Psychodrama Group Therapy with Children, a training course

2

Training course in Gaza with Stefan Flegelskamp and Agnes Dudler from 2014 – 2017 medico international switzerland, GCMHP and Institut für Psychodrama SZENEN, Cologne Germany

Psychodrama Group Therapy with Children

Part 1 of the guidance to Symboldrama with traumatized children
I. Introduction
II. The history
III. Basic Aspects
1. The way children play
2. Group therapy with children
3. Therapists and children meet in PD
IV. Requirements and thoughts before the group starts
1. Age of the children
2. Therapists
3. Forming the group – right mixture
4. Number of participants
5. The room
6. The material
V. The phases of a group session and it`s rituals
VI. Basic principles of Psychodrama with Children in Group therapy

Psychodrama Group Therapy with Children, in an Individual Setting

Part 2 of the guidance on “Symboldrama with traumatised children” – Symboldrama with a Single Child – Monodrama with Children –
I. Introduction
II. Basic Techniques of Intervention in the Play Phase
1. Mirroring
2. Role taking, role exchange, role reversal and role inversion
3. Doubling
III. Core Needs of Children
IV. Understanding Disorders in Children
V. Case Examples
1. Case example: Symboldrama, or working with parts of the Personality, with children
2. Case example: Monodramatic roleplay
3. Case example: Family work with children, or parent-child work
VI. Closing Phase
References

Psychodrama Group Therapy with Children

Part 1 of the guidance to Symboldrama with traumatized children

I.  Introduction

These instructions are supposed to help our colleagues in Gaza, who participate in the 3years course „Symboldrama with traumatized children“, to learn and use the basic strategies of psychodrama therapy with children. The basic attitudes and interventions are presented following the contents and first steps of development within the first training group in Gaza that started in May 2014.

The training and theses instructions are based in the special psychodrama therapy with children developed by Alfons Aichinger and Walter Holl, which could also be called „Symboldrama“. Their main book on this topic will soon be translated into English (and maybe into Arabic too) and will be published by Springer at the end of 2016.

Meanwhile this brochure supports and shows the topics and content of the first training group in an Arabic country and follows the process explaining the methods used. Quotes are taken from the mentioned book by Alfons Aichinger and Walter Holl „Gruppentherapie mit Kindern. Kinderpsychodrama Band 1“, 2nd edition 2010, Springer, Germany.

II.  The history

The project „Psychodrama with Children“ in Gaza is carried by medico international switzerland and the GCMHP (Gaza Community Mental Health Program). Medico International Swiss is engaged in Gaza since many years and has made possible the first psychodrama training group finished in 2011 cooperating with GCMHP and PMRS (Palestinian Medical Relief Society). They support the supervision and advanced training of these certified psychodramatists. During their supervision the need of working with children came up. Children and even more traumatized ones need a different treatment than grown-ups. In western countries many therapists avoid to work with (traumatized) children in groups. Also in psychodrama you need a modified way of „putting problems on stage“ when working with children.

The psychologists Alfons Aichinger and Walter Holl developed a special kind of psychodrama therapy for infant groups in Germany since the beginning of the 80ies, which was adapted by Stefan Flegelskamp for the work with gravely traumatized children. This kind of therapy is well known in Germany and other countries of Europe. It was presented to colleagues in Gaza within 2 workshops to test, if this method is adaptable and useful in Gaza too. The resonance was very positive and in 2014 a group of 26 participants from different organizations working with children started this training course. Six of them have already finished the main training in psychodrama. Two of them are trainers of the remaining 19, who participate in a basic psychodrama training course that is part of the program and runs parallel.

The whole training will last 3 years and affords 6 weeks of training in „Symboldrama with Children“ directed by Stefan Flegelskamp, Agnes Dudler and Dorothea Ensel from the Institute for Psychdrama SZENEN, Germany, and at least 250 hours of basic psychodrama training and self experience directed by Enserah ….. and Enas Jouda from Gaza.

III.  Basic Aspects

 1. The way children play

„A child is very serious when playing“ is what Rousseau says in his novel „Emile“. Also Johan Huizinga referred in his book „Homo Ludens“ (the playing human-being) to the meaning of each play. He says that children are very good in constructing their own reality. They choose the appropriate roles themselves and are able to find their own solutions for their everyday problems.

Children play, choose subjects, places and roles. That is the way they express themselves, develop and have fun. One can say that this is the origin of the psychodramatic therapy. Jacob L. Moreno, the founder of this method, based his psychodramatic work on this kind of play and included the basic steps and elements of the human development.

The psychodramatic therapy of children differs profoundly from treating adults with this method and demands a lot of the psychodrama therapist. Children communicate differently from grown-ups. Playing is their instrument of expressing their inner world and they use symbols to do so. One can say: Playing is their „royal way“ (Freud) to express the unconscious. They search for their possibilities by „Doing and Acting“. They test their inner images by acting it out and bringing it on the appropriate stage.

Traumatized children rarely do have words for the great horror they suffer from. You can only understand those children by entering their world by playing with them and getting into contact with them by taking a role in their play. In a „symbolic drama or play“ which is a variation of psychodrama for children they can express their painful experiences. It gives them a kind of protection from being overwhelmed by their trauma. Playing children show a high grade of creativity. They find roles with aspects of fun and convenience instead of falling back into their roles of suffering. They become lively beings and can feel their livelihood and realize themselves as active human-beings. The child can also control the action of getting close to the dreadful experience he/she has had. This gives a feeling of safety and protection and he/she can start to experience self-efficiency again. In the play the child can control and influence the events. By doing so and by being creative livelihood and self confidence come back.

Moreno realized in the play an aspect that can be explained as follows: People who play experience a new possibility to enter into their own creativity and thus take an active part in creating their own way of life. That is why symbolic play and symbolic acting are very important in the therapy of children. It creates affective and cognitive flexibility and fields of learning (for children). Modern neurosciences confirm how necessary emotions and the active involvement of the body are for any change of behavior and coping strategies.

„Children are children, are children, are children“. This saying describes the experience that children of all cultures and languages like to play – all over the world! The play is an instrument of communication and the world of symbols gives room for expression in safety. It`s a fact that children who can not express themselves verbally are very well able to communicate with their surrounding by playing. The only question is: DO WE UNDERSTAND THEM?

Main aspects: Playing is global – psychodrama appropiate for children – world of symbols – safe space for traumatized children

2. Group therapy with children

To learn how to act and behave in a group can only be learned in a group. This simple statement of social learning describes the necessity of this kind of setting for a therapeutic work. A great part of the development and socialization of a child takes place in groups; of special influence are peer groups. They provide a natural resource for their development. Thus psychodrama group therapy for children has been successful for years. In this setting children learn to make arrangements with each other to regulate their joined action in a common „play“. The arrangements may limit the individual freedom with respect to others; and at the same time they create a common ground and a frame to the benefit of all. The experiences made over years show that children accept those rules and mostly respect them. They appreciate what they gain, a frame of security and reliability, where conflicts can be acted out in a safe way.

„The peer-group allows to try and practice new roles which are not determined by age and sex as it is done in families. Standards can be examined for their reliability.

The method of psychodrama leads to overcoming egocentrism and evokes socialization in the sense of communication and cooperation. Aspects of egalitarian components are confirmed by appreciation and disapproval. The child is requested to determine his/her relation to the other children. Intentions and claims have to be communicated and rules and sanctions have to be discussed and agreed upon in the group, and perhaps they will be changed later. These new experiences of acting leads to a profound change of the self-concept.“ (Aichinger/Holl p. 9)

Unfortunately group therapy with children is not as appreciated by many therapists as it should be, because the group-treatment of children is difficult and demands high flexibility of the therapist. Especially the therapists and teachers who have had to deal with children with behavioral problems in groups will understand this immediately. Children who have received too much or not enough awareness of the person to whom they relate most closely start quickly to compete with each other and push each other vehemently into their symptoms. They make the therapists feel powerless and insufficient, falling into a sort of helplessness or other behavior they detest. Many therapists therefor try to avoid these feelings and prefer the individual therapy, instead of recognizing the experience of their own powerlessness as countertransference and use it in order to understand the children`s problems in a deeper way. By avoiding this experience they miss an important aspect of the treatment. But to be able to make good use of it a special awareness and understanding of what is happening are necessary, also a knowledge and the skills to choose and intervene with adequate tools.

Groups are unique as place where a good social and „new“ behavior can be trained and than be transferred to the social situation in schools and kindergardens or in their family. In an individual therapy session the child receives the full awareness of the therapist. He/she feels secure and no other child can disturb his/her world. Needs and demands of other mates and competitive actions do not intervene. This fact has advantages and disadvantages.
Before starting the therapy it has to be checked carefully which setting is appropriate for a child.

Main aspects: socialization in the group – countertransferenc as a key -enough room and healthy limits – rules and freedom in acting – new experiences

3. Therapists and children meet in PD

By accepting the play as the adequate form of communication of children a change in the method of psychodrama practised by the psychodramatists Alfons Aichinger and Walter Holl was developed. They describe this fact as follows: “We had to become aware of non-verbal expressions and had to learn to understand actions in their meaning and their symbolic containment and simultaneously intervene by finding the right response. We solved this by becoming part of the play, taking a role actively in a way to encourage and support healing processes in the children. This becoming part of the play normally is not done working with adults.“ (a.a.O. p. 13)

Usually children are clever and normally they act intuitively in the right way to help themselves. In the therapy with grown-ups the psychodynamic attitude of the expert requests working through the patient`s past with its painful emotions of sorrow, grief, rage and shame. Moreno`s remark „the second time heals the first time“ also refers to this proceeding.

Children also want to express and work on the problems they have, but very differently. They don`t want to go again into the role of the victim that is weak and dependent but on the contrary they choose the opposing role of the mighty and powerful actor in the scene they have in mind. They want to be self-effective and powerful and give the roles with painful experiences such as shame and injury to the others.
This is where the therapist has a very important and special function in the psychodrama with children. In their normal surrounding the stronger children give these roles to the weaker ones. In psychodrama the children choose their roles by themselves. Here the therapist takes such roles of victims if necessary and experiences the traumatic or painful feelings the children have undergone earlier. This is a great chance to realize what the child has gone through and what kind of feelings are hidden in the symptom.

That is why a profound self experience and psychodramatic role training is essential for psychodrama therapists who want to work efficiently with children. They have to be able to take the role of a victim and stay aware that it is a role, while they experience what the child does not want to feel again. Their task is to express these emotions in the play, which gives the child the satisfaction and reparation of trauma, that he/she no longer is the victim but the perpetrator who can do to others what has been done to him/her. This is one part of the restoration of the child`s damaged self esteem.

The therapist has to be able to take this not personal but as a precious possibility to the hidden pain of the child. He/she has to be able to act on two stages: The formal one of therapist and patient, and entering in the play the stage of the symbolic drama, where the child might be the offender and the therapist the victim. The psychodramatic principle of acting „as if“ makes this possible. Through the experience in these roles it is possible to find a constructive solution beyond the spiral of victim and offender.

Examples are:The lion (child) who breaks out of it`s cage gives the zoo director (therapist) all his existential fears; the astronaut puts shame on the immobile alien. The therapist acts out of the role he/she got from the child. This is a difficult and sometimes very demanding task specially when the play of the group is very complex or seems chaotic. The therapist has to be creative to make suggestions that can initiate the way to a constructive solution. A constructive solution means to go beyond victim and offender, to find a situation where the child can use the strength and power in it`s role to protect weaker ones instead of killing or torturing others. A god solution has no losers.

If this process is successful it opens the door to a positive development The healing process takes place inside the children and shows up in a change of their behavior. The world of symbols for the child is the place of change. This symbolic world with it`s „as if“ reality provides protection, as the children (with the accompanying help of the therapist) define the modalities, scenery, roles and what shall happen. By giving children the opportunity to be respected and have room for their needs on the symbolical stage healing forces are evoked.

In the play the children do not show their injuries or want to experience them again but they travel into a symbolic world, where they are allowed to play powerful roles or if small and dependent with a strong guardian, who protects them. In any case they want an experience that heals former injuries. The therapist must help them to develop their ideas and find their appropriate action. He/she takes up their ideas in the play and the roles they chose. Whenever the therapist wants to intervene he/she can do it by making suggestions concerning the structure or the procedure of the story, by asking questions to enrich the story and making proposals. He/she is the stage-director with the task to make the scenario performable and takes care that no child is hurt, but the children are the authors. He/she has to follow their prescriptions, help them to find and develop their roles and conduct them if necessary to a good experience or solution for all. If there shall be a change of roles or a turn of plot the children decide it.

When therapists are asked to take the role of a victim, they should express the feelings contained in this role during the play or afterwards (or both). This is, as already mentioned above, a healing experience for the children, that a powerful adult like the therapist is on the symbolical stage subject to their power. For example if the therapist as victim cries aloud for pain, tries in vain to run away, shows fear and shame, the children feel powerful and restore their damaged self-confidence. Adults have to relearn the state of „as if“, young children have not yet lost the access to this room.
It can as well be that the therapists get the role of protecting the children and being the one s they can rely on, for example some children are young cats or rabbits who need shelter, food and care-taking by a couple of farmers, or wounded animals or soldiers who need a doctor.

And almost always children are in need of appreciation, which they can take easily in the role of a lion, who is admired by the therapists for his strength and beauty, or a beautiful and very fast horse, a giraffe who is very tall and can look farther than everybody else. Also the anxious child as little rabbit hidden in a nest can be admired that it is so witty to hide when there are dangerous animals around. Feeling seen and appreciated is a basic need rarely anybody has got enough of and it is very effective in restoring a wounded self.

This kind of psychodrama asks for therapists who are prepared to go into the play, who are prepared  to take the roles necessary and can endure the fact of being overwhelmed by the children or even being tortured, off course always symbolically, „as if“ as we say in psychodrama. By doing so the children can restore or built up their own power and strength. This gives a basic security for the treatment they need according to their emotional situation.

Very often the therapists play „good roles“ in which they have to express appreciation and admiration of the children. This can be done by saying how strong and brave the wounded animal was to survive the dangerous situation it was in. They have to underline the cleverness of the fearful animal to hide or of the giraffe who has no enemies. This kind of admiration could not be mentioned in the real context of therapist and patient, it would cause embarrassment and refusal and would rarely have any kind of positive effect. In the symbolic play it is very much appreciated.

One sort of chosen scenes are situations where the parents are proud of their children, have a certain glance in their eyes when their kids do something for the first time and thus encourage the next step of development. The therapists in some roles can also feel this joy and proudness of such parents and they can and should express it actively. The reaction of the children will show how much of this is needed.

If the therapists decide what and how to play and give the children their ideas and roles for the play, children tend to become rebellious because they feel being limited and patronized. They always want to express their reality by themselves. If they are not respected in this basic need they will do to the therapist what is often enough done to them by adults. But once they have realized that it is more fun to make the therapist helpless in the symbolic play than in the reality of the circle, a good relationship and confidence into the work grow and the treatment in the group will be successful.

Important aspects: communication by playing – therapists as teammates – treatment in roles – understanding and intervening in action – therapist as victim – being the director

IV. Requirements and thoughts before the group starts

1. Age of the children

The symbolic play has a limit in age: children up to 12 years live in a world of symbols. Later it is no longer available. The symbol-drama is a world of protection also for teens and grown-ups but they have a defense against entering it while for younger children it is familiar and normal.
The best age is between 4 and 12.

Forming a group the children should be of almost the same age, f.e. 6 – 8, 8 – 10, 10 – 12, because the problems of kids of the age of 6 differ from the ones of the age of 10. The difference of age inside one group can be 2 years, otherwise it will be too difficult or frustrating to find a suitable topic. The hierarchy and the dynamics of a group should not be determined by age.

2. Therapists

When beginning this kind of work there should always be two psychodramatists who direct a group together. As long as the therapist is not well experienced in this kind of work he/she will have difficulties to become aware of all actions and fulfill all the functions necessary. It seems a great effort but the effect is progressively higher when there are two therapists. It really needs a lot of training, experience and supervision to develop the skills necessary. It would be good to have a female and male psychodramatist but this is not absolutely necessary. More important is that they are good colleagues who complete each other.

3. Forming the group – right mixture

When the group is built up one should take care of the age and a mixture of problems and symptoms to keep a sort of balance. Children who act directly and have a lack of control, tending to violent outbursts can learn from children who are emotionally restricted and the other way around. If there are too many children with the same problems in one group they are limited in model learning from each other. It can also be that they start a competition who is provoking the biggest amount of awareness from the therapists.

4. Number of participants

For beginners in this method it is preferable to have 4 members in the group. For the children it is positive because they can experience a lot and for the therapists the group is small enough to respond to the needs of all children. If you have children with behavioral problems it is already an advantage to have 4 children in the group. It is easier to direct them, if you have a chance to get and stay in contact with each child.

Also children of the age of 4 to 5 ask for a lot of awareness of the therapist. Therefore the group should not have more than 4 members. Group leaders who have a lot of experience and whose groups are well-chosen can deal with 6 children.

The mixture of the sex should either be half male and half female or there should be a boy-group and a girl-group.

5. The room

Very important is the room itself. It should not be too large or too small. There should not be too many objects and furniture. A small gymnastic-hall of 50-100 qm would be ideal. If the room is too big the children get lost and it is more difficult to keep the children in contact with each other and to establish a close play. If there is lot of furniture in the room the children are distracted and the objects are of interest. The children want to play with them or possess them and the therapists have to take over the role of prohibiting and limiting the children`s action instead of giving them the chance to open themselves and find new possibilies.

6. The material

The material for the play should be colored cloths or shawls: a blue one for water, a green one for grass, a yellow one for sand, and other colors to define places in the play. They can also be used to mark borders or other things; and they can serve for dressing up.
We take wooden playing material for construction of the company Baufix in order to represent tools like pistols, mobile phones, radio units, hammer and so on. Basically the children are not allowed to bring their own toys because there might come up a group-dynamic conflict about the objects. And we prefer material that is not so fixed in its meaning and can be used in multiple ways to symbolize what`s needed.

Main aspects: limit of age – female and male therapist – group size and mixture – room and furniture – material

V. The phases of a group session and it`s rituals

In general the time frame of group therapy in Germany is „3 x 1“ which means:
once a week / one hour / one year. This cannot be realized in all institutions and often the frequency and duration of a therapeutic treatment of a group is shorter. Less than an hour each meeting might be too short to come to a real process intensive enough. A shortening demands a change in the focus of the play and in the kind of interventions. If you shorten the time of group therapy it will be better to use more pedagogical interventions and play stories or fairy-tales which will be described in a chapter below. Known stories take not such a long time of development with the children as newly invented stories do.

Rituals are repetitive elements of communication in each session which stay always the same and are well-known by everybody. Often they exist of many symbols which give the children security and support the possibility to build up very carefully a relationship between the children and the therapists.

1. Every group session starts -after having greeted the children in a very friendly way – with the first question:

„What do you like to play today?“

Having heard the suggestions for the play – they are very egocentric at the beginning – it is the therapist`s task to develop a common idea for the play together with the children`bringing their ideas together into a playable story all can agree on. There should be a lot of attractive and individual roles for all of them. And there is no voting on the idea of the common story because the children who have been outvoted often disturb the play of the others for revenge to show their  anger. A simple idea is enough for the beginning. Long scripts and plans will never be realized in the course of the play because there will come up new ideas and different impulses during the play.

2. Children choose their roles: Only after having reached a common agreement on the idea of the play a second ritualized question will be put up:

„Which role would you like to have in the play?“

Very often the children choose intuitively the adequate role for themselves: The choice shows their need which can be satisfied later in the play. The therapists must help the children to explore their wish which is connected to the choice of their role. They do this by asking questions of understanding. They ask e.g. „is the lion young, strong, hungry, hurt, angry“ and so on. This information gives important hints to the kind of action of the play and the therapists get to know what are the child`s wishes in the role. At the same time new ideas and actions can be evoked by the questions, e.g.: „Is it possible that the Ninja-fighter can read traces, drive cars and recognize secret writing?“
A question like this could help and lead to the first arrangement/agreement with the children.

3. Roles of the therapists:  After the roles have been chosen and explored by the children, the third step follows:

„What role do the therapists play?“

The children are allowed to give the therapists the roles after having come to a common agreement. The kind of role demanded by the children touches very often the role of a proud director of a circus (admiration) or the role of an angry bank director. This can lead to the understanding of the children.

In the process of reaching an agreement one can see the behavior of the children and the group dynamic of this group: Some already want to play out aggressive impulses whereas other children are not sure at all and want to be looked after and encouraged. The question is who`s and which subjects dominate and which ones are rejected and need support. Very often the boys want to start quickly and become knights who fight. By doing so they get the feeling of being strong. The girls want to be admired as princesses and be treated with respectful care. At such a point it is good that the therapists take different roles to with be able to answer to a big variety of interests. The male therapist e.g. plays the knight who likes to fight and can be defeated by the boys, and the female therapist can become a chambermaid of the princesses, combe their hair, put on make-up, ask them for their need, serve them and admire them.

4. The scenery: After having found the idea of the play and the roles of the children and the therapists are defined the fourth step follows:

„Which places and costumes do we need for our idea?“

The whole room should be the stage. Each child has her/his own individual place which should be marked out, decorated and made safe. The therapists help by doing this and do not forget to arrange a room for themselves to which they can retire if necessary.

The building-up of the stage needs a good overview and interventions. Children who compete with each other should not have their rooms close to each other. Every child should have enough room to start from and enough distance to their neighbor. If it is too close aggression could come up. A well structured stage has an important influence on the play. Places to hide, water courses, an alarm system, secret passages, camps or storehouses and pantries animate and encourage the children`s fantasy and enrich the ideas of the play. Equally important is that the children dress up appropriate to their roles and build up „playing tools“ with the wooden material of Baufix.

These 4 steps take 20-25 minutes. In this part of the session social learning is asked. The children endure this demanding process (patience, concentration, listening to others are asked) because they know that it is worth while: the play follows now.

5. The contents and interventions of the play are described in following chapters. The play itself takes about 25-30 minutes

  1. Towards the end of the play the children are asked:

“How do you want the play to end?“

The end should be satisfying for all the children which means there are neither winners nor loosers or only winners.

  1. The act of „de-roling“ (getting out of the roles again) starts with taking off of the costumes and is followed
  1. by a final meeting in the circle for the last go-round. The important questions then are:

„What did you like in the play today? With whom did you like to play together?“

The therapists also give a positive feedback to the roles and positive interventions between the children. A sharing of the experienced feelings and thoughts can also be given by the therapists, but shortly, not too long.

  1. The clearing-up of the objects and the room is done by the therapists. It is important that the children can leave the session inspired by the experience of their roles. The process of after effects can be easily disturbed and interrupted by orders and educative instructions or admonitions.

Main aspects: Frame of time: 3×1 – rituals and phases – helpful questions – development of a pliable story – dressing-up – arranging and installation of the stage – finishing the play – no losers – closure and feedback – clearing of the room.

VI. Basic principles of Psychodrama with Children in Group therapy

A. Three basic needs in groups

  1. Safety
  2. Appreciation
  3. Belonging

B. Attitudes

  1. Follow the iniative of the children and guide them
  2. The choice of the role indicates the solution
  3. Respect the symptoms, try to understand their function by letting the children act them out (maybe even reinforce them) before you try to change or develop them into a more constructive way.

C. Steps of psychodramatic group therapy

  1. Find a common story; question: “What do you want to play?”
  2. “Which role do you want to play?” and explore the role.
  3. Ask the children which role you as therapists shall take and explore it.
  4. Set up the stage together with the children. (Do it carefully and in a way, that every child knows what is where.)
  5. Dress up for the roles.
  6. Start the play with a ritual like a sound or clapping hands or a pre-scene: everybody sleeping in his/her bed, nest … and then announce the morning: everybody gets up and starts to play in their roles.
  7. Let the play take its process. If there is a need for a more constructive change, make suggestions, (“Could it be possible, that …?”), not directions. The children decide.
  8. Stop it with a ritual (see 6)
  9. De-role by taking off the extra clothing
  10. Reflecting round:
    Ask the children for experiences of positive interaction.
    Feedback of your and the co-therapists experience in the given roles and share the feelings you had f.e. of fear, shame, humiliation, helplessness, joy.

D. Don’ts

  1. Don’t let them bring their own toys.
  2. Don’t let them play your partner. Beware to respect you belong to different generations.

3. Let the children finish with the round (III.10). Putting away things and clearing up is your task, not theirs.

Psychodrama Therapy with Children, in an Individual Setting

Part 2 of the guidance on “Symboldrama with traumatised children”

Symboldrama with a Single Child – Monodrama with Children

I. Introduction

Psychodrama in a bipersonal setting is called differently: Monodrama, Psychodrama à deux, individual psychodrama or, like proposed by Brazilian colleagues: one-to-one psychodrama (Figusch, 2009, p. 12). Psychodrama as individual therapy with children incorporates the following phases, which are familiar from adult psychodrama and group therapy with children:

  • warm-up comprising the steps: inventing a story, choosing a role and establishing a scene
  • play phase
  • closing phase

A significant difference to group therapy with children lies in the absence of other children to join in the drama or an opposite-gender therapist[1]. So roles are given to intermediary objects such as animal figures or dolls in order to provide children with a chance of expressing their problem in a scene. The therapist generally also has to take on different roles and bring them to life.

The play and the constellation of the self-chosen symbols (animal figures) give the child an opportunity to present his intrapsychic and interpersonal conflicts. This is processed using the familiar basic psychodrama techniques of mirroring, role exchange and doubling, albeit in a slightly modified form.

Main aspects: Monodrama, intermediary objects, intrapsychic and interpersonal conflict.

II. Basic Techniques of Intervention in the Play Phase

  1. Mirroring

Mirroring is used as an intervention technique in a variety of therapeutic procedures to promote self-insight and positive experiences of relationships. A significant psychodrama mirroring technique for adults involves the protagonist joining the director at the edge of the stage to watch a scene which he just played out himself while an auxiliary ego takes on his position temporarily. The support provided by the therapist and the distance provided by this external position can enable the protagonist to recognise aspects which were not accessible to his perception from within the scene. The different point of view allows a new perspective and can remove the ‘blinkers’ or ‘blinders’ which were restricting his perception. The therapist helps him to accept and process this.

Children, however, mostly find this type of mirroring provocative, embarrassing or even humiliating. So in child psychodrama a different variant is used, which corresponds more to the concept of mirroring in depth psychology: providing emotional resonance. This is done as follows: The therapist observes behaviour, types of play, physical and facial expressions and then, in the voice of the role she is playing, addresses this to the child, in his role. In this way, when the therapist perceives or suspects a particular inner state or emotion in the child, she can verbalise this and offer it to him. The reactions of the child will then either confirm what has been spoken or enable corrections. So mirroring is an aid to mentalisation: in other words, making it possible for the child to perceive and mentally process his emotions.

This is a significant function performed by parents in early childhood as the child can read his mother’s or father’s face and perceive how he is seen by them and what kind of emotions and reactions he provokes in them.

A further step towards mentalisation and the child gaining an awareness of what he, in his role, is triggering in the other person, is the technique of ‘inner monologue’ called “soliloqui”: the therapist speaks out loud what is happening to her in her role in the play. As a variation of mirroring, this form of ‘talking to oneself’ has proven to be very effective in child psychodrama (Aichinger 2010, p. 71).

According to Aichinger (2010, p. 68), another important task of the therapist in her role as auxiliary ego is to express admiration. (‘Auxiliary ego’ is the term used in psychodrama for the role and function of the therapist in her role as a co-player of the child.) Here, all conceivable positive characteristics of the role of the child or youth are named and spoken with admiration. This stimulates and strengthens a positive sense of self in the child.
This process of mirroring that expresses admiration, which leads to an increase in courage and self-esteem due to feeding back positive contents of the enactment (Aichinger, Holl 2010, p. 68), can also be carried out from the edge of the stage as a narrator. In other words, while the child is playing with the symbols (or the other children, in a group setting), a therapist can temporarily enter the role of a narrator or an external observer and speak from this viewpoint. A special way this could be done is as a journalist or filmmaker from a well-known newspaper or television station, who comes and expresses great appreciation from this role and talks as if speaking to a large audience.
In this way, the ‘shining in the eyes of the parents’ can be achieved, which is fundamental for the development of a positive self-image. This technique is especially effective for children with a self-esteem disorder, who often draw attention to themselves with aggressive behaviour.

Main aspect: intervention technique, mentalisation, auxiliary ego, ‘shining in the eyes of the parents’

  1. Role taking, role exchange, role reversal and role inversion

“The term role taking was coined by G.H. Mead (1934) and refers to the ability to put oneself in the shoes of another person and become aware of that person’s thoughts and feelings from within. This ability, a function of the mirror neurons, makes it possible for us as humans to recognise the sensibilities, desires and aims of another person and to adapt our own behaviour accordingly. Role taking involves both cognitive and affective aspects of a role.” (R. Schaller, 2009, p. 3)

In psychodrama these terms are used in different was. Role taking describes the act of embodying a certain role; this act is part of the further described techniques too. The term role exchange (as distinct from role taking or role reversal in the form used by Moreno) refers to a direct swap of two social roles between two people in a group or in a single setting between patient and therapist. Often this technique is also called role reversal. Role exchange can be regarded as the most important technique in interpersonal psychodrama. In group settings, it is used frequently in conflicts between members of a group: during an enactment the person A changes into the role of person B, and B temporarily takes over the role of A. Later, these two roles will be swapped back again and feedbacks exchanged.

In the case of role reversal, the protagonist changes role and place with his antagonist, a chosen symbol or object and in this new location and new role will then feel his way into the situation. Subsequently, he changes back again. This procedure is very frequent in individual as in group therapy settings. In this way, changes can be made with non-present conflict partners or inner aspects of the protagonist (as enacted in a role) in order to find better access to these. For example, changing to the role of ‘the brave man’ can allow the protagonist to experience an encouraging aspect of himself.

There can be many aims and effects of the reversal or change of roles:

  • encouraging and enabling a change of perspective
  • deconstructing egocentrism
  • demonstrating a new role (in the enactment of the protagonist) to the others
  • increasing empathy and understanding (above all, in the protagonist) for an interaction partner
  • experiencing ourselves as others see us, receiving a feedback on the effects of our behaviour
  • exploring the meaning of symbols, inner aspects or other symbolic roles
  • loosening up defensive attitudes and deadlocked situations
  • recognising and reshaping patterns of interaction between the partners involved.

In child psychodrama, it is always the child who chooses the roles and initiates role inversion from the rejected role into the desired one. This choice enables the child to do actively what he suffered passively. In play, children re-enact unresolved conflicts and traumatic situations. It has been observed that they never choose their own real roles as victim in which they have experienced powerlessness, embarrassment, pain, fright or contempt: they hand over this role to the therapists and take on the powerful complementary role[2] themselves (i.e. inversion of the roles). So the therapist as auxiliary ego receives the task of playing the role which the child finds or found themselves in as part of the real-life traumatic situation. This type of role taking of the complementary powerful role, also known as role inversion, is always performed by the children and youth themselves, generally without being aware of it (Aichinger, Holl 2010, p. 57). It helps the child to experience himself as effective again and to regain a say in how he lives.

Being assigned the inferior role makes several things possible for the therapist:

  • to experience and hence to understand what the child has gone through ‘from within’;
  • to intervene with mirrors, acknowledging and admiring the child and his strengths.

Sometimes children do preserve the original role assignment without inversion, but in the enactment they then give themselves magical powers or invent circumstances which help them to avoid landing in the inferior position by enabling them to defend themselves and to force the adult into the victim role (Aichinger 2010, p. 58f).

This technique of expanding a role as well as well as the technique of role inversion help the children to liberate themselves from the victim role with its adverse effects by taking the complementary role and using this to regain confidence and an ability to take action. This confirmatory experience makes it possible to overcome the burdensome  or traumatising situation and its consequences. It also encourages the child to adopt new ways of behaving (Aichinger, Holl 2010, p. 58).

Main aspects: initiates role inversion, powerful role, magical powers

  1. Doubling

In the classical form of doubling, a participant or the director stands just behind and to the side of the protagonist and speaks out of the protagonist’s role (i.e. using ‘I’ statements), voicing thoughts or feelings which they can sense in the protagonist or believe they can recognise, but which are not being expressed by him.

This technique is used in order to:

  • support the protagonist
  • encourage him to express his feelings
  • motivate him to explore himself
  • investigate ambivalence.

It can also be an aim of doubling to work out various personality traits of the protagonists or to resolve resistances and defensive attitudes.

The technique of doubling takes advantage of the fact that external people often have a sense of the feelings and motivations within the protagonist which he himself cannot perceive or does not dare to express. Additionally the protagonists can be presented with surprising new ideas and given the chance of questioning these and deciding whether he wants to take (some of) them on or not.

In child psychodrama, doubling means taking on an auxiliary ego role next to the child, which then enhances whatever the child wants to play and express. The therapist provides ideas for action, firm support and guidance, so she can be seen as a “supportive double” (Aichinger 2010, p. 73f).

Another version is to intervene as “narrator” – as developed by the Austrian psychodramatist Hildegard Pruckner (Pruckner, 2001, p. 33). As narrator, during the enactment the therapist often describes what is happening on stage. In this way, she can verbalise things which the group members, or in an individual therapy setting the child, cannot perceive from within their role. This procedure has similarities to the method of “empathic doubling” described by Aichinger and Holl (2010, p. 72f).

The same techniques can be used in individual or monodramatic work with children as well as in group therapy. However, in individual settings, the therapist has to take on many different roles so the story developed by the child can be played. Alternatively, hand puppets, animal figures or symbols need to be used as substitutes (Aichinger and Holl, 2002).

Main aspects: auxiliary ego role, supportive double, narrator

III. Core Needs of Children

The main techniques of psychodrama are targeted specifically towards the four basic needs of children:

  1. The need to have an adequately meaningful place in a situation and in the world; to be seen; and the feeling of belonging.
  2. The need to take action, finding a path or creating a passable path, in order to actively shape his life circumstances.
  3. The need to have an appropriate effect on others, to assume a place in an active interrelationship, and to be needed.
  4. The need to develop or find appropriate solutions and to be a creator.” (Krüger, 2002, p. 276)

This corresponds approximately to be basic needs which Aichinger repeatedly emphasised as being core motivations for “symptoms” or (disturbing) behaviour, which also form the pillars of the psychodramatic work being outlined here:

  • Bonding and intimacy
  • Self-Efficiency
  • Self-esteem (an improvement in)
  • Joy of life / action / playing

 1. Understanding Disorders in Children

According to psychodrama’s understanding of disorders, symptoms are described as failed or inappropriate acts of adjustment or adaptation:

“A disorder in experience or action has its origin in acts performed in order to adapt to life conditions which at that time could not be adjusted to in another way. …”
(Schacht 2010, p. 89).

Adjustment acts by children to deal with the war situation in Gaza can be multi-layered and primarily need to be seen as coping strategies or an approach to the problems of a life-threatening environment. A child’s acts of adjustment happen ‘with good intentions’ in a wartime situation which can be neither understood nor controlled, where strong feelings of fear, powerlessness, anger and grief prevail. This can result in manifold forms of dissociation, over-excitation and avoidance. This situation is intensified when adults, who a child considers to be strong, are experienced as powerless and fearful too. Or if they cease to be readily available as a familiar caregiver and themselves appear vulnerable instead of being a source of protection. Generally, the population in Gaza has been suffering for generations from the consequences of occupation and repeated war and a collective intractability in the political situation in the Middle East forms a significant element in the chain of severe stress situations.

In order to avoid further stressing their mourning parents, children then suppress their own feelings. Unexpressed feelings of guilt that they are still alive whereas others died can often be the triggers for severe aggression or for over-assimilation. Children shape their approaches to problems by strengthening previous competencies and behaviour which they have experienced as being successful. If a child was quiet and praised for its even temper, this can then become complete silence or cessation of communication when strengthened. Lively, robust children can become aggressive and over-impulsive tyrants. Daydreams can provide protection against flashbacks which reoccur frequently.

The top priority for any psychodrama procedure in trauma therapy is to try to understand the child’s problematic behaviour and appreciate it as an attempt to find a solution for a problem; the symptom was the best coping strategy available. A viable therapeutic relationship can be established if the child can experience himself as being understood and accepted, instead of feeling he is a problem. On this basis it becomes possible to help the child to integrate his problematic behaviour and not be controlled by it. Children often know intuitively that this behaviour is the result of an attempt to deal with a problem and they do not immediately want to give up that attempt (i.e. that behaviour). In fact, they might even fight against the therapist if they feel her main or only aim is to change this.

Main aspects: adapt to life conditions, coping strategies, unexpressed feelings, over-assimilation, trauma therapy

V. Case Examples

  1. Case example[3]: Symboldrama, or working with parts of the personality, with children

Farah[4] was a contented 6-year-old girl before both her parents died in the last war. Since then she has been living with the family of her uncle. She is described as being unapproachable, quiet, distant, isolated and sometimes also aggressive. Her noticeable distancing as well as her aggressive behaviour led to Farah being invited to the clinic.

 The therapist asks Farah to select an animal figure to symbolise one of her strengths. She chooses a rabbit and, encouraged by mirroring comments from the therapist, explains how it has big ears that can hear everything. It can also run very fast if things get dangerous. Further, it has very soft fur and likes to be stroked.

When asked to select an animal to represent her problems, she chooses a jaguar because it is dangerous and people are afraid of it. For herself she chooses a wise tortoise with its protective shell.

 She assigns the individual figures (parts of her personality) a place. Now the therapist asks her about her strengths, and the interplay between them is explored. When does the jaguar come? And when does it get dangerous? Could the rabbit and the jaguar ever become friends? How? The therapist chose a ‘clever’ fox to represent her. From within the fox role, she now interviews the different animals.

Farah asks how the wise tortoise can become the boss again. She is happy to hear that no other animal has to disappear to make this possible, but rather, each animal simply needs to find its right place. Especially the jaguar, since, as it turns out, he also has a lot of useful knowledge, such as where water and food can be found.

The procedure of the therapist:

In the first step, the therapist has the child choose an animal figure to represent herself, then for the problematic personality aspect and then interviews these animals. The interview does not focus on their problems but rather on their strengths. Afterwards, the child chooses a figure for her strengths.

The aim of the therapy is to achieve cooperation, friendship and integration for the figures (personality aspects) and not to fight against or exclude or even destroy any individual parts of the child. Timid rabbits are very alert and they seek or create safety and know where to find protection; aggressive jaguars are able to put up a fight and scare others away. To experience all these qualities being seen and evaluated positively rather than as a disturbing behaviour, which leads to trouble for the child at school, gives the child recognition and allows a feeling of self-efficiency to develop again.

The therapist explores the abilities of each part of the personality and the needs which lie behind them. This happens within the protective framework of a symbolic game that allows the child distance and room for manoeuvre. As the child tries to mediate between the animals and to promote contact between them, she becomes more present and open and begins to enjoy the play. Farah seems to be very relieved when she notices that she does not have to chase away the jaguar; instead it becomes clear how socially useful it is and how well it can cooperate with the others.

2. Case example: Monodramatic roleplay

 A 6-year-old girl who acts very withdrawn is brought to a therapist again because she continues to show very aggressive symptoms after the war. Both parents lost close relatives in the war and are very occupied with their mourning. In particular, the mother seems to be overwhelmed by this and although she used to devote a lot of attention to her daughter, she now expects her to function almost like an adult and look after her younger siblings.

 Asked what she wants to play now, she replies that she wants to play a princess, with a clown (the therapist) to entertain her and make her laugh. Then she wants to celebrate her 20th birthday and all her friends should come and bring her nice presents.

 Just as in group therapy, the therapist asks the child for a suggestion for the next play and then she has the child select roles for herself and for the therapist. These roles are then investigated thoroughly, as a warm-up, in order to enhance the contact and for the therapist to gain initial instructions as to the enactment. Example questions are: Is the clown funny and nice? Or is he clumsy and mean?

Afterwards they set the scene on stage: Where does the princess live? Does she have a throne? A stable with ponies? And where does the clown live? Then both child and therapist dress up and the enactment can begin.

In the case example, the girl dramatically enacted a grand fulfillment of wishes: Instead of being subjected to overwhelming expectations and a lack of appreciation, she is a celebrated princess. With the clown she can finally laugh and be happy again after all the sadness which has dominated her home. She enacts for herself a happy and confident moment by choosing to celebrate her birthday within her princess role.

Furthermore, for this she chooses an age where she is adult and thus less dependent. Burdensome feelings have no place in this play. She very clearly reveals what she is lacking and what she is longing for: recognition, appreciation and joy.

3. Case example: Family work with children, or parent-child work

 An aggressive 12-year-old boy comes to therapy with his despairing mother. Jamal4 is very scared of his father, who swears at him often and beats him when he comes home. Jamal has begun to hit and torture animals.

He would like to act out a horse race. The idea is that he shall be a famous jockey and will win the race. The mother should play the steward and race director who hands over the prize to the winner. He wants the therapist to play the racehorse.

In the first race he strikes the horse, forces it on brutally and curses it. He wins, receives the prize and is very happy. Without prompting, he praises and strokes the horse. In the second race, Jamal loses because the horse limps, collapsing at the finishing line. Now he wants the steward to take care of the horse.

In family therapy, too, the child should be the one to name the play and the roles for each participating adult. Here, the therapist needs to be sure to support the play of the child and the parents, either from within her own role or as the therapist. No parent should be punished or embarrassed. The idea for the play and choice of roles needs to be developed appropriately by means of possibility questions (“Could it be that…?”) which enable the therapist to also make suggestions on how to shape the play. Where possible, the child and parent should have the chance to solve problems together and cooperate constructively.

In his enactment, Jamal wishes to have a strong mother who praises him and celebrates his victory, but also intervenes when he hits the horse and furthermore takes loving care of the failed horse. He is looking for a mother who sets limits to the father when he hits and humiliates the child.

In the play he imitates the ‘persecutor behaviour’ of his father. The therapist experiences the child’s own unpleasant feelings in the role of the horse (role inversion). From within this role, she was able to express feelings of shame and anger and also a desire for protection from the steward. Asked how the story could go on, Jamal describes the second scene, were he does not win because the horse is too weak. Here, the therapist is able to voice the pain, humiliation and suppressed anger that the boy experienced. In this way, he then feels that he has been seen with his distress and this also strengthens his self-efficiency and gives allowance to his feelings of weakness.

The “as if” rule

In all of these scenes it is important to always observe the “as if” rule. Nobody is allowed to be hit or injured for real: everything is pretended or acted out “as if” it were real. Symbolic action is generally something which younger children still understand very easily, but older children have perhaps lost this understanding so it is important to remind everybody of this rule and to intervene (as therapist and the director) if it is not complied with.

VI. Closing Phase

The enactment should come to an end at least five minutes before the end of the session. If it is not over earlier, at 10 minutes before the end of the session the therapist can ask a question similar to those used in group therapy such as: “How should this play end?” The group/ the child can then find a solution together with the therapist which is as satisfactory, integrated and constructive as possible and then go on to enact this.

As in the group, it is best to use the same sentences every time to declare an end to the play. Then costumes can be removed and the therapist and child released from their roles (and also the animal figures etc). Participants leave the stage and return to their chairs. Clearing up is the responsibility of the therapist in an individual setting, too.

With children, the closing phase is short: long discussions would undermine the effect of the play. The therapist asks the child, “What did you like about the play today?” If appropriate, she gives a short, positive, descriptive feedback on the roles and the successful interactions. She can also share the feelings and thoughts she experienced in her symbolic role. This makes particular sense if it can strengthen the child again.

Main aspects: as if, symbolic action, descriptive feedback, successful interactions, share the feelings

[1] For the sake of ease, in this document the therapist will always be referred to as ‘she’ and the child as ‘he’ but both genders are implied in both cases.

[2] Roles never exist only of their own accord. For each role there is also a complementary role, such as in mother-child or victim-persecutor. And even if a child initially only takes on one role, the complementary role will also be learned. When a traumatic situation reoccurs in the child, both victim and persecutor roles will definitely appear. From these two, the child always experiences one of them as being superior.

[3]The case examples have been contributed by participating colleagues. They describe actual patients who received therapy. The group participants themselves play the children they present.

[4] Names changed

References

 Aichinger, A. & Holl, W. (2010)*: Psychodrama – Gruppentherapie mit Kindern, 2. Auflage Wiesbaden: VS Verlag für Sozialwissenschaften, 2010

Figusch, Zoltan, Ed. (2009): From one-to-one psychodrama to large group socio-psychodrama. Lulu.

Krüger, Reinhard T. (2002), Pruckner, Hildegard (2001), Schacht, Michael, Schaller, Roger: German, Austrian and Suisse authors not yet translated into English

* This book is going to be translated and published by Springer in 2016