Creative Arts-Based Group Therapy with Adolescents

Theory and Practice

Craig Haen, Nancy Boyd Webb, Craig Haen, Nancy Boyd Webb

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138572515
• eBook ISBN: 9781351332163
• Topic: Psychology
• Subtopic: Clinical Medicine
• Index: Psychology

Creative Arts-Based Group Therapy with Adolescents provides principles for effective use of different arts-based approaches in adolescent group therapy, grounding these principles in neuroscience and group process practice-based evidence. It includes chapters covering each of the main creative arts therapy modalities—art therapy, bibliotherapy, dance/movement therapy, drama therapy, music therapy, and poetry/expressive writing therapy—written by respected contributors who are expert in the application of these modalities in the context of groups. These methods are uniquely effective for engaging adolescents and addressing many of the developmental, familial, and societal problems that they face. The text offers theory and guiding principle, while also providing a comprehensive resource for group therapists of diverse disciplines who wish to incorporate creative arts-based methods into their practice with teens.

Section 1

Overview

1
Engaging Adolescents in Group Work

Principles for Effective Practice

Craig Haen and Nancy Boyd Webb

Many years ago, I (Haen, 2007) sat in the circle of an adolescent boys’ group I was leading that took place in a boarding school. It was the start of a new cycle, and several members were entering the group for the first time. A new 16-year-old member walked into the room. He stopped, pointed at me, and yelled, “You’re a child molester! You’re a child molester!” The room froze in silence, all eyes on me: waiting to see how I might handle this moment.

Internally, in a few seconds that seemed to stretch for minutes, so many feelings and associations percolated—my own experiences of being called “gay” when I was younger, my desire to be liked by my peers as a teenager, my masculine adult need to overpower—and so many urges toward action rose up, chiefly to authoritatively set limits and make my shame go away. Fortunately, I was able to not act on any of those impulses. Instead, what emerged from my lips was a chuckle. I turned toward this new member and said, “Thank you, no one’s ever greeted me quite that way before. Come, sit down and join us.”

This boy’s distinctive entry that first session evolved into a weekly ritual that was marked by his entering the group and loudly calling me whatever new and terrible thing he could think of. Eventually, his testing of our relationship and the boundaries of the group space gave way to him bravely disclosing his childhood molestation by his uncle. While he might have found his way to this disclosure eventually, our contention is that his trajectory was eased by that initial meeting and my thankfully being able to suppress my pull to act out of urgency, and instead welcoming his whole self into the space.

As in the previous clinical vignette, we have rarely received as sharp an education on being therapists as we have from our adolescent patients, and facilitating groups with them maximizes both the challenges and the potential. Despite the many fine writings that exist on clinical work with adolescents, few have the capacity to convey the visceral experience of being in a room full of teenagers. They can be angry, passive, confrontational, sarcastic, and unwilling to admit their need for any kind of help or therapy. They can also be charming and sweet, but often their positive characteristics are overshadowed by a ‘chip-on-their-shoulders’ stand-offish attitude that leads to conflict with parents, teachers, and other adults, and in turn causes the youth to feel misunderstood and isolated. This age group is perhaps most illustrative of Siegel’s (2010) analogy depicting mental health as a river bordered by two banks: one marked by rigidity and the other by chaos. Within each adolescent group exist teens who tend to reside on one or the other end of that river, as well as members who flip between banks, sometimes multiple times in the course of a single session.

The group leader’s education by adolescents often comes in the form of ongoing calls for authenticity (of expression, of presence, and of regard) on the part of the leader, as well as a wariness of the typical techniques that therapists employ (Edgette, 2006). Adolescent patients can present challenging requests and questions, primitive dynamics and behaviors, and mischievous attempts to derail the therapeutic process. As Phillips (2011) reminded, “Their development depends on their need to frustrate us [therapists]” (p. 189). It is therefore quite understandable that some practitioners avoid working with adolescents out of discomfort. A social work student once reflected her reluctance to work with teens by asking, “Why should I go overboard trying to help kids, when they only resent my efforts and don’t see any need for help?”

Practitioners who successfully engage with adolescents have found ways to look beyond their surface presentations of bravado, because they realize that those outside personas are often armor intended to shield their more vulnerable interiors, and they may not know productive ways of interacting with others when they are upset. Teenagers also have the potential to take risks and to form meaningful connections that allow for a degree of change that is not always possible in individual treatment. It is true that I (CH) have at times felt a pull toward canceling my adolescent groups before sessions began, and have often left those same sessions feeling exhilarated by the process.

While there are existing guidelines for effective group practice with adults, many authors (Donald, Rickwood, & Carey, 2014; Lee et al., 2014; Shechtman, 2014) have contended that adolescent patients require different approaches and a distinct set of clinical skills, and that it is inappropriate to assume that findings from adult research and practice can simply be applied to therapy with young people. For this reason, theorists have outlined differential models of group development for adolescents, and researchers have started to identify differences in group process. For example, Dies (2000), highlighting the adolescent need for autonomy, proposed that groups of teens evolve in the following fashion: initial relatedness; testing the limits; resolving authority issues; working on self; moving on. Likewise, Shechtman and Leichtentritt (2010) established the importance of bonding between adolescent members and group leaders, which was found to be a significant predictor of outcomes for youth. While it is now well established that the quality of the therapeutic relationship is solidly connected to outcomes in group therapy, this correlation is even more robust with young people (Burlingame, Whitcomb, & Woodland, 2014).

Acknowledging that there may be considerable barriers to engaging teens in effective practice, we endeavor in this chapter to outline a set of principles for conducting creative arts-based group therapy with adolescents that is informed by the practice and supervision of such groups over many years. These principles are intended to be integrative and transdiagnostic, applicable to a wide range of adolescent groups regardless of therapist theoretical orientation or patient symptom categories. They are grounded in practice but supported by various streams of research. While they address the use of the arts as a core method of treatment, the principles outlined may be applied equally to a range of treatment approaches. Many of the chapters to follow illustrate wise and successful interventions, and this chapter serves as an introduction to highlight and frame these approaches.

Embracing Adolescent Development

Many authors (e.g., Malekoff, 2014; Steinberg, 2014) have outlined stages of adolescent development and have articulately captured this time period, which is marked by vast physiological and psychological change. We will not reiterate these stages here, except to highlight the significance of the fact that teenage selves are in forward motion (Karkou & Joseph, 2017), immersed in a process of evolving and becoming. As Kaduson (2016) noted, “What is unique about the stage of identity is that it is a synthesis of earlier stages and an anticipation of later ones” (p. 335).

Effective clinical work with adolescents involves accepting and supporting developmental processes, rather than viewing them as barriers to more mature modes of engagement (Haen & Weil, 2010). In doing so, the group leader expects certain limitations while capitalizing on the possibilities inherent to neuroplasticity, which makes teenagers particularly primed for learning and change (Jensen & Nutt, 2014). These principles are oriented to welcoming adolescent identity in its fullness, shaping and channeling resistant energy rather than attempting to confine or limit it. They offer ways of drawing on and fostering group dynamics to effect change. However, as a precursor, we begin with a discussion of effective leadership.

The Position of the Leader

Hurster (2017) noted that group leaders working with adolescents have to balance a number of roles in relationship to the members, including parent, teacher, therapist, and model. These roles call on the creativity and flexibility of therapists to a degree that working with adults often does not (Aronson, 2002), and group leadership skills are particularly critical to effective outcomes in adolescent groups (Shechtman, 2017). Hurster wrote:

The group therapist with youth is compelled to be at once a model for identification, a limit-setter, an educator and resource for information, a container and creator of a safe environment, a facilitator of identity play, and always therapeutically engaged in encouraging clarity of emotional expression, thoughtful choices, and the exercise of free will.

(p. 69)

It is not only normal, but frequently necessary, for adolescents to test the leader’s trustworthiness through acting out and pushing boundaries. In doing so, they are often seeing how much of their whole selves they can bring to the group process. Will only their civil and compliant parts be welcome, or can the group leader see and embrace them in all their messiness (Haen, 2011)?

As Brady (2017) captured, subversion is a key feature of adolescence, ranging from mild forms of questioning the status quo to more dangerous attempts to overthrow the world of adults through destructive or violent behavior. Such subversion presages the development of an autonomous self that determines teens’ personal ideologies and what is important to them (Kaduson, 2016). In groups, attacks on the leader are often initial test-runs at dealing with conflict with peers (Grover, 2017). The leader’s receiving of these moments without defensiveness, and with an eye toward setting both firm and reasonable limits while also facilitating reflection about what’s happening (either in the moment, or later when affect has become more manageable), can pave the way for teens being able to communicate with one another more effectively.

As such, it is part of healthy group development that adolescent members coalesce to claim more control over what happens in the group, allowing leaders to gradually step back. Manassis (2012) framed this as movement from dictatorship to democracy. The leader’s abilities to balance seriousness with playfulness and humor (Malekoff, 2014) and to model responsible authority may be especially important when the leader is from a dominant cultural group and the members are primarily from nondominant groups (Haen, 2015b), or in settings such as hospitals and residential facilities where there is already a vast power differential between group members and staff (Creeden & Haen, 2017).

Adolescents often necessitate an openness from group leaders, as primary role models, that other populations do not. With teens, a more distanced therapeutic style is not conducive to effective practice, and so group leaders must be willing, from a stronger, self-aware place, to participate alongside the members without taking center stage. They also should be willing to try to answer members’ genuine questions (those not intended solely to provoke) about them thoughtfully and with some transparency, giving consideration to the potential therapeutic purposes for doing so (Aronson, 2002). For example, teens struggling with sexual identity development often benefit from being able to ask an adult about sex, sexuality, and sexual orientation, and from having these questions responded to with sincerity (Rofofsky, Kalyanam, Berwald, & Krishnakumar, 2017).

Ultimately, the group leader’s capacity to be present and to use their presence to engage teens can have a significant bearing on the success of groups (Himelstein, 2017). For example, implementation of creative arts-based approaches requires asking adolescent members to voyage into the unknown, which can at times be frightening for young people, especially if uncertainty became coupled with fear during past trauma. As such, it is important that leaders scaffold the experience for the group. Experiential techniques are likely to fail if the group leader does not present them with enthusiasm and an inviting approach (Gillam, 2018).

Wilson (2017) asserted the importance of therapists taking up the position of being a ‘possibilist’ in the face of the hopelessness that can pervade the lives of many adolescents. He wrote:

To take a calculated risk in practice requires an attitude that welcomes uncertainty in the belief that such a step will bring with it a degree of hope and new possibility. This attitude of spirited practice is like the ‘feel’ a musician brings to his playing; it is something beyond technique, something that conveys an emotional engagement with the music, transcending mere repetition of the notes. It has soul.

(p. 47)

Group Planning

The task of creating a group for adolescents involves planning and collaboration with practitioners in locales where referrals are generated. Often these come from the school setting, and many groups occur in schools. Others may be held in outpatient clinics, inpatient hospital units or residential programs, or various community settings. Teens who have been identified as having difficulty with peers or family members and/or in adapting to the school environment may be referred to a social worker, counselor, or creative arts therapist who conducts groups. It then becomes the challenge for that practitioner to determine the structure of the proposed group in terms of member selection, size, open format (in which new members can join frequently) or closed format (in which membership is fixed), duration and frequency of sessions, and the types of activities to include (Finneran, Nitza, & Patterson, 2017). Some groups are organized around shared experiences—such as parental divorce, substance abuse prevention, or traumatic exposure—or diagnoses. Others may consist of mixed group membership without a common theme, except for the fact that the teens are exhibiting problematic behaviors that have concerned an adult.

Prior to reaching out to the adolescent for an exploratory interview, the leader must decide certain factors about the proposed group. Among these are the group’s gender composition (whether single or mixed gender), age range of participants, and whether the group will be open-ended or time-limited. These decisions will be guided by the leader’s goals for the group, which may be modified once the sessions begin and the members express their wishes and concerns about the purpose of the group.

Burlingame et al. (2014) reported that, of the many elements involved in conducting a group, pre-group preparation has the strongest connection to treatment outcomes. Even in short-term settings in which a formal screening interview is not possible, taking a few minutes to prepare a teenager for entering a group can help to alleviate anticipatory anxiety. During a pre-group interview, the group worker assesses the teen’s ability to participate in a group, orients them about what to expect, begins to foster a therapeutic alliance with them and their parents, and may establish goals for participation (Pojman, 2017). This process often includes some contracting about shared agreements for what it means to be a member of this particular group (Dumais, 2017). Rutan and Shay (2017) cautioned: “We believe the single biggest error group therapists can make in leading open-ended therapy groups is not having a clear set of group agreements that members accept before entering the group” (p. 227).

The following considerations can help guide a leader during the screening interview:

• Introduce the group as an option for the adolescent’s participation.
• Emphasize that the group will consist of pe...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• About the Editors
• About the Contributors
• Foreword
• Preface: The Stresses and Challenges Facing Adolescents in the Second Decade of the Twenty-First Century
• Section 1: Overview
• Section 2: Creative Arts Therapies in Action
• Section 3: Clinical Applications