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Feelings of unmanageable and overwhelming anxiety in children and young people are on the increase. Triggers can include exam stress, sensory overstimulation and feelings of social isolation through lack of friendships.

In schools, there are varying levels of expertise to support youngsters on an individual basis, and the squeeze on special educational needs and disabilities (SEND) funding is reducing this support. Waiting lists for CAMHS support continue to lengthen, but the number of youngsters in need continues to grow.

A way forward could be to create more therapy groups, in which children and young people have a safe space to work together on naming, sharing and processing their feelings and difficulties. Children on the autism spectrum are particularly vulnerable, as they often struggle with expressing how they feel and have heightened sensory sensitivity. Managing day-to-day transitions or processing the tone or volume of a teacher’s or parent’s voice can be problematic for them. They are also vulnerable to social exclusion and bullying from peers, because they either find it difficult to read and respond appropriately to subtle social nuances, or they simply withdraw, due to the strain of being in a busy classroom or family.

Twenty years ago, I set up my own private practice and, as part of that, started running therapy groups (the Friendly Group). These were primarily, but not exclusively, for children with a diagnosis of high-functioning autism (or Asperger’s Syndrome). The groups comprise eight children and two adults. Rather than focusing on their difficulties as deficits, I wanted to draw out of the children the competencies that they already had. I truly believe that all children have the capacity to learn, and that learning comes from what they are already interested in and feel good about. The main approach I use has been based on the principles of group psychotherapy and, in particular, on the work of Irvin Yalom.¹ However, unlike a strictly psychotherapeutic group, the adults in the Friendly Group offer some guidance and structure within the sessions. Rather like Kurt Hahn’s philosophy of Outward Bound,² the children are impelled into experiences and reflections through the opportunities that are offered to them.

The inevitability of anxiety in a new group

We all recognise those tense and alert feelings when joining a new group. Being in a group with people we don’t know triggers our defence systems. Adults (and many children too) manage this initial uncertainty by being on their best behaviour, but when the ‘chaotic mess’ of anxiety is expressed in children, we see it in their behaviours, such as silliness, interruptions, talking without a pause, hiding inside clothing or under furniture, and other ‘disruptive’ behaviours. The group leader has to be attentive moment by moment and be able to wonder aloud, giving narrative to the unfolding events and naming and explaining the emotions the children might be feeling. The habitual behaviours in a group give us clues about the way children behave and have relationships with others outside the group.

As a group leader, it is important to remind ourselves that we are also a group member and are being affected by the emotional temperature of the session, so we listen and watch and take note of our own emotions. When a group of children becomes agitated, we can easily become agitated ourselves, allowing the disturbing feelings to not only be projected onto us, but also get into us. We may even begin to behave in a defensive way, mirroring some of the group behaviours. This can also happen if we unconsciously identify in others something about ourselves that we don’t like (projective identification). When this happens, our capacity to think is being attacked; but so is everyone else’s. Everyone is feeling something that is too difficult and frightening to be thought about. When children challenge authority, they are demonstrating that they’re struggling to take charge of themselves. At these times, when we step back, we can take advantage of the turbulence and use it as an opportunity to facilitate the growth of the group.

Teachers have often told me that when there has been disruptive behaviour in a group by one of the children, it is tempting to exert authority over that one child. However, when they have been able to replace their ‘teacher hat’ with their ‘therapist hat’ and bring the situation to the group, by wondering aloud how the rest of the group feels, the children themselves have been able to engage in expressing their feelings. In this way, what could have been a problem has become an opportunity for the adult to facilitate reflection about disturbance, anxiety and consideration for others.

Another common way that children manage anxiety and avoid thinking about their own worries is to give others advice. We need to be alert to the child who always has a resolution to offer. Their contributions can be seductive, because they seem to be showing empathy, but – unless they’re sharing their personal experiences – their comments are simply an emotional defence and perpetuate the obstacles to their own growth and development.

Facilitating group process: working in the here and now

So much of children’s experience today is based on activity that is target driven and measured. However, the Friendly Group (as described in my recently published book, Making Friends³) is about giving children the space and opportunity to work together on expressing their feelings in the here and now, with whatever crops up during the session, rather than being tied to adult-led activities and outcomes. We work with process rather than content. I have described this in my book like this: ‘Instead of simply attending to what is being said, or how the children are behaving, which in therapeutic language is called the content, we are focusing on process, making sense of the here-and-now feelings and experiences about what is happening.’

One of the resources I use to facilitate group process is a set of Bear Cards,⁴ which have images of bears expressing a range of feelings. These cards allow the possibility of thinking and talking about feelings in a non-threatening way. In a group situation, even the children who find it too difficult to speak are a part of the process as they hear and witness their peers expressing how they feel. Furthermore, we, as group leaders, add comments of acknowledgement, such as: ‘I can see that it’s difficult for you to think about these uncomfortable feelings right now.’ Or we make comments to promote relational connections, such as: ‘I wonder how it makes you feel to hear A tell us his story of feeling so scared?’ and ‘I wonder if any of you have felt scared like A?’ The children and young people begin to work as a group and, over time, a chain of memory is created, which in turn promotes feelings of belonging and a sense of community for them – a community that is small enough for them to feel a part of.

In a recent session of a mixed group of 11–13 year olds, we invited the children to ‘pick a card of a bear that looks like you feel if you see a friend or someone you know being bullied’.

We used the term ‘bullied’ because it is commonly used by the children and allowed them to interpret the word as they wanted. I’ve noticed that, although sensitive and autistic children can find it difficult to show empathy, they often ‘feel the feelings’ of others intensely (particularly anxiety, sadness and anger), but don’t know what to do with these feelings. They also find it very difficult to read another’s empathic response or understanding, giving the impression of being emotionally insensitive, when in fact, the opposite is true.

On this occasion, the children took turns to show and talk about their cards, but the turn-taking soon became fluid, and a meaningful exchange and flow of group consciousness emerged, with very little prompting or help from the adults. This is a small extract from the session, using the children’s actual words. The language can seem rather formal at times, but it is how some children on the autism spectrum speak.

O: I feel angry when I see someone being bullied. I feel shocked that someone would actually do that… Yesterday a boy was called ‘nerdy’ because he wears glasses… I told the teacher.

M: That’s evil… He might need glasses.

T: I agree. [T wears glasses]

M: You can’t trust teachers in my school.

T: That was good that you stood up for your friend, O.

C: If the bully is younger than you, you can stand up to them, especially if you are bigger.

M: I’m never sure what to do. I feel bad and regretful… I walked past a boy like that yesterday and didn’t do anything. I didn’t know what to do. I didn’t tell any teachers because they never understand the exact problem at hand, so I don’t trust them.

T: I feel exactly the same as you.

M [again]: By the way, I’ve just discovered that I have autism… and I feel a little less alone in the world now.

C: Have you? I’ve got high-functioning autism too. [C leans forward to offer M her right hand, and they shake hands across the group] K: And I found out recently that I have autism. I’m happy to have the label… It’s an explanation for my behaviour that I’ve never understood.

W: I’ve got mild autism too. When I was younger, I didn’t want to leave my mum to go to school.

M: I get upset about things that I don’t really need to get upset about as well, but I can’t share it with you because it’s private. [The group sighs and nods in knowing unison]

T: I get really confused and upset about bullying. It’s so difficult to talk about because the bully I’m telling you about is a sort of friend. She hangs around when me and my good friend are together. Then she bullies my good friend when we’re not all together. I’m not sure if it would make it worse if I told the teacher.

W: I know I’m too scared to do anything because I’m worried that the bully might turn on me. And that makes me feel guilty.

C: This is all making me feel too distressed. [C is pulling the hood of her jacket up over her head] If you feel unhappy, ask for help. We don’t know if something might have happened to the bully to make him or her behave in this way. That happened to me in my old school.

It was at this point that I acknowledged, with my colleague, C’s distress and also C’s insight that the bully might also be hurting inside as a result of some kind of trauma. C pulled back the hood and told the group what had happened to her. I also ‘wondered aloud’ how it felt to be able to say she felt distressed. C then said she felt good because others understood. At the end of the session, she told the group that the discussion about bullying had been the best part! The others felt the same.

A safe space

A safe space – a gap to think – to bear the disturbing thoughts – to process something different – to pause and reflect before acting – to have a chance to work out for yourself what to do – to revisit what you have already done – to tap into a deeper part of yourself without the knee-jerk reactions taking over and the usual patterns happening – to think without adult advice or ‘taking over’ on your behalf – to be in the presence of others who can listen and accept you without getting emotionally involved on your behalf, or butting in, or fixing it.

The safe space of a therapy group is a pause between the regular activity before and after in our life. Just the act of thinking about and expressing chaotic and anxious feelings with those we trust can make them more manageable and understandable. If another acknowledges the feelings with something like, ‘I understand how you feel’ or ‘I can see that you are upset’, we might sigh with the relief of being understood, and can begin to think more clearly again. It was Wilfrid Bion who first described these ideas as ‘containment’.⁵

Containment needs to be at the heart of all therapeutic practice, but is all the more important when working with groups. Our practices at the start and finish of each session are containment. We start with ‘checking in’, using a stone for each child to hold as they speak. We finish with Murray White’s Lighthouse Goodbye,⁶ where the children take turns to ‘say goodbye’ with their eyes only. The environment is very important for containment: the lighting, the room temperature, the colour of the paintwork, what the children sit on. We sit in a circle on cushions on a carpeted floor.

There needs to be a clear framework to the sessions so the children know that ‘we do this, then we do that’, and so on. We have a clear framework of six ‘rhythms’, a term that I feel captures the gentle flow between the different parts of the session. I describe this in detail in my book, Making Friends.³

The key principle of the Friendly Group is that it is a place where children can feel safe. Within that principle of safety, there are seven aspects:

• Containment – including the physical environment and the framework of the sessions.
• Fostering the growth of relatedness – where the children and young people are learning through direct experience.
• Authority – learning to trust authority (both of the adults, and within the children and young people themselves).
• Supporting the whole family – regular group sessions/email contact for parents.
• Being non-judgmental and kind – recognising everyone’s value through positive, caring and empathic relationships.
• Offering encouragement and appropriate challenge.
• The Friendly Group is a microcosm of the outside world of family and school.

Many people are nervous about working with groups of children, but I would say, ‘Have a go!’ Find a colleague to work with you. I find that working with teachers is wonderful. At first, you can feel rather visible, working alongside another professional, away from the intimacy of one-to-one work. But children are always hopeful and forgiving, however much we feel unsure to begin with. I love the groupwork more than anything else. I feel it is such a privilege to watch and listen to vulnerable and autistic children successfully helping each other and making friends with one another. To be witness to such compassion is both humbling and inspiring. It’s my hope that, in time, there will be therapy groups like the Friendly Group in every school and clinic in the country.

Anita M Hughes is a chartered educational psychologist and author with nearly 40 years’ experience of working with children and adults. For the last 20 years she has had her own private practice, running the Friendly Group, offering counselling and providing training to practitioners.

References

1 Yalom ID, Leszcz M. The theory and practice of group psychotherapy (5th edition). New York: Basic Books; 2005.
2 Hogan JM. Impelled into experiences: the story of the Outward Bound schools. Wakefield: Educational Productions; 1968.
3 Hughes AM. Making friends: how the Friendly Group supports children and young people on the autism spectrum. London: Worth Publishing; 2017.
4 Veeken J. Bear cards: feelings. Victoria, Australia: Qcards; 2012.
5 Bion W. Learning from experience. London: Maresfield; 1984.
6 White M. Magic circles: self-esteem for everyone in circle time (2nd edition). London: Sage; 2009.

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