Clinician’s Corner

 

Tug-o-War for Resolving Morning Conflicts (2011)

by Jami Osborne, MA, CAGS, RDT, LMHC, Rehearsals for Growth Certified Therapist

BACKGROUND AND DIAGNOSIS INFORMATION

Robbie is an 11-year-old Caucasian male, living with his single mom, Angie (age 34), and his maternal grandmother Donna (age 54). In the upstairs apartment of their two-family home, Robbie’s cousin and best friend Kyle and his mom, Angie’s sister, live with Kyle’s dad and two little sisters.

Robbie had 3 episodes of infantile fevers over 105 degrees during the first 6 months of his life, all requiring hospitalizations of over a week at a time. Robbie’s dad has a history of substance abuse, and exhibits many symptoms of bi polar disorder, with psychotic features. Dad is not currently in treatment for any of his presenting problems. Grandma Donna suffers from chronic major depression symptoms, and presents much older than her 54 years. Angie is the sole financial support for the family, as well as providing emotional support for the extended family and educational advocacy for her son.

I have been working with Robbie for almost four years. Angie reported that early on Robbie had a list of disconcerting behaviors, including: obsessive thinking (seat belt on his car seat needed to be redone multiple times because he insisted it was”buckled wrong”), tantrums, trying to escape from moving cars, pulling bedroom door off the hinges (at age 5), putting holes in walls, throwing and breaking things, and apparent total of emotion during the episodes with great remorse afterwards. Robbie was struggling with school, especially completing homework, and the transitions from home to school in the mornings (facilitated by Grandma Donna because Angie is at work by 7 am), and the immediate after-school hour until Angie got home from work at 4:30 pm. Robbie would have tantrums in the mornings, refusing to get ready for school, refusing to leave the house, calling Donna names and telling her he hated her. He would visit the school nurse, sometimes multiple times each day, complaining of feeling nauseous and wanting to go home. At one point, Angie was at risk of being fired because of all the interruptions Robbie’s calls were creating.

Initially, Robbie and I met at a local community youth commission. He loved the games, including Sorry, Trouble, Uno and Mancala which I utilized to help him practice frustration tolerance and emotional regulation. Robbie was then and continues to be a “tumbleweed in a hurricane” whenever he is agitated. He will tumble, roll, wiggle, jump, rapidly change the subject or ask to play ball in the house if the topics he opens up during the session begin to feel too intense for him to deal with. Robbie’s executive function learning disability is behind these behaviors, I think, because they occur most often when he appears to be “flooded by the words.” I have been encouraging him to use that phrase “flooded (or “drowning”) in words” to help his family understand when he is at his limits. An interesting physical characteristic of Robbie’s walk: he is nearly always on tip-toe, even when he runs during a baseball game or rides his scooters. He has a preference for being in socks, no shoes, and struggles to walk “heel-to-toe” reporting it is “painful, it hurts to make my feet do that!”

On the other hand, Angie told me (and I witnessed) Robbie could be sweet, polite, considerate, and very helpful. Robbie shows a great affinity for seeing the patterns in life – Chinese checkers is easy for him, and Mancala is a favorite game. Robbie showed excellent strategy skills whenever we played Battleship, winning nearly every time!

My initial diagnosis of Asperger’s Syndrome was confirmed two years into treatment by a full battery of intelligence and neuro-psych tests. Treatment approaches have included, and are not limited to, play therapy, (free-play, sand tray, and games already mentioned), creative arts therapy, (drawing, painting, building with blocks or legos, etc), talking (until Robbie began to tumble around the room), behavior modification (sticker charts, rewards for positive changes, etc), and EMDR. Our focus has been on emotional regulation, appropriate expression of emotions, frustration tolerance, and calming anxiety induced OCD behaviors.

THE TUG-O-WAR DAY

Shortly after we moved our therapy sessions form the youth commission offices to Robbie’s home, I arrived one afternoon to a battle zone. Robbie was angry with Donna, and she was frustrated and angry with him. The reason, they both agreed, was communication difficulties, especially regarding transition times (getting Robbie home from school with a variation in routine and route had resulted in today’s fight) that each described as a “tug-of-war” to get things done.” I took this as my invitation to try one of the Rehearsal’s for Growth action methods I had recently learned with them. Robbie was used to playing with me, so he was curious and willing. Donna, struggling with her own mental health challenges and the aftermath of the afternoon’s conflict, was less open to the idea. To her credit, she played anyway!

Round-one instructions were simple: “you are playing a game of tug-o-war and there is an invisible rope here. I will be the ref. You each pick up your end of the rope and get ready to play, making it look as real as possible. When you are ready, I will say ‘go’ and you play. Only one condition: no “taffy rope,” so if one of you pulls in the other must lean out.” They played fairly, and Robbie won this round because Donna just dropped the rope with little tug on her part first. Robbie reported he liked winning (something I knew from all the play therapy we had done in the past). Donna reported this is the way things usually were between them, she didn’t really put up a fight because then he would have a bigger tantrum to get his way. She said she “hate the way it feels to always be the one to lose.”

Round-two: “Same rules, except this time Donna must win! Robbie can put up a tug, but ultimately Donna has to be the winner.” Robbie protested, but played fairly, pulling hard, but letting Donna win. Donna wanted to drop the rope again, until I reminded her that this time she would be the winner. Then she stuck with the game. “I don’t like letting her win,” Robbie said. Donna was grinning from ear to ear! I had never seen her smile before! She told us it felt great to win, something she couldn’t remember experiencing since she was a little girl.

Round-three: same rules as round one, only this time Donna put up more of a fight and Robbie ultimately said, “this game was a draw.”

Wrap-up: I asked Robbie and Donna to play with the feelings they discovered during the play. Robbie was to remember the sadness he felt when Donna gave up because she was afraid of him. He had said this upset him because he didn’t want her to be so sad all the time. Donna was to use the phrase, “It’s my turn to win, Robbie” whenever he was refusing to listen to her and there was a real need to stay on schedule, i.e. getting to school on time or home from school for an appointment.

Two months after this session, I checked in again on how the tug-o-war was going and Robbie told me he had taught the game to Angie and his Aunt , played it with Kyle and thought it was a fun way to “make choices about who’s idea gets to happen next” during play. He had modified the game into a conflict-resolution tool! Donna said it was helpful, ” when I remember to stand my ground, which doesn’t happen consistently enough.”

Occasionally Robbie will ask for a family session with Angie. We have used a variety of action methods to foster cooperation between Robbie and his family. Overstimulation continues to be the biggest problem for Robbie. He seems to completely forget all his hard-won regulatory skills when there is too much unstructured time paired with too many external stimuli. For example, Angie reported that “school vacation week together with a carnival and a sleep-over proved to be too much for Robbie and he had a major meltdown/tantrum complete with hitting family members, throwing things and flailing on the floor. When he calmed down and went to his room he had no idea what had happened or why and the rest of the family was shaken. The look on his face was like a monster from a bad movie!” Clearly, there is more work to be done, and more Robbie has to teach us about his mental health condition.

Application of Rehearsals for Growth to the Martin Family (2012)

by Debra Dean-Ciriani, MS, LMFT, RfG-CP

As an MFT working predominantly from a Structural Family Therapy perspective, I first saw the Martin family in September of 2010. The IP was their 11 year old son, who had been diagnosed with ADHD and, they reported, was causing all the problems in the family.

The first session was with the entire family that consisted of the father, mother, and four children, ages 6 months to 13. From the beginning, it was clear that the family was in crisis, and that it was not only their 11 year old son who was contributing to the problems. The children were wild and did not take directives from their parents, which most often led into conflict between the parents over how to discipline the children.

After a couple of sessions to join with the family and create an assessment of family dynamics and problems in the parental hierarchy, I met with the parents as a couple. I first had them narrate the actual story of “How We Met,” and they delighted in recounting their very romantic courtship. This opened the door for them to talk about how their families of origin had reacted to their relationship and eventual marriage, and segued into conversation about what each had expected for their marriage and from their partner in marriage. Not surprisingly, they found they did not agree on many things, and they both realized they had not really ever talked about their expectations.

A few sessions later I asked them to participate in “Tug of War” and “Mirrors”, after which we identified, discussed and processed how they differ on issues of control and equality. Dad did not like the “power up” posture in either of the exercises, while mom said she liked making sure she won at “Tug of War”, and being the leader in “Mirrors.”

Further discussion revealed that the mother runs the household and the children, while the breadwinner father is subordinate at home. Dad enforces few consequences for the children’s negative behavior, but anytime he does try to be firm with the children, mom criticizes his decision, often in front of them. We discussed the importance of both supporting the other’s consequences given and carried out for their children’s negative behavior, disagreeing only in private.

When repeating the “Tug of War” exercise several times they became progressively more playful and engaged, with the mother letting go of control and enjoying the exercise rather than trying to win. During “Presents,” the mother’s desire to have a vacation from the children was revealed. They had not had a vacation together since they married; in session they discussed where and when they would go for a romantic getaway, holding hands and laughing a lot. Yet also at this particular session, both spouses expressed their feelings of isolation in the marriage, blaming each other for not “being there” enough.

The couple sessions with were crucial in helping them find a middle ground for their parenting and, more importantly, their spousal relationship. Enacting “Hands Through Puppets,” they realized how they had physically drawn away from each other and were able to laugh at themselves, but also grasp that with four children in the picture they had ceased being intimate. Both of them desired a return to intimacy, and just touching each other in this exercise brought them closer and able to discuss their desire to restore intimacy and fun into their marriage. They laughed a lot during the exercise, and after were able to express their feelings of loneliness and isolation in their marriage. As the wife welled up with tears, her husband took her hand, which led to them embracing.

When the children joined the sessions again I started with “Gibberish”. I find it amazing how much easier this is for the youngest children, and gets progressively harder as the ages go up. “Gibberish” broke the tension within the family, and eventually became their preferred way of starting our sessions. Mom, who could not say one gibberish word at the first attempt, eventually got the hang of it and allowed herself to be in the moment with her family. I also had the parents do “Mirrors” with the children, where again mom wanted to control. When paired with her mother the 13-year-old daughter yelled at her, saying it was her turn, and saying, “stop trying to control everything like you always do!” After some processing, Mom did stop trying to control, and their Mirrors enactments ended up being more playful than confrontational.

After achieving their treatment goals, the Martin family terminated treatment shortly before moving to another state. They wrote me months later to say they were doing well, reporting that they now laugh more, talk a lot more, and had become experts at speaking gibberish! Using a variety of RfG techniques throughout this family’s treatment had helped them define and establish healthy boundaries, restore intimacy, increase healthy verbal interaction between the spousal couple, and improve the family dynamics. With the parents now co-equal and at the top of the parental hierarchy, the family had met their goals for creating change and growth, and restoring balance and harmony in the family.

Effectiveness of using Rehearsals for Growth with a couple and their family in crisis (2013)

By Debra Dean-Ciriani, MS, LMFT, RfG-CP

The “L” couple came to me for family therapy, both to work through marital discord and to overcome significant difficulties in raising their five children, ages 7 to 16. The parents, Ethan and Charlotte, never married, had been together for 18 years and had five children together.  Jimmy, the eldest, is 16, has special needs, mute, and intellectually challenged. Second born Jennie is 15, then Ronnie who is 13, and twin girls, Iris and Jasmine, who are 7 years old. Therapy continued for about two months, but it was apparent even earlier that problems in the marital subsystem needed to be addressed to continue productive family therapy. Accordingly, family sessions were interspersed with two periods of couples therapy, each lasting about a month.

The critical issue between the couple was Ethan’s discovery one year ago of an affair Charlotte was having, though now ended. News of the affair was brought to my attention not by the parents, but by their daughter Jennie in an individual session with me. The goal for therapy at that point was to help Ethan regain trust in Charlotte and strengthen intimacy and communication between them so they could restore balance and harmony to their relationship and to the family.

Therapy with the couple started by using the RfG exercise How We Met; this was extremely helpful in informing me about their Puerto Rican cultural rituals and celebration, as well as expectations they had for their marriage at that time. For example, having children without marrying is common in their shared culture, and having children out of wedlock was not considered unusual or taboo in any way. Before their having children, I discovered they had dated, but Charlotte was seeing other men during that time, which Ethan revealed was extremely distressing for him. It took Charlotte about eight sessions to actually admit to her affair. Once the affair was in the open the door opened for them to create change and growth in their relationship.

Charlotte was guarded and reticent to speak in sessions. Using Stories from Feelings gave her a chance to release her repressed emotions and feel she was being heard and understood by Ethan. The subject of her stories revolved around stress because she was overwhelmed by working full time and mothering five children. After the exercise, a productive discussion ensued about how angry she was that Ethan works on weekends, leaving her stuck by herself with the kids. It helped them share feelings about needs and expectations in raising the kids, and brought them closer to one another emotionally.

Very evident in working with the couple was how often Charlotte blocked Ethan’s efforts to be close to her or to compliment her. Stop and Go worked well to demonstrate to the couple how they block each other, and how blocking was preventing intimacy and communication between them. This exercise created a good amount of laughter and at the end of the exercise, when Ethan tried to hug her, she did not resist.

When the couple presented as polarized and guarded, I used ice-breakers like Mirrors, Gibberish, No, You Didn’t, Poet’s Corner, or You Will, I Won’t to bring them fully into sessions, able to engage. This added fun to therapy and helped them see that humor is important in their relationship and for their family.RfG methods were used both with the parents alone and with the family. The couple was diligent in taking what they garnered in therapy and applying it to their daily lives. The children loved coming to therapy and often entered the sessions speaking gibberish or wanting to do some theatrical improv. The family has interwoven structure and rules with humor and more shared time together in playful activities. The chaotic and unruly behavior of the five children at the beginning of therapy had become by its conclusion a more balanced and productive therapy experience.

The greatest successes for the couple have been their ability to reconnect emotionally, and to discuss, process and resolve trust issues.  After being in therapy for five months they married, and are still being seen to work through the challenges of raising teenagers! RfG methods were a consistent part of weekly therapy, and helped this couple regain trust, work through power struggles in their parenting, and realize how playful interaction and physical contact can increase communication, bring security and safety back into their relationship, and create a more nurturing and loving marital and family bonds. As therapy continues, these exercises will be used and expanded upon, and will remain a valuable tool for the therapist with this family and many others.

Using RfG in Groups with Children Exhibiting “Acting Out” Behaviors (2014)

By Maureen Sand, MSMFT, RfG-CP, RfG-CT

Many of the children who attend the clinical after-school program in which I work attempt to be “in charge” through tantrums. They have difficulty following the directions of adults, often across settings. In family therapy sessions, I will often suggest an enactment that is a version of Master/Servant games that the families and I have called, “Employer/Employee.” I instruct the family that we are very good employees and we are going to do everything that we are asked to do. In response, I explain that we may earn a pretend paycheck, be given a make-believe bonus, or be “fired.” If we are “fired,” we are not out of the game. I explain that when we are fired, we leave the playspace temporarily. The “fired employee” will walk to the wall, touch it, and then return to the playspace and continue in the role of employee. I then take the role of “Boss” first, in order to demonstrate to the family members the tasks that may be given to the “employees.” I will often ask family members to pretend to type invoices, file, or take the company car to be washed.

After several instructions and as the family members begin the enactment, I then ask a family member to be the boss. I often start with an older sibling, and then the child who is the identified patient. Eventually, the parents and the children are all given a turn. If a family member does not want a part in the enactment, I ask the family member to be a “good audience” and let me know how we played our parts.

As participants progress in the enactment, there are often smiles, laughter, and good-natured protests when someone is “fired.” The children enjoy telling the adults what to do. Near the end of the enactment, I will instruct everyone that we are “bad employees.” I ask that the participants not listen to the boss. I will then give the child who is the identified patient a chance to give instructions to the “bad employees.” The family members and I will give reasons why we cannot comply to the boss’s request. Although the child may become frustrated, he is often still smiling and playful as he fires the “bad employees.” If time allows, I may allow a sibling to take the role of boss to “bad employees.” However, I do not ask the parent to direct participants who are “bad employees” as they are already very familiar others not listening to them.

At this point, I end the enactment. I ask the children members how it felt to have their instructions followed. The family members will often say that they had fun and they enjoyed others listening to them. I then ask the parents, and they will often say that they enjoy having others listen to their directions. I then ask the child who directed the “bad employees” how it felt when people didn’t listen. They usually say that they felt angry or frustrated. Many of the children will describe how they felt frustrated in their bodies. We then talk about how frustrated their parents and teachers feel at such times.

A Day in the Life of an RfG Clinician (2016)

By Maureen Sand, MSMFT, RfG-CP, RfG-CT

It’s summer and Sharon gets to the agency a half-hour before the children arrive and the groups begin. The morning includes three one-hour groups per day, after which the children have lunch and then have an hour of structured activity. The children look forward to the “fun time,” of the structured activity. However, as a clinician trained in “Rehearsals for Growth,” Sharon has a way to help the children have fun all day long!

Today, Sharon is excited because it’s the day that one of the groups that are offered is an identified “Rehearsals for Growth” group. The group averages between eight and ten children and the age range is between five and twelve. Sharon works with one other therapist and with a staff member. Although Sharon is the only therapist trained in Rehearsals for Growth, her colleague is interested in learning the therapeutic approach. Sharon thinks that, together, they make a good team.

Sharon is planning to do “Mirrors” as the main activity, but Sharon is also adept in changing her plans to “go with what is in the room.” If another therapeutic game or enactment is a better fit, she will improvise and use that enactment instead. Sharon smiles at the thought of needing to improvise when offering a “Drama Improv” approach!

As Sharon heads down the hall, she sees that William has already left the classroom and the day has just begun! At five years old, he is one of the youngest children in the program. William was referred to the program by his school counselor due to his hyperactivity and crying bouts in school. William had witnessed domestic violence and has stated that he worries about his mother. Today, William is being watched by a staff member, Carl, and William is not being cooperative. As Sharon knows that William enjoys speaking “gibberish,” she greets him in “gibberish.” William responds and Sharon and William share a “gibberish” conversation. Sharon then puts out her hand and William takes it. Sharon and William enter the classroom, as he has been distracted from his initial upset.

Sharon invites the children who want to participate in the “Rehearsals for Growth” group to form a circle with their chairs. Other group members elect to remain on the sidelines. They are the audience. The children already know that the games and enactments are voluntary. The group members understand that if they are not participating, they will earn group participation points for being good audience members. The children start with stretches. Sharon offered a stretch, which the children did, and then she invited Carl to offer a stretch. The children took turns offering stretches to their peers and the group members and staff follow their lead. At this point, Henry and Johnny, who were previously the “audience,” have joined the center group as they wanted a chance to demonstrate a stretch.

Sharon does not often start processing this early in the group but this time, she does. “How did it feel to offer a stretch and then have your friends follow your lead?” Peter said, “It felt good.” Peter had been in the program for three months and has three months to go. When he started, Peter had trouble with bullying but now he is helpful with the younger children. Julie, a ten-year-old girl, agreed. She said, “I felt like people were listening to me.” Julie’s parents are separated and she does not see her dad. Julie was a referral from the Department of Children and Families.

The other therapist, Kate, then began another warm-up, “Pass the Clap.” The children passed the clap around the circle. Kate timed the clap and they tried to improve their rate. Henry exclaimed, “Ten seconds! We did it in ten seconds!” Henry is new to the program, as he was admitted a month ago. Henry, eight years old, was referred by his Outpatient Clinician as he was not making progress and was still having problems in school. Like William, Henry tries to run out of the classroom when he is upset or bored. Henry seems to like the Rehearsals for Growth group and is usually quick to volunteer. Sharon and Carl than took on the role of changing the direction of the clap. Other children were given an opportunity to change the direction of the clap. The mood and affect in the room became lighter as the children were smiling and clapping.

Although Sharon meant to progress to the “Mirrors” enactment, William, the five-year-old who was outside the room earlier, spoke gibberish to Sharon. Responding to “what was in the room,” Sharon introduced “Poet’s Corner.” Sharon and Kate demonstrated the enactment. William raised his hand to go next and he and Kate did a round. After this, the children took turns. They seemed to enjoy both the “Poet” and the “Translator” roles. At this point, Johnny, a six-year-old, who did not want to wait his turn for a role, approached the “stage.” Sharon asked him to “hold the microphone,” which he readily did. Julie rose from her chair and Sharon asked her to “direct the spotlight” towards the actors. Sharon then asked Ramon, who didn’t have a role, to do the countdown, “1-2-3, Action!” Ramon is eleven and is usually very quiet but today he yelled out the countdown. Multiple scenes of “Poet’s Corner” were played. As the children participated in the enactment, they naturally began to accept each other’s offers. The “Poets” used their hands and their facial features to convey their story as well as the gibberish. The “Translators” were able to read the gestures and incorporate them in the story. If the “Poet” pointed in a far off direction, the “Translator” said that the “Poet” was from “far, far, away.”

Many of the children who were participating as “Poets” also wanted a chance to be the “Translator.” And this is where Sharon struggles. She knows that if everyone is given a turn to do both roles, some of the children will tire of the enactment and will become bored, leading to off-task behaviors. She had warned the children that not everyone will have a chance for both roles. However, Sharon feels guilty for ending the enactment before everyone has had both turns, as it does not feel fair, yet she recognizes the signs that the children are becoming restless. Also, with some children taking on auxiliary roles of the “microphone holder” and the “spotlight,” it was not easy for Sharon to keep the scenes organized and some participants became a bit unruly. Sharon made a note on her clipboard to bring these concerns up in her next supervision.

At this point, Sharon asks the audience for “shout outs.” William was praised for his ability to speak gibberish. Henry was praised for his acting ability. The actors were asked to process how they felt during the enactment. Johnny reported that he felt successful. They were asked about other times in their lives that they felt successful. Johnny said, “When I got a hit in baseball!” The children were asked how they felt their translator did with their story. “I thought my translator did great,” Julie said. “It was teamwork!” The children were asked if there were times that they were “understood” or if they had times that they were “misunderstood.” Julie helped to explain the concept of “being misunderstood” to the younger children.

As the group wraps up, the children were encouraged to take off their “acting clothes.” They pretended to place their costumes in the middle of the circle. Henry pretended to light a fire to burn their costumes and Johnny pretended to help him. Kate asked the children to identify a “take away” and Sharon went first to demonstrate as several group members were new. “I take away creativity,” Sharon said. Other “take-aways” included: “having fun, being creative, speaking gibberish,” and “being a poet.” Carl passed out small prizes (decorated pencils) as a reward before they transitioned to their next group session. Sharon then took a deep breath and relaxed as Kate started an anger management group.

After the three group sessions were completed and the children ate lunch, Sharon held an individual session with Henry. Henry was using the sand tray as a soothing activity but did not want to talk. Sharon and Henry “co-created” a story by using the “Fortunately/Unfortunately” enactment. Sharon prompted each sentence by saying “Fortunately” and then “Unfortunately.” Henry became more animated as he furthered the story and seemed proud of his efforts. This enactment led to his being able to talk about what was bothering him and how he could deal with such situations in the future.

A couple of hours later, Sharon also walked towards the exit, having completed her documentation of the sessions. Sharon had also made some notes from the “Rehearsals for Growth” group to ask her supervisor. Although her supervisor is not trained in Rehearsals for Growth, she has many years of experience in running groups with children and Sharon appreciates her feedback. This therapeutic drama approach has become more accepted over the years that Sharon has been with the agency. She smiled to herself, remembering the playfulness of the family members during their session. “It was a good day,” Sharon thought, as she walked out the door, and into the warm, summer afternoon.