, I said, "Yes, but sharing and respecting each other seem to be problems for you with you r brothers at home; this also seems to be a problem for you and the others in the group today." They continued to play in their separate parallel pla y. One of the youngsters asked if he could go to the bathroom, to which I responded with a question about whether he felt he could not wait. He was not sure, and I said that our time would be up in about another five minutes. This youngster then said he was going to pick up all the toys and train parts he was playing with, commenting, "I can always play alone," when the others did not respond to his invitation to play or pick up the toys with him. I said that he seemed to have forgotten about the bathroom, and that perhaps playing alone was a reference to playing with his penis as he does in the bathroom. His penis is his, and it is always there and available to play with whenever he is alone. This youngster responded laughingly, with mock shock, saying, "Oh, Dr. Sugar!" and continued laughing. Since the connections between the feelings of loss, separation, and an imminent vacation with their parallel play and isolation were not understood at that time, no comments were made . After the vacation ,
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material again came up related to this theme, at which time their play behavior was interpeted in relation to feelings of loss and separation anxiety. In one session, some of the boys were playing with play-dough, and one of them was making a figure which he called a doctor wrapped up with Goldilocks, adding, "The doctor is smothered; he is killed." Another youngster responded with an affirmation. The second one then followed, "Could it be that you are talking about Dr. Sugar?" The first youngster said, "It could be, but it's not! I tell people I am coming to see a doctor but not a psychiatrist." The second youngster said, "I come here Tuesday and Thursday and tell them I'm seeing a psychiatrist." Later in the session, the second youngster, who had been defending me, played with a play-dough figure which he announced was the father figure. He dropped it in such a way that it fractured, and this was applauded by the other members of the group. I interpreted his getting rid of father by father's suicide, since he had made some comment about father jumping off a building or a bridge and committing suicide during the fall. This youngster responded, "They're gone again, mother and father are off on a cruise for two weeks again." The oedipal issue was apparent, but the hostile paternal transference to the therapist seemed the more pertinent one and was focused on. In another session, one of the boys, annoyed at having been reminded about the use of the play materials, made a figure with a large nose out of the play-dough and called this "Mr. Beepers with a big nose." Another youngster said, "That's you, Dr. Sugar." With this I responded, "I'm the guy with the big nose; your feeling is that I am a nosy guy," and they all laughed. The hostile feelings being displaced onto the play-dough character by the first youngster were very evident, and were connected with some angry feelings at some teachers who had been discussed earlier in that session. The focal point in discussing the teachers in that session had to do with one youngster's having failed a mathematics test that ~articular week and bringing the report of the grade into the sesSIOn.
CLINICAL EXAMPLES
A psychotic, retarded latency boy who had been in individual therapy for a lengthy period was brought into combined therapy. He had a very difficult time in the group, but eventually was able to relate to several of the other youngsters, particularly to one youngster who had cerebral palsy and was also in the educable, retarded
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range. Later, a new member of the group, who was an inhibited child with a learning disorder, became friendly with the first child. The second youngster seemed quite upset about his friend's deserting him. He talked about a star falling and regressed to playing with tinker toys; he made fans which were going very fast and kept falling apart. This had been a typical pattern of his play early in therapy, when he played with tinkertoy fans, in and near water, making them go very fast, spill and splash. At such times he feared he was on the verge of falling apart; then he frequently destroyed things. His anger about feeling deserted was interpreted, and his anxiety was related to the fact that he felt his world was falling apart due to the loss of his friend. He responded, "After all, my friend goes to my school." This matter was dealt with further in subsequent sessions, and he was able to accommodate to this change in the relationship. A shift in pairing occurred, and he became friendlier with another youngster in the group. The shift in pairing, although a trying event, was a very important and integral part of this youngster's therapy and induced further ego development. One youngster with the diagnosis of separation anxiety had difficulty with school subjects because he was unable to concentrate and attend in class. He was very upset about leaving home, since he was afraid he would not have his mother when he returned. His parents had recently divorced after several stormy years of separation and reconciliation. When he came into his first group therapy session, he was anxious, unable to get involved with any of the youngsters, and he reacted to me as if I were the only haven of safety, somewhat like his mother. He stayed beside me throughout the first session, and at one point early in the session sat on my lap for a few minutes. After a while, he was able to look up and watch the other youngsters involving themselves in various ways and talking with each other, but he remained close by my side. In the next session, he was able to move away from me. His anxiety was interpreted later and the fear of loss of mother was connected to his reaction, since he had in essence lost father, when father had left home several months before. One youngster was brought into treatment because of his parents' complaints that he was very feminine, wore girls' clothing, and often acted like a female entertainer around the house and in school. When he was brought into the group, he told the group in a very exhibitionistic fashion about his symptoms, although he seemed somewhat embarrassed. He was about to demonstrate, when he saw another youngster in girls' clothes. He appeared to
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enjoy the second youngster's behavior, but then decided that he would not imitate him. Although he had been wearing female clothing regularly at home, he never did this in the group and discontinued it at home, as brought out some time later, since he could now see himself through the behavior of the other youngster. Later he was able to suppress these impulses. SUMMARY
A description of interpretative group psychotherapy for outpatient latency-age children has been presented along with illustrative clinical material. Comparisons and contrasts with paratherapy, play groups, and activity group therapy are indicated. The indications for interpretive group therapy are the child's emotional conflicts and needs, and the ability to utilize such therapy. Children with behavioral disorders and neurotic conditions are most likely to benefit from such an approach, although some carefully selected psychotic children also may profit.
REFERENCES
GINOTT. H. G. (1958), Play group therapy. Int. j. Group Psychother., 8:410-418. GRATTON, L. & RIZZO, A. E. (1969), Group therapy with young psychotic children. Int. j. Group Psychother., 19:63-71. KARSON, S. (1965), Group psychotherapy with latency age boys. Int. j. Group Psychother., 15:81-89. LIFTON, N. & SMOLEN, E. M. (1966), Group psychotherapy with schizophrenic children. Int. J. Group Psychother., 16:23-41. MARCUS,!. M. (1966), Costume play therapy. ThisJournal, 5:441-452. SCHEIDLINGER, S. (1965), Three group approaches with socially deprived latency-age children. Int. j. Group Psychother., 15:434-445. SCHIFFER, M. (1969), The Therapeutic Play Group. New York: Grune & Stratton. SLAVSON, S. R. (1950), Analytic Group Psychotherapy. New York: Columbia University Press. - - (1952), Group therapy for children in latency. Int. j. Group Psychother., 2:77-82. SPEERS, R. W. & LANSING, C. (1965), Group Therapy in Childhood Psychosis. Chapel Hill, N.C.: University of North Carolina Press. SUGAR, M. (1967), Group therapy for pubescent boys with absent fathers. This Journal, 6:478-498.
The focus in this paper is on interpretive therapy in outpatient groups, not upon paratherapy or action groups or activity therapy groups. Interpretive group therapy takes place in a specific, constant, and stable setting-the usual playroom-which is designed to facilitate the demonstration of conflicts, defenses, and fantasies through verbalization and play. The therapist's activity is interpretive in a relatively nongratifying group setting where it is possible for the child's feelings to be understood through observing symbolic or representational behavior in the playroom. An appreciation of the specific aspects of latency children's type of thinking, psychosexual level, and typical defenses, as well as experience with individual child therapy, is necessary before embarking on group psychotherapy with children. Many mothers arrange play groups for their children wherein the children have a rotational scheme of playing with the same group of age-mates in different homes. While it may be a growth-promoting experience for the child, in that he learns to socialize with other children and other adults, it is unreliable and indirect as a therapy. Other types of play action groups in many communities include settlement houses, community centers, neighborhood parks, city recreation departments, clubs, Brownies, and Cub Scouts. Activity group therapy requires an extra large room with many crafts and hobby type of materials (Slavson, 1952; Schiffer, 1969). Schleidlinger (1965) described group work with socially deprived children, but he did not indicate if any of them required or received interpretive therapy. Karson (1965) used a six-month limit for children in group therapy, providing a corrective emotional experience by accepting and gratifying some dependency needs and allowing symbolic instead of direct gratification of hostile impulses. Dr. Sugar is Clinical Professor of Psychiatry, Louisiana State University Medical Center, New Orleans, Louisiana. Reprints may be requestedfrom the author at 17 Rosa Park, New Orleans, La, 70115.
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INTERPRETIVE GROUP PSYCHOTHERAPY
Interpretive group therapy may benefit many youngsters of latency age who have behavioral or neurotic disturbances. I have treated a wide variety of children with varying degrees of success through this modality. Their difficulties have ranged from ulcers, asthma, transvestite tendencies, and psychotic symptomatology to learning and behavioral disorders, and anxiety and phobic reactions. The children have come from intact and broken homes, institutions, and deprived backgrounds. The therapist in interpretive therapy remains friendly and informal, but he does not aim to be a better parent to the children or to gratify them directly. Instead, he encourages them to seek the participation of the other children in play. The child eventually feels free to express himself in play and words with fantasy material so that his defenses can be seen, understood, and interpreted. Everything that the child demonstrates need not be interpreted, and what is interpreted should be determined on the basis of the important unconscious themes. Attention should always be given first to the most superficial levels of resistance, and what is conscious and troublesome should be managed before proceeding to unconscious matters. Transference reactions are not as intense or clearcut in children in latency and preschool years, as the children are dependent on the parents or guardians with whom they live. A clear-cut transference neurosis does not develop, but intense transference reactions are regularly present and should eventually be interpreted when appropriate. Indications for Group Therapy for Children
Often in guidance clinics or community mental health centers, because of the many patients waiting to be seen and the inordinately long waiting list, groups are hastily formed without adequate attention to the individual patient's needs, or the training, experience, and readiness of the therapist to utilize group work with children. The same often happens in residential institutions so as to ease the burden of guilt about not having individual therapy time with each child. In private practice, the problem is often the reverse, with a practitioner having to wait a while for a number of suitable children to start a group; or if several children leave, wondering if he should terminate the whole group or wait to see if perhaps another child or two will come along who will be suitable for the group.
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Although characterizations have been made (Slavson, 1950, 1952; Schiffer, 1969; Ginott, 1958) about the type of child who is suitable for group therapy, none has been entirely satisfactory. Ginott's (1958) list indicates a wide variety without any exclusions, since he feels that group therapy is the proper approach for every child. Slavson (1950, 1952) and Schiffer (1969) advise that only the psychotic, the antisocial, or the aggressive child need be excluded from their groups. Depending upon the type of therapy offered, these writers may be correct, since if the focus is activity or action, the children may enjoy a great deal in this setting. However, for the purposes of interpretive group therapy with children, somewhat more specific indications would be helpful. The child who is deaf, or blind, or who has a serious neurologic or orthopedic disorder may be quite handicapped in such a setting, unless in a homogeneous group with a specially trained therapist. The child with a marked degree of intellectual retardation, the autistic, or the one who panics whenever he is close to other children similarly might be unsuitable for such a group. Perhaps an approach to considering the types of children who could be seen and treated in a group should revolve around the individual's need and the type of group he is to be offered. In an interpretive therapy group, the child has to be able to use play or language to express his conflicts and fantasies, and to be able to profit from interpretations being made to him. He would therefore need at least a low-average intelligence and would need to be responsive to verbalizations to some degree. The child who is deprived or severely antisocial should not be in a group with neurotic or borderline psychotic children for interpretive therapy. Such children profit more from activity groups, clubs, or individual therapy to help make up for some of their deprivation. The child who is totally action-oriented and does not use words will need a preparatory period of individual therapy rather than to be put into a group where play of a symbolic or representational nature and verbalizations are used. The child with a severely disorganized ego cannot attend to or concentrate on many stimuli, and he would be in a difficult position in a group with other children. The child who has marked anaclitic or symbiotic needs would not function well in a group unless the group were homogeneous and had multiple therapists (Speers and Lansing, 1965). Lifton and Smolen (1966) rarely allowed "free" play for their groups of schizophrenic children because it promoted confusion or withdrawal. After a lengthy preliminary period of intensive individual therapy with such children, however, some of them may
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be suitable for inclusion in a heterogeneous group with neurotic or borderline children . I have treated some psychotic youngsters in a therapy group, who had previously had one to three years of individual therapy and who continued in combined or group therapy with moderate improvement interpersonally and intrapsychically. One youngster who was at the educable, retardate level intellectually was treated individually for about two and a half years to help him with his borderline state, and then placed in a therapy group. The most suitable child for a group is the one who has a behavior disorder that is in the neurotic range or who has a psychosomatic disorder, neurotic symptoms, inhibitions, or sexual problems that are treatable and responsive to verbalizations. One child whom I saw might have been a suitable candidate for interpretive group therapy, but because of his needs and his diagnosis, he was treated individually instead. This youngster had had a number of losses over several years preceding the evaluation, and at that time he was neurotically depressed. The major themes involved in his depression were connected with losses and sibling rivalry. Individual treatment seemed more appropriate than subjecting him to another loss, that of the individual relationship he had established with the therapist. This would have been a reproduction, to some extent, of the famil y situation, and would not have worked successfull y at that time. The child who has done a good deal of work individually and has settled many of his conflicts, but who still has problems about peers as well as severe sibling rivalry, ma y be placed in an interpretive therapy group at such time to deal with these particular conflicts. Of course, this conflict will be connected with other areas of his psychic life that are unsettled , and combined therapy might be considered for such a child. I use this approach frequently with children who are having intrapsychic conflicts and problems with peers, with severe social withdrawal, inhibitions, hyperactivity, or anxiety. A preliminary period of individual therapy is necessary; otherwise, the child may turn down an offer of group therapy because of intense anxiety about the embarrassment he will experience. Interpretation at that point may not be useful, and if he is put in a group, it may not be successful. If, however, the child is seen individually for as long as needed to deal with some of the conflicts, then he may later be put in a group and seen in combined therapy; both types of therapy may then contribute to his further development and the resolution of his conflicts. Combined therapy brings up special complications and resistance for the group ther-
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apy, such as the child's feeling special and not talking much in the group, saving material for the individual sessions, or the reverse. Composition of Group
Ginott's (1958) suggestion that children in play therapy should be of the same age may be impractical, especially in private practice. In my own experience, preschool children in a therapy group may be with other children within a year or two of their age. In the latency age, the children may have a three-year age spread. Besides age, the level of maturity, the social adjustment, and the achieved school grade are considerations in group composition. A child of 10 who is in the educable, retarded range, and extremely deficient socially, would probably be out of place in a late-latency or pubescent group, but might be comfortable and work satisfactorily in a group with 6- to 8-year-old children. Although some people advocate mixed-sex groups for children, I believe that this overlooks the child's needs and developmental lines. The child of school age seems to do better in the same gender group. Boys in latency do not particularly wish to associate with girls, because they are making serious efforts to become identified with male figures. Girls at that age are having difficulties giving up their attachment to father, identifying with mother, and resolving their castration complex. For these reasons, it would be difficult to work interpretively with such children in a mixed-sex group. Members of a girls' latency group will talk about secrets or about household and baby things, whereas they might be embarrassed or fearful of ridicule if they discussed such things in the presence of boys. The maximum number for such a group should be 6. If there are too many active, anxious, hostile, or hyperactive children, it may be wiser to limit the number to 4 or 5. Below this number, the group does not have enough of a spread for interstimulation and identification with other behavioral patterns as well as interdictions that one member may espouse against another. The Parents As Part of the Setting
Once the child has been evaluated, an explanation is due him and his parents of the type and rationale of therapy. Before the child is ever seen for evaluation, the parents need to explain the reason for the visit. The therapist may connect data from the evaluation with the behavior or symptoms to the child and parents. An explanation should be given of how the child might be helped by therapy. A
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visit to the playroom before embarking on therapy may be useful for both parents and the child. The parents also need to be informed about the duration of therapy, the arrangements for the sessions, and the fees. Because the latency child usually gets fatigued after 45 to 60 minutes, a 45minute session is sufficient at the early latency level and preschool level. At a later age, a 60-minute session works satisfactorily. If possible, the session should interfere as little as possible with the child's playtime. In one group which had its sessions scheduled at 4:00 P.M. on a Friday, the resistance became apparent after a month or so of irregular attendance; Friday afternoon after school was a sacred time devoted to the children's special pleasurable pursuits. When the session was shifted to the morning, the work in the group continued satisfactorily, since it also decreased schooltime slightly. From time to time the therapist needs to see the parents to deal with their current concerns in managing the child, or with related data that they recall about the earlier years. The child and parents need to be informed that their data will be used in the therapy as indicated, although the child's material is confidential. But general statements about the child's progress may be made to the parents, and questions may be asked by the therapist. Group Arrangements
The arrangements are such that the group is open-ended within the limits of age, sex, and diagnosis mentioned earlier. In a clinic or residency training program, this is often difficult, as the group starts at the beginning of the academic year and ends according to the trainee's availability. In a community mental health center or guidance clinic setting, there is usually a long waiting list, and patients may have group therapy for one year, or some other arbitrary period, so that the people on the waiting list can be treated. Such groups may function satisfactorily with these time limits because of the pressure on the therapist as well as the patients to move on rapidly. In private practice, there is not usually a large waiting list of children within a specific age range, and a group might not be able to function if it were kept closed. By keeping it open-ended, children may come in as they have a need for group therapy, and leave when their needs are met. Since it takes time for youngsters to adapt to being in a group and dealing with their fears of exposure, shame, sharing, and with feelings of rivalry, a youngster is not taken into the interpretive therapy group when brief treatment is considered optimal for his
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condition. The patients for such a group have chronic problems which require lengthy work for a satisfactory effect, and the child is accepted for the group on the basis of being in it for a minimum of six months, although the treatment may be somewhat shorter or longer. The arrangements for confidentiality are clarified to each child and his parents so they understand that the members of the group do not reveal matters of group content or identity to people outside the group, including parents, and they do not socialize while they are group members. Frequently, a child is brimful of excited or anxious feelings after a session and, having a need to discharge them, immediately starts blurting out some material from the group when he gets into the car with his parents. The parents are told that this may happen, and when it does, they should not chide the child, but should try to understand the anxious or excited state which precipitated it. They may then remind the child of the need for confidentiality, and to bring up his feelings in the next group session, or the parents may call for an extra individual appointment. The Playroom and the Opening Sessions
By contrast with activity group therapy, which requires a large room with many toys, tools, craft materials, and the like, the playroom required for interpretive group work with children is of ordinary size and need not be filled with extra toys, crafts, or anything unusual. The playroom, with toys, a play table for a dollhouse and doll figures, need encompass only about 8 by 14 feet to be quite comfortable. Frequently an interpretation is required to relieve the initial anxiety that is connected with the expectation of having treatment here similar to that done by the pediatrician. An explanation is also due the child about why he is here and what the process consists of. Once this is done and the child is brought in to the playroom, he is in a setting in which production of fantasy is encouraged without promotion of guilt, anxiety, or embarrassment. The playroom should lend itself to the production of fantasies, questions, the playing out or speaking of various conflicts, rather than be involved with reality intrusions. The playroom for a group of children should not invite destruction, contain crafts or numerous new stimuli week-to-week, or be hazardous. Food need not be regularly available, but may be needed as an organizer or stimulus, especially in the initial phase. Toys are required for interviews so the children can use them (1) as a means of (nonverbal) communication; (2) in the enactment of
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scenes which they cannot describe but need to externalize; (3) for the expression of instinctual drives and for direct or substitute gratifications. Toys may be of the smallest practical size, of an indeterminate shape, and malleable. The following items seem useful: several open shelves with toys; a table with four to six small chairs; a doll house and table for it; a blackboard; a full-length wall mirror; lighting and windows that are protected or recessed; running water and a sink; play-dough; a sandbox (if possible) ; a doll family-man, woman, child , baby (relative sizes are important)-that may be malleable or not; some dollhouse furniture with a play tea set; a bathroom furniture set; puppets; costumes and clothes for the children to dress up in (Marcus, 1966); checkers; chess; various card games (like Old Maid); drawing materials (crayons, chalk, pencils, paper, fingerpaints); string; round-ended scissors; animal figures (one wild set and one tame set); cars, trucks, and airplanes (in specific or symbolic form); rubber knives and guns (that do not shoot anything); and a play nurs- . ing bottle. There should be a comfortable chair for the therapist, so that he may sit off to one side and observe the whole group without intruding, but be available for interpretive or supportive efforts. The room should be soundproofed so that parents in the waiting room will not become excited by the children's words or sounds during the group session. A radio playing in the waiting room provides good masking; double doors are useful, as are extra thicknesses of soundproof material on the doors and in the walls. Some five to ten minutes before the end of the session, the children should be notified that the session is about to end. This device helps children (in individual or group therapy) to wind down from the level of excitement or the high level of anxiety that they ma y have reached through some play. It gives them some warning that the play-pretend time is about to be over, and they can start harnessing their ego functions to leave the therapy session and go out into the real world again. This gives them time enough to regroup emotionally and to avoid the feeling that they have been abruptly cut off from some treasured activity. During this time, I begin to pick up and put toys away. I do not invite the children to assist, nor do I refuse their assistance if they offer it. THE INITIAL PHASE IN LATENcy-AGE GROUP THERAPY
The you ngster in a latency group relates to his therapist and to his peers. When the patient first enters the group, he is an isolate un-
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known to the others, and they, similarly, are not known to him. Each is concerned with his own problems and how this strange situation is going to be gratifying or useful to him. By the end of the initial phase, the group has developed a certain amount of relative stability in group dynamics and only relative cohesion. This amount of progress is a prerequisite for learning about themselves and their interactions for their therapy in the group. During this initial phase, they are learning how to get along in the group. They may be standoffish initially, playa game repetitiously, or surreptitiously look over the other members of the group, but rarely ask anything about them or even be ordinarily assertive. Certain resistances on the part of new members in the initial phase are a reflection of the patient's adjustment to a novel and unstructured situation, his anticipatory anxiety, expectation of being directed by another authority, and other attitudes related to displacement. The therapist can help the group work through this phase ifhe fully observes the patient's troubles and the sources of anxiety which are typically present in every phase of group life. Every patient and every therapist is anxious about the first meeting of a new group or a new member in a group. 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. The child's initial resistance is related to his realistic disappointment in the anticipated functioning of the therapist in the frustration of his transference expectations. No specific goals are set for the patient and each one is groping along still uncharted pathways. There are also the frequent, intense dependency needs. The dependency needs, the realistic disappointments, and frustrations peak in the first few sessions, at which time there is often a desire to drop out of the group or a fear that the group is going to drop him, caused by the patient's fear of rejection, his isolation, and unfulfilled needs. In brief psychotherapy groups, the intial anxiety is usually relieved, and if a group extends for only 6 to 15 sessions, not much may be achieved beyond this. Such a group then maintains the illusion of being directed by the therapist, who seems to function as a directive leader in the patient's mind, or the illusion may be that the group therapy sessions are really a class given by the therapist. Only if the therapist avoids falling into the role of directive leader or teacher, can the group move beyond the initial resistances. Otherwise, he will function in a nontherapeutic way by becoming active, directive, and authoritative, and the group will become leader-
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centered instead of group-centered. Such groups do little in the way of the interpretation of the child's conflicts and helping him understand his emotional difficulties. The therapist's use of the defaulting technique, on the other hand, and his refusal to assume an authoritative, directive role will make the group members turn to each other and begin interacting, showing each other and the therapist some of their conflicts. During this initial state the sessions may be dull, with long silences, feelings of embarrassment, or continued repetitious, obsessive play, isolation, and avoidance of one another as well as the therapist. The number of variations in the observable phenomena is immense and reflects the imaginativeness and uniqueness of the patients in each group. The dependency on the therapist is manifested early by the youngsters' looking to him for suggestions as to what to do, how to function, where to go, where to sit, and what games to play. When the therapist suggests that they might want to play with one of the other youngsters instead of with him, they appear hurt at being rejected and become sullen, putting up the toys or the game and sitting quietly for a while. Transference phenomena are at times less well concealed than in adult groups. This may induce the therapist's countertransference behavior to be more open as well, and at times to be more destructive to the grou p, especially if he has significant unresolved conflicts from his own latency age. Youngsters may look to the therapist as a father or favorite uncle, expecting him to behave as such a relative does . By knowing the history of the patient, the therapist is aware of the source of the displacement and can simply observe it, without interpreting initially or playing out the role of the transference figure that the patient wishes. Some transference reactions occur between patients, who may react to one another as if they were siblings. Sibling rivalry and oedipal rivalry are open, although often nonverbal, and are usually . expressed in fights or in picking at each other to obtain the "prize" seat or the best toy. The displacements and projections usually involve teachers or their friends who are not in the group, or their siblings at home. Pairing is often reflected in the same two or three members of the latency group seating themselves in the same situation or playing the same game several weeks in a row; thus they exclude the others in the group as well as the therapist. Sometimes pairing occurs between a patient and the therapist, the patient repeatedly trying to involve the therapist in helping him with his project or secluding him by talking only to the therapist, or sitting or standing near the therapist.
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Fight phenomena are very open; actual fighting may occur among several members of the group, or they may begin throwing things at each other, which somehow are not well aimed and seem to land on or near the therapist. Occasionally, a patient may discontinue visits after having sworn allegiance to the group forever the week before. This decision is usually imparted by a phone call from the parents, and at this point it is vital to explain the phenomenon to them and enlist their help in having the patient return to deal with this reaction more appropriately in the group sessions. The group members may manifest cohesion in a variety of ways, such as their involvement in building something, learning how to draw or play chess and exclude verbal interaction or exploration of emotions; or they may isolate the therapist from them-in a sense, a negative cohesion. The "nobody can help me" type of patient in a latency group will wonder aloud what he is doing there, since working on things with other boys is not helping him. Or he may bring marbles to play with the others or try to turn the group into a class in construction work. By any of these or other devices, he completely avoids the issue of therapy, while complaining about the fact that he is not getting any. Avoidance and rejection of help may occur, as it did when one patient retreated into a shelf containing toys and hid from the rest of the group. Monopolizing may occur through various devices, such as requesting continual help from the therapist, shutting off the others from any interaction with the therapist as well as themselves. The monopolizer may shut out the others by continually repeating his problems, his difficulties in his timetable, and so forth. In a latency group there is often an auxiliary leader, comparable to the assistant doctor of adult groups, who will engage in hostile exchanges with the therapist, make attempts to take over the group, and threaten to fight. The bully in the group will try to control all games or behavior, and in a sense is an auxiliary leader, but is also monopolizing. The group as a whole may show reaction to a focal conflict by a tremendous increase in the amount of noise they make with verbal exchanges, insults, singing, dancing, playing pseudodrums, or throwing toys about. Patients may use the differences in age, education, and position between them and the therapist to provoke and exaggerate their problems with authority. In this type of resistance, the whole group may join with the bully or the auxiliary leader. They may voice their feelings about this: "I came here to get out of school. Let's play baseball instead of sitting around here. You don't understand me, but the other guys here will because they are my age." The initial phase may last from 6 to 15 sessions.
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THE MIDDLE PHASE
The end of the initial phase is not a specific, titratable point, but it can be observed, and the transition to the middle phase can be tabulated by a variety of factors. One of these is that the group arrives at the recognition that the therapist will not direct them, teach them arithmetic, give advice, teach chess or poker; most members will discontinue turning to the therapist when they speak; all heads are turned to the patient speaking rather than to the therapist. The patients ask personal details about one another and recall them appropriately in subsequent sessions. They begin talking about problems that have been troubling them, and may even set up a peer court, asking the opinions of the other members (Sugar, 1967). The change will also be marked by changes in behavior, such as reduction in physical contact, verbal insults, and throwing things. Members will engage in a more playful technique in their hostile exchanges. Some of their verbal or physical exchange will also be an expression of some interest in or negative feeling about members of the opposite sex; they may tend to work together on something more constructive but involving a majority of the group throughout most of the session. The middle phase may last three months to three years and is the period of maximum distortion. Most of the work in therapy occurs in the middle phase. The children are now very dependent on the group, and there are fewer absences for minor events like "a cold" or "a dental appointment." They identify more with each other and compare notes more readily about their parents, teacher, siblings, and symptoms. They now consider the likes and dislikes of the group members and bring along specific items of interest, such as baseball and football cards, because of .rhe greater identification with each other. If the therapist focuses on one child, the others feel as if the whole group is attacked. The children now discuss their nightmares and dreams. They are encouraged to respond to the dream by sharing their feelings and experiences about the content, to clarify real from magic happenings, and to interpret the dream. When dreams are brought in, it also indicates a decrease in resistance, and if the group members work on it, it is a sign of a cohesive working group in the middle phase. It is especially helpful if the therapist can make some positive remark to the individual and the group about the dream. There are now some glimpses or clear-cut evidence of multiple transferences. The therapist can facilitate the therapy in this phase by promoting pairing by dynamics and defenses, reducing guilt, "going around," and universalizing the child's experience or feel-
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ings. Interpretations based on the group feeling may activate an individual to respond, and interpretations may be made to the individual or to the group, based on individual or group behavior. THE TERMINATION PHASE
This phase may last three to six months. The child is now able to give more, to play cooperatively, not defensively as in the past. He has now improved in relations to all group members, so that even those whom he dislikes he does not go out of his way to provoke, and he has come to see some good qualities about each of the members as well as the therapist. His transferences are less troublesome as they have been worked on. He is more realistically oriented, shows improved functioning as well as a decrease in symptoms and often a change in defenses. In this phase, the child no longer needs the group, but the group profits from his attendance since he is now more fair and easier to be with. The child may voice something about this, but he still attends regularly and does not look for ways to skip. When termination and a date for it are discussed, the youngster and the group members usually have some sadness and separation anxiety. But they often also have a feeling of envy and gladness that he "made it" and that someone is winding up. SOME GENERAL OBSERVATIONS
The youngsters are told at the beginning of the therapy that they may play with any of the toys in the room, but may not hurt anyone or destroy things in the room, or become involved physically with one another. Nevertheless, the therapist may occasionally have to separate two youngsters who are about to become engaged in fisticuffs. If they get involved in fighting or sexual play, such as hugging or kissing, then silent observation, a reminder of the arrangements, or an interpretation may be suitable. Should this continue, and group excitement grow, the therapist may need to intervene physically: first, by standing next to them silently; then, if necessary, by separating them. Some youngsters like to bring in some of their toys (their treasured possessions), and these are welcomed as communication about themselves, and then used therapeutically as much as possible. Occasionally, youngsters may bring in candies or other edibles as a treat or bribe for the therapist or the other youngsters. The therapist thanks the youngster for his thoughtfulness, gives
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him and the others permission to enjoy the treat, but does not accept the food himself if there is bribery involved. Turning the group room into an arena for baseball or football games is not allowed. Occasionally, limits have to be altered according to new developments. For instance , in one group session the you ngsters were making paper airplanes, which they were Hying across the room. Various feelings were being expressed through this behavior, and some of these were being interpreted: one you ngster flew an airplane upward in the high-ceilinged room; this was viewed by the others as showing great competence, both as a pilot and as a manufacturer of airplanes . However, when the paper airplane landed on the fluorescent tube at the juncture of the tube insertion into the socket and blew the lights out, it became apparent that this play activity was not safe, and limits had to be imposed on the direction of flying the airplanes. Further efforts to fly them in a curve, forcing the airplane upward, with a hope of landing it on the fluorescent tube and blowing out the lights again, led to disqualification of thi s activity altogether. Youngsters who are seeing the therapist individually ma y tr y to get him involved in games in the group session and exclude the others; or if they cannot manage the rivalry situation with another youngster, they may tr y to get the therapist on their side through the medium of a game or having him involved in their play. The therapist should tr y not to become centrall y involved in the pla y and games in the group, since he then loses his perspective as an observer beyond the one child and ma y arouse sibling rivalry. He can suggest th at th ere are others in the room with whom the yo u ngster ma y pla y this game, and if the child complains that no one will pla y with him, the therapist brings up the topic for everyone to explore. When two youngsters play a game of cards or checkers, and one of them seems unable to use his intelligence, I have interpreted the situation as it developed and wondered about his various plays or moves in a particular game in this connection. This may also aid in identification with the the rapist and in learning to share. One youngster complained bitterly that I was intervening on the other youngster's behalf in the checker game , and that it was unfair. I agreed that I was trying to help the second yo u ngste r learn to think better generally, to be able to pla y a better game with him . The first you ngste r was having a marked siblin g rivalry transference relationship to the seco nd boy and a hostile maternal transference reaction to me . I pointed out to th e first you n gster that he
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could think, but that he used his thinking to oppose parents and others in a defiant fashion; further, that he could even think of the consequences of his acts, but he did things to see if he could get away with them because he was so angry at his parents about unfulfilled things; that he used his thinking to control others. A third youngster in the group stopped what he was doing, intrigued by this, and curious about how it applied to himself. I told him that he too could think, but when he felt hopeless, he became jumbled up in his behavior and thinking. At such times, this youngster often became boldly deceptive, and he was aware that he was now prevaricating less. A fourth youngster came over then and said, "What about me?"-indicating that he wanted to know what I thought about him and his thinking abilities. I mentioned that he seemed to be afraid to think, and therefore he acted as the entertainer to get people to like him; in that way he avoided the fear of being hurt, as he did not have to think thoughts that might make him afraid. Excited or Disorganized States
Sexual and aggressive themes usually surface more quickly in group therapy than in individual therapy with children. When the particular play or toy is too exciting and seems to foster a child's becoming disorganized or destructive, the therapist may have to go from being a silent observer to commenting, confronting, interpreting, moving near the child, or limiting the child's activity. The latter may be done by removing the child from the specific play materials or by having him sit by the therapist for a while. If the child or group members ask why, the response should include a comment about the child's inability to control himself very well at the moment as he seems so excited and uncomfortable, and about the therapist's interest in helping him to be more in control. More specific interpretations may be made as the situation indicates. Later, the child may be allowed to resume the play if he feels he can control himself better. Restrictions usually involve water, clay, play-dough, fingerpaints, or similar materials, but the materials are left out for other children to play with. This contrasts with the approach used by Lifton and Smolen (1966) and Gratton and Rizzo (1969) with groups of schizophrenic children, wherein there are no play things and the children have to relate to one another or the therapist. When group contagion and excitement are about to go beyond the limits of safety or to be injurious to anyone, the materials may be removed and only verbal interchanges allowed until better individual and group control is
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regained. It is not always necessary to intervene when a certain amount of excitement or disorganization occurs, but it should be carefully observed as to quality, degree, and direction. Transference R eactions
Many varieties of transference reactions are evident throughout the group sessions. Whether they are 'inter p reted , and how, depends on the level, the timing, and the readiness of the patient particularly involved, as well as that of the group. Interpretations may be to the individual or to the group as a whole. Some examples follow of particular situations in different states of development in group therapy with children. I was going on a two-week vacation after a particular session to which a number of the group members (ages 8 and 9) were late in arriving. Each one asked about the absentees when he arrived. They did not seem to be interested in participating with one another, as they had been doing for some months previously; when they did use some of the toys, they did not interact or play with each other as they had . Instead , they engaged in the parallel play of preschool children. When I commented on this, one child responded as if he had been attacked , and countered with a hostile barrage. When I pointed this out, he responded: "You said we could do whatever we want and we were doing it." In turn, I said, "Yes, but sharing and respecting each other seem to be problems for you with you r brothers at home; this also seems to be a problem for you and the others in the group today." They continued to play in their separate parallel pla y. One of the youngsters asked if he could go to the bathroom, to which I responded with a question about whether he felt he could not wait. He was not sure, and I said that our time would be up in about another five minutes. This youngster then said he was going to pick up all the toys and train parts he was playing with, commenting, "I can always play alone," when the others did not respond to his invitation to play or pick up the toys with him. I said that he seemed to have forgotten about the bathroom, and that perhaps playing alone was a reference to playing with his penis as he does in the bathroom. His penis is his, and it is always there and available to play with whenever he is alone. This youngster responded laughingly, with mock shock, saying, "Oh, Dr. Sugar!" and continued laughing. Since the connections between the feelings of loss, separation, and an imminent vacation with their parallel play and isolation were not understood at that time, no comments were made . After the vacation ,
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material again came up related to this theme, at which time their play behavior was interpeted in relation to feelings of loss and separation anxiety. In one session, some of the boys were playing with play-dough, and one of them was making a figure which he called a doctor wrapped up with Goldilocks, adding, "The doctor is smothered; he is killed." Another youngster responded with an affirmation. The second one then followed, "Could it be that you are talking about Dr. Sugar?" The first youngster said, "It could be, but it's not! I tell people I am coming to see a doctor but not a psychiatrist." The second youngster said, "I come here Tuesday and Thursday and tell them I'm seeing a psychiatrist." Later in the session, the second youngster, who had been defending me, played with a play-dough figure which he announced was the father figure. He dropped it in such a way that it fractured, and this was applauded by the other members of the group. I interpreted his getting rid of father by father's suicide, since he had made some comment about father jumping off a building or a bridge and committing suicide during the fall. This youngster responded, "They're gone again, mother and father are off on a cruise for two weeks again." The oedipal issue was apparent, but the hostile paternal transference to the therapist seemed the more pertinent one and was focused on. In another session, one of the boys, annoyed at having been reminded about the use of the play materials, made a figure with a large nose out of the play-dough and called this "Mr. Beepers with a big nose." Another youngster said, "That's you, Dr. Sugar." With this I responded, "I'm the guy with the big nose; your feeling is that I am a nosy guy," and they all laughed. The hostile feelings being displaced onto the play-dough character by the first youngster were very evident, and were connected with some angry feelings at some teachers who had been discussed earlier in that session. The focal point in discussing the teachers in that session had to do with one youngster's having failed a mathematics test that ~articular week and bringing the report of the grade into the sesSIOn.
CLINICAL EXAMPLES
A psychotic, retarded latency boy who had been in individual therapy for a lengthy period was brought into combined therapy. He had a very difficult time in the group, but eventually was able to relate to several of the other youngsters, particularly to one youngster who had cerebral palsy and was also in the educable, retarded
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range. Later, a new member of the group, who was an inhibited child with a learning disorder, became friendly with the first child. The second youngster seemed quite upset about his friend's deserting him. He talked about a star falling and regressed to playing with tinker toys; he made fans which were going very fast and kept falling apart. This had been a typical pattern of his play early in therapy, when he played with tinkertoy fans, in and near water, making them go very fast, spill and splash. At such times he feared he was on the verge of falling apart; then he frequently destroyed things. His anger about feeling deserted was interpreted, and his anxiety was related to the fact that he felt his world was falling apart due to the loss of his friend. He responded, "After all, my friend goes to my school." This matter was dealt with further in subsequent sessions, and he was able to accommodate to this change in the relationship. A shift in pairing occurred, and he became friendlier with another youngster in the group. The shift in pairing, although a trying event, was a very important and integral part of this youngster's therapy and induced further ego development. One youngster with the diagnosis of separation anxiety had difficulty with school subjects because he was unable to concentrate and attend in class. He was very upset about leaving home, since he was afraid he would not have his mother when he returned. His parents had recently divorced after several stormy years of separation and reconciliation. When he came into his first group therapy session, he was anxious, unable to get involved with any of the youngsters, and he reacted to me as if I were the only haven of safety, somewhat like his mother. He stayed beside me throughout the first session, and at one point early in the session sat on my lap for a few minutes. After a while, he was able to look up and watch the other youngsters involving themselves in various ways and talking with each other, but he remained close by my side. In the next session, he was able to move away from me. His anxiety was interpreted later and the fear of loss of mother was connected to his reaction, since he had in essence lost father, when father had left home several months before. One youngster was brought into treatment because of his parents' complaints that he was very feminine, wore girls' clothing, and often acted like a female entertainer around the house and in school. When he was brought into the group, he told the group in a very exhibitionistic fashion about his symptoms, although he seemed somewhat embarrassed. He was about to demonstrate, when he saw another youngster in girls' clothes. He appeared to
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enjoy the second youngster's behavior, but then decided that he would not imitate him. Although he had been wearing female clothing regularly at home, he never did this in the group and discontinued it at home, as brought out some time later, since he could now see himself through the behavior of the other youngster. Later he was able to suppress these impulses. SUMMARY
A description of interpretative group psychotherapy for outpatient latency-age children has been presented along with illustrative clinical material. Comparisons and contrasts with paratherapy, play groups, and activity group therapy are indicated. The indications for interpretive group therapy are the child's emotional conflicts and needs, and the ability to utilize such therapy. Children with behavioral disorders and neurotic conditions are most likely to benefit from such an approach, although some carefully selected psychotic children also may profit.
REFERENCES
GINOTT. H. G. (1958), Play group therapy. Int. j. Group Psychother., 8:410-418. GRATTON, L. & RIZZO, A. E. (1969), Group therapy with young psychotic children. Int. j. Group Psychother., 19:63-71. KARSON, S. (1965), Group psychotherapy with latency age boys. Int. j. Group Psychother., 15:81-89. LIFTON, N. & SMOLEN, E. M. (1966), Group psychotherapy with schizophrenic children. Int. J. Group Psychother., 16:23-41. MARCUS,!. M. (1966), Costume play therapy. ThisJournal, 5:441-452. SCHEIDLINGER, S. (1965), Three group approaches with socially deprived latency-age children. Int. j. Group Psychother., 15:434-445. SCHIFFER, M. (1969), The Therapeutic Play Group. New York: Grune & Stratton. SLAVSON, S. R. (1950), Analytic Group Psychotherapy. New York: Columbia University Press. - - (1952), Group therapy for children in latency. Int. j. Group Psychother., 2:77-82. SPEERS, R. W. & LANSING, C. (1965), Group Therapy in Childhood Psychosis. Chapel Hill, N.C.: University of North Carolina Press. SUGAR, M. (1967), Group therapy for pubescent boys with absent fathers. This Journal, 6:478-498.