Creative Group Therapy! Using creative measures with teens!

Jan 25, 2012   //   by Richard Figueira   //   Blog, East Providence, Lincoln, Rhode Island, Marriage, Mental Health, News, Self Help, Stress, Uncategorized, cranston  //  No Comments

The Adolescent Struggle for Autonomy and Self-Identity:

Using Creativity in Group Therapy

By: Aryssa Washington, Roger Williams University (2011)

Therapeutic work with adolescents is often seen as a challenging task, especially in the initial stages of the therapy processes (Allen, 2005). It is important to remember that while some adolescents may be in therapy voluntarily, others are required to participate in therapy by parents and/or court mandate. Since adolescents are not often in the position to initiate the process of therapy, they may express apprehensive attitudes that work against the formation of a healthy therapeutic relationship. As with adults, some teens may not have the insight to perceive the need for therapy. Also, adolescents involuntarily participating in therapy may feel that clinicians are allied with their adult guardians, as opposed to with them. Regardless, if the therapeutic experience is new, most youth will be processing feelings of discomfort in the therapy environment; thus, creative and culturally-aware approaches that address adolescents’ uneasiness and resistance become a necessary feature in therapy (Allen, 2005).

According to Erikson, social and cultural experiences are integral to human development (Zayas, 2001). His theory expressed the need to cogitate both the individual and the common needs all humans share (Zayas, 2001). During latency and preadolescent development, youth are challenged with assuming socially-specified roles and balancing a sense of autonomy with the sense of inferiority (Erikson as cited in Zayas, 2001). For adolescents, developing a sense of individuation and independence is an important achievement, and the society surrounding the youth “provides the guidance, opportunities, challenges, motivation, experience, counsel, and instruction for accession into adulthood” (Zayas, 2001, p.363). In accordance with Erikson’s theory, youth will rehearse the roles that perceived to be essential to later success in life, as observed within his/her social culture (Zayas, 2001). The confidence that is associated with a sense of autonomy helps form the adolescent’s identity, and occurs when he/she feels supported (Zayas, 2001). Because of the universal adolescent struggle with self-identity and independence, group therapy is often thought to be an effective option. Aadolescents, with and without a clinical disorder, have ongoing issues with low self-esteem, and developing problem solving skills (Hartz & Thick, 2005; Richmond, 2000). Group work with adolescents often aims to address this over-arching issue, in the process of targeting more specific issues such as, behavioral/conduct problems, trauma, medical illness, and substance abuse (Veach & Gladding, 2007). One way of targeting the issue of self-esteem, self-identity, and autonomy, as it is associated with more specific clinical issues, in adolescent group therapy is through creative therapy modalities.

Creativity, in the therapeutic setting may be described as the “ability to produce work that is both novel, and appropriate” (Sternberg & Lubert, as cited in Veach & Gladding, 2007, p.72 ). Creativity is the creation of original work by clients that is useful to the therapeutic goal. Contrary to popular belief, creativity is not to be misconstrued as unstructured work. Many therapists recommend the use of creative therapies within the construct of some theory basis—most often found as an adjunct to cognitive behavioral or client-centered group therapy (Veach & Gladding, 2007; Pardeck, 1994).  In fact, working creatively in groups with youth requires structure, albeit a subtle use of directives when facilitating groups (Vick, 1999; Backos & Pagon, 1999; Pifalo, 2002).  For the purpose of this paper, creative therapies and expressive art therapies are used interchangeably.

Expressive arts therapy, as posited by person-center theory, includes “movement, art, music, writing, sound , and improvisation  in a supportive setting  in order to facilitate growth and healing” (Rogers, 1993, pg. 3). Person-centered theory supports the notion that all individuals are innately creative, thus expressive art therapy can be used as a process of self-discovery through emotional depth and self-expression. Humanistic principles support that the focus of expressive art therapy has nothing to do with the end product or the mechanical principles of any art form, but its focus is on the clients ability to “let go, express, and release emotions and to gain insight from studying the presented symbolic and metaphoric messages” (Rogers, 1993, pg.4). For adolescents, the production of artwork operates as a medium of ownership and a means to explore personal identity. The group setting provides the social support necessary in increasing confidence, as well as provides another modus to gain insight and learn new ways of thinking from social peers. Based on the adolescent struggle for self-identity, and desire to be self-productive, this paper examines the use of several creative therapy methods with different adolescent populations.

Music Therapy

Music therapy may include the creation and/or deconstruction of musical pieces. This could comprise the analysis of musical lyrics, the composition of musical pieces, or even playing beats on a drum (Towse, 2007). In their overview of the literature on creative techniques with adolescent groups, Veach and Gladding (2007), found that music therapy was often used to help improve social communication and as a preventative measure by increasing the development of coping skills. DeCarlo and Hockman (2003), found that the use of RAP therapy in conjunction with psychoeducational therapy promoted prosocial behaviors. These researchers posited the use of rap music in order to connect with African American juvenile offenders, status offenders, and high school students (with no record) from the same urban setting. The rap music served as a connection between therapy and the contemporary customs of the youth.  The rap therapy condition analyzed the lyrics of chosen songs that related to the specified psychodeducational topic of the day. While very much a goal-oriented treatment, DeCarlo found it was important to use cultural customs, to relate to the adolescents on their level, in order to influence desired behaviors.

Movement

A common use of movement, or dance, therapy is with adolescent female groups (Veach & Gladding, 2007). Movement therapy often has a preventative focus for young females experiencing radical body changes, or with teenage females struggling with self-image or self-identity conflicts (Block, 2001). In her clinical work with female adolescents and in dance, Block (2001) has created a framework for dance therapy in efforts to address young women’s issues with self-confidence, identity, and image. Again, the group setting functions as social support and a forum for discussion and insight development. In her framework, Block (2001), proposes that the members chose an undesired body part to lead with in a sequence of movements. Then the girls go into a group and discuss how social media and cultural assumptions contribute to their own perceptions of their self-image and self-concept. Following this, the group works as a team to build a dance with their new perceptions of the previously unwanted bodily feature.  The final stage is for the members to create a dance that illustrates how they view their bodies now (Block, 2001). In this type of dance therapy, transformation occurs when the teens become aware of his/her Self, and how society may contribute to the formation of one’s Self. The members must also become aware of others and how they relate (physically and mentally) to others (Block, 2001).  The resultant creation is an external demonstration of how he/she views him/herself. The performance of the Self for the group helps to facilitate confidence in how the youth identify themselves.

Literature

The use of literature in therapy is often termed “Bibliotherapy.” In essence, participants read specifically themed books, poems, or news articles, to explore particular issues that the members of the group may be dealing with (Pardeck, 1994; McArdle & Byrt, 2001). Bibliotherapy is often used as an adjunct to cognitive behavioral therapy with teen groups because it is a creative method that allows for therapists to address cognitive distortions or faulty impressions adolescents may have. Group members work through the stages of identification, catharsis, insight, and universality in relation to the main character and the other group members. Group bibliotherapy usually includes interactive projects, writing exercises and discussions (Pardeck, 1994). This creative methodology has been effective with various teen and even adult populations, but there has been a large amount of research done with the use of bibliotherapy and juvenile delinquent populations, or with teens that have emotional and aggressive regulation difficulties (Bogestad et al., 2010; Schetman, 2000; McArdle & Byrt, 2001).  McArdle and Byrt (2001), and Pardeck (1994), found that bibliotherapy was efficient in providing a place for emotional purging, problem solving opportunities, increased personal insight, and a medium for positive expression.

Expressive Writing

Prominent psychologist, Stanley G. Hall’s “intellectual emancipation” concept coincides with Aristotle’s notion of empowerment through understanding language and how it is used (Leary, 2006). The idea of teaching writing principles and then allowing the individual to narrate his/her own story applies to the use of expressive writing in group therapy with adolescents. As with bibliotherapy, expressive writing provides the means for emotional purging, self-expression, and personal insight. Expressive writing is often used with juvenile offenders, youth suffering from chronic or acute illness, or with youth who have suffered some form of trauma (Baerg, 2003; McArdle & Byrt, 2001; Veach & Gladding, 2007). The issue, as it relates to these aforementioned populations, is the youth’s feelings of powerlessness and/or low self-esteem.  According to Dr. Kane (as cited in McArdle & Byrt, 2001), the aim of expressive writing is to generate creativity and empowerment which is likely to assist in the establishment of self-identity.  In most cases, the group members are taught basic writing principles and are given a writing prompt, the resultant product provides each member with a narration of his or views and experiences (McArdle & Byrt, 2001). Basically, it provides teens with a tangible visualization of his/her thought processes and cognitive patterns.  This provision of self-understanding promotes feelings of power and self-esteem in situations where adolescents may not actually have/ or did not have a lot of control over. McArdle and Byrt, (2001), also found that in adolescent forensic populations, expressive writing promoted social interest, helped develop decision-making skills, as well as aided in increasing youth accountability.

Drama Therapy

Drama in group therapy with adolescents can be used as both a preventative or intervention method. For instance, group members may be asked to role play and act out parts of life in order for them to practice different behaviors (Veach & Gladding, 2007).  One study used Shakespeare’s play Hamlet, to explore the idea of consequences in relation to personal choices and accountability (Veach & Gladding, 2007). Participants were asked to act out the play and discuss the various choices the characters made in relation to how they would respond and the associated consequences.

With the intention of promoting positive youth development, Dutton (2001) used drama as a preventative measure for preadolescent youth. Positive youth development included building competencies, increasing the teens self-worth, and promoting the recognition of individual and group strengths (Dutton, 2001). In this type of drama therapy, the initial step is to form a group, then to get the group to form an identity, and then to get the group to use the forum as a place to enhance decision-making skills. In Dutton’s study (2001), a group of ten members was formed and then asked to put on a performance using any art medium they chose. The group facilitator acted as a monitor, mediator, and was there to reflect the ideas of group members. The main decisions had to be made by the group as a whole. The ten members agreed to do a Hip Hop drama, and created their own group name. The group was provided with a snack, over which they discussed ideas, concerns, and problems. They also created their own session times to accommodate students with busy schedules, and agreed to go see a different play outside of therapy to get ideas. Eventually, the group chose and performed Romeo and Juliet, which included setting up a dress rehearsal, charging admissions, advertising, and selling concessions during intermission. Allowing the teens to create together and agree on all major decisions, promoted a sense of autonomy, and helped in the development and verbalization of problems, concerns, and decisions. Granted this creative modality generates a sense of autonomy and prosocial behaviors, certain populations of youth may not benefit from such a therapy as it relies heavily on participant responsiveness and group work.

Activity Therapy

Activity therapy is basically the extension of play therapy with children, however, developmentally appropriate (Paone, Packman, Maddux, & Rothman, 2008). For the most part, the literature shows that activity therapy with adolescents is often used to promote a sense of achievement, teamwork, and prosocial behaviors (Veach & Gladding, 2007). Paone et al. (2008), used activity therapy with at-risk ninth grade students to examine the effects of group work on the development of moral reasoning. Paone et al. (2008), measured moral reasoning via pre and post test scores on the Maintaining Norms Schema Subscale of the Defining Issues Test 2 (DIT-2). This study addressed issues regarding the adolescent struggle of autonomy versus the constraints of social authority. Paone et al., (2008) posited that the moral values that help humans make decisions about what is right versus what is wrong, are formed by the observed patterns each individual learns(or perceives) in his/her social surroundings. This notion supported the use of the group as a social support unit and environment to observe and re-learn new behaviors or thoughts.

Participants were split into 12 small groups (N = 61) and received either group activity therapy (GAT) or group talk therapy (GTT). Each group was given 5 different dilemma situations over the course of 10 weeks.  While the GTT group simply talked through the issues and consequences presented with the dilemma, the GAT group had several stages.  First, the GAT group was presented with the dilemma by the group facilitator, then the group participated in a developmentally appropriate structured activity relating to the dilemma. Afterwards, the members could have free play by themselves or with other members, and the final stage consisted of a snack and discussion table.  Throughout all of these stages the facilitators reflected feelings, content, and behaviors to be incorporated in the activity (Paone et al., 2008).  The results revealed that the increase in moral reasoning was greater for those who had received the group activity therapy intervention. This creative therapy is heavily structured, but implements movement, interest (or fun), and interaction. The idea that youth can learn by simply being youth and having fun, was important in understanding how group activity therapy works. With this technique, teens can do developmentally appropriate activities that are set up within the context of situation the group facilitator desires the youth to derive knowledge from. Activity therapy allows for adolescents to actively make personally relevant choices/decisions as it relates to a problem, as well as see other ways to handle the same problem.

Art Therapy

Art therapy (visual art) has been used with a variety of juvenile populations. Hartz and Thick (2005), used visual art therapy with female juvenile offenders and found that it improved their self-esteem. They also found relevance for the discussion of social change elements when the group was discussing each other’s art work. Fliegel (2000) and Vick (1999), found that art therapy was useful in short-term psychiatric inpatient treatment programs for adolescents. An abundance of literature exists on the use of art therapy with sexually abused adolescents, and adolescents who suffer from chronic and acute illnesses. Unfortunately, most of the research with these two populations of teens in particular is focused on females. The emotional component of expressive art is used to its advantage with these two juvenile populations.

Pifalo (2002) found that art therapy provided female adolescents with a sense of power and control, which increased their overall self-esteem. Allowing the adolescents to explore their emotions in creating art and then attaching their own meaning to it put the power back into the hands of the victim. Pifalo (2002) also found that therapy through art reduced the anxiety, posttraumatic stress, and overt disassociation of adolescent victims. Backos and Pagon (1999) revealed similar results with their study of female adolescent sexual abuse survivors. They found that art therapy allowed survivors to first withdraw, then reflect, and finally explore their associated emotions and thoughts. The goal of their experiment was to assist adolescent survivors in forming a sense of a unified persona, with a feeling of mastery, or control over his/her life (Backos & Pagon, 2008).

According to Baerg (2003), many adolescents may not have the words to effectively express the depth of emotion they feel with regards to their sexual abuse or medical illness—art operates as a modus to express first, explore, and then attach meaning. Baerg (2003), who does art therapy with adolescents with chronic or acute illness, states that her role as the therapist is to make general and encouraging comments about the artwork group members present, and allow that individual to discuss their own work further, find their own meaning, and provide their own insight. The use of art in this fashion allows adolescents to feel in control, and provides them with the opportunity to explore those emotions and thought processes. Baerg (2003) also found that with adolescents suffering from a medical illness, showcasing his/her art work was an important part of group and individual therapy, because it enabled the members to tell their story as they perceive it in a very supportive setting (which an individual may or may not have outside of the group; Pifalo, 2002).

Conclusion

What seems to be an important focus of group therapy with adolescents is the fact that during this developmental stage, an individual may be struggling with more than a clinically diagnostic disorder (i.e. psychotic disorder, personality). Most teenagers are in that stage where they are trying to figure out who they are and who they want to be. Alongside the question of self-discovery, adolescents struggle to be independent, productive and successful, but they also fear the responsibilities associated with independence (Richmond, 2000). Both of these concerns result in conflicts with self-confidence and self-esteem, especially if the youth exist in an environment that lacks social support or proper role models of the desired success. What I found interesting was that the use of creative mediums in group therapy with adolescents often aimed to address these two over-arching issues.

Structure is a major element of therapy to be conscious of when using creative techniques, because adolescents do require more structure than adults in order to reach a therapeutic goal. In some art therapy settings, facilitators actually went as far as lighting a candle at the beginning of the session and blowing out the candle before the end of the session. The symbolic boundaries the lighting created allowed for the emotions or trauma an adolescent may have been expressing during the session to remain contained in that setting so the depth of the experienced emotions did not flow over into participants daily lives. In another study, the art materials were set up as a demarcation of creative space versus discussion and instruction space.  There also appeared to be more use of foods/snacks in group therapy with adolescents, which, from my experience, is a fantastic idea.  In a couple of the studies I presented, a snack was set up to separate the space of creation and activity, from the discussion and social interaction space.

Prior to doing the research on various creative group therapy methods, I thought that expressive arts was seen as ineffective or a waste of time in the therapeutic arena, but I found that most of the creative art therapies with adolescents are used in brief, or short-term therapy. For example, the predominate number of the studies presented in this paper had a therapy period of approximately 10 sessions or 10 weeks. Because I desire to do clinical work with both children and adolescents in individual and group settings, I was excited to discover that these creative methods really are not all that unconventional. I was impressed with how easily applicable creative methods are to theories such as cognitive behavioral, positive, existential, and humanistic.

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