Introduction.

I would like to share some ideas behind the use of group game therapy in the programs of Edmonton Integrated Services (EIS) during the time I worked for this agency as a Program Clinician. At that time EIS operated eight group homes for children referred by the child protective agency. In three of these homes, described as receiving and assessment homes, children could spend up to three months waiting for a permanent placement. Each of these homes had four full-time staff members and could accommodate up to six children. My role was to provide psychological consultation to the staff regarding future placement, presenting problems and intervention strategies.

The issue arose how could I fulfill my duties within the position's time constraints (50% of my time was devoted to another long-term program). I suggested a group game therapy format, in which I spent one hour a week playing games with the residents of each home. This format offered the following advantages:

1. It allowed me to observe all the residents in a relatively natural situation, in which children responded to each other and myself spontaneously
2. There was typically little resistance to this activity
3. It allowed for flexibility in the environment in which fluctuation of children was high and it was possible to have quite a different group from one week to another
4. There was room for staff involvement.

With the respect to the last point my agreement with the staff was that they could join our sessions at their discretion. When they did they had a chance to build a less formal, more relaxed relationship with the residents. We also had agreed that they could cue during the session if they believed that the child's behavior was getting out of hand (and it occasionally did). The sessions were voluntary, which seemed to reduce resistance to them. The residents could choose to do their "quiet time", if for any reasons they did not want to participate, which in itself was valuable information.

Population.

Though all kind of children could be found in EIS’ homes, the majority of them could be described as "delinquent". Most came from broken families with little or inconsistent parenting practices. They were often chaotic, hyperactive and had difficulties with the rules and routines of the group homes. Many of them had been sexually or physically abused. Involvement in drugs or alcohol, antisocial peer groups and sexual reactiveness was not uncommon. They were often behaviorally challenging and resistive to any intervention (such as individual or family counseling). Most of the children were between 12 and 18 years old.

The Technique of Game Therapy.

Any game can do it. I occasionally use board games, such as "Snakes & Ladders" or "Monopoly", but most often play cards or dice with the residents. Cards or dice are easy to carry and offer maximum flexibility as far as developmental levels of the children are concerned. The game should not be too difficult or too long as it would discourage some children. It should be sophisticated enough to keep their interest. Some popular card games such as "Crazy Eights", "Go Fish", "Concentration", "Thirty One" are good enough to maintain the interest of most of the children in this age group. Very often children suggested their own games, especially these they felt strong in. As long as they can agree which game to play, there is no reason not to try it. Occasionally I ask them to "teach me" their games. The position of experts is naturally pleasant for them. In dice I typically play the game of "Ones & Fives", in which players may accumulate points (10 for 1, and 5 for 5) as long as they throw these numbers. I often offer chewing gum for the winners, though typically every child gets one gum just for participation.

The secret to the success of this approach is the natural playfulness of the therapist. As an old contract bridge fanatic I have always been comfortable with the medium of cards. The therapist should be able to regress a bit and simply have fun while playing games. Otherwise the children may start to suspect that there is more to this contact than just playing. For the same reason I avoided labeling this activity as "therapy" (and I asked staff not to do it either). Children most often called it the "cards time" and there was no need to change the name.

Therapeutic Possibilities.

Although the primary objective of this format was to allow for direct contact with the residents and to collect information about their behavior and interactions (this information was later used in case conferences and staff meetings), the group game sessions offered many therapeutic opportunities. These opportunities can be considered from at least four perspectives, i.e. play therapy, cognitive/behavioral therapy, social learning theory and ericksonian therapy. I assume that the reader knows these popular orientations so I will not present them in depth. Rather I will concentrate on how the sessions could be seen from these perspectives.

Play Therapy.

Play Therapy is most often done with individuals. Still some of its premises seem to be valid in the group format. Play therapists believe if the child is allowed to play in the environment in which he/she feels accepted and free to express his/her feelings, that the child will find ways and courage to process underlying, most often unconscious, conflicts and traumas. For instance, it is not uncommon for children who were physically abused to display aggressive impulses toward toys, animals, other children and occasionally the therapist. Aggressive play then can be seen as an attempt to bring to the surface (of the consciousness) traumatic experiences, repressed impulses, etc. By being more in touch with these impulses the child may obtain a sense of mastery over them, and thus become more "whole", integrated.

The same appears to be true in the group format. Aggressive and sexual contents were often present in the behavior of the residents. There was typically a lot of teasing, arguing, and fighting. Sexually reactive behaviors were also often observed. One could say that the children tried to use each other in the process of one's own healing. These spontaneous behaviors took place within the limits of the group session (direct physical assaults or discharges of sexual energy were not allowed), thus forcing the children to maintain some level of control. I believe that, as long as children do not harm themselves, it is better that these forces emerge in the controlled environment of the session.

Most of the traumas may not be fully integrated through just the game therapy, which under ideal circumstances should be complemented by individual counseling. It was my impression however that the level of emotional tension after the group game therapy was often reduced. Thus the children were freer to concentrate on reality and positive choices they could make for themselves.

Cognitive/Behavioral Therapy.

Group game therapy brings many natural opportunities to intervene on a cognitive/behavioral level. While playing games, children often make remarks about themselves, their families, and their experiences that reflect their self-esteem. Those with poor self-esteem may say - "I am dumb" or " I suck (in this game, in games that require calculations, etc.)". Their insecurity is often apparent in their unwillingness to try new games or for this matter any games that include a risk of failure. Some of their comments may reflect the family dynamics (e.g. "My older brother always beats me in this game", etc.).

Whatever the comment, the therapist may try to create a change by impacting the child's thinking. First of all, the therapist should not leave unresponded strong, irrational, demeaning comments that the child makes about him/herself. For instance, the therapist may say - "No (!), you are not dumb. You have just made a small mistake and it happens even for the best players." The therapist may ask for evidence or justification of the comment (e.g. "What evidence do you have that ...?", "Why do you think your brother is always better?"). The therapist may point to the inconsistencies in the child's self-perceptions (e.g. "You say that you always lose, while you have just won the game", etc.).

In general, most of the common objectives of cognitive therapy (counterbalancing negative self-statements, reducing all-or-nothing, black-or-white thinking, and orientation toward reality) could be achieved during the group game therapy. The therapist may also be more "proactive". I often do not wait for the negative thinking to emerge but offer as many positive comments about the participants as I naturally can. I may say things such as - "You are good!", "You solved this hand very well!", "Where did you learn to play so well?", etc., which typically results in the child feeling good about him/herself. I may also occasionally choose to lose a game in order to create the experience of a success for the child. In certain cases these positive experiences were carried far away and long after the original game situations. Children, who feel good, are typically more positive, more cooperative, and more responsive to staffs' requests. From this point of view the group game therapy can also be seen as a supportive therapy.

Group game therapy is also an intervention on the behavioral level. Children who are withdrawn or apathetic are stimulated through the game and often display broader affect after the session. On the other hand the natural flow of the game (rules, necessity to wait for one's turn, etc.) forces the hyperactive children to slow down and to pay attention to details and what others do in the game. As cards offer practically an unlimited choice of games, it is possible to tailor the game to the specific behavioral needs of the residents.

There is naturally a lot of room for positive and negative reinforcement during the group sessions. I try to avoid cueing children the same way as it is typically done by staff (my role is different). Still I have plenty of opportunities to approve or disapprove of behaviors. I often praise children for prosocial behaviors, such as attempts to negotiate, willingness to compromise, etc. On the other hand, I may show displeasure (and often just a look is good enough to pass the message) for behaviors that are too disruptive, too aggressive or too demeaning to others. These subtle cues are often very effective because the therapist offers something valuable to children (namely the enjoyment of the game), which can be retracted if their behavior becomes unacceptable. In drastic situations, timing out of the child (sending back to his/her room) may occur. I try not to overreact though. Ignoring minor attention seeking behaviors is believed to be the most promising way of extinguishing these behaviors.

Social Learning Theory.

In brief, social learning theory maintains that new behaviors can be acquired by observing how other people behave. From this point of view, being with a well mannered, composed, integrated and relaxed therapist may be an invaluable lesson for children. I especially try to model courtesy, respectfulness and willingness to compromise.

Modeling that seems especially suitable in the game context is that of the ability to handle frustrations and defeats. Most of EIS’ residents had difficulty in this area. Often rejected by their parents or other authority figures, these children had fragile selves, which was frequently manifested in the compulsion to win, to stay "on top" by whatever means available and to handle even small setbacks. It is thus very important if the therapist can show them how to lose without being defeated, how to lose with charm and humor, or how to see the defeat in perspective ("I have lost the battle, but I may still win the war", etc.). In other words, the therapist tries to model how to be strong and resilient.

Another area in which modeling can take place during the group game therapy is that of personal boundaries. Children often invade each other's space, and at times they invade the space of the therapist. It is a good opportunity to model the protection of one's own boundary through statements such as: "Please, do not touch me!", "I know that you like me, but, please, keep your hands for yourself.", or "It is causing me discomfort when you try to touch me." Tactfulness and gentleness but also certain firmness by the therapist is essential here.

One can see this issue also as a possibility for healthy bonding. Most of the children create a bond with the therapist. While being friendly, empathic and approachable, but also a separate human being, the therapist may try to model to the children what a proper distance can look like.

Children not only invade others' physical spaces, but even more so their emotions. Teasing, put-downs, and attempts to hurt someone's feelings are quite common. Occasionally these "charging" behaviors are displayed toward the therapist. Again this is a good opportunity to demonstrate a constructive response. The therapist may choose to ignore minor attacks, or alternatively to admit that his feelings were hurt. I may say for instance - "What you have just said was very unpleasant. I hope you did not mean it," or "Please, stop doing (saying) this as it is unpleasant for me." I try to choose simple and short responses so they are easier to learn.

Again, in situations like this, the therapist tries to model moral strength and resilience. He/she is like a mountain, solid and unmovable. The therapist may empathetically absorb some punches, but does not punch back. In this way the therapist models also how to disengage (from at times heated confrontation), something most of these children had terrible difficulty with.

Ericksonian Therapy.

Finally, the group game therapy can be seen as a trance situation in the Ericksonian sense. Concentration on cards or dice may lead to a semi-hypnotic state in which children are more open for therapeutic suggestions and metaphors. This opens practically unlimited space for the therapist's creativity. I personally try to take advantage of certain similarities between the world of game and the real world (such as rules, competition, success/failure) to introduce potentially useful coping statements. Let me give you a few examples.

For instance, when playing with a depressed or suicidal child I may make the following comments (generally intended to instill hope) about the game that can be transferred to the real situation of the child:

"In games (life) YOU (should) never give up!"
"There is always another game (day)!"
"The situation in the game (life) changes quickly."
"I was losing before and now I am winning."
"It (the game, life) is not finished until it is finished."

Other coping statements that come quite naturally in the game situation are:

"Sometimes YOU win, and sometimes YOU lose" (implies that the child may be more successful next time and that occasional setbacks are part of life).
"What can YOU do if ... (you get cards like this)" (implies that there are things beyond the child's control).

I may try to help the child feel good about him/herself through comments such as:

"Are you lucky or what?"
"I have never seen anybody as lucky as you!"(implies positive outlook of life and the sense of being chosen or special).
"You have smart fingers" or quoted before:
"YOU are good!"
"Where did you learn to play like this?" (implies more mastery than the child may experience).

I may try to impact the child's ability to respond positively to rules of the game (group home, life) saying:

"These are the rules of the game and we can not change them (especially in the middle of the game)."
"Hard law but law"(Dura lex set lex) (implies that the world with rules is better than the world without rules).
"You have got to listen to/respect the rules if you want to win", etc.

I also try to offer the children as many choices as possible, which may to some extent counterbalance their perception of being always subjected to limits and regulations. For instance, I may ask - "Do you WANT to deal?" rather than say - "You deal."

Summary.

Apparently simple situations of game playing offer excellent opportunities for both observation and therapeutic intervention. This intervention can be conceptualized from many theoretical perspectives, such as play therapy, cognitive/behavioral therapy, social learning theory and ericksonian therapy. The beauty of the game format lies in the fact that most children are not even aware they are involved in intervention, thus do not resist it. A group format is also relatively more efficient in terms of the therapist’s time. You may want, however, to educate your coworkers about this approach as it is not unusual for some people to be judgmental. To the unprepared observer it may look like the therapist is “only” playing cards instead of doing something "really useful". I hope this paper demonstrates that there is much more to playing cards than just playing cards.

Last updated: 2001/07/09
 

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