Psychotherapy of Children With Conduct Disorders Using Games and Stories
In Psychotherapy of Children With Conduct Disorders Using Games and Stories, Dr. Richard A. Gardner demonstrates his approach to working with children who present with this common disorder. Children with conduct disorders are often incapable of understanding their own behavior, making this therapy very difficult. By using games and stories, Dr. Gardner allows young clients to self-disclose through metaphoric stories and within the boundaries of game play.
In this session, Dr. Gardner works with a 12-year-old girl named Ruth who refuses to interact with him. His repeated invitations to her to play a therapeutic board game called "The Talking, Feeling, and Doing Game" result in her increased willingness to disclose her feelings.
This video features a client portrayed by an actor on the basis of actual case material.
Ruth's father and mother were divorced approximately 11 years ago, after a troubled 1-year marriage. Ruth's mother had been flagrantly unfaithful to her husband since the beginning of the marriage. Ruth's father gave up on the marriage after 2 months and moved to a distant state to start over again. After 6 months, Ruth's mother arrived, announced that she was pregnant, and begged for reconciliation. Ruth's father acquiesced, but when Ruth was 4 months old, her mother abruptly left, without letting Ruth's father know where she was going or how she could be contacted. When Ruth was 4 years old, her mother reappeared briefly for a visit, but left just as suddenly. She had made no further attempt to contact Ruth in the ensuing years.
Ruth's father remarried approximately 7 years ago, when Ruth was 5, to a woman who had a daughter who was about a year younger than Ruth. Ruth's father and stepmother had their first son together 2 years later; another son arrived 1 year after that. Ruth's adjustment to living in a stepfamily was poor from the start.
Ruth's primary problems were lying and stealing, problems that had escalated during the past several years. She stole not only from storekeepers but also from friends, relatives, and even her own immediate family (her father, stepmother, stepsister, and two half-brothers). When confronted with her thefts, she would profess wide-eyed innocence, wondering how the accuser could be so misguided as to accuse her.
Ruth's father believed that there was a genetic component involved in these transgressions, because Ruth behaved exactly like her biological mother, who, as a child and adolescent, had a reputation for lying and stealing. He knew Ruth could not have learned these behaviors from her mother, because the mother had been absent since Ruth was 4 months old.
A few months before the referral to Dr. Gardner, Ruth had spread rumors at school that her stepmother had been physically abusing her. This lie caused a great deal of commotion and anxiety on the part of school personnel who had to grapple with reporting what they thought of as an unfounded allegation. They did not report the incident, with the stipulation that the parents find counseling for Ruth.
Ruth's first therapy experience was a failure. Ruth refused to speak one word to the psychiatrist, who eventually recommended long-term inpatient therapy, which the family could not afford. The situation became so intolerable that the stepmother gave the father a choice: "Either Ruth leaves the house or I'll leave with the other three children." As an interim solution, the father arranged to send Ruth to his mother's home, and his mother shared the obligations of Ruth's care with the father's siblings.
The plan was for Ruth to remain in this situation over the summer while she received intensive psychotherapy for her problems with lying and stealing. In this way, Ruth's father hoped to save his marriage and integrate Ruth back into the family when school started again in the fall.
Dr. Gardner agreed to see Ruth three times a week, much more frequently than he would have under other circumstances. But this intensity was necessary to get a significant amount of psychological work done over a relatively brief period.
- What is your impression of Ruth?
- How typical or atypical are her life experiences and her current behavior?
- What do you believe are the core issues for Ruth?
- What is the utility of these initial formulations?
- Before reading the next section, what topics and issues do you think will be addressed in the initial sessions?
Seven sessions, including the initial telephone session, preceded the videotaped session.
Session 1 (initial telephone session): In this 1-hour telephone conversation, Ruth's father described the current problems Ruth was having as well as her developmental and family history. Dr. Gardner agreed to meet with Ruth and other family members for assessment and treatment planning.
Sessions 2 through 7: The paternal grandmother brought Ruth for her second session, during which Ruth spoke very little and responded only perfunctorily to a few of the simplest and most nonrevealing questions in The Talking, Feeling, and Doing Game. The grandmother provided Dr. Gardner with further background information, but she made it known that she had no confidence in psychotherapy, and she was only bringing Ruth to therapy at the behest of her son and other children.
The next two sessions were conducted with Ruth and her father's siblings. The father had four siblings (two brothers and two sisters), all of whom were married and had children. Whereas the grandmother took care of Ruth during the week, Ruth's paternal aunts and uncles were rotating the responsibility of caring for Ruth on weekends. Each of these families reported having trouble with Ruth, and these problems were addressed in joint sessions. Money was stolen, Ruth was accused, and Ruth invariably responded with incredulity that someone would suspect her.
It was clear from the outset that the family members were getting increasingly frustrated with Ruth, and they asked how long therapy would take. Dr. Gardner's responded that he could not know how long therapy would last and that he might not be able to help Ruth at all. This response appeared to add to their frustration. Dr. Gardner assured the family that he was committed to helping Ruth. He further attempted to reassure them that Ruth's attendance, her protestations notwithstanding, indicated that she recognized the importance of her sessions to some degree.
To learn more about Ruth's underlying psychodynamics, Dr. Gardner invited Ruth to provide him with self-created drawings and stories. The main themes that emerged were formidable hostility and a sense of loss and abandonment. However, Ruth made little direct reference to her mother as the abandoner. More prominent in her stories were her methods of expressing hostility, especially in situations in which there were no repercussions. In fact, repercussions for actions were conspicuously absent from Ruth's stories.
In later sessions, Dr. Gardner again tried to engage Ruth in The Talking, Feeling, and Doing Game, but he was only partially successful. She would either refuse to play the game at all or when she did "play," she would only respond to the most simple and nonrevealing cards.
Dr. Gardner did not consider Ruth's apparent lack of involvement reflective of Ruth's noninvestment in therapy. Rather, he views "a body in the room" as an indication that the person on some level wants to be there.
Dr. Gardner continued to play The Talking, Feeling, and Doing Game in these sessions, even when Ruth refused to directly participate. He devised responses to cards that would bring to the fore Ruth's underlying anger and feelings of loss and abandonment and would reinforce the themes that he believed would help her face her problems and deal with them more constructively.
- Were the initial sessions as you expected?
- As you read the summary of the preceding sessions, were there any areas or topics that you thought should have been covered but were not?
- What other information would you seek to assess the patient?
- Before viewing the tape, what do you think will unfold in the taped session?
- What issues will be discussed?
- What will the relationship between Dr. Gardner and Ruth be like?
Stimulus Questions About the Videotaped Session
In the first few minutes of the session, Ruth repeatedly declines to play The Talking, Feeling, and Doing Game. Dr. Gardner articulates and accepts Ruth's negativity about the game and about sitting in the chair that is closer to him in the therapy room. At the same time, he pointedly continues to set up the game pieces in preparation for play.
- What are the therapeutic benefits of using board games and other types of games in psychotherapy with children?
- What do you think of this initial intervention that appears to both join with the patient and pursue the therapeutic task in the face of her resistance?
- What alternative approaches might you use in dealing with Ruth's overt resistance?
Immediately after this intervention, Dr. Gardner intentionally misstates Ruth's age to evoke her participation. By doing so, he elicits additional affect and negativity.
- What are the advantages and disadvantages of engaging a resistant child in this manner?
In his first move in the game, Dr. Gardner draws a card that says "act like a spoiled brat." He elects not to act out such behavior and instead goes on to describe the negative interpersonal reactions that people have to this kind of behavior.
- What is the therapeutic intent of this discussion?
- What is the therapeutic rationale for this intervention?
- What effect does the discussion appear to have on Ruth at this point in the session?
Dr. Gardner retrieves a second card in the game that reads, "You're looking through a telescope into someone's window. What do you see?" In response to the card, he concocts a story about a girl, her mother, and her father during a time when the parents are discussing their divorce.
The pivotal scene in the story is where the mother states that she does not want to have custody of her child. Dr. Gardner elaborates on the girl's later emotional reactions to the maternal abandonment and invites Ruth to share her thoughts about the story. Once again, Ruth refuses to talk or participate in the game.
- At this point, if you were the therapist, what would you do next?
- Would you continue with the game or would you switch tactics?
As a segue from this story to another point he wants to make, Dr. Gardner states that the girl in the story finds a book in the library titled The Boys and Girls Book of Divorce and, in the session, he picks this very book up from the table next to him. He begins to read from a selection called "Fields' Rule."
- What are the pros and cons of reading from a book to a child in session as opposed to directly relating the content to the child in a therapeutic conversation?
- Generally, what do you think of using bibliotherapy with children?
- With adolescents? With adults?
About 10 minutes into the session, Ruth breaks her silence by asking in an irritable tone, "How much longer do we have to stay here?" Dr. Gardner responds first with a factual announcement of the time and the number of minutes left in the session. Then he comments, "Your father says that you must come here."
- If you were the therapist, how might you have responded to Ruth's question about the time remaining in the session?
- Under what conditions would you respond to her question in terms of either process or underlying feelings rather than responding concretely to the question?
For the next 5 minutes, in a complicated series of affectively charged interactions, Ruth calls Dr. Gardner a "retard," tells him that she hates him, and voices a series of complaints about him being inattentive to her in the previous session. In the midst of these brief, intense affective displays, Dr. Gardner focuses on affirming the appropriateness of Ruth's self-assertion, and he seeks to address her complaints by offering to rectify the situation.
- In such a complex series of transactions, how does a therapist know how to respond?
- As Ruth's therapist, under what conditions would you focus on one of the other issues that she brought up?
- As you imagine yourself being Ruth's therapist, what feelings might her negative remarks engender in you?
About 16 minutes into the session, Dr. Gardner returns to a theme Ruth had brought up earlier—his not being able to hit patients. He confirms to Ruth that he does not and is not allowed to hit patients. Then, he uses the opportunity to explore the topic of the rumored abuse of Ruth by her stepmother. Ruth responds by making a series of inconsistent and conflicting statements. Dr. Gardner calmly persists in requesting clarification in a systematic fashion.
- If you were the therapist, how would you deal with Ruth's incongruent statements?
- At this point in therapy, would you remark directly on the incongruities?
- If so, how would you do so?
About 23 minutes into the session: Ruth emphatically states that she hates Dr. Gardner and again calls him a number of names, one of which is "reject." Dr. Gardner focuses on this word, first in terms of her rejection of him in the therapeutic relationship and second in terms of critical events in Ruth's life (i.e., Ruth's mother's rejection of her).
- What effect does this have on Ruth?
- On the therapeutic relationship?
Toward the end of the session, Dr. Gardner builds on the impact of discussing the maternal rejection and then attempts to link the rejection to Ruth's lying behavior in the present.
- In the constant interplay of breadth versus depth in a session, how do you decide when to make such a link between past events and current behavior?
- What are the pros and cons of doing so?
Dr. Gardner perseveres in his therapeutic agenda throughout this difficult session, despite Ruth's repeated negativity and her overt resistance.
- As the therapist, what would you be feeling in response to Ruth's behavior?
- What might you (honestly) be tempted to say or do?
- How might Dr. Gardner's interpersonal and therapeutic perseverance enhance the probability of a successful outcome in the long run?
- Did the session progress as you anticipated?
- Was Ruth as you expected? Was Dr. Gardner?
- What are your general reactions to the session?
- What did you feel was effective in the therapy? What do you think were the strengths and the weaknesses of this approach?
- Now, after reading about the patient and viewing this session, what are your diagnostic impressions or characterizations of her problem?
- How would you proceed with Ruth's therapy?
- What goals would you set?
- How many sessions do you think it would take to achieve these goals?