INTEGRATION OF INDIVIDUAL AND GROUP THERAPY INTHE TREATMENT OF A PROBLEM BOY

CHARLES MILLER, Case Worker, AND S. R. SLAVSON, Director of Group Therapy'Jewish Board of Guardians

New York City

T H I S paper describes the nature and results of an experiment in which caseand group work techniques were integrated in a treatment plan of a ten year

old boy. It attempts to show how group experience can complement case worktreatment, and how both can be dynamically inter-related in the treatment ofbehavior problems.

Marvin, age 10, was referred to the clinic by a summer play school, where itwas noted that he day dreamed a great deal, was "very absent minded," and didnot play with other children. At home the boy was unmanageable, demanding,and constantly behaved in a way calculated to exasperate his mother. There weretantrums of an extreme nature and constant quarrels with a sister two yearsyounger, but physically larger than Marvin. He had no friends and spent almostall of his time at home. At school he did average work, but was unpopular withthe other children because of his tendency to annoy and quarrel with them. Thecase worker found Marvin to be very insecure, with marked feelings of inferiorityand unable to relate himself wholesomely either to children or to adults.

The home situation was a destructive one for Marvin. There was a long historyof domestic friction. When he was referred for treatment, the parents had beenseparated for some time and the father came to see the children infrequently.The mother, a tense, neurotic woman, identified the boy with the father anddefinitely favored the other child. There were indications that Marvin was anunwanted child and had been rejected from the time of birth. The mother'sguilt accompanying this rejection had prompted her to greatly overprotect himduring his earlier years. He had never played with boys of his own age, and wasquite a "sissy." As a result of the many deprivations, his ego structure was verypoorly developed.

Through the case work experience, Marvin was able to achieve some measureof security. After a short period of uncertainty, during which he was fearful andstrained, he threw himself into the relationship with warmth and affection. Heexhibited an intense need for the worker, whom he substituted for his father.Beginning with the infantile patterns which characterized his personality, hewas demanding, jealous, and lapsed into fits of anger when frustrated. He wouldmake a scene when he had to go home. He didn't see why the worker ought togive other boys time too. If he lost a checker game he would angrily accuse theworker of cheating and sometimes leave the office. When Marvin did not go intoa tantrum, refusal to meet his demands for gifts, movies, or more time, resultedin a babylike whining, crying and pleading.

As Marvin became aware of the worker's acceptance and slowly became moresecure, his need for extreme forms of behavior decreased. The strong attach-

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INDIVIDUAL AND GROUP THERAPY: MILLER AND SLAVSON 793

ment to the worker was used to have him give up his infantile patterns, and treat­ment became a process in which Marvin found it possible to accept increasinglimitations ~nd having fewer demands met. There was a gradual diminution ofhis demands, he would leave the office without complaining, and tantrums wereentirely absent.

At the same time that Marvin was being treated, his mother was seen by aworker from a family agency, which also handled the general family situation.Financial help and other case work services were rendered. As the mother wasable to achieve some insight into her own needs and became aware of her in­fluence upon Marvin's behavior, her criticism and nagging lessened and she wasable to give the boy a greater measure of attention and affection. Thus, the im­provement in mother and boy operated dynamically to lessen the destructiveattitudes toward each other.

Throughout the period of case work treatment, however, Marvin continuedto be unable to make friends or to enter into any kind of group situation. Aftereight months of treatment, he made a poor adjustment at camp. His lack ofgroup experience, his inferiorities, both real and imagined, and his insecurity inany relationship in which he was not completely accepted, made any group orcompetitive situation intolerable. An experimental tour of a settlement houseprecipitated marked regression. He became depressed, and appeared physicallyill, turned pale, seemed unable to walk, and had to sit down to rest. AlthoughMarvin had been able to give up his more extreme symptoms because of thesecurity he felt with the worker, he was as yet unable to test out this new securityin any kind of social situation.

While it was felt that case work treatment over an extended period wouldbenefit the boy, the availability of a therapy group prompted the decision torefer him there. Such a group provided a social situation in which there was aminimum of control and flexibility. It was thought that Marvin might be ableto utilize and develop the security he had achieved with the case worker, andthat the group was so organized as to make it possible for him to test out hisinsecurities without too great fear of rejection.

After ten months of treatment, Marvin began to express his unhappinessabout lack of friends and the subject of the group was then brought up. At firsthe refused to entertain the idea, but after a period of indecision and fear, heagreed to make the effort to please the worker.

The Department of Group Therapy was added to the clinical facilities of theJewish Board of Guardians to meet a need long felt by case workers. It is basedupon four fundamental principles, and organized to meet four correspondingneeds in children. These are:

r) The need for acceptance (love); 2) the need for ego satisfaction; 3) theneed for creative activity; 4) the need for social re-education. The meetingsconsist of work with various materials through which the creative interests ofthe individual child can be satisfied. He is entirely free to do whatever he likes.If he does not desire to work, he can be idle, observe others at work, play, or he

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may be destructive. As a result, many small groups spring up where boys andgirls work together on a common project; help one another out with jobs; in­struct each other; or converse about school, teachers, movies and other subjectsof common interest. Gradually, though this takes a long time, the members learnthat they must clean up the mess they have created in the room, set the tablefor refreshments, cook and serve the food-for every session ends with a lightrepast-and wash and put away the dishes. For a time the group worker doesthis, until the members of the group realize they can be helpful. Frequenttrips to places of interest, picnics and outings form a part of the activities oftherapy groups. After an evaluation of this work over a five year period, it wasfound that these simple, informal relationships, resembling those of a good fam­ily, make for changes in the children's attitudes toward the group and latertoward the world generally.

The groups serve those children who are difficult to reach in the interviewsituation and who, primarily, require an attenuated socializing experience. Italso provides this experience for children who cannot be absorbed into ordinarygroups because of their personality difficulties, those ranging from extreme with­drawal to overaggressiveness. Groups are limited to eight members and areorganized on the basis of treatment needs, personality, age and place of residence.Referral is made from the intake desk or by the agency's case workers. In addi­tion to the detailed summary which is sent at time of referral, conferences areheld by the case worker with the director of the department. The child may beinvited directly through the group, or may be taken by the case worker. Thetrained group therapist, who supervises each group, is aware of each child'shistory and difficulties. Control and direction in the group are motivated entirelyby case work considerations. Both group and individual records are kept, thelatter being sent to the case worker and filed in the case record. The group thera­pist and the director of the department hold regular conferences with the caseworkers and supervisors for the purpose of evaluation and further planning.When necessary, a staff psychiatrist is called in to these conferences. Conferencesmay be called either by the case worker or the director of group therapy,depending upon the situation.

In the case under discussion, it was decided to hold regular and frequent con­ferences at which were present the case worker, the group therapist, and thedirector of group therapy. Developments in both the case and group situationswere followed closely and discussed in detail; the case and group work thinkingwas integrated and used as the basis for further planning. A detailed summaryof each integration conference was filed in both records.

Marvin's group was composed of seven boys of approximately the same age.At first Marvin was very withdrawn, particularly in the presence of a large num­ber of boys. He looked sad and forlorn and did not participate in conversationsor activities. He was fearful of the group, and was less tense only when fewerboys were present. As he slowly learned that no pressure was to be put upon himand there was no threat of competitive activity, his withdrawal after a few weeks

INDIVIDUAL AND GROUP THERAPY: MILLER AND SLAVSON 795

turned into very aggressive and over-boisterous behavior. His favorite occupa­tion was to stride over a boy and pretend to be riding him. He screamed andshouted, ran wildly around the building, chasing other children, or activatingthem to chase him.

Marvin attempted to monopolize the group worker as he did the case worker.When trips were taken, he would stay near the worker and try to keep the otherboys away. At the indoor meetings, he would constantly draw attention to him­self and block, often through violence, other boys from getting close to the worker.Careful but firm attempts were made to prevent too close an attachment, bothbecause of the boy's own need for independence and because of the negative ef­fect upon the other members of the group.

As Marvin slowly became more secure and found that his tentative aggressionswere being accepted, he became the most aggressive individual in the entiregroup. If all the others decided on one place to go he would insist upon another.Group pressure, however, frequently compelled him to compromise or to giveway to the wishes of the majority. An important factor in this progressive de­velopment was a rather strong attachment which Marvin formed with anotherboy, who was usually able to overcome his stubbornness by putting an armaround his shoulder and pleading with him on the basis of friendship and groupspirit. Marvin would melt under such demonstrations.

The following is abstracted from the record of the integration conference heldtwo months after Marvin joined the group:

Group worker reports that Marvin tried to monopolize him. Resents attention toother boys. Always opposes group decisions, accepting them finally with poor grace.Always tries to gain attention of boys and worker by unusual behavior. He is a poor sport.However, he is friendly with one boy, and shows good sportsmanship in relations with him.Still very insecure. Unable to join in any activity. Sometimes aggressively challenges boysto fight, but retreats when challenge is accepted. On the whole, he is a disruptive element.At first very withdrawn, he is now a boisterous obstructionist and other boys dislike him.

Case worker feels Marvin is repeating pattern seen in case work situation. Makesefforts only on basis of security with father person. Group worker will have to meet boy'sneed as far as possible for time being. Competitive situations to be avoided. M. is en­thusiastic about group worker, feels disloyal, becomes guilty, and protests greater affectionfor case worker. Note that Marvin can establish relationship with another adult and withone boy. Director points out that Marvin's extreme behavior is result of complete free­dom in group. It is a testing period. He cannot believe that anything but infantile be­havior will get him attention he needs. Only on basis of actual experience will he learnotherwise.

To a considerable extent Marvin was able to compensate for his feelings of in­feriority and rejection by taking a leading part in the preparation and serving ofrefreshments at each meeting. He would cook, set the table and serve the food,ordering the others around as they helped him. The time came when he was ableto go out with another boy and buy food, something which he had been afraid todo before.

A pivotal treatment situation in the group was a party which Marvin arrangedfor his sister, who represented an important aspect of the boy's difficulties. Al-

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though younger than Marvin, she was physically larger, tyrannized over himand took advantage of her superior position in the home. When her birthdaycame, he decided to give her a party at his club. The party was given with a greatdeal of ceremony and preparation, and for once Marvin was complete master ofthe situation. Although his sister attempted to make fun of him and correct hisbehavior, he paid little attention to her and derived a tremendous amount ofsatisfaction from being in the superior position.

In the early period of his membership in the group, Marvin was unable to losea game or accept any defeat without becoming terribly upset and uncontrollablyhostile. He would not only scream that he had been cheated, but actually attackhis opponent physically. As time went on, however, he noticed that other boysaccepted defeat without much ado, that nobody seemed to feel it was a loss ofprestige and, he too, began to accept defeat with more equanimity.

After Marvin had been in treatment for 21 months, the latter 9 months ofwhich he had been a member of the group, changes began to be evident in theboy's personality. He was no longer apprehensive, did not have alternate periodsof hostility and fright, was able to play with other boys, had made friends anddid not have an outstanding need to make bids for special attention. He no longerattached himself exclusively to the group worker and was able to go home aloneor with other members of the group. The mother reported his considerable im­provement at home, with complete disappearance of the more extreme formsof behavior. At school it was learned that Marvin was a likeable, helpful young­ster with lots of class spirit and with no indications of withdrawal or unpopular­ity. Perhaps the most interesting indication of growth was the camp report madeby a trained case worker. This report stated that, while Marvin continued tohave a need for special attention and was called a "sissy" by some boys, hefinally won the respect of the group by his efforts, made friends, was accepted asan integral part of his bungalow group, entered into activities and generally en­joyed his vacation. It was also found that the boy's bids for special attention,which were consistently rejected, did not result in any kind of negative behavior.When he returned from camp in the Fall of 1938, he registered by himself at aneighborhood house and began to question the necessity for his continuance withthe case worker and in the group. He was much freer in asserting himself; wasable to greet and speak with people spontaneously, and even went out of his wayto meet some people whom he wanted to know. All these changes were evident inthe case work relationship, where they were recognized and fostered.

After Marvin had gone to camp, and had been in the therapy group for oneyear, the integration conference brought out the following material:

Group worker reports that Marvin is now able to participate in various creative ac­tivities. He was thrilled when he finished a key case, the first thing he had ever made.He is much better integrated into the group. He enters competitive situations with fairsuccess. Although never on a bicycle, he insisted on learning when this was the day'sactivity. The other boys rode well. Marvin was very happy and boastful about hisprogress. Worker never saw boy so genuinely happy. Marvin accepts group decisions,

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and has given up his more extreme behavior. He seems more secure, and has less need togain attention in an infantile way. He is quite friendly with some of the boys.

Case worker suggests that Marvin be encouraged to try as many activities as possible.Boy is completely inexperienced in masculine activities. It was decided to have athleticactivities when it becomes warmer.

Case worker says Marvin is beginning to question necessity for regular interviews, butbecomes very guilty. Although beginning to assert himself, he still fears his drive to beoutgoing and aggressive. He is beginning to separate from worker. He is much more ableto accept frustrations and limitations. He joined settlement house on own initiative.General improvement in school and home is noted by the case worker.

Throughout the time that Marvin attended the group, he was seen regularlyby the case worker. He was given the opportunity to express his doubts, fearsand insecurity regarding the group, and on the basis of the encouragement andsupport which he received, was able to continue to make further effort. Many ofthe patterns he developed in the group situation were carried over into the casework relationship and were accepted and handled there. Each successful effortwas met with praise and encouragement, and failures with non-critical accept­ance.

When Marvin was going through a period of extreme aggressiveness in thegroup, his manner in the interview was that of a "tough guy." For the first timehe used profane language, tried to bully the worker with threats and attemptedto impress with a hard-boiled exterior. He would furtively watch how this wasbeing received and learned that he could test his attempts at aggressivenessagainst the worker as well, without fear of rejection.

After much indecision, Marvin finally was able to make a key case in thegroup. Characteristically, he belittled his effort and expressed dissatisfactionwith it. He felt he could never make anything worthwhile. The case workerpraised the key case, said he wished he had one like it and Marvin surprised theworker by making one for him. In the boy's presence it was shown to severalpeople, all of whom expressed admiration. Marvin was quite overcome; he feltthat perhaps he did have some ability and, in a few weeks, had made a numberof other objects. Now it was not necessary for him to feel inferior to the otherboys in this respect, and he gained the feeling of adequacy and achievement onthe basis of actual experience. In this and other ways were his efforts crystallizedand furthered in the case work situation.

Marvin was able to achieve initial growth in the case work situation and todevelop enough strength to make further effort, as evidenced by his ability tojoin a group. The group provided a non-threatening, accepting environment inwhich the boy could test out his new-found strength and his repressed drive foraggressiveness and independence. Contrasted with the home situation where theboy was rejected, inferior, threatened, and wanting to be a baby and a girl, thegroup situation provided a masculine environment in which growing up did notrepresent rejection and loss of love. At the same time, the case work relationshipprovided the necessary stabilizing and supporting influence which the boy usedas a basis for growth.