Process Research in Child Group Counseling/Psychotherapy

Zipora Shechtman, PhD

Although the effectiveness of group interventions with children has been well established, little research-based knowledge on the processes in child group psychotherapy is available (Barlow et al., 2000; Dagley et al., 1994; Hoag & Burlingame, 1997; Kulic et al., 1999). Such research is essential for the development of a theory of group work with children. Moreover, process research, in contrast to outcome research, informs clinicians about constructive practice and thus improves child group psychotherapy. 

Several of our process studies at Haifa University have focused on verbal interaction in child group counseling/psychotherapy. The group members were preadolescents who expressed psychosocial special needs. Variations of the Hill Verbal Response Mode System (Hill, 1986; Hill, 1992; Hill & O’Brien, 1999), which provides observer ratings of interactions among group members, were used in these studies. The identified group interactions led to a recommended mode of group intervention with children. This article will describe the results of these studies.

High Frequency of Self-Disclosure
In our first study (Leichtentritt & Shechtman, 1998), we investigated children’s verbal responses in three stages of group development (i.e. initial, working, and termination). The most frequent type of children’s response (both for boys and girls) was self-disclosure, then feedback and questions. All the other responses (e.g., encouragement, directives, and paraphrases) were rare. For instance, the average frequency for self-disclosure in the initial stage of group development was 9.82 and 13.87 for boys and girls respectively, compared to .95 and .49 for feedback. Interestingly, self-disclosure was high from the initial stage of the group onward, mostly generated by structured therapeutic activities or games, and by questions. 

Our findings suggest that preadolescent children have a high need for self-disclosure and little reservation about sharing private facts and experiences or expressing emotions. However, children need assistance in expressing themselves ,e.g., through structured questions, games, or activities. These results depart from the common knowledge on adult groups, for which structured activities or games are only rarely recommended. Meaningful self-disclosure is expected mostly in the working stage of adult groups, whereas in this study, children kept the level of self-disclosure high from the beginning stage onward. 

These results suggest that children behave differently from adults in groups. Thus, it is important to investigate group processes in children’s groups, rather than draw conclusions from the experience and literature of adult groups.

Group Process compared to Individual Process 
The second study investigated group processes in comparison to individual therapy processes with highly aggressive children (Shechtman & Ben-David, 1999). Out of the six types of group behavior that were examined—asking for help, experiencing, insight, simple responses, future goals, and alliance with therapist—experiencing was the most frequent response during group therapy. "Experiencing" refers to affective exploration of feelings, behaviors, or reactions concerning one's self or one's problems; it includes catharsis. It is considered a central mechanism of change in any type of therapy. Experiencing accounted for 30 percent of responses in group, compared to 20 percent in individual treatment. Furthermore, the therapy groups were characterized by fewer simple responses than the individual treatments. The higher levels of experiencing and reduced simple responses evident during group therapy point to the more meaningful processes in group work relative to individual counseling.

Interpretive Interactions
Interpretive interactions, including feedback, confrontation, and interpretation, are another important category of verbal interaction. These skills are the heart of group work with adults (Morran, Robison, & Stockton, 1985), and they are also considered important pathways in adolescent groups (Cramer Azima, 1989). In a recent study (Shechtman & Yanuv, 2000), we investigated the type of interpretive interactions (supportive versus non-supportive) that children use during groups, and the productiveness of these exchanges. “Productive" responses included insight, change, or the exploration of thoughts or feelings. In contrast, "nonproductive" responses included resistance, agreement, requests, or simple responses (Hill & O’Brien, 1999).

The results showed that children tended to use more non-supportive interpretives than supportive ones, leading to mostly non-productive responses from peers. Confrontation was the most frequent interpretive interaction and usually generated nonproductive responses, even when delivered in a supportive manner. Interpretation was extremely rare in the children’s verbal responses. Only feedback, when provided in a supportive way, produced productive responses. These results suggest that in this clinical setting, group leaders should discourage confrontation and encourage supportive feedback, a skill that most children do not naturally possess and in which they need to be trained. Letting children interact spontaneously can be quite detrimental to the group process. 

Implications for Practitioners
The results of these process research studies inform practitioners in several ways. Preadolescents seem to have a high need for cathartic experiences and for sharing personal experiences and feelings, which they do with relatively few reservations. This trend of behavior may be attributed firstly to the developmental needs of establishing their social status and creating close same-sex friendships. Self-disclosure is one effective way to achieve such goals. Second, the supportive climate characteristic of our groups, as well as the special group activities used, encourage children to share their stress and concerns with peers. But, it is obvious that they react negatively to confrontations from other group members, even when presented in a supportive way. They are more tolerant of feedback and interpretation, but only when presented in a caring manner; judgmental feedback and interpretation tend to be rejected. 

Our conclusion is that children need mostly support and encouragement in the group setting. They may not have the strength to deal with criticism. Most children in our groups are the product of a non-accepting and criticizing environment, and need corrective experiences in their interpersonal relationships. They want to be listened to, and need mostly attention, encouragement, empowerment, and assistance with their emotional and practical difficulties (O’Rourke & Wortbyt, 1996). 

As with other group patients who are low in psychological mindedness (McCallum, 1999; Piper et al., 1998), or are terminally ill (Spiegel, 2000), expressive-supportive group therapy may be more helpful than interactional-dynamic therapy. The primary objectives of expressive-supportive therapy are to improve the patient’s immediate adaptation to his or her life situation, build ego strength, and teach problem-solving skills, objectives congruent with the accepted definition of child group psychotherapy (Dagley et al., 1994; Hoag & Burlingame, 1997).

Such a recommendation bears important implications for child group therapists. Child group leaders need special training, but this is rarely provided (Soo, 1993; Sugar, 1993). They need to know how to develop a climate of trust and support through the training of group members to use interpersonal skills effectively. They also need to develop special skills for promoting self-disclosure. For instance, in our work with aggressive children (Shechtman, 1999) we use bibliotherapy, movies, and art therapy to facilitate self-expressiveness, to develop empathy, to connect them to their inner feelings, and to develop insight.

Process research in child group counseling and therapy is in its infancy. Many important issues are still awaiting exploration, including therapeutic factors, the therapist’s role, stages of group development, difficult situations, and cultural influences, to name but a few. Clearly group process is a feasible area for investigation, with important implications for clinical practice with children. 

References

Barlow, S. H., Burlingame, G. M., & Fuhriman, A. (2000). Therapeutic application of groups: From Pratt’s “thought control classes” to modern group psychotherapy. Group Dynamics, 4, 115-134.

Cramer Azima, F. (1989). Confrontation, empathy, and interpretation: Issues in adolescent group psychotherapy. In F. J. Cramer Azima and L. H. Richmond (Eds.), Adolescent group psychotherapy. Madison, VI: International Universities Press.

Dagley, J. C., Gazda, G. M., Eppinger, S. J., & Stuwart, E. A. (1994). Group psychotherapy research with children, preadolescents, and adolescents. In A. Fuhriman & G. M. Burlingame (Eds.), Handbook of group psychotherapy (pp. 340-370). New York: Wiley. 

Hill, C. E. (1986). An overview of the Hill Counselor and Client Verbal Response Modes Category System. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 131-169). New York: Guilford Press.

Hill, C. E. (1992). An overview of four measures developed to test the Hill process model: Therapist intentions, therapist response modes, client reaction and client behavior. Journal of Counseling and Development, 70, 728-738. 

Hill, C. E. & O’Brien, K. M. (1999). Helping skills. Washington, DC: American Psychological Association.

Hoag, M. J. & Burlingame, G. M. (1997). Evaluating the effectiveness of child and adolescent group treatment: A meta-analysis review. Journal of Clinical Child Psychology, 26, 234-246.

Kulic, K. R., Horne, A. H., & Dagley, J. C. (1999, August). A comprehensive review of prevention groups for children and adolescents. Paper presented at the annual meeting of the American Psychological Association, Boston, MA. 

Leichtentritt, J. & Shechtman, Z.(1998). Therapist, trainees, and child verbal response modes in child group therapy. Group Dynamics, 2, 36-47.

McCallum, M. (1999, June). Supportive therapy: Unique or common? Paper presented at the plenary discussion of the Society for Psychotherapy Research, Braga, Portugal. 

Morran, D. K., Robison, F. F. & Stokton, R. (1985). Feedback exchange in counseling groups: An analysis of message content and receiver acceptance as a function of leader versus member delivery, session and valence. Journal of Counseling Psychology, 32, 57-67.

O’Rourke, K. & Wortbyt, J. C. (1996). Support groups for children. Washington, DC: Accelerated Development.

Piper, W. E., Joyce, A. S., McCallum, M., & Azim, H. F. (1998). Interpretive and supportive forms of psychotherapy and patient personality variables. Journal of Consulting and Clinical Psychology, 66, 558-567.

Shechtman, Z. (1999). Bibliotherapy for treatment of child aggression: The program and a single-group study. Child Psychiatry and Human Development, 30, 39-53.

Shechtman, Z. & Ben-David, M. (1999). Group and individual treatment of childhood aggression: A comparison of outcomes and process. Group Dynamics, 3, 1-12.

Shechtman, Z. & Yanuv, H. (2000, February). Interpretive interventions: Feedback, confrontation, and interpretation. Paper presented at the American Group Psychotherapy Association Annual Conference, Los Angelos, CA.

Soo, E. (1993). Editor’s note. Journal of Child and Adolescent Group Therapy, 3, p. 77

Spiegel, D. (2000). Group therapy for cancer patients. New York: Basic Books. 

Sugar, M. (1993). Research in child and adolescent group psychotherapy. Journal of Child and Adolescent Group Therapy, 3, 207-226.

Zipora Shechtman, PhD, is Senior Lecturer, Faculty of Education, Haifa University, Haifa, Israel.

This article was published in the February/March 2001 issue of The Group Circle.