Duo Therapy A Potential Treatment of Choice for Latency Children

Jennie Sage Fuller, M.S. W.

Abstract. Duo therap\', a modalit\ in which l\\'() unrelated children an: seen together on an ongoing basis, provides an e('()nomical means of increasing sen'ice while maintaining a treatmelll specificalh responsi\'e to the de\'('lopmental problems of latenn-age children. A theoretical base drawn from indi\'idual and small group theon' is presented. Indications for the nlOdalirv and its potential ach'antages and limitations arc' desnibed, Stages to lx' expected in the unt()lding of the therapeutic process are delineated.

This papel' will provide a theoretical base for duo therapy dra\\'ing upon a combination of individual and small group theory. The literature regarding the treatment of t\\'() children conjointly is sparse; Bimbaum (1975) I'eponed work with peer-pair thel-apy of withdrawn children, and Evelson (1958) described the conjoint psychoanalysis of twins, Only one empirical study of this duo therapy has been conducted (Mitchell, 1975). For many latency-age children, neither individual nor group therapy seems an ideal modality. A group may not provide the necessary attention, and some children for whom peers provide a stimulus and permit distancing from the therapist may be unable to interact with a group. Individual treatment may not provide an impetus for improved peer relationships, Some children become too comfortable in individual treatment. Duo treatment is therefore not a compromise but a form of treatment for certain children that encompasses aspects not found in group or individual treatment. Its social intent is to help a child form a stable, deep, relationship with one child and thus provide The author is a Senior Supen'ising Social Worker at the Youth Guidana Center of the Greater Framingham Mental Health ASJocwtion, This paper was presented in part at the 2ith Anllual Meeting of the American Association of Ps)'chiatric Sen.'ices for Children, New Orleans, Louisiana, Nor'ember 1975, Reprints rna)' be reque"ted from the author at Framingham Youth Guidance Center, 88 Lincoln Street, Framingham, MA 01701.

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the basis for other peer relations leading to constructive grou p relationships. SETTING

The cases to be described were seen at a child guidance clinic serving ten towns in an area west of Boston. The clinic population is fairly evenly distributed among socioeconomic classes, the largest group being white lower-middle class. I saw the first clinic duo of two 9Yz-year-old girls from September 1972 to December 1973. Group treatment had been recommended for each girl who had major difficulties with peer relationships. Since no appropriate group was available, it was proposed that they be seen conjointly to deal with a common central problem expressed by the two girls in maladaptive, yet complementary ways. Similarly, the strengths of each seemed to complement the other. It appeared that they might assist one another in developing more gratifying, adaptive behavior. During 1975, 25 pairs were formed and treated at the clinic. The average length of treatment was 8 months. Most duos were of latency age and the same sex, fairly evenly distributed by sex. Parents were seen simultaneously, often by the child's therapist. Thus duo treatment grew from a well-thought-out "experiment" to an accepted and more widely utilized treatment modality. INDICATIONS FOR

Duo

THERAPY

Though criteria are not well developed, guidelines for referral for group therapy are pertinent to duo therapy. In particular, "social hunger," a capacity to relate and a desire to be with others, is one of the most important criteria for group membership (Lawrey and Slavson, 1963; Rosenbaum and Kraft, 1972; Ginott, 1968). This is also an important criterion for a duo member. Children in most diagnostic categories could benefit from duo treatment. Exceptions may be autistic or severely withdrawn schizophrenic children. A child's capacity to offer socially viable personality assets to another is most important. Just as thoughtful selection is important for group success, the attainment of a "good enough" duo match is critical to success of the treatment. We have deemed the existence of complementary personality and behavioral characteristics as most useful in achieving a match that could be conceived of as an "interlocking jigsaw puzzle." The similarities shared by the two children provide a sense

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of commonality and cohesion; the differences provide some objectivity and behavioral and perceptual alternatives. Yalom (1970) states of group therapy, "Quite frequently it is the patients rather than the therapists who will point out each other's strengths and assets" (p. 11). This heterogeneous matching is different from Birnbaum's (1975) homogeneous pairs of withdrawn children. Indeed, it is the specific intention of our duo arrangements to match children who have some differing characteristics. Age or relative maturity are crucial factors in duo matches. Since children in the elementary school years differ greatly in their abilities, activities and interests, commonality is best in this area. Clinic pairs are usually same-sex matches, seemingly a natural grouping that need not be disturbed. Socioeconomic status and general intelligence level are also factors to consider in matching. Generally, children whose parents have relatively the same socioeconomic status feel more comfortable with each other. A very deprived child, matched with a very wealthy one, might feel even more deprived or alienated. Although this might be worked through in treatment, an inordinate amount of time might be spent on this issue. A less workable issue is that of intelligence level. While children's other abilities may differ greatly, the larger the difference in intelligence level, the more difficult the communication. Two 12-year-old retarded girls made a good match, whereas neither would have done well in duos with bright girls. Although similarities in socioeconomic class and intelligence are desirable, similarities in skills and interests are even more important. Problem areas and behavior styles are two other important matching criteria. Slavson (1964) states, "though patients may differ widely in ego functioning, in their defenses and symptoms, the best results are obtained when their nuclear problems are the same" (p. 204). Thus Max and Alan, age 9, were matched because both sets of parents were about to separate. Max's reaction was withdrawal, while Alan's was acting out. It was hoped that together they could find alternative ways of expressing their reactions to this situation as well as to others. With a mixture of both similar and differing problem areas, children can identify each other's difficulties and offer some objectivity in helping their partner. Differences in behavior style seem conducive to growth, though too much divergence may be overwhelming or repugnant to members. Diversity of diagnosis in group composition is a controversial issue. Some therapists feel diagnosis does not matter at all; others, that commonality o[ diagnosis is of paramount importance. Slavson

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(1964) states, "The therapeutic process is more effective when patients of diverse clinical entities are grouped together than when patients are clinically homogeneous. Clinical homogeneity reinforces individual reactions, hindering the progressive How of communication and resolution of problems" (p. 210). I believe that diagnosis is important to consider when matching, but that the same diagnosis is not necessary. It can be nonproductive unless behavior styles are different. Most clinic pairs are diagnostically "next door" matches. TREATMENT PROCESS

Duo treatment aims at promoting each child's progression in his own development through identification with the healthy functions of the other child and the therapist, while curbing, undermining, or working through the child's less desirable personality traits. It involves helping children appropriately to use and help one another. The therapist's role is to facilitate this process through stimulation of the group process, and through intervention by support, confrontation, limit setting, clarification, and selective interpretations. The first step in beginning a course of treatment is screening. Screening provides a recheck on the match and an opportunity for each child to meet the therapist to discuss problems and goals of treatment. It also provides a time to discuss fantasies and anxieties about treatment, specifically the duo situation. Meeting the therapist first helps the child to clarify his or her goals in treatment and to gain an alliance with the therapist before meeting a partner who is yet another stranger. Since parents may also have concerns or misperceptions, it is desirable to include them for part of the child's screening interview. Parents may then continue to be seen by the duo therapist or, if seen by another therapist, they may meet with the duo therapist occasionally. The clinic is experimenting with seeing parents of the two children together for occasional meetings as the treatment of the children progresses. Such meetings are determined by the characteristics and interests of parents and children. The second step for the children is the initial duo meeting. They are usually anxious about meeting each other and very curious. Some need a lot of support, even when well prepared, to talk about themselves or to ask questions. In Doreen's and Joyce's first duo session, Doreen shyly said to me, "Joyce looks about my age." I suggested she could ask Joyce her age. This stimulated further ques-

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tions about each other. They delighted in their common areas and were able, with support, to state their biggest problems and ways of handling them, finding likeness and differences in both. They were then able to discuss their fantasies about what their duo partner would be like-Joyce, "A monster like my sister"; Doreen, "Someone who wouldn't talk to me"-and their delight that things were different. A contract was set to meet weekly together for the school year, and reevaluate at the end of that time. Although these two girls were more verbal than many children, usually the same issues are covered in the first session. The process of duo treatment can be understood within an established theoretical framework. Garland et at. (1973) developed five stages of group treatment which have been useful in better conceptualizing the duo treatment process. The five stages are: (1) preaffiliation, with issues of approach-avoidance, and ambivalence; (2) power and control, with issues of rebellion, autonomy, permission, protection, and support; (3) intimacy, issues around interpersonal involvement, sibling rivalry, playing out of love-hate conflicts, and the recognition of personality growth and change; (4) differentiation, acceptance of each other's uniqueness, objective evaluation, high cohesion with less rigidity of roles; and (5) separation, the termination period where the group moves to find new resources, and temporary regression. recapitulation, and evaluation. These stages are not rigid and fixed, but How into each other and are interdependent. In the preaffiliation stage the children become acquainted with the worker and each other. Much conversation is directed to the therapist, rather than the other child. The therapist is usually perceived at this point as offering the less rhreatening relationship while the children test each other out. In the early phase of duo, it was often noted that children ask the therapist's direction in what to play or how to solve a problem, or want the therapist to play with or observe them rather than their partner. Much parallel play goes on which the therapist can allow while gently supporting increased interaction. For example, when Bonnie and Laurie were both drawing young female figures, I commented on the girls' similarities so that the girls began to draw one another. Such interaction was a means of becoming closer while maintaining some distance, a stance typical at this stage. The power and control phase quickly follows the preaffiliation stage. It is a very active time when limits will be tested and set (often by the children themselves), denial and projection of problems are confronted, and competition for the leader and between

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children is paramount. There is often a good deal of acting out. The issues of transference and countertransference become more apparent. My speculation is that duo treatment may create a more intensive transference and countertransference situation than either group or individual treatment because of the re-creation of the small family unit, with competition for the parentlike figure. During this period, duo pail's have been known to run races to see who gets to the therapist's office first, or to step on each other to attain the closest bodily contact with the therapist. Laurie would try to lock Bonnie out of the room, just as she tried in similar ways to eliminate her sister in the intense sibling rivalry situation. Duo sometimes generates comparison by the worker of the two children, with one being favored, owing to the therapist's past relationships. I first favored Joyce. as she was more like myself as a child and more verbal. However, when I realized this, it became an important task to build up Doreen's strengths and draw out her little used good verbal ability. The therapist has a large job in making herself or himself aware of transference reactions, both personal and by the client. During this period the therapist hopes to decrease her or his role and increase the therapeutic interaction of the pair. The intimacy stage superficially resembles latency, which supposedly is a quiescent time after the stormy oedipal period. Although it may be a quieter period, it is not true that nothing happens either in latency, or this phase of treatment. The therapist is less "needed" at this time and children are more involved with each other. A great deal of work can be done once the youthful clients have tested out each other and the therapist, established rules, and defined their problems and tasks. There is a greater degree of closeness and sharing. Lena and Betsey were able to comment on each other's feelings about the loss of their fathers and to provide mutual support. They were calmly able to bring up their hidden secrets: that Lena felt her parents favored her brother and wished to be an only child, and that Betsey had always wanted a sibling. Interaction is intense at this time, and the therapist is sometimes left out or ganged up on. Sometimes the pair has shared a secret, and kept it from the therapist, and reveals it only now. In the differentiation stage, after commonalities have been discussed and integrated and a certain stability has been achieved, each child's uniqueness seems a focus. Children are often able to risk more, bringing up and working through their most difficult problems. Doreen was able to support Joyce's attending several family sessions and allowing her sister to be included. In the family

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sessions, Joyce, having incorporated Doreen's behavior, played a major role in her sister's gaining comfort in the therapeutic situation. At this point some maladaptive defenses are dropped and "loose ends" of treatment get worked through in a cooperative effort. The final phase is the termination and separation stage of the duo unit. During this period some regression may be expected, it is usually quickly noted by the members themselves. Past losses come up and termination feelings are discussed. The therapist expresses her or his own feelings when the children cannot. With their duo ally, children often feel freer to ask personal questions of the therapist, showing that they see the therapist as a real and separate person rather than an idealized transference object. DISCUSSION

The conceptualization of the duo treatment process is still in its early stages of development. It is obvious that the main technique the therapist uses is the gradual support of children to help each other, intervening less as treatment proceeds. In addition, duo therapy facilitates the diagnostic and therapeutic use of play. In latency children, conflicts and fantasy tend to be acted out in play more frequently than expressed verbally. Yet therapeutic play may be limited in individual sessions, since latency-age children, who are characteristically involved in play with other children, may react differently to play with an adult. The quantity and quality of fantasy material may be enhanced, or at least may be more reflective of difficulties in peer interactions, when another child is present. Since "critical looseness" is often present in latency, peers may be able to comment on the negative or positive aspects of another child's behavior more freely than an adult. The aim of any treatment is to help children find the best means of using their own ego strengths; the added aim of duo treatment is to help children productively to use and get gratification from age-mates outside their families, in order to promote social and psychic growth. Duo therapy is especially appropriate for children whose limitations impede normal development from primary dependence on the family unit to greater reliance on autonomous and social skills. It is especially useful for latency children whose developmental tasks are mastery, internalization of controls and values, and attachment to a peer group. Very young children may be too invested in solitary or parallel play to make good use of duo treatment. Adolescents may find duo too threatening owing to upsurge

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of sexuality and the wish to be both unIque and part of a large group. Duo treatment has its limitations. Mismatches are a hazard. Some children will not be able to work well in duo because they cannot make a therapeutic alliance with both the worker and the other child. If, despite care in matching, the children cannot form a relationship, intensely dislike each other, or do not display the anticipated commonality, duo work is likely to be difficult if not impossible. Premature termination of one or both children requires special consideration. Parental ambivalence about the duo modality also requires careful handling: some parents fear contamination of their child by another "disturbed" child; others worry about confidentiality; and others are so ambivalent about any treatment that they bring the child irregularly, causing a tenuous duo situation. Therapists who condone or allow undesirable traits to developowing to lack of skill or unconscious factors~ontribute a further difficulty. Duo treatment can also pose administrative problems. The matching process itself takes time both from the referring worker and the worker responsible for matching pairs. Secondly, duo, while being more economical than individual therapy, is more expensive than group therapy. Thirdly, so little is known about duo treatment that supervisors may be unfamiliar with the relevant theory and techniques. These issues need further study. Questions that need to be answered include: what types of children are most, and least, successfully treated by duo treatment? What is the most suitable matching? Duo treatment is potentially the treatment of choice for a large portion of child guidance clientele.

REFERENCES BrRNBAL'~I, M. P. (19i5), Peer-pair psychotherapy.]. Clill. Child Psychol., 4:13-16. EVELSOS, E. (1958), Una experiencia analirica. Rev. Psicoanal., 15: 16-21. GARLAND, J. A., jO!\'ES, H. E., & KOLODNY, R. 1.. (19i3), A model for the stages of development in social work groups. In: Exploratiolls ill Group Work, ed. S. Bernstein. Boston: Milford House, pp. 29-5i. GINOTT, H. G. (1968), Innovations in group psychotherapy with preadolescents. In: Innovations in Group Psychotherapy, ed. G. M. Gazda. Springfield, Ill.: Charles C Thomas. pp. 272-294. LAWREY, L. G. & SLAVSON, S. R. (1963), Group therapy special section meeting. In: Group Psychotherapy and Group Functioll, ed. M. Rosenbaum & :'vI. Berger. ~ew York: Basic Books, pp. 228-241. MITCHELL, C. A. (1975). Duo therapy: an innovative approach to the treatment of children. Thesis, Smith College School for Social Work.

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:\1. & KRAFT. I. (I97~). (;roup ps\rholherapr for childrcn. In: Manllll! of Child P,.whopal.!w!oKY, ed. B. B. Wolman. New York: ~lcGra\\'-Hili. pp. !1:F,-950. SI.A\'SO:-:. S. R. (1964), A Textbook in Ana!ytic (;roliP Psychotherapy, "c'" York: Illlernalional L'ni\'ersitics Press. Y.uml. I. (I !170). The Them",' and Pra(/ice of Group PsycllOlhrmj;),. l':c'" York: Basic Books. ROSE:-:R\DI.

Duo therapy: a potential treatment of choice for latency children.

Duo Therapy A Potential Treatment of Choice for Latency Children Jennie Sage Fuller, M.S. W. Abstract. Duo therap\', a modalit\ in which l\\'() unre...
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