DVD - Group Activities that Heal

Sigmund Freud in 1909 was the first to use play to uncover his client’s unconscious fears and concerns. Hermine Hug-Helimuth began using play as a part of her treatment of children in 1920 (Hug-Hellmuth, 1921) and 10 years later, Melanie Klein and Anna Freud formu­lated the theory and practice of psychoanalytic play therapy. This type of play therapy continues to be one of the most respected forms of child therapy, usually conducted by analysts.

Psychoanalytic Play Therapy
Anna Freud and Melanie Klein wrote extensively about how they incorporated play into their psychoanalytic technique. Whereas the former advocated using play mainly to build a strong positive relationship between child and therapist, the latter proposed using it as a direct substitute for ver­balizations. The primary goal of their approach was "to help children work through difficulties or trauma by helping them gain insight" (Schaefer & O’Connor, 1983). Anna Freud has repeatedly pointed out that "the essential task (of therapy) is to remove the obstacles that impede (the child’s) development and to allow his progressive develop­mental forces and ego resources to complete the task of development" (Nagera, 1980, p. 22). Klein (1937) felt that an analysis of the child’s transference relationship with the therapist was the main source of insight into the child’s underlying conflict.

Freud and Klein took the basic concept of free associa­tion, one of the basic precepts of adult analysis, and in its place substituted the child’s natural tendency to play (Nagera, 1980). They proposed that play uncovered the child’s unconscious conflicts and desires and that play was the child’s way of free-associating. While Klein proposed that the child’s play is "fully equivalent" to the adult’s free associations and "equally available for interpretation," Freud’s theory viewed play not as an equivalent to adult free associations but as an ego-mediated mode of behavior "yield­ing a substantial body of data" but requiring supplementa­tion from a variety of sources, including parents (Esman, 1983). Psychoanalytic play therapy, predicated on the analysis of resistance and transference, emphasizes the use of interpretation, recognizing the child’s ability to use play symbolically to manifest internal concerns. Nagera (1980) documents that even though significant differences existed in the theoretical tenets of Freud and Klein in the beginning, throughout the years there has been more of a convergence between the two theories. Fries (1937), a student of Anna Freud’s, delineates the distinctions between the two theories, emphasizing Freud’s preference to withhold inter­pretation.

Esman (1983) describes the focus of play in psychoana­lytic child therapy: "It allows for the communication of wishes, fantasies, and conflicts in ways the child can tolerate affectively and express at the level of his or her cognitive capacities" (p. 19). He goes on to say that the therapist’s function is to "observe, attempt to understand, integrate, and ultimately communicate the meanings of the child’s play in order to promote the child’s understanding of his or her conflict toward the end of more adaptive resolution" (p. 19).

Structured Play Therapies
In the late 1930s, a more goal-oriented therapy, known as "structured therapy," was developed. This therapy emerged from a psychoanalytic framework and from a belief in the cathartic value of play and the active role of the therapist in determining the course and focus of therapy (Schaefer & O’Connor, 1983).

Anna Freud had initially found the use of affective release useful, but on the basis of later experience she en­couraged this type of work only in cases of severe traumatic neuroses. David Levy (1939), stimulated by Anna Freud’s conclusion and by Sigmund Freud’s concept of "repetition compulsion," introduced the concept of "release therapy" for children who had experienced trauma. Levy helped the child recreate the traumatic event through play. The goal of this type of play was to help the child assimilate the negative thoughts and feelings associated with the trauma by reenact­ing it over and over again. Levy cautioned against using this technique too early in therapy, before a strong therapeutic relationship had been formed. In addition, he took care to avoid "flooding," in which the child is overcome by strong emotions and thus unable to assimilate them.

Other well-known contributors to the literature on struc­tured therapies include Hambidge and Solomon. Solomon (1938) thought that helping a child express rage and fear through play without experiencing the feared negative con­sequences would have an abreactive effect. Hambidge (1955) was even more directive than Levy, who provided toys to facilitate the child’s recreation of the trauma: Hambidge facilitated the child’s abreaction by directly recreating the event or life situation in play.

Relationship Therapies
Otto Rank and Carl Rogers, also considered non-directive therapists, were the major proponents of relationship therapy, which is based on a particular theory of personality "which assumes that an individual has within himself not only the ability to solve his own problems but also a growth force that makes mature behavior more satisfying than im­mature behavior" (Schaefer, 1980, p. 101). This type of therapy promotes the full acceptance of the child as he/she is, and stresses the importance of the therapeutic relation­ship. Moustakas (1966), another prominent leader in the field of child therapy, emphasizes the genuineness of the therapist as pivotal to the success of therapy. He strongly advocates the importance of the here-and-now as the nucleus of therapeutic success. Axline (1969) also gives credence to the importance of the therapeutic relationship, viewing it as the "deciding factor" (p. 74). Axline’s writings, particularly the widely touted book Dibbs in Search of Self (1964), have clearly delineated the benefits and desirability of nondirec­tive therapy.

Behavior Therapies
In the 1960s the behavior therapies, based on the principles of learning theory were developed. Such therapies apply the concepts of reinforcement and modeling to relieve behavior problems in children. The behavioral approaches are precise­ly concerned with the problem behavior itself, not with the past or with feelings that might have preceded or accom­panied the behaviors. No attempts are made to achieve affective release, to do cathartic or abreactive work, or to help children express feelings. Behavioral approaches are applied directly to children in the playroom or are taught to parents for use in the home. This type of therapy has broad applica­tion to childhood problems, particularly those that stem from a lack of adult guidance and limit setting. Within this framework play is used as a means to an end, not as inherent­ly valuable in and of itself.

Group Therapy
Slavson (1947) experimented with group situations in 1947, guiding latency-age children through activities, games, and arts and crafts designed to help them "release emotional and physical tensions" (p. 101). In 1950, Schiffer developed what began to be known as "therapeutic play groups" (Rothenberg & Schiffer, 1966) in which children could interact freely with minimal intervention from the clinicians. The unique aspect of this type of therapy, according to Schaefer (1980), is that "the child has to learn to share an adult with other children" (p. 101). Group therapy enjoys a certain contemporary popularity, partly because it can be provided at lower cost and partly because there has been a growing belief in the effectiveness of this modality. Yalom (1975) documents numerous "curative" benefits provided by group therapy, including the following: installation of hope, universality, imparting of information, altruism, corrective recapitulation of the primary family group, development of socializing tech­niques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. Kraft (1980) elucidates that effective group treatment must contain the following elements:

Leadership, preferably with male and female co-therapists, involves developing cohesiveness, identifying goals for the group, showing the group how to function, keeping the group task-oriented, serving as a model, and representing a value system. In carrying out these tasks, the leader may offer clarification of reality analysis of transactions, brief educational input, empathic statements acknowledging his own feelings and those of members, and at times delineat­ing the feeling states at hand in the group. (p. 129)

Group therapy has traditionally been believed to have application to the treatment of abusive parents (Kempe & Helfer, 1980). A treatment approach used effectively with abusive parents is known as Parents Anonymous (PA), founded in California in 1970. PA uses a formerly abusive parent as a group facilitator in addition to the mental health professional. There are currently over 1,200 PA groups in the United States.

Another very well-known treatment model, Parents United, relies heavily on the group format. Parents United was established in 1975 by Dr. Hank Giarretto as the self-help component of the Child Sexual Abuse Treatment Pro­gram (Giarretto, Giarretto, & Sgroi, 1984), now known as the Community as Extended Family. Separate groups are formed for the incestuous parents and for the non-abusive partners. The children’s groups are known as Daughters and Sons United, and the groups for adult survivors are known as Adults Molested as Children (AMAC) groups. There are currently over 135 active Parents United programs across the United States.
Mandell, Damon, et al. (1989) wrote a useful and timely book on group treatment for abused children, with parallel treatment for caretakers. Throughout the book the authors use different play techniques to help the children open up about their abuse and to build trust among themselves. They defined the objectives of group treatment as follows:

•  Define acceptable behavior of group members and intro­duce a respect for boundaries.
•  Promote group interaction and reinforce cooperative efforts.
•  Introduce and encourage the discussion of common ex­periences to reinforce a feeling of togetherness and promote group cohesion for both children and caretakers.
•  Improve self-esteem through validation of individual feelings and ideas, acknowledging each member’s im­portance in contributing to the group experience.
•  Help group members to understand the purpose of the group.
•  Enhance caretakers’ capacity to begin to view their children with increased sensitivity, understanding and empathy. (p. 27)

Another pilot project, by Corder, Haizlip, and DeBoer (1990), used structured group therapy to treat sexually abused children ages 6 to 8, and focused on issues comparable to those of Mandell and associates. The goals in the pilot project included integrating the trauma, improving self-es­teem, improving problem-solving skills, self-protection for the future, improving ability to seek help, and enhancement of the child’s relationship to the nonabusive parent.
In another preliminary group project with sexually abused boys, Friedrich, Berliner, Urquiza, and Beilke (1990) advocate more open-ended therapy and selection of group members by developmental level (not chronological age) in order to promote better peer interaction.

Group therapy is not without its controversy. I have often heard the concern that the group might inadvertently en­courage the child to overidentify with the victim role and that groups have the potential of "contaminating" one child with the emotional concerns of another. Yet another concern, which I share, is that sometimes groups are run in random ways, go on for indefinite periods of time, lack clear goals, and suffer from inconsistent and inexperienced leadership. However, these concerns are discussed in the book by Man-dell and associates and do not undermine the potential benefits of the group experience.

Sand Tray Therapy
No summary of the major models of child therapy would be complete without making note of the significant contribution of Dora Kalff (1980), who created sand therapy. Sand therapy, based on the principles of Jungian therapy, sees the sand tray as symbolic of the child’s psyche. The sand therapist inter­prets the child’s use of symbols and placement of objects in the tray and observes the child’s passage through distinctive phases of healing. While many child therapists use sand play in their therapy, this type of play therapy stands alone, embedded in its own theory and technique.
- Gil, Eliana, The Healing Power of Play: Working with Abused Children, The Guilford Press, New York: 1991.

Parent–Child Interaction Therapy: current perspectives

- Lieneman, C. C., Brabson, L. A., Highlander, A., Wallace, N. M., & McNeil, C. B. (2017). Parent-Child Interaction Therapy: current perspectives. Psychology research and behavior management, 10, 239–256. doi:10.2147/PRBM.S91200..

Enactive account of pretend play and its application to therapy

- Rucinska, Z., & Reijmers, E. (2015). Enactive account of pretend play and its application to therapy. Frontiers in psychology, 6, 175. doi:10.3389/fpsyg.2015.00175.

Personal Reflection Exercise #12
The preceding section contained information about the historical development of play therapy. Write three case study examples regarding how you might use the content of this section in your practice.

Update
From talking cure to play- and group-therapy: outpatient mental
health care for children in the Netherlands c. 1945–70

- Bakker N. (2021). From talking cure to play- and group-therapy: outpatient mental health care for children in the Netherlands c. 1945-70. History of psychiatry, 32(4), 385–401. https://doi.org/10.1177/0957154X211024919

Peer-Reviewed Journal Article References:
Davis, E. S., Loeb, D., & Lee, T. (2021). Implementing play and language therapy to work with preschool children with language and behavioral issues. International Journal of Play Therapy, 30(2), 157–166.

Dillman Taylor, D., Purswell, K., Cornett, N., & Bratton, S. C. (2021). Effects of child-centered play therapy (CCPT) on disruptive behavior of at-risk preschool children in Head Start. International Journal of Play Therapy, 30(2), 86–97.

Findling, J. H., Bratton, S. C., & Henson, R. K. (2006). Development of the trauma play scale: An observation-based assessment of the impact of trauma on play therapy behaviors of young children. International Journal of Play Therapy, 15(1), 7–36.

Myers, C. E., Bratton, S. C., Hagen, C., & Findling, J. H. (2011). Development of the Trauma Play Scale: Comparison of children manifesting a history of interpersonal trauma with a normative sample. International Journal of Play Therapy, 20(2), 66–78.

Parker, M. M., Hergenrather, K., Smelser, Q., & Kelly, C. T. (2021). Exploring child-centered play therapy and trauma: A systematic review of literature. International Journal of Play Therapy, 30(1), 2–13.

Online Continuing Education QUESTION 26
According to Yalom, what are several "curative" benefits are provided through group therapy? Record the letter of the correct answer the CEU Test.