Psychotherapy of Children With Conduct Disorders Using Games and Stories
For individuals in the U.S. & U.S. territories
In Psychotherapy of Children With Conduct Disorders Using Games and Stories, Dr. Richard A. Gardner demonstrates his approach to working with children who present with this common disorder. Children with conduct disorders are often incapable of understanding their own behavior, making this therapy very difficult. By using games and stories, Dr. Gardner allows young clients to self-disclose through metaphoric stories and within the boundaries of game play.
In this session, Dr. Gardner works with a 12-year-old girl named Ruth who refuses to interact with him. His repeated invitations to her to play a therapeutic board game called "The Talking, Feeling, and Doing Game" result in her increased willingness to disclose her feelings.
This video features a client portrayed by an actor on the basis of actual case material.
Ruth's father and mother were divorced approximately 11 years ago, after a troubled 1-year marriage. Ruth's mother had been flagrantly unfaithful to her husband since the beginning of the marriage. Ruth's father gave up on the marriage after 2 months and moved to a distant state to start over again. After 6 months, Ruth's mother arrived, announced that she was pregnant, and begged for reconciliation. Ruth's father acquiesced, but when Ruth was 4 months old, her mother abruptly left, without letting Ruth's father know where she was going or how she could be contacted. When Ruth was 4 years old, her mother reappeared briefly for a visit, but left just as suddenly. She had made no further attempt to contact Ruth in the ensuing years.
Ruth's father remarried approximately 7 years ago, when Ruth was 5, to a woman who had a daughter who was about a year younger than Ruth. Ruth's father and stepmother had their first son together 2 years later; another son arrived 1 year after that. Ruth's adjustment to living in a stepfamily was poor from the start.
Ruth's primary problems were lying and stealing, problems that had escalated during the past several years. She stole not only from storekeepers but also from friends, relatives, and even her own immediate family (her father, stepmother, stepsister, and two half-brothers). When confronted with her thefts, she would profess wide-eyed innocence, wondering how the accuser could be so misguided as to accuse her.
Ruth's father believed that there was a genetic component involved in these transgressions, because Ruth behaved exactly like her biological mother, who, as a child and adolescent, had a reputation for lying and stealing. He knew Ruth could not have learned these behaviors from her mother, because the mother had been absent since Ruth was 4 months old.
A few months before the referral to Dr. Gardner, Ruth had spread rumors at school that her stepmother had been physically abusing her. This lie caused a great deal of commotion and anxiety on the part of school personnel who had to grapple with reporting what they thought of as an unfounded allegation. They did not report the incident, with the stipulation that the parents find counseling for Ruth.
Ruth's first therapy experience was a failure. Ruth refused to speak one word to the psychiatrist, who eventually recommended long-term inpatient therapy, which the family could not afford. The situation became so intolerable that the stepmother gave the father a choice: "Either Ruth leaves the house or I'll leave with the other three children." As an interim solution, the father arranged to send Ruth to his mother's home, and his mother shared the obligations of Ruth's care with the father's siblings.
The plan was for Ruth to remain in this situation over the summer while she received intensive psychotherapy for her problems with lying and stealing. In this way, Ruth's father hoped to save his marriage and integrate Ruth back into the family when school started again in the fall.
Dr. Gardner agreed to see Ruth three times a week, much more frequently than he would have under other circumstances. But this intensity was necessary to get a significant amount of psychological work done over a relatively brief period.
- What is your impression of Ruth?
- How typical or atypical are her life experiences and her current behavior?
- What do you believe are the core issues for Ruth?
- What is the utility of these initial formulations?
- Before reading the next section, what topics and issues do you think will be addressed in the initial sessions?
Seven sessions, including the initial telephone session, preceded the videotaped session.
Session 1 (initial telephone session): In this 1-hour telephone conversation, Ruth's father described the current problems Ruth was having as well as her developmental and family history. Dr. Gardner agreed to meet with Ruth and other family members for assessment and treatment planning.
Sessions 2 through 7: The paternal grandmother brought Ruth for her second session, during which Ruth spoke very little and responded only perfunctorily to a few of the simplest and most nonrevealing questions in The Talking, Feeling, and Doing Game. The grandmother provided Dr. Gardner with further background information, but she made it known that she had no confidence in psychotherapy, and she was only bringing Ruth to therapy at the behest of her son and other children.
The next two sessions were conducted with Ruth and her father's siblings. The father had four siblings (two brothers and two sisters), all of whom were married and had children. Whereas the grandmother took care of Ruth during the week, Ruth's paternal aunts and uncles were rotating the responsibility of caring for Ruth on weekends. Each of these families reported having trouble with Ruth, and these problems were addressed in joint sessions. Money was stolen, Ruth was accused, and Ruth invariably responded with incredulity that someone would suspect her.
It was clear from the outset that the family members were getting increasingly frustrated with Ruth, and they asked how long therapy would take. Dr. Gardner's responded that he could not know how long therapy would last and that he might not be able to help Ruth at all. This response appeared to add to their frustration. Dr. Gardner assured the family that he was committed to helping Ruth. He further attempted to reassure them that Ruth's attendance, her protestations notwithstanding, indicated that she recognized the importance of her sessions to some degree.
To learn more about Ruth's underlying psychodynamics, Dr. Gardner invited Ruth to provide him with self-created drawings and stories. The main themes that emerged were formidable hostility and a sense of loss and abandonment. However, Ruth made little direct reference to her mother as the abandoner. More prominent in her stories were her methods of expressing hostility, especially in situations in which there were no repercussions. In fact, repercussions for actions were conspicuously absent from Ruth's stories.
In later sessions, Dr. Gardner again tried to engage Ruth in The Talking, Feeling, and Doing Game, but he was only partially successful. She would either refuse to play the game at all or when she did "play," she would only respond to the most simple and nonrevealing cards.
Dr. Gardner did not consider Ruth's apparent lack of involvement reflective of Ruth's noninvestment in therapy. Rather, he views "a body in the room" as an indication that the person on some level wants to be there.
Dr. Gardner continued to play The Talking, Feeling, and Doing Game in these sessions, even when Ruth refused to directly participate. He devised responses to cards that would bring to the fore Ruth's underlying anger and feelings of loss and abandonment and would reinforce the themes that he believed would help her face her problems and deal with them more constructively.
- Were the initial sessions as you expected?
- As you read the summary of the preceding sessions, were there any areas or topics that you thought should have been covered but were not?
- What other information would you seek to assess the patient?
- Before viewing the tape, what do you think will unfold in the taped session?
- What issues will be discussed?
- What will the relationship between Dr. Gardner and Ruth be like?
Stimulus Questions About the Videotaped Session
In the first few minutes of the session, Ruth repeatedly declines to play The Talking, Feeling, and Doing Game. Dr. Gardner articulates and accepts Ruth's negativity about the game and about sitting in the chair that is closer to him in the therapy room. At the same time, he pointedly continues to set up the game pieces in preparation for play.
- What are the therapeutic benefits of using board games and other types of games in psychotherapy with children?
- What do you think of this initial intervention that appears to both join with the patient and pursue the therapeutic task in the face of her resistance?
- What alternative approaches might you use in dealing with Ruth's overt resistance?
Immediately after this intervention, Dr. Gardner intentionally misstates Ruth's age to evoke her participation. By doing so, he elicits additional affect and negativity.
- What are the advantages and disadvantages of engaging a resistant child in this manner?
In his first move in the game, Dr. Gardner draws a card that says "act like a spoiled brat." He elects not to act out such behavior and instead goes on to describe the negative interpersonal reactions that people have to this kind of behavior.
- What is the therapeutic intent of this discussion?
- What is the therapeutic rationale for this intervention?
- What effect does the discussion appear to have on Ruth at this point in the session?
Dr. Gardner retrieves a second card in the game that reads, "You're looking through a telescope into someone's window. What do you see?" In response to the card, he concocts a story about a girl, her mother, and her father during a time when the parents are discussing their divorce.
The pivotal scene in the story is where the mother states that she does not want to have custody of her child. Dr. Gardner elaborates on the girl's later emotional reactions to the maternal abandonment and invites Ruth to share her thoughts about the story. Once again, Ruth refuses to talk or participate in the game.
- At this point, if you were the therapist, what would you do next?
- Would you continue with the game or would you switch tactics?
As a segue from this story to another point he wants to make, Dr. Gardner states that the girl in the story finds a book in the library titled The Boys and Girls Book of Divorce and, in the session, he picks this very book up from the table next to him. He begins to read from a selection called "Fields' Rule."
- What are the pros and cons of reading from a book to a child in session as opposed to directly relating the content to the child in a therapeutic conversation?
- Generally, what do you think of using bibliotherapy with children?
- With adolescents? With adults?
About 10 minutes into the session, Ruth breaks her silence by asking in an irritable tone, "How much longer do we have to stay here?" Dr. Gardner responds first with a factual announcement of the time and the number of minutes left in the session. Then he comments, "Your father says that you must come here."
- If you were the therapist, how might you have responded to Ruth's question about the time remaining in the session?
- Under what conditions would you respond to her question in terms of either process or underlying feelings rather than responding concretely to the question?
For the next 5 minutes, in a complicated series of affectively charged interactions, Ruth calls Dr. Gardner a "retard," tells him that she hates him, and voices a series of complaints about him being inattentive to her in the previous session. In the midst of these brief, intense affective displays, Dr. Gardner focuses on affirming the appropriateness of Ruth's self-assertion, and he seeks to address her complaints by offering to rectify the situation.
- In such a complex series of transactions, how does a therapist know how to respond?
- As Ruth's therapist, under what conditions would you focus on one of the other issues that she brought up?
- As you imagine yourself being Ruth's therapist, what feelings might her negative remarks engender in you?
About 16 minutes into the session, Dr. Gardner returns to a theme Ruth had brought up earlier—his not being able to hit patients. He confirms to Ruth that he does not and is not allowed to hit patients. Then, he uses the opportunity to explore the topic of the rumored abuse of Ruth by her stepmother. Ruth responds by making a series of inconsistent and conflicting statements. Dr. Gardner calmly persists in requesting clarification in a systematic fashion.
- If you were the therapist, how would you deal with Ruth's incongruent statements?
- At this point in therapy, would you remark directly on the incongruities?
- If so, how would you do so?
About 23 minutes into the session: Ruth emphatically states that she hates Dr. Gardner and again calls him a number of names, one of which is "reject." Dr. Gardner focuses on this word, first in terms of her rejection of him in the therapeutic relationship and second in terms of critical events in Ruth's life (i.e., Ruth's mother's rejection of her).
- What effect does this have on Ruth?
- On the therapeutic relationship?
Toward the end of the session, Dr. Gardner builds on the impact of discussing the maternal rejection and then attempts to link the rejection to Ruth's lying behavior in the present.
- In the constant interplay of breadth versus depth in a session, how do you decide when to make such a link between past events and current behavior?
- What are the pros and cons of doing so?
Dr. Gardner perseveres in his therapeutic agenda throughout this difficult session, despite Ruth's repeated negativity and her overt resistance.
- As the therapist, what would you be feeling in response to Ruth's behavior?
- What might you (honestly) be tempted to say or do?
- How might Dr. Gardner's interpersonal and therapeutic perseverance enhance the probability of a successful outcome in the long run?
- Did the session progress as you anticipated?
- Was Ruth as you expected? Was Dr. Gardner?
- What are your general reactions to the session?
- What did you feel was effective in the therapy? What do you think were the strengths and the weaknesses of this approach?
- Now, after reading about the patient and viewing this session, what are your diagnostic impressions or characterizations of her problem?
- How would you proceed with Ruth's therapy?
- What goals would you set?
- How many sessions do you think it would take to achieve these goals?
Conduct disorders are among the most common problems for which children are brought for treatment, and they pose a formidable challenge for psychotherapists. These youngsters have a minimal capacity for insight into their problems, and their motivation to work on their difficulties is often very low.
Many insight-oriented and expressive therapies fail to help these youngsters, particularly those treatments that are unstructured. Children with conduct disorders need structure and limits and tend to do better with therapists who are a bit obsessive in their personal style.
The goal of treatment is to help the patient deal with the fundamental problems and conflicts of life. For children with conduct disorders, this entails learning a series of psychological skills. These include awareness and appropriate expression of feelings (especially anger and sadness), self-assertion, ability to delay gratification, anticipation of consequences of injudicious behavioral choices, and ability to generate healthier options when internal or external conflicts arise.
For children who are incapable of, or unreceptive to, the development of conscious insight (as is the case for conduct-disordered youngsters), these skills are best taught symbolically and allegorically through stories, metaphors, parables, and discussions of third parties. Concrete examples are preferred over abstractions and generalizations.
Dr. Gardner finds that being transparently honest and judiciously self-disclosing, particularly of experiences that relate to the youth's present struggles (e.g., the consequences of my periodic inability to delay gratification as a child), helps to build the therapeutic relationship. In the context of this relationship, the child is able to tolerate the anxiety and pain inherent in experiencing his or her core issues (e.g., abandonment, loss, abuse), of which Dr. Gardner speaks openly and directly.
Among the psychotherapeutic techniques that are most useful for engaging such youngsters is The Talking, Feeling, and Doing Game. In this board game, both therapist and patient move playing pawns around a curved path, which results in selecting talking cards, feeling cards, and doing cards.
Responding to the card's question or instruction enables the player to receive a reward chip. Examples of questions include the following:
- "Everybody in a class was laughing at a boy. What had happened?"
- "You overhear two people talking about you, and they don't know that you're listening. What do you hear them saying about you?"
- "If the walls of your house could talk, what would they say about your family?"
- "A girl was the only one in the class not invited to a birthday party. Why wasn't she invited?"
These questions give the therapist the opportunity to speak directly or metaphorically about the child's problems and give the child the opportunity to self-disclose at a safe distance.
The last question, for example, gives the therapist a platform for describing the social consequences of behaviors such as lying, stealing, and bullying; identifying the feelings of sadness and anger that accompany being excluded from a group; and suggesting alternative ways of behaving that will have more rewarding consequences for the child. This game has proven successful for drawing many (but certainly not all) resistant youngsters into meaningful psychotherapeutic endeavors.
Dr. Gardner uses games and stories in his work with children and adolescents. What does this lead you to expect about his work? Will he be active or passive? Will the session be structured or unstructured? Directive or nondirective? Will it focus on the past or on the present? Will the session focus on behaviors, on thoughts, or on feelings? What do you expect to be the relative balance between attention to technique versus the interpersonal interaction?
Richard A. Gardner, MD, (1931–2003) was clinical professor of child psychiatry at the College of Physicians and Surgeons at Columbia University. Dr. Gardner published more than 250 books and articles on various aspects of child psychiatry.
He developed three innovative games for child psychotherapy, which have proven particularly useful with children who are resistant to traditional psychotherapy. These include The Talking, Feeling, and Doing Game, The Storytelling Card Game, and Dr. Gardner's Pick-and-Tell Game.
Dr. Gardner maintained an active private practice in child and adolescent psychotherapy and lectures extensively throughout the United States and abroad to both legal and mental health professionals.
He was certified in psychiatry and child psychiatry by the American Board of Psychiatry and Neurology. He was a life fellow of the American Psychiatric Association and a fellow of the American Academy of Child and Adolescent Psychiatry and the American Academy of Psychoanalysis.
Dr. Gardner is listed in Who's Who in America and Who's Who in the World.
- Gardner, R. A. (1973). The talking, feeling, and doing game. Cresskill, NJ: Creative Therapeutics.
- Gardner, R. A. (1988). Psychotherapy with adolescents. Cresskill, NJ: Creative Therapeutics.
- Gardner, R. A. (1988). The storytelling card game. Cresskill, NJ: Creative Therapeutics.
- Gardner, R. A. (1992). Dr. Gardner's pick-and-tell games. Cresskill, NJ: Creative Therapeutics.
- Gardner, R. A. (1992). Psychotherapeutic techniques of Richard A. Gardner (2nd ed.). Cresskill, NJ: Creative Therapeutics.
- Gardner, R. A. (1994). Conduct disorders of childhood: Psychodynamics and psychotherapy. Cresskill, NJ: Creative Therapeutics.
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