Therapeutic Storytelling Intervention Group Therapy

Ron Phillips

OVERVIEW: Therapeutic Storytelling Intervention (TSI) is a strategy that guides adolescents on their quest for achieving identity. The book Gem of the First Water is the journey of an unnamed Boy on his journey of self discovery. The Boy enacts the issues and struggles of life and for the listeners/readers his responses to each dilemma serve as the platform for meaningful group discussion and even more importantly personal mindful consideration.

BACKGROUND

Many past innovations result from great need. I stumbled into creating the TSI process because the traditional group therapeutic approach did not work for me.

                                    Is it working? No? Then change what you are doing.

                                                                                                            -William Glasser MD

My wife Mary and I founded Creative Alternatives Inc in 1976 as a residential treatment facility for emotionally disturbed children located in northern California. Creative Alternatives served as a wonderful laboratory for developing a new adaptation to a very old form of childhood education. Storytelling is age old and until the advent of television and the Hi Tech games revolution, was the model for transmitting the stories, values and traditions of one generation to the next. From Creative Alternatives inception in 1976 it grew rapidly, and by 1980 we had 65 children from all over California. We wanted our delivery of care to be integrated, so in the late 70’s I went to the University of San Francisco (USF) to become a qualified therapist. My USF education was first class and I achieved my Masters of Family Therapy (MFT). However it did not equip me with the tools necessary for running group therapy sessions with multi-problem kids who are historically and universally resistant to therapeutic interventions. The USF training in the facilitation of groups was based on Dr. Irvin D Yalom’s model of group therapy (adult model), which emphasizes peer developed rules, group boundaries and structure.

I hypothesized and considered that the best model of intervention for my population was a group format. This thinking was based on empirical fact that peers greatly influence each other by what they say or don’t say, by the way they look, and by what they do. The idea was right; however my model to achieve an effective culture of therapy was wrong. Dr. Irvin Yalom’s protocols for running effective groups work well with adults and motivated adolescents; however, I immediately learned they did not work with multi-problem adolescents. The success of the group using his model is dependant on each individual’s level of self disclosure and agreement by the group members on the rules of engagement and group rules of confidentiality.   Forget it! From the very moment I began every kid in all 6 of the initial groups started formulating an exit procedure out of the group and in all 6 groups’ chaos was their response. Why didn’t Yalom’s proven method work? Adolescents are a totally different developmental group.   Adolescents strive to be similar. Check out

groups of kids walking together at any mall. In all groupings of meandering kids they are dressed similarly; the last thing an adolescent will do is strive to be different.

So the instant I started setting up rules for the group based on them sharing their deep ‘stuff’- they started dropping out. This explains the poverty of literature on successful groups run with multi-problem teens; there isn’t data (that I’m aware of) because there aren’t any successful groups of any consistency or duration run. Teens vote with their feet. Before me was an enactment of my hypothesis – the mighty power of peer influence. Adolescents do indeed influence each other. They told me with their collective actions that they were not about to agree to the group rules and would fight tooth and nail to knock over the group therapy. The reason for this is also very clear – they were afraid of being revealed, they fear humiliation.

I learned from William Glasser that if what you are doing isn’t working – then change. I applied this to the obvious failure of my initial start at running group therapy. What adolescent would risk putting themselves into a position of exposure? It didn’t work nor will the adult model ever work with adolescents. The developmental issues of adolescence made the idea of self-revealing so developmentally wrong. I still believed that group therapy for teens was so right, but how to get it to work? I applied the great lesson I learned while practicing Reality Therapy and changed my therapeutic approach.

My early groups based on an adult proven approach didn’t work and each of my six weekly groups were more like a “shark frenzy” than therapy and I was the bait; there was no effective life change occurring. In fact the most frequent words were, “Fuck you!” I reluctantly persevered and after two or three groups of sheer stress in order to fill time I shifted from a topic of pure boredom to telling a story. I stumbled into storytelling and from that week it’s been my life’s work.

I started telling a story and the very moment I started painting mind pictures, the kids’ listened. Not only did they hear what I was saying, they were interested and asked questions and responded to questions without the ever present opposition and defiance. They immediately began participating in the new form of group therapy session with enjoyment and without attitude. Early into the onset of TSI it became apparent I was actually talking to these kids on the other side of their attitude. The front door approach didn’t work, so, metaphorically speaking, I took TSI ‘through the bathroom window’ and I’ve been going ‘in and out the bathroom window’ running groups using exactly the same story and approach since 1985. What started out originally as a survival method, is now a refined sophisticated psychological intervention that invades the imagination of listeners and works freely in the listeners’ unconscious mind.

From the beginning I wanted each story to have some therapeutic meaning or life lesson, so that we could have a bit of a discussion, thus meeting a group therapy definition. To my great surprise not only did they listen but were able to relate to the presented issues and the story led to meaningful post-story discussion. It was even of greater surprise to discover that the next week they would retain last week’s content and demanded continuity by wanting to know how the unnamed ‘Boy’ got from where he was last week to the present place. The listeners wanted connection, they insisted on the stories becoming a journey. Suddenly the penny dropped.   My interns, Dan Brewer MFT., and John Hopper MFT and I realized that our kids were some of California’s most therapizedkids and they were listening to learn. We quickly realized that this approach was effective because as we learned later, they were listening from an absolutely undefended and totally receptive altered state of consciousness. Once insight occurred I started saturating the story with universal lessons of life.

PROCEDURE

Most new group members come to the group apprehensive, resistant and thinking “how will I get out of this mess I’m about to get into?” The new group members are exactly like the original kids I worked with back in the mid-eighties. They attend the first group with fear and their pervading thought is that they don’t want to be there. Therefore my entire first group approach is unique and designed to establish effective engagement. As I’ve mentioned my approach is unique to most group therapies. Typically I can sit down with a diverse and unknown circle of adolescents/latency youth and within 10 minutes have the Gem Journey started with everyone knowing pretty much everything they need to know.

GETTING STARTED: GROUND RULES

Step 1

I learn everyone’s name. It’s actually very simple to learn 8 to 10 names.

Step 2

Promise: I tell them, “I am going to give each of you something worth more than Gold. Yep! I said it, more than gold.” I then ask randomly of a group participant, “Hey Jim do you believe me?” The common answer with arms folded protectively across chest is “hell no”. To which I respond: “I don’t blame you, I wouldn’t believe me either – however you won’t forget I said this on the first day. Yep, more than Gold!”

Step 3

The rules: 1. My rules are: make yourself comfortable. “I’m going to take you on a journey and you are going to dig it! Close your eyes if you want- sit on the floor if you want.
However….I do ask that you stay in your own circle. By that I mean………When Jim’s talking I wouldn’t dream of talking and when I’m..……………” I often then tail off without finishing sentence. The leaving off technique is interesting because you can empirically watch the kids putting words to finish off the unspoken sentence.

Step 4

The Paradox: The all important paradox message is, don’t bullshit yourself or the process. If I ask you a question that you don’t think is anyone’s business, especially mine or you can’t think of an answer – then I insist that you say ‘pass’. I then add; ever been in class and a teacher asks you a question and your mind goes blank—duh what’s up Doc? What should you do? “PASS.” “The one thing I do ask if you do give an answer, it’s gotta be what you really think and feel. If you bullshit me or yourself you’ll miss the….” I often only half complete a sentence relying on unconscious process to complete and consolidate the theme.

Then without any more talk, I fire into the process and start telling the first chapter. Students visibly relax when I begin. I believe everyone enjoys a story, and I can without reservation make that statement after telling the exact same story since 1985. After the ever so brief introduction the students realize that they won’t be embarrassed from the anxiety and fear of being revealed and that it’s alleviated by simply being able to just say “pass”. Interestingly many kids later relate that they initially decided to pass on every question for the duration of the whole group. Once these brief non-intimidating rules, promises and paradoxes are introduced most kids relax to the point that some even close their eyes and get in a comfortable position and listen, all this is observable by their clear body language. I then proceed to paint wonderful mind pictures in the telling of Gem of the First Water.
I also make the declaration, “I will never embarrass you, so come to group and relax; that’s a promise.” It is my belief that the simple combination of beginning instructions, paves the way for group success by being so non-threatening it gives the story telling process an opportunity to succeed. I also re-enforce this premise by doing a round at the end of the first session asking each kid if the group was as bad as they thought it was going to be. I then go on to add it will never get any heavier than today. I don’t want to ‘psychologize you’ ‘alphabetize you’ or ‘mesmerize you’…I just want to tell you a story. Generally the kids respond by stating it wasn’t nearly as bad as they thought it would be and bingo the group is off the ground.

THE JOURNEY BEGINS: GENERAL SESSION

After the brief introduction the initial group is run essentially the same as general sessions. All groups are predictable in format. It’s the predictability and structure that create a safe, non-threatening environment that adolescents soon learn to enjoy and not fear. Keeping this safe environment is paramount to group success. For example, if you have a group room that is subject to disturbances, your group is likely to fail. Keeping interruptions to a minimum is essential. All cell phones turned off, the land line taken off the hook and even a do not disturb sign on the door are all key group issues. The facilitator must model the requests by turning off his/her phone and not attending to distractions, with the message that what we are now about to do or are doing is something more important than anything else.

Step 1

Warm up: I generally run groups on a weekly basis, having found it is important to have time to allow the themes to breathe. This allows time for the issues to get thoroughly worked over in mindful unconscious process. Running groups with no time between them is less impacting than groups with a good ‘time’ gap.
To start off a group session I do rounds asking everyone “what has been the best thing in your life over the last week?”
I then start with a recap of the last story with questions. Kids like to answer non threatening questions that are simple. For example in chapter two, the Boy has a tattoo of a multi-piece puzzle on the palm of his left hand. In groups down the line, I will ask an individual or the group as a whole; “Say, what was on the Boy’s hand?” That would be a generalized question the entire group is free to respond to. Or I might ask Jimmy “what’s one word to describe the boy”, or “what’s one word to describe how you are a little bit like the boy?” If I notice Jimmy faltering, I rescue, “if you can’t think of anything just pass, no big thing.” After bringing the group up to speed to where we left off, I then launch into the next segment.

Step 2

Story: I tell the story in the next chapter or chapters. Note, some story sessions involve more than one chapter. For example in the eighth session, I tell three chapters: 8, 9, 10. In the ninth session I tell 11, 12 and 13. The talking book (set of 5 CD’s of author telling the story) follows the session sequence.

Step 3

Facilitated Discussions: The discussion component of the TSI group is very important. Not only do students/clients listen from an unconscious undefended position, they are also listening to learn. The accompanying Guide has numerous already proven questions that if skillfully presented results in interesting discussions. The quality of these are often so healing in nature I shake my head in wonder. I do not coax or insist or push post group discussion. If, after I’ve put everything I wish the students to mindfully consider ‘on the table’ and for whatever reason no flow of conversation comes about, I end the session with a session close down procedure.
Since every one of the participants is new to the process I maintain a very non-threatening interactive position. For the first several groups I emphasize and reinforce the pass rule. Early in the group journey process, my first questions are easy to answer and mostly require only a single word reply. “Ok, Jimmy give me one word to describe when those old people in Foulicia’s dungeon first got stuck?” If Jimmy doesn’t pass and yet seems keen to respond, only hesitant, I might reduce the stress by next asking, “Did they first get stuck when they were young or old?” Most often participants will comply with a nod or a yeah. Each chapter is purpose built with key themes and guided questions created to simulate thinking and discussion. There is a story guide which highlights themes, important lesson points, and questions I use to stimulate discussion.

Step 4

Session close down: Most stories’ finish leaving the listeners’ wondering what’s going to happen next, which is exactly the impression I want the kids to leave with. Once I assess that the pertinent material has been covered and have adequately asked all the key questions, I then close by doing a round asking each student/client “what are you going to take home with you?” If a student says “I don’t know” or “Nothing?” I give them a post group suggestion, a question for them to think about; a theme I wish to embed that is relevant to the story of the day. For example, if the session’s story centers on the listeners’ becoming aware of what they think about, I construct a post group suggestive thought. I might ask Jill (if she stated she wasn’t sure exactly what she was taking home) “Hey Jill why don’t you consider tonight right before you go off to sleep – you know that very quiet time just before you nod off – think about what you say to your self the instant you are asked by one of your parents to do something you don’t want to do. Think about what happens next? Is it a battle? Are you in the habit of thinking I don’t feel like it to almost everything you are asked to do? Is it an easy thinking habit to get into? What if instead of, I don’t feel like it, you can’t make me, Jill, why don’t you say to yourself, Oh ok.”
I do try to ask at next start-up if Jill did explore the question. I am always amazed at how often a post group question is considered and reported about at the next session. The scope of post group suggestions is enormous and the beauty of the method is that these suggestions can be tailored to suit the kid. Although the post-group question was directed to Jill her question had a contemplative impact on all the other members. It is also interesting how often a post-group question for one child will be mindfully considered by others. Now after years of running groups, I tailor a question for a specific student and expect it to be considered by others if the question strikes a personal chord. The post-group question I liken to going into a shoe store, some of the questions fit perfectly while others aren’t even considered because they already resolved their position on the issue or developmentally are not ready to even consider.

CHAPTER CONTENT EXAMPLES

There are twenty six purpose built chapters in Gem of the First Water. All the chapters have importance however some are important for Journey connective/segway reasons with minor therapeutic lessons, while others introduce profound life lessons with object lessons in the form of learning models. In this brief overview I’ve chosen two chapters to highlight. Chapter 16 entitled Worms Wolves and Chapter 20 entitled, Outskirts of Splendora. The chapters leading up to Worms Wolves are instructional chapters full of life principles. The Pool of Right Decisions (Chapter 14) theme is establishing the concept that good choices/decisions result in positive self image and good feelings. Chapter 15 Desert of Simple Choice exposes the internal struggle between what a person should do coming into conflict with what they feel like doing. The Boy is confronted with three dilemmas (moral, pride/ego, altruistic). In each case he makes good choices.
My University of San Francisco degree had a family therapy emphasis which influenced aspects of the Gem Journey. In the first year I was developing the TSI group journey process it became obvious about midway through the journey, that students were developing expectations of each chapter’s dilemma. Scripts, and a state of habituation was forming and settling in amongst the participants resulting in listeners losing their intensity for the journey.
The Gem Journey development in the first year was dynamic and evolving with every new episode so when a kid made the unsolicited statement in the post Desert of Simple Choice (Chapter 15) discussion; “that the Boy is just a ‘do good candy ass,’ he just always does what everyone wants him to do, you can tell me the story and I’ll tell you what he does.” I agreed, and woke up to what was happening and created the next story with a major unexpected event in fact so unexpected the boy who highlighted the script was totally surprised. From a systemic stand point I was scripted and the next story Worm’s Wolves totally caught the listeners ‘off guard.’ The script of expectation breaks, resulting in renewed listening/learning intensity.

“The Boy wakes up on the wrong side of the campfire. He’s tired of listening, he’s tired of all the effort he has been putting forth, he’s sick of the uphill hassle. He is in a terrible mood; the way he feels, the content of his thoughts and certainly his actions are all negative – he is full of attitude, easily pissed off – everything is annoying.”

This chapter paints a mental picture of the flow chart of a bad choice. His “Me Day” intensifies and he arrives at the first cactus where he makes a choice based on what he feels like doing rather than what he innately knows he should do. The Boy goes down hill full of the dangerous endogenous I don’t care attitude. The Fox warns him numerous times that this isn’t the right way, however his mind conversation is full of ‘I don’t care thoughts’ which over-ride rational thinking and he simply doesn’t listen and continues on his wrong path. The fox finally realizes the Boy is not going to turn around and accepts it. Several times he reminds the Boy that this was supposed to be the easiest part of the journey. Wolves surround and drive the Boy and the fox up a cactus. This chapter ends with the Boy experiencing the consequences of a seriously bad choice. Worms Wolves is a wonderful metaphor of the “how, when, why’s, of a bad decision. The result of his ‘Me Day’ not only affects him it also greatly affects the fox. The flow of this chapter mirrors life and serves as a wonderful teaching model. The journey is full of equally powerful mind pictures that provide easy unopposed learning scenes that flow into natural post story discussion within the context of the group and probably more importantly carries on in individual mindfulness throughout the week.

Below is a flow chart of the bad choice (Figure 26.1). The moment the Boy awoke he had an attitude. His negative thinking produced negative feelings that resulted in anger, lies, and blame dominating his actions and decisions. Chapter 16 was purpose built to model the steps leading to loss of direction and trouble. The Boy had a habit of making decisions based on doing what he felt like doing. His choice offers participants a clear unambiguous mind picture that is integrated into new thinking and behaviors.

The second example I’ve selected to demonstrate the depth and scope of journey content is chapter 20 The Outskirts of Splendora. Again I would ask the reader to refer to the website: www.tsi.co.nz where all four components of chapter 20 will be available for review. The order I would like you to follow is first to read the chapter. Then watch the commentary of the themes, lessons and key questions that I ask the students. Which ones achieve best practice use of the chapter? Next watch the Christchurch video that highlights one segment of the chapter. Finally, read the guide and mindfully workout your answer to the questions and teaching. Each chapter has a self contained lesson and some chapters like Chapter 20, have numerous talking points.

A wonderful aspect to the journey theme is that chapters or segment of chapters can be used to fit appropriate therapeutic situations. Therapists are from time to time thrust into situations that require some form of brilliance to help achieve meaning to the occasion. One example might be: yearly it seems I’m faced with a situation where the clients/students have experienced a recent trauma and I might use the “Canyon of Sadness” vignette from chapter 20.

In March of 2010 Christchurch New Zealand experienced the most devastating urban earthquake which literally flattened the Central business section of the city. People were killed and there were many serious injuries. Entire residential suburbs were evacuated and condemned, displacing thousands of families. Almost all the historic building was damaged beyond repair. The people of Christchurch and Canterbury region were traumatized. The Young New Zealanders foundation and TSI created a helpful kit sent to all the schools in the region. The video will give the readers an idea of how excerpts from the Gem Journey can be used.

RATIONALE

Once kids engage they really get into the journey and look forward to the process without resistance.
Each chapter is purpose built to convey essential life lessons. Embedded in the easy to visualize stories are; teaching themes, life principles’, and models of behavioral instruction all conveyed in the context of the journey. A big reason that students become engaged is because each chapter leaves the participant with a degree of suspense.
As a child I loved the cartoon Crusader Rabbit and Rags the Tiger. The cartoon always left me wondering what was going to happen next. Each segment finished with either one or both the heroes in dire straits. Rags hanging on a limb over a cliff he couldn’t possibly survive should he fall. Silly, silly stuff, however the picture lodged in my mind all week, compelling me to see the next episode.
Now for a story for you; When I was about 10 we lived in a tiny little sleepy village south of San Francisco called Sharps Park now part of Pacifica. It was Saturday morning early and my mates and I were on the beach heading north. I had my dad’s work watch on to let me know when I had to start heading home to see the cartoon. All week long I looked forward to finding out how the dilemma was resolved. Well here we were walking just beyond the water mark and we spotted several hundred yards up the beach a giant something that shouldn’t be there, a gigantic whale. Naturally we were all over it, for the whale represented the ultimate in discovery for the captains of play. I was in a personal quandary knowing my distance home and the morning marching rapidly on. Finally my desire to see the cartoon overpowered me and I leaped off the whale and headed home. My mates thought I was brain dead leaving the treasure.
The Gem Journey acts on the unconscious in exactly the same way. It captures the imagination, causing the participants to mindfully consider the embedded issues of the moment and also considering them all week long. Most leave group wondering what will happen next?

Unconscious State of Listening: The magic of storytelling is that individuals actually go into an altered state of consciousness – a subdued state where they listen to the story with singular focus. It is thought that a listener can be thinking many times faster than another person talking. Experience and client feedback leads me to believe this to be factual. Over the years and from numerous participants I have received feedback that while the story is being told, a very interesting event happens to them deep in their minds. A transformation of thinking transpires unconsciously. The listener sees ‘the boy’ and his dilemma as common to their dilemmas. Without bringing attention to it or having to highlight the importance of what the Boy is experiencing, an individual’s thinking changes from hearing a story of a Boy, a third person experience, into hearing the story vicariously transforming into the role of the Boy enacting the story dilemma, as though it was themselves wrestling with the alternative choices. This feedback is from both boys and girls. I have heard countless times, “hey Ron when you tell the story I become the boy”. Another interesting comment that I’ve heard numerous time is the girls confuse the gender and respond to my questions referring to ‘the boy’ as ‘the girl.’ One police education officer from the South Island changed the peer hero from ‘The Boy’ to ‘The Girl”. He related the journey worked just as well having the hero a girl. What I’m attempting to relate is similar to getting lost in a book. When reading we get “totally into it”, we take that adventure; we envisage those dangers and marvel at the grandeurs, all as though we were actually there in a first person role. What I consider even more terrific is this vicarious first person experience is even more intense with storytelling. Once the story starts, listeners easily fall into the altered state of consciousness, experiencing the story as though looking into a mirror. I believe it happens to almost all the participants who do the groups. My sense is that the intense identification begins from the very onset of starting to relate the day’s yarn. Because listeners’ insert themselves into the journey they personalize and tailor the lessons to their own experiences.
Once the story begins, an observer can easily identify a softening of mood. Behavioral changes occur, and the changes are sudden and obvious (they can be termed empirical). Body positions shift and adjust to make the listener more comfortable, noise levels lessen, muscles relax and idiosyncratic behaviors increase; for example, one listener might start rubbing a hand on his/her face or scratch an arm or be gently rocking, interlocking fingers in a repeated manner. Colleagues over the twenty-five years I’ve been running TSI groups collaborate this observation. “Its like once you start telling the story they zone out and become hypnotized,” commented a recent co-facilitator. Students listen without interference from the usual culprits: anger, denial, projection; before my eyes I can see defense mechanisms relax allowing mindfulness in its purest form to transpire. Once I realized that this methodology worked, I started saturating/embedding the Journey with all kinds of important lessons, themes and models of instruction. I was talking to kids and being listened too.

State of Identification: The state of identification is achieved in almost every clinical session. Once the story starts all the listener’s cares, frustrations, fears, unresolved conflicts etc. simply drift away for a brief period of time. The power of the story causes a profound change from defense mechanisms dominating thoughts, to the state of mindfulness. I can think of no better example of the story altering consciousness’ of the participants than one group I ran at Berkeley Lodge (a Creative Alternative group home where I had my practice) in about 1987. Two separate groups of kids arrived a bit early for the group and had to wait outside the door because I was engaged. All of a sudden all hell broke loose right at the door. I rushed over to discover that two teenage boys had punched each other. Both boys got in a great hit. One boy received a serious split lip (later required stitches) and the other boy a massive black eye. After the drama of separating them, neither boy wanted to miss out on the next story. We allowed them to continue after everyone agreed that at the first hassle one or both were gone from the group. The boys immediately settled each with ice towels and they listened without incident. They even participated in the post group discussion. However at the very conclusion of the group they eyed each other and the conflict resumed.
It’s the sweet state of identification that makes the gem journey so powerful because information is so easily transmitted from facilitator to recipient. In the altered state listeners are absorbing the information and because there is no interference a facilitator can be creative and all kinds of ancillary information that supports the themes can be inserted within the group context. For example in Chapter 2 The Spiders Web the Boy is trapped by an enormous Spider that looks down at him and says, “Welcome to now sucker!” The Boy then responds to stress/fear/frustration etc in the same manner he does in ordinary time. He “goes off” – massive tantrum behavior – swearing, rushing randomly around, throwing dirt and sticks as the Spider looks down and laughs causing its massive belly to giggle like a plate of jello. After some group discussion, participants’ arrive at the conclusion that the Boy merely acted in the same manner he usually does, an enactment of his normal responses. Participants are easily introduced to an ancillary discussion on how anger actually works. The ‘fight or flight’ reaction can be described and discussed. It’s a miracle what your body does the instant you perceive stress. Sympathetic and parasympathetic nervous systems kick in and you get ready to fight or run for your life.

“Do you know what your body does? You should find out, it’s amazing.”

Because the group is receptive I can do some wonderful teaching. In the session of the Spider’s Web I actually go through the series of the instant body changes that prepares a person to fight for their lives or haul….. Listeners can easily see how their instant emotional response to say “turn off the computer” is a huge overreaction. The journey and its discussions provide opportunity for teaching and learning insight.
“Can a person get in the habit of getting angry?”
“Should a person get that angry over being asked to take out the garbage? Turn off the computer, come to dinner now?”
“What do you say to yourself when you are asked to do something you don’t want to do?”
“Do you light up like a Christmas tree?”
“Why do they call anger management courses anger management courses?”

The story is wonderful in allowing extended education of the receptive listeners. For example I might do a round asking each member what car they would choose if money was no object. Later in this focused discussion I would come back to their car choice and ask them if every time they got into their new corvette they’d rev it up past the red line?
“What would you be doing to your new car?”
“Are you in the habit of getting angry over little stuff?”
“Ever get very angry and 45 minutes later ask yourself why you got so angry over that little thing?”

The Journey allows numerous opportunities both within the story being told and in post group discussion to relate important information. I may in the midst of telling the days story and slip/drop into the story a little axiom knowing the listeners are totally open to consideration. The journey allows for stories within the story. I share little axioms in an almost subliminal manner during states of pure rapport, the time where everyone is on the same page. Every group session offers moments of pure engagement and often during this unopposed moment (and sensing the opportunity) I will out of the “clear blue sky” insert little axioms or a short story within the story into the journey context without missing a beat. Or I might at groups’ end as they are exiting, say to someone, little axioms like:

“Pretty is as pretty does.”
‘Quick to listen, slow to speak, and slow to get angry’
‘Don’t doubt in the dark what you know to be true in the light’
“Make good choices and you’ll see the world – make lousy choices and you’ll get to know South Auckland really well.”
“You know you guys make me a rich man”

Or personal individual stuff:
“Pretty amazing that Jim went home and cleaned his room.”
“Can you believe that Samantha went to school every day last week?”

In the state of connection I do lots of prophecy setting for individuals.
“Wow! Some of you because you took this journey will get on a different flight and will see the world. Some of you are going to do real important work” etc.

I have fun with kids on the journey – it’s a very fun process that most kids dig.

CHALLENGES AND SOLUTIONS

Discipline problems are rare, but they certainly do occur. Kids oppose the process for several reasons and are simply not going to co operate regardless of the therapist’s skills in circumventing resistance. It may be that the kid has something they’d much rather do at the time slot and the time conflict is insurmountable. This population of kids never settle into the group. I believe that all behavior has meaning and I question kids who present large initial resistance. Generally I will wait until after group however at times it necessary to find out why sooner.

Genuinely asking often gets a logical explanation that quite often I agree with; a kid might be part of a team and the team holds practice at 3:30 on Tuesday. I too would rather be playing baseball with their team or going to drama class at this time and agree with them that nowisa very lousy time and notthe right time for them to be doing the group. I do not sacrifice the group by struggling for control with the individual. I never think that my stuff is more important to them than their stuff.

Another common reason for resistance is oppositional defiant kids in the habit of being disruptive. I will let them know that they will tell me next group by what they do if they want to take the journey at another time; “no worries if you don’t.” Last year I had two boys who made the choice based on their actions not to continue and both did stop. However the other 6 kids continued and benefited. I might add both the boys want to do a group this year based on the information they heard from those that continued.

EVIDENCE-BASED SUPPORT

In early 1997 I was quietly running several groups a week at Campbell Lodge – now Whirinaki the child and adolescent mental health clinic services for South Auckland. Bruce Hart a therapist colleague was watching the numbers of youth consistently attending group and one day told me, “Ron I searched the mental health literature and nowhere can I find the levels of group compliance you are having.” Up until that exact point in time and space I paid no attention to the phenomena of attendance. His comment produced instant insight. Gem of the First Water is having profound effect on listeners and was having the same impact on the members as the Crusader Rabbit cartoon had on me, and they came to group because their imagination was captured. I now started paying attention and realized numerous examples of compliance were commonplace during the course of every group. The young adolescent on the run from home or residential placement shows up at group. Another common example is students who come to group while still ill. Or the student who only comes to school on group day or the house bound client that ventures out for group. The TSI process gets past the number one hurdle: the story is heard and lodges in the mind in conscious and unconscious form. An individual’s imagination has been accessed.

Following Bruce’s observation, several research papers were written studying TSI. In 1997 Sarah Fortune, a clinical psychologist in the service undertook naturalistic outcome study of TSI in the clinical setting. Below are the results. This study was conducted within the group of colleagues at Campbell Lodge and now called Whirinaki Counties Manukau’s child and adolescent mental health service. There was no financial backing for this study it was conducted by colleagues’ intrigued by the amazing compliance numbers initially compiled by the secretary for administrative reasons.

SETTING AND PARTICIPANTS

Catchment area: This study was based on 347 children and adolescents who attended TSI group therapy at a public outpatient child and adolescent mental health service in South Auckland, New Zealand. The catchment area for this service was at that time populated by more than 400,000 of which more than one third were under 20 years. At that time European/Pakeha made up 52% of the community, Pacific peoples 27%, Maori 17% and Asians 15% of the community. The rates of unemployment (10.1% in this area vs. 7.5% nationally), single parent families (23% vs. 19%), number of people living in each house (3.3 vs. 2.7) and proportion of adults with no educational qualifications (29% vs. 27.6%) were higher in this community compared with other parts of New Zealand (Statistics New Zealand, 2002). It is acknowledged that the local context will influence the wider applicability of this information.

The Clinic:A multidisciplinary team including child psychiatrists, clinical psychologists, psychiatric nurses, social workers and family therapists worked with children, adolescents and their families who represented the 3-5% of the population in greatest need of psychiatric services. Children and adolescents up to the age of 20 years (if still in school) were treated using a combination of crisis interventions, family therapy, group therapy, medication and individual therapy. Attempts were made to involve the wider systems of care for the young person including the family, school, social work agency, police and health care providers with which they have contact. Inpatient admissions are possible at a regional child and adolescent psychiatric unit.

Selection of participants:Patients were assessed by two mental health clinicians as part of usual clinic practices and a treatment plan generated which may include any combination of family therapy, group therapy, medication, or individual therapy. All patients who attended the clinic between 1997 and 2001 and who were referred to group therapy were included in this study.

Procedure and Measures:Demographic data was collected from routine clinical records. Individual attendance data at each group session was collected by administrative staff. A clinical profile of patients attending TSI was generated in 1999 as part of quality improvement using a using a pre and post intervention design. Questionnaires were given to group members and their parents attending the initial group session and again at the completion of the group process. Parents of all patients were asked to complete the Childhood Behaviour Checklist (CBCL). Children were asked to complete the Childhood Depression Inventory (CDI) and adolescents completed these measures and the McMaster Family Assessment Device (FAD) and Beck Scale for Suicide Ideation (BSSI). These measures were found to have acceptable reliability with this population with Cronbach alpha ranging from .83 (FAD) to .95 (BSSI).

Psychiatric diagnoses were not routinely generated by clinicians during the period of this study and are therefore not reported. However another clinical audit in this service around the same time suggested that nearly 50% of patients presented with a mood disorder, 17% presented with disruptive behaviours, including conduct disorder and oppositional defiant disorder, 7% had PTSD and 27% experienced difficulties such as childhood sexual abuse, parent/child relationship issues or neglect (Fortune, 2002). This population was also known to experience high rates of known risk factors for psychosocial distress such as suicide behaviour, substance abuse, parental psychopathology, physical abuse and childhood sexual abuse (Fortune, 2002). The early TSI groups were particularly targeted at boys, but over the period of the study TSI was increasingly utilised with both girls and boys. One quarter (n = 78) of group participants were Maori and two thirds European/Pakeha (n = 238). Two thirds of patients attending the group were adolescents and one third was under the age of 12 years.

Table 26.1   Demographic profile of group participants

Between three and six groups were completed each calendar year with variance reflecting fluctuating staffing numbers, particularly in 2000. The groups were conducted over an average of 16 sessions could be condensed to 9 sessions if required or extended for up to 20 sessions dependant on the requirements of the group members and clinicians.

Table 26.2 Duration and number of participants in each group 1997 – 2001

Three out of every five patients attended more than 60% of sessions and were described as ‘graduates’ with no significant difference in rates of graduation between males and females. Half of non-graduates had legitimate reasons for dropping out of the group such as moving out of the area or the family having significant problems with transport. Average attendance among patients who commenced TSI was 65% from 1997 – 2001. Among graduates average attendance rates were between 86% – 89% which allows for one session missed due to illness and another to attend a school camp or similar.

Maori were more likely than other ethnic groups to begin the TSI group but not graduate while Pacific Island children and adolescents were more likely to be referred to the group by their key worker and never commence the group (x2 (6, N = 347) = 34.32, p = .000).

Table 26.3   Attendance and retention rates for group participants 1997 – 2001

From Figure 26.2 it can be seen that average attendance at group sessions declined with an increasing number of sessions, but not among those who graduated from the programme. It appears that successful engagement with the therapeutic process can be defined by a return after session three.

Pre and post test data were available for a small sub-set of 46 children and adolescents. Due to the small sample size caution should be used in interpreting the following results; using the CBCL measure, parents rated significant reductions in withdrawn (t(25) = 3.05, p = .005), somatic (t(25) = 2.50, p = .02) and anxious/depressed behaviours (t(25) = 2.55, p = .02) among their offspring. Parents also rated their children has having fewer attentional difficulties (t(25) = 2.88, p = .008). Parents reported an overall improvement in their child’s behaviour at the completion of the group compared with at the beginning of the group process (t(25) = 3.15, p = .001).

Figure 26.2   Average attendance rates per session for graduates, non-graduates and total sample.

Table 26. 4   CBCL scores pre and post group intervention

The relatively small number of children and adolescents who completed the CDI before and after the TSI group rated themselves as significantly less depressed at follow-up (t(33) = 2.41, p = .02) with the strongest effect seen in the domain of perceived ineffectiveness where the mean score fell from 2.97 (SD = 2.29) to 1.76 (SD = 1.78) (t(36) = 3.10, p = .004).

Adolescents perceived an improvement in the way in which their family functioned at follow-up using the McMaster Family Assessment Device (t(21) = 2.21, p = .04). The strongest improvements, among the small number of respondents, were seen in the extent to which adolescents felt the roles of family members were clear and congruent (t(21) = 2.77, p = .01) and the degree to which family members were affectively connected and involved with each other (t(21) = 2.69, p = .01).

Table 26. 5   Childhood Depression Inventory scores pre and post group

Table 26. 6   Family functioning as perceived by the adolescents

Adolescents reported a significant reduction in their overall suicidality following the group compared with prior to attending the group (t (17) = 2.73, p = .01). Caution should be taken in interpreting these results, due to the small sample size.

SUMMARY

Gem of the First Water and the supporting guide is the first of three similarly constructed stories that highlight the issues of our lives and make up the Splendora Trilogy. Hopefully this glance into the working content of Gem and the TSI process that delivers the themes and lessons will stimulate your interest to find out more.

The research is what it is: a five year study developed by work mates interested in understanding the empirical results they were seeing week in and week out. No funds or special extras were given to them, only the pure motivation of investigating the phenomenon of teenagers attending a therapeutic group held after a long school day at a mental health clinic often a long way from their school and home. Why in the world would 60 % of the kids who start, come to 90% of the sessions over a four month period?

Whakatika: arise stand up start your journey.

REFERENCES

Abraham, P. P., Lepisto, B. L., & Schultz, L. (1995). Adolescents perceptions of process and speciality group therapy. Psychotherapy, 32(1), 70 – 76.

Beautrais, A. (2000). The Canterbury suicide project: aims, overview and progress. Community Mental  Health in New Zealand, 8(2), 32 – 39.

Coatsworth, J. D., Santisteban, D. A., McBride, C. K., & Szapocznik, J. (2001). Brief strategic family therapy versus community control: engagement, retention and an exploration of the moderating   role of adolescent symptom severity. Family Process, 40(3), 313 – 332.

Fortune, S. A. (2002). Suicidal behaviour among a clinical sample of children and adolescents in New Zealand. Unpublished report: TSI International.

Glasser, W. (1965). Reality Therapy. New York: Harper and Row.

Glasser, W. (1984). Take Effective Control of Your Life. New York: Harper Collins.

King, C. A., Hovey, J. D., Brand, E., & Wilson, R. (1997). Suicidal adolescents after hospitalization: Parent  and family impacts on treatment follow-through. Journal of the American Academy of Child &        Adolescent Psychiatry, 36(1), 85-93.

Mishna, F., Kaiman, J., Little, S., & Tarshis, E. (1994). Group therapy with adolescents who havd learning disabilities and social/emotional problems. Journal of Child and Adolescent Group Therapy, 4(2),       117 – 131.

Phillips, R. (1989). Gem of the First Water a Fable for Our Times(Third ed.). Auckland: Therapeutic Story  Telling International.

Rotheram-Borus, M. J., Piacentini, J., Van Rossem, R., Graae, F., Cantwell, C., Castro-Blanco, D., et al. (1999). Treatment adherence among Latina female adolescent suicide attempters. Suicide & Life- Threatening Behavior, 29(4), 293 – 311.

Spirito, A., Plummer, B., Gispert, M., Levy, S., & et al. (1992). Adolescent suicide attempts: Outcomes at follow-up. American Journal of Orthopsychiatry, 62(3), 464-468.

Statistics New Zealand. (2002). Manukau City Census 2001 area data. Wellington: Government Print.

Trautman, P. D., Stewart, N., & Morishima, A. (1993). Are adolescent suicide attempters noncompliant with outpatient care? Journal of the American Academy of Child & Adolescent Psychiatry, 32(1), 89 – 94.

Yalom, I. (2005). The Theory and Practice of Group Psychotherapy. New York: Basic Books

RESOURCES

If you too are interested, check into the ‘journey that everyone should take.’

All materials are available through the website: www.tsi.co.nz