Peter Zelaskowski

ADOLESCENCE AND GROUP PSYCHOTHERAPY

Back to writing

Preamble

When I first decided to write a paper on the theme of groupwork with adolescents I was motivated firstly, by a desire to develop the theoretical basis and concomitant practice for my work as a teacher in Southwark's Intermediate Treatment (IT) service, and in so doing give something in return for the time-off I have been granted over 2 years on Wednesday afternoons, in order that I might be supervised at Barts, and secondly by a wish to explore how group-analytic methods and principles might be applied to this area of work. I believe now that I was seeking to bridge the gap between my experiences as a teacher and as a group analytic trainee, that at times felt poles apart. The specialist area of teaching within which I work, located rather uneasily between the Education Department's Pupil Support Services and Social Services' Childcare Provision, has no tradition of analytic and psychodynamic thinking and is particularly underdeveloped in the region of groupwork theory and practice. However, these original motivations for writing this paper now seem rather florid and grandiose. So in the spirit of keeping my feet on the ground and being less hard on myself, my objective here is to write a theoretical paper exploring a little further into the territory of adolescent group psychotherapy, focusing on some of the key areas of debate, theory and practice which have arisen during the time I have been working with adolescents.

Introduction

There is little doubt that group psychotherapy is considered by most clinicians to be the treatment of choice for adolescents.

(Cramer Azima, ch. 1, Adolescent Group Psychotherapy)

My intention here is to look at group approaches to the treatment of adolescents in crisis. Many writers refer to adolescence itself as a time of crisis in the normal process of individuation and my starting point here will be the nature of this crisis as a developmental stage geared towards performing specific tasks. I will then go on to look at the possible advantages of group approaches to the treatment of adolescents and in doing so attempt to establish why it should be considered to be the "treatment of choice". My next step will be to sketch out a diagram of the field of group psychotherapeutic approaches to working, in particular, with disturbed or delinquent adolescents, outlining possible means of conceptualizing the range of therapeutic approaches to groupwork with adolescents. I will then go on to discuss, what for me are currently, the key concerns of working with this age group in groups, namely: boundary problems as summarized by Harold Behr; social, intellectual and emotional sources of difficulty for the therapist as conceptualized by Terry Bruce; and finally I will briefly outline some of the risks inherent within the role of adolescent group leader.

Adolescence

They say he is going backwards, indeed, he is, because he attempts to make a big jump.

Nietzsche - Taken from Peter Blos, On Adolescence, p92

The whole of adolescence can be characterized as a boundary state which demarcates childhood from young adulthood.

Harold Behr, Group Analysis, vol. 21, no. 2, June 88.

Adolescence is a period of dramatic and revolutionary change. In western cultures it is the time of life, either most reviled, depicted as posing the greatest threat to the established order of things, or most celebrated and romanticized, in particular within the sphere of popular culture, for its creative and challenging energies. At its onset, adolescence can be seen as the beginning of the end of childhood and as such is a time of mourning for the loss of the relative dependency and security of childhood, characterized by attempts at recapturing what was lost. At its end, it can be seen as the beginning of adulthood, the time when the individual literally and/or metaphorically leaves home and separates from the family of origin, into a state of relative independence. As such it is a time filled with anticipation and foreboding in the face of freedom and separation, characterized by extreme and premature displays of independence and self-destructive and violent attempts to preserve the relative state of dependence.

Peter Blos, a Psychoanalyst, describes adolescence as:

the terminal stage of the forth phase of psychosexual development, the genital phase, which had been interrupted by the latency period.

He then goes on to provide a definition:

Adolescence is here viewed as the sum total of all attempts at adjustment to the stage of puberty, to the new set of inner and outer - endogenous and exogenous - conditions which confront the individual.

It has been called a second edition of childhood, in that like childhood "a relatively strong id confronts a relatively weak ego". The adolescent resorts to the means and defenses of infancy and early childhood to cope with the biological fact of puberty, a period of rapid physical sexual maturation during which the body changes shape, effectively gains new parts and starts to behave in strange new exciting and disturbing ways. The relative state of psychic equilibrium established during the latency period is suddenly jolted and thrown into a relative state of crisis by the onset of puberty. Erikson was concerned to not look at adolescence as an affliction but as a "normative crisis", i.e., a normal phase of increased conflict characterized by a seeming fluctuation in ego strength, and yet also by a high growth potential....He also stresses the contribution this crisis makes to the process of character formation, in determining the me and not-me of individuation. The developmental tasks of acquiring a more or less intact ego and a separate identity from one's parents capable of surviving away from the family are performed at the boundary between me and not-me, a space where tastes, preferences, desires, interests, impulses, wishes, laws, rules, reality, etc., are constantly tried, tested, rejected and accepted. The task of separation may entail a total and often violent rejection of one's parents, and any societal manifestations of parental authority, hand in hand with a turning towards one's peers, "youth" or "peer cultures" are idiomatic expressions of adolescent needs. The adolescent has been forced, so to say, into a self-chosen and self-made way of life. All these efforts of youth are attempts to transform a biological event into a psychosocial experience, and, as Erikson suggests, social systems offer time and space, "institutionalized psychosocial moratoria", during and within which a sense of "inner identity" can be achieved. The adolescent needs this time and space to fulfill his/her socially and psychologically important developmental goals. However, in an increasingly complex and secular world, wherein there is little agreement, and fewer rites of passage marking, as to when childhood and adulthood end or begin, the adolescent is forced to turn inwards towards him/herself and his/her peers for solutions and answers to such questions as, "who am I?"

The Treatment of Choice?

There is probably no time in human development when one uses groups in a more powerful way than during adolescence.

J. Scott Rutan. Foreword to Adolescent Group Psychotherapy, Edited by Azima and Richmond.

Much of the literature on adolescence I have scanned for this paper forms an apparent consensus around the view that group, rather than individual, psychotherapy is the preferred and appropriate form of treatment for the disturbed adolescent. This consensus conflicts dramatically with the pain and humiliation I have so often felt and experienced as the adult working with a group of adolescents. Unsurprisingly therefore it would, on the whole, appear to be the form of psychotherapy avoided by most psychotherapists. Witness the paucity of training courses in this area, in a sense reflecting and colluding with what adolescents are striving to achieve through their often bizarre and destructive behaviour. Given the extreme difficulties of working in groups with adolescents, (which I will return to later) then why groups?

Freud observed, in "Group Psychology and the Analysis of the Ego" (1921) that the group precedes the individual, both historically and in the development of a child. The individual emerges from the group, from which it is initially undifferentiated, with a separate identity. It is the function of the group to provide a milieu for the development of individuality. Here we have what would appear to be a paradox, that is, that our individuality is a function of our membership of groups. This resonates with the Foulkesian view that man is essentially social and that the group is the basic psychological unit. The individual is but a nodal point in the group such that intrapsychic phenomena can only be understood interpsychically, in the context within which they occur. Thus the adolescent search for identity, as a social phenomenon which occurs in groups, is best analyzed in the context of groups and best encouraged to progress, when halted, through treatment in groups.

The adolescent, in turning away from his/her parents, by way of defending against identity confusion, turns instead to it's peers. The peer group, which has many forms and manifestations, provides the adolescent with a group identity which steers it towards adulthood. Throughout, the adolescent needs to confront a meaningful authority figure, against which it can kick and gain a sense of independence. However, it cannot do this alone. A therapy group of peers provides the necessary emotional support to enable this to happen, unlike in individual treatment where the risks of challenging the therapist are much greater. The peer group therefore, as the naturally occurring social phenomenon by which the adolescent separates and acquires a sense of identity, is also the therapeutic milieu in which, clinically, such developmental tasks can be achieved. As Azima and Richmond acknowledge, in their preface to "Adolescent Group Psychotherapy", (1989):

The peer group is the natural developmental habitat in which the adolescent manifests his struggle for independence, a separate identity, and a transitional model for adulthood.

Adolescent Group Psychotherapy and Delinquency

It would appear that the treatment of the delinquent has been the major focus in the development of adolescent group theory and practice. This is possibly because the delinquent presents with such extreme, often violent, destructive and threatening forms of resistance. The range of types of treatment varies from the more analytic, using the unconscious and emotional interactions of the group, through forms using an active and/or expressive medium such as music, dance, movement, art and drama, reliant more on catharsis and self-expression as therapeutic tools, through to more behaviourist approaches using such devices as contracts, rewards, punishments and structural means to effect psychological change. It would be impossible and inappropriate in such a context to explore and assess the effectiveness of each, so here I will limit myself firstly, to a brief set of definitions of forms of delinquency, secondly, to a statement of possible treatment goals for any therapeutic intervention with adolescents, and finally to a means of conceptualizing the whole field of treatment in terms of a permissive/directive continuum.

Schulman (1957) outlined four categories of "dissocial behaviour" in delinquency:

1) delinquency associated with intellectual retardation or organic brain pathology;

2) delinquency associated with incipient or early psychosis;

3) delinquency primarily related to neurotic conflicts (internalized conflict); and

4) character-disordered delinquency (externalized conflict) Cramer Azima and Richmond, p145.

The latter two have received most attention, in particular the last, referred to by Winnicott as the "antisocial tendency" for whom, the moment is paramount. Since the impulsive adolescent fails to plan ahead and is guided by the supremacy of feelings, his or her behaviour is often reckless, inconsistent and frequently dramatic. Action is considered magical and therefore a solution to any discomfort. There is, in fact, a psychopathology of thought. This raises the central problem of how this behaviour can be contained for even the most limited therapeutic goals to be achieved.

Didato (1974) provides us with a measure of the problem with his relatively modest set of four therapeutic goals for adolescent groups:

1) To increase the capacity to experience powerful affects (positive and negative, without acting them out);

2) to increase capacity for empathy;

3) to strengthen identification with the therapist;

4) to encourage new behavioural patterns in helping the group resolve intergroup conflict through non-physical verbal means.

Cramer Azima and Richmond, p155.

What sort of provision can best achieves these goals and meets the needs of the "antisocial" adolescent who, according to Winnicott,

stirs up the immediate environment in an effort to make it alert to danger, and organised to tolerate nuisance.

Quoted from Tina Lucas, Group Analysis, 1988 Vol. 21.

The neurotic delinquent, however, would appear more suited to group therapy. Able to internalize conflict, his antisocial behaviour being the attempt to resolve these conflicts in the external world, the neurotic experiences anxiety and guilt and relatively meaningful and warm interpersonal relationships. Slavson considers this latter characteristic a necessity for group treatment, in particular the capacity to be affected by interpersonal experiences and, indeed, the "social hunger" or desire for them in the first place.

Neurotic and antisocial forms of delinquency, in a sense, shape the field of adolescent group psychotherapy, as can be seen when we look at the range of treatment models. I would suggest three possible useful means of conceptualizing this range:

1) Using a directive/permissive approach;

2) using an activity/talking approach;

3) using a teaching/therapy approach.

I shall be focusing on the first of these, however, in the case of the latter it is important to note that the majority of us spent our adolescence in groups, usually large, in schools. Furthermore, it strikes me that good teaching is essentially therapeutic, in that it engages the individual more than just intellectually and, at the same time, acknowledges the momentous changes that each and everyone undergoes whilst at school, and indeed helps facilitate and direct that change. That this is not always the case is to the detriment of the education system and, it is my belief that schools could do well to learn from the world of therapy to, in particular, look more closely at how they respond to behaviour and attendance problems amongst pupils and the supervision and support of disaffected, disillusioned, needy and often emotionally damaged teachers.

John Evans (1965), a group-analytic psychotherapist, wrote,

At times adolescents, especially delinquents, behave in such a way that the therapist must choose between limiting their behaviour or abandoning a work group or regarding them as unsuitable for treatment.

Cramer Azima and Richmond, p152.

This, for me, goes right to the heart of the problems of working with disturbed adolescents. How permissive can and ought one be and at what point is behaviour limited, constrained or even punished, because presumably at some point the group, a group member, the therapist or the therapy may be put at unnecessary risk. It could be argued that this is essentially a problem relating to inclusion/exclusion criteria and appropriateness of fit of treatment. For example, Slavson argued that delinquents with a "psychopathic personality structure" were inappropriate for his "activity group therapy", through which,

improvement is achieved through the relationship with the therapist and group members and through reality testing in a permissive and accepting group climate.

Cramer Azima and Richmond, p147.

Slavson preferred the neurotic with a "social hunger", able to confront him or herself and others over conduct as the patient was given the freedom to act within the limits of his or her own superego demands and ego resources. This example is typical of essentially permissive approaches which place an emphasis on freedom of expression and the development of a supportive accepting environment. Limit-setting is considered a task for the group, which is encouraged to function as a self-maintaining unit. The therapist’s role in such a group is essentially a supportive one.

Tina Lucas, a group-analytic psychotherapist, outlines a psychotherapy group which she describes as being a secure and "holding environment" wherein, almost paradoxically, the limits and security of the group are maintained through the therapist nurturing a permissive atmosphere, by keeping an analytic attitude of non-judgmental acceptance and tolerance of whatever comes along, without resorting to reprisal or punishment. However, she then goes on to qualify this by stating that there are times when the therapist must be able to take control and set limits:

Excessive acting-out must be prevented and it may be necessary to take direct control either verbally or by removing a child from the room if the therapist is convinced that the disruption is too great for the group and that the child cannot bring himself under control.

It would seem then that by permissive we should not read "anything goes" but rather more a benevolent attitude which seeks not to punish or reject, irrespective of the pressure put on the therapist by the group member to do so. This then begs the important question as to how the therapist is able to know when he or she is acting benevolently or malevolently. This, in turn, leads me to conclude that the degree to which a psychotherapy group of delinquent adolescents can be permissive, is a function of the capacity of the therapist to withstand what occurs, without resorting to vengeful and punitive measures. It also raises the issue of the therapist's need for "holding", an issue I will return to when discussing the risks of working with this particular age-group. The permissive approach, therefore, would appear to be best suited to the mature neurotic with relatively good controls rather than the impulsive and relatively infantile "antisocial tendency", for whom a more directive limit-setting approach is advocated. Just as an overly controlled approach can tend to infantilize by nurturing dependency then an overly permissive approach can tend to perpetuate and collude with the acting-out of omnipotent fantasies.

In terms of more directive approaches several factors present themselves to me as of vital importance:

1) the appropriateness of the limits/boundaries/rules;

2) their clarity to all operating within the therapeutic setting;

3) the degree to which they are agreed upon;

4) the consequences of stepping over the limit; and

5) the degree of consistency and fairness applied in their enforcement.

The process of setting limits for the id dominated impulse oriented adolescent can take many forms. Contracts, whether of a general nature or individually tailored, signed and agreed by as many interested parties as possible, can serve as a good starting point. The contract may entail a realistic amount of goal setting and can be referred to and revised later during the treatment, when appropriate. Confrontation is a form of limit-setting commonly used during the course of treatment. Rachman and Raubolt (1983) identify several forms of confrontation appropriate to adolescent group psychotherapy:

1) Gradual confrontation - the ongoing challenge of individual by group or leader. There is no emergency situation or immediate need to change.

2) Intensive confrontation - persistent "therapeutic pressure" is applied to an individual or group to face the impulsive delinquent behaviour. Used approaching an emergency.

3) "The showdown session" - an emergency situation where immediate, dramatic action is necessary. A breakthrough is sought.

Directive approaches would appear, therefore, to involve the therapist in a more active and confrontational role, in attempting to penetrate into and bring about change in the relatively less permeable type of adolescent. The need for the therapist to be empathic and accepting, however, appears no less urgent and, in some senses, is possibly more so given the very negative and soured atmospheres that can be generated by intense acting-out.

I will finish this section with a clarifying comment from Arthur Hyatt Williams, a Tavistock Psychoanalyst,

The real need of the child part of the adolescent may be for limits and boundaries and these may be more urgent than the need for freedom and independence which stem from the more adult part of the adolescent.

Boundary Problems

Society and individuals generally seek to avoid extreme positions whilst adolescents seem to seek them out.

Marlyn J. Miller, Adolescence and Authority (1975)

Adolescence straddles the boundary between childhood and adulthood and is, according to Harold Behr, a "boundary state" in which extreme positions are adopted by way of examining and testing boundaries. This is, naturally, of particular concern to the group psychotherapist.

When adolescents gather in groups the group boundary comes under immediate scrutiny and assault. This assault on the boundaries may be more or less gradual, subtle or dramatic but will, nonetheless, occur and recur. (Harold Behr)

Behr distinguishes five types of "concern with the group boundary".

1. Dropping-In and Dropping-Out. Manifestations of this are: constant comings and goings from the room; "I need to go to the toilet"; coming late; leaving early - I have felt immense pressure at times as a teacher to end a session early; very early arrivals - this is a very common problem where I work, which can pose immense management problems, more so than coming late; unwillingness to leave; and sporadic attendance.

2. Bringing parts of the outside world into the group. The "transitional object", may be animate - a pet, a niece, a friend - or inanimate - a "sound system", a flick-knife - to which the young person appears to have formed an intense inseparable attachment. A 16 year old boy I worked with became particularly attached to an old wheelchair he found in a centre store and particularly enjoyed showing us how adept he had become at using it, doing "stunts and wheelies".

3. The boundary between talking and action. This is a particular problem given the adolescent propensity to act rather than talk out. Many practitioners advocate a more action or drama based type of group, e.g., psychodrama, sociodrama and group-analytic drama, by way of working with this propensity than always working in spite of it. Violations of body space such as kicking, punching, hitting, groping, unsolicited cuddling are actions which at some stage will need addressing.

4. Testing the therapist's boundaries. This can entail "blatant, crude and disconcerting" interrogation regarding marital and parental status, sexuality, sex-life, opinions, politics, motivation, i.e., "do you really care?". Behr advocates a more self-disclosing approach, but never beyond "the bounds of personal comfort", to enhance the modeling factor so vital to the identity seeking adolescent.

5. Teasing as a boundary phenomenon. Teasing, according to Behr, is an "exquisitely ambivalent communication", geared towards greater closeness or pushing someone away and as such is very much about the boundaries between differing emotions, feelings and transferences. It can be benign, playful, affectionate and gentle or it can be vile, aggressive and sadistic.

Boundary work is in a sense, therefore, the essence of work with adolescents and from my experience this can often entail a great deal of uncertainty, in that often one has the feeling of being on the edge of something, about to break through, but never quite getting there.

Sources of Difficulty

I believe that when one first embarks upon group work with adolescents it is rather like finding oneself tossed out into the jungle.

Terry Bruce (1978)

We have seen that being in a group can make it easier for the adolescent and that in general it is considered their most appropriate treatment milieu. However, for the therapist it may be a much more demanding and difficult sort of group to work in than others. Terry Bruce identifies three sources of difficulty, social, cognitive and emotional, particular to groupwork with adolescents.

The social source of difficulty relates to the adolescent cultural phenomenon of the gang, which provides a sense of "corporate identity" for young people with otherwise impoverished emotional and intellectual lives. The point about a gang is that it is turned to as a means of excluding and keeping out adults and as Bruce observes,

it is very common for a therapist to feel that he really has nothing at all to offer the young people.

And just as culturally the gang connotes violence, it is at the times when one feels young people forming into a gang that one feels most threatened, under attack and in the midst of violence.

The intellectual or cognitive source of difficulty relates to the egocentric childhood assumption that symbolic representations of objects really are the objects and that the objects cease to exist when they're not around. The capacity to abstract and conceptualize only develops later during adolescence. The "antisocial" adolescent, in particular the regressed and narcissistic delinquent who, compounding this, may also be caught up in sibling battles, is essentially egocentric and experiences difficulty acknowledging the existence or validity of the thoughts and feelings of others and as a consequence has a problem, getting a relatively objective view of their own thought processes. Group-as-a-whole interpretations or remarks would thus have little meaning or effect.

Finally, the emotional source of difficulty relates to the developmental task of leaving home and the need, according to Winnicott, to take the parents place. Winnicott is implying that in terms of the unconscious we are not just talking about a withdrawal of libido from parental objects but their actual destruction. Winnicott would say that in the unconscious this is tantamount to murder. The sense of lurking menace, violence and fear that I have referred to throughout this essay in a sense now becomes explicable, as do the murderous thoughts and feelings I have had as an adolescent group worker. One needs to be prepared for having projected into one the most extreme emotions. Paradoxically, however, the adolescent needs to have adults around, to replace, unconsciously attack and murder, and who will most importantly in fact survive. Bruce does then, however, sound a useful warning by observing that "whatever the skills of the person running the group" there are times when impulsively aggressive young people will succeed in wrecking or destroying what is offered to them.

The Risks to the Therapist

What the adolescent does to the worker and what the worker does to the adolescent, come together, separate out and merge again so that what usually presents itself as a problem or sometimes a crisis appears as a very confused situation.

Arthur Hyatt Williams.

I come to this section as a teacher all too painfully aware of the pitfalls of working with difficult, abused, damaged, etc., young people, having engaged in interactions which have had that certain downward spiraling feel where there is inevitably only one outcome. Teachers are particularly exposed to the dangers of working with adolescents. They work in large groups with vast numbers of young people, with little space to reflect openly and honestly on their work. The nature of the unconscious communications between teacher and pupil can be extraordinarily damaging, with teachers breaking down or leaving the profession and pupils being driven out by vengeful and punitive teachers. The people most at risk, according to Arthur Hyatt Williams, are the "heroes and heroines", the excessive carers who have personality problems, have had little or no therapy themselves and zealously go too far without resorting to help. He lists several possible outcomes in the context of therapy:

1. a simple denial, leading to counter-denial and a breaking-off of treatment, or a crisis;

2. anxiety, depression, persecution in the therapist who may go on to act out in accordance with own inner problems;

3. a more punitive and authoritarian approach;

4. the therapist dumping on the patient.

Invariably, when working with delinquent adolescents, great pressure is brought to bare on you to take on quite specific roles. The more delinquent the adolescent the greater the pressure put on the worker to repeat patterns of abuse quite familiar to the young person. The danger to the worker is getting seduced into some compromising situation, a violent protagonism or a sexually charged liaison, which not only destroys the therapeutic process but puts the worker's career at risk. The worlds of education, social work, residential care and therapy abound with such stories.

I will conclude, finally, that the task of unraveling one's own stuff from the client's stuff is a fundamental task for any therapist if he or she plus client are not to be put at risk.

Concluding Comments

The group is generally considered to be the appropriate therapeutic milieu for the adolescent. The balance between freedom and restraint is a critical one when treating the crises and traumas of adolescents in groups. Adolescents need sufficient freedom to explore and find themselves and sufficient restraint placed on their impulses. The balance is in large part a function of the degrees of regression and delinquency and the capacity of the therapist to withstand what occurs. Too much freedom or too much restraint would appear to be symptoms of an unhealthy therapeutic alliance, which will fail to meet the needs of the young person and expose the therapist to unusually severe risk.

A Few Reflections

Writing this paper has been a particularly affirming experience, in that, much of the literature that I found and used, focuses on aspects of working with adolescents which I have been grappling with as a teacher and aspects of working as a therapist I have been grappling with, with adults. Thus the writing has helped me clarify much and, although, I have not really made references to them, has brought back many of those rich, turbulent and traumatic moments that have so laced my recent working life.

BIBLIOGRAPHY

Behr, Harold, Group Analysis with Early Adolescents: Some Clinical Issues. Group Analysis, June 88, Vol. 21 No. 2

Blos, Peter, On Adolescence, A Psychoanalytic Interpretation. The Free Press, 1962

Bruce, Terry, Group Work with Adolescents. The Journal of Adolescence, 1978, 1. 47-54

Cramer Azima, Fern J. & Richmond Lewis, H., (Editors), Adolescent Group Psychotherapy. International Universities Press Inc., 1988

Deutsch, Helene, Selected Problems of Adolescence. . International Universities Press Inc., 1989

Hyatt Williams, Arthur, The risk to those who work with disturbed adolescents. Source unknown.

Lucas, Tina, Holding and Holding-On: Winnicott’s Ideas in Group Psychotherapy with Twelve to Thirteen Year Olds. Group Analysis, June 1988 Vol. 21 No. 2.

Meyerson, Simon (Editor), Adolescence and Breakdown. George, Allen & Unwin, 1975.

Meyerson, Simon (Editor), Adolescence, the Crises of Adjustment. George, Allen & Unwin, 1975.

Willis, Sally, Group-Analytic Drama: A Therapy for Disturbed Adolescents. Group Analysis, June 1988, Vol. 21 No. 2.