This article was downloaded by: [Ecole Hautes Etudes Commer-Montreal]

On: 16 August 2015, At: 17:17

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: 5 Howick Place, London, SW1P 1WG

Journal of Child Sexual Abuse

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/wcsa20

Structured Therapeutic Games for

Nonoffending Caregivers of Children Who
Have Experienced Sexual Abuse
a b c
Craig I. Springer , Giselle Colorado & Justin R. Misurell
a
Newark Beth Israel Medical Center, Newark, New Jersey, USA
b
Yeshiva University, New York, New York, USA
c
The Child Study Center at NYU Langone Medical Center, New York,
New York, USA
Published online: 10 Jun 2015.

Click for updates

To cite this article: Craig I. Springer, Giselle Colorado & Justin R. Misurell (2015) Structured
Therapeutic Games for Nonoffending Caregivers of Children Who Have Experienced Sexual Abuse,
Journal of Child Sexual Abuse, 24:4, 412-428, DOI: 10.1080/10538712.2015.1022295

To link to this article: http://dx.doi.org/10.1080/10538712.2015.1022295

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the
“Content”) contained in the publications on our platform. However, Taylor & Francis,
our agents, and our licensors make no representations or warranties whatsoever as to
the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content
should not be relied upon and should be independently verified with primary sources
of information. Taylor and Francis shall not be liable for any losses, actions, claims,
proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or
howsoever caused arising directly or indirectly in connection with, in relation to or arising
out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
 Conditions of access and use can be found at http://www.tandfonline.com/page/terms-
and-conditions
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015
 Journal of Child Sexual Abuse, 24:412–428, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1053-8712 print/1547-0679 online
DOI: 10.1080/10538712.2015.1022295

INTERVENTIONS AND PERCEPTIONS OF ADULT

SURVIVORS AND NONOFFENDING CAREGIVERS

Structured Therapeutic Games for

Nonoffending Caregivers of Children Who
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

Have Experienced Sexual Abuse

CRAIG I. SPRINGER
Newark Beth Israel Medical Center, Newark, New Jersey, USA

GISELLE COLORADO
Yeshiva University, New York, New York, USA

JUSTIN R. MISURELL
The Child Study Center at NYU Langone Medical Center, New York, New York, USA

Game-based cognitive-behavioral therapy group model for

nonoffending caregivers utilizes structured therapeutic games to
assist parents following child sexual abuse. Game-based cog-
nitive-behavioral therapy group model is a manualized group
treatment approach that integrates evidence-based cognitive-be-
havioral therapy components with structured play therapy to teach
parenting and coping skills, provide psychoeducation, and pro-
cess trauma. Structured therapeutic games were designed to allow
nonoffending caregivers to process their children’s abuse experi-
ences and learn skills necessary to overcome trauma in a non-
threatening, fun, and engaging manner. The implementation of
these techniques allow clinicians to address a variety of psychoso-
cial difficulties that are commonly found among nonoffending
caregivers of children who have experienced sexual abuse. In addi-
tion, structured therapeutic games help caregivers develop strengths
and abilities that they can use to help their children cope with

Received 2 October 2014; revised 16 December 2014; accepted 8 January 2015.

Address correspondence to Craig I. Springer, Psychological Services Clinic, Rutgers
University, 152 Frelinghuysen Road, Piscataway, NJ 08854. E-mail: craig.springer@rutgers.edu

412
 Structured Therapeutic Games 413

abuse and trauma and facilitates the development of positive

posttraumatic growth. Techniques and procedures for treatment
delivery along with a description of core components and therapeu-
tic modules are discussed. An illustrative case study is provided.

KEYWORDS game-based cognitive behavioral therapy (GB-CBT),

trauma, child sexual abuse (CSA) evidenced-based practice, struc-
tured therapeutic games (STGs)
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

The recognition of the importance of caregiver involvement in the treat-

ment of childhood problems and disorders has long been discussed in the
literature (Barmish & Kendall, 2005). Caregiver participation in therapy has
been shown to result in higher attendance rates, lower dropout, and better
therapeutic outcomes (Briggs, Runyon, & Deblinger, 2011). With caregiver
treatment involvement, children are likely to feel a greater sense of support,
are more likely to utilize therapeutic interventions at home, and caregivers
are more likely to value the therapeutic process, prioritizing it over other
competing activities (Bratton, Ceballos, Landreth, & Costas, 2011). Caregiver
involvement is especially paramount for the treatment of child sexual abuse
(CSA), because of which children’s trust in others has been violated and
sense of security has been shaken (Myrick & Green, 2013). Furthermore,
the negative impact of abuse often extends beyond the child to the entire
family, impairing caregivers’ ability to function and be emotionally available
for their children (Alisic, Boeije, Jongmans, & Kieber, 2012; Myrick & Green,
2013). Moreover, the literature has shown that caregiver involvement and
engagement in treatment is related to better treatment outcomes (Dowell &
Ogles, 2010; Manassis et al., 2014). While all of these reasons provide com-
pelling evidence for the importance of caregiver involvement in treatment
for CSA, there are many factors that interfere with caregivers’ willingness
and ability to participate. These include logistical obstacles (e.g., employ-
ment, transportation), but often the emotional and motivational factors are
most influential.
The psychological barriers to caregiver involvement in treatment for
CSA can be a result of a host of factors including feelings of guilt, concerns
about judgment, worries about being emotionally overwhelmed, and fears
about the therapeutic process itself (Myrick & Green, 2013). Clinicians can
effectively get caregivers involved and invested in the therapeutic process
by enhancing treatment by addressing concerns through the use of palatable
and engaging therapeutic methods. If treatment is administered in a manner
that is enjoyable, emphasizes collaboration, and processes emotionally laden
material in a gradual, emotionally sensitive, and supportive manner, caregiver
receptivity to treatment is likely to be increased. One method suggested in
the literature as a vehicle for developing skills and processing information
 414 C. I. Springer et al.

in a motivating and engaging manner is through the use of structured thera-

peutic games (STGs; Misurell, Springer, & Tyron, 2011; Springer & Misurell,
2012).
The use of STGs has predominantly been discussed in the context of
working with children. Games are thought to enhance the therapeutic and
learning process through their here-and-now focus, goal-directed nature, and
the motivation that they provide through healthy competition between play-
ers (Springer & Misurell, 2015). Furthermore, through their clearly delineated
rules and objectives, games create clear expectations and a lack of ambigu-
ity, contributing to a nonthreatening atmosphere. Therapeutic games have
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

been found to be efficacious for motivating and helping children with symp-
toms of attention-deficit/hyperactivity disorder, social skills deficits, conduct
problems, and anxiety disorders (Cavett & Drewes, 2012; Goodyear-Brown,
Fath, & Myers, 2012; Lowenstein & Hertlein, 2012). Lowenstein and Hertlein
(2012) describe several play therapy techniques helpful in engaging fami-
lies in the therapeutic process by allowing the families to further discuss
important family aspects and psychological issues with games aimed at
recalling positive attributes and strengths of the family. Similarly, Goodyear-
Brown and colleagues (2012) developed the flexibly sequential play therapy
approach for children with posttraumatic symptoms that utilize play tech-
niques and prop-based games to provide trauma-specific psychoeducation,
moderate some of the discomfort related to trauma content, and help the
children create a more cohesive narrative of their abuse. Cavett and Drewes
(2012) discuss the benefits of integrating play therapy with trauma-focused
cognitive-behavior therapy skills because it supports children’s feelings of
control, joy, and mastery. Games have been discussed as particularly useful
in the treatment of trauma since they seemingly make it easier to deal with
the high level of discomfort and avoidance that often accompanies such
experiences (Goodyear-Brown et al., 2012). Furthermore, games and play
have been described as allowing the traumatized brain to cool down, act,
and think more effectively, contributing to decreased arousal and a sense of
calm (Schaefer, 2003).
The utility of therapeutic games for enhancing motivation and interest
has been discussed in the treatment literature for children and adolescents.
However, while it would seem that these treatment methods would bene-
fit adults in similar ways, there has been very limited discussion of using
games with adults. Schaefer (2003) contends that the paucity of research and
literature on adult play therapy is due to societal views that depict play as
unproductive and infantilizing for adults. In his edited book, Schaefer (2003)
argues that play can be used effectively to help adults process and heal from
distressing life experiences as well as to address emotional, physical, and
social deficits caused by a traumatic childhood. More specifically, he explains
that games appear to allow adults to gain emotional control, stimulate intel-
lectualism, enhance social skill development, and facilitate generalizability
 Structured Therapeutic Games 415

by mirroring real-life situations. Furthermore, games and other forms of

play are known to provide a pleasurable experience to deal with serious
material. Finally, they are an effective means to nonverbal communication,
allowing for processing material that may be difficult or unable to be dis-
cussed verbally (Schaefer, 2003). For all of these reasons therapeutic games
would seemingly be helpful for assisting adults in processing traumatogenic
experiences.
The limited body of research on the use of games for adults has dis-
cussed the utility of traditional games (e.g., Uno, Sorry!, Payday) for treating
adult substance abusers who have trauma histories, indicating that games
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

are helpful in establishing rapport and overcoming resistance in treatment

(Schaefer, 2003). In addition, the military has developed and utilized video
games for combat training and for cognitive rehabilitation following trau-
matic brain injury (Burke et al., 2009; Rego, Moreira, & Reis, 2010). The
purpose of the present article is to discuss the caregiver group component
of a therapeutic model titled game-based cognitive-behavioral therapy (GB-
CBT; Springer & Misurell, 2015). GB-CBT utilizes STGs to assist caregivers
following their children’s experiences of sexual abuse (Springer & Misurell,
2010). The caregiver group, which runs concurrently with an elementary-
school-aged child’s group, allows for caregivers to process their emotional
reactions to their children’s abuse experiences and its aftermath and to assist
children in acquiring the skills necessary to support their children’s recovery
and the healing of their family in a supportive peer-group environment.
GB-CBT-GM integrates CBT and structured play therapy. Treatment is
delivered in a group therapy format using STGs to promote caregivers’ par-
ticipation and interest in treatment. Although, caregivers may experience
intrinsic motivation to engage in treatment, the use of points serves to
enhance motivation and enjoyment through both healthy competition and
a desire to be successful. Group games consist of various formats includ-
ing card games, puzzles, timed races, and trivia competitions. Some of the
games are played individually, while others involve working together as a
team. Games are used as a primary technique to deliver evidenced-based
CBT components that have been established to be important for treating
children and their caregivers following childhood sexual abuse. These CBT
components include psychoeducation about childhood sexual abuse, parent
management training, developing emotional regulation and coping skills,
exposure and processing of their children’s abuse experiences, and bolster-
ing skills to keep their children safe from potential risk (Springer & Misurell,
2010). In addition to the utility of the games, providing treatment in a group
format allows for the recognition that there is commonality of experience,
interpersonal learning and sharing of information, and catharsis (Misurell
et al., 2011; Springer & Misurell, 2010). While STGs have typically been used
to deliver and practice skills within a CBT framework, practitioners could
 416 C. I. Springer et al.

elect to integrate these techniques within the context of other theoretical

orientations.
The GB-CBT-GM caregiver group typically consists of 12 90-minute
weekly sessions, runs with 2 clinicians, a male and a female, and has
between 6 and 8 nonoffending caregivers per group. The group involves
reviewing material covered in the children’s group, teaching of parallel skills
and topics, bolstering parenting skills, providing opportunities for caregivers
to process their reactions to their children’s abuse experiences, and learn-
ing how to make informed choices to keep children safe. The goals of this
group are to help caregivers effectively teach and reinforce adaptive skills
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

to their children, teach caregivers how to be emotionally and physically

available to assist their child with abuse processing, and to help caregivers
create an atmosphere of safety and open communication. Similar to their chil-
dren’s groups, caregiver skills are covered and processed through the use of
STGs. The GB-CBT-GM caregiver group provides caregivers with in-depth
knowledge of procedures and content of their children’s group in addition
to providing them with information on how to support their children now
and in the future.
The session topics are arranged in a similar fashion to those in the
GB-CBT-GM children’s groups in that nonabuse material and general skill
building is covered initially, while abuse-specific material is covered during
later sessions. Earlier sessions focus on rapport building, emotional expres-
sion skills, and parent management training, while latter sessions focus on
psychoeducation about sexual abuse and healthy sexuality, cognitive coping
and relaxation strategies, gradual exposure, and personal safety skills.

GB-CBT-GM CAREGIVER GROUP

The session structure for the GB-CBT caregiver group begins with a discus-
sion of caregiver reactions to previous caregiver and child group sessions.
Caregivers are then presented with information about what their children
covered during that week and the specific methods that were used. This is
followed by the rationale and psychoeducation about the topic and skills
that will be covered in the caregiver group. STGs are then utilized to further
develop their knowledge and to experientially practice the therapeutic skills
that were taught. Therapy sessions conclude with processing the session’s
activities and the assigning of homework to practice skills at home.

Session 1: Introduction and Rapport-Building

The rationale and group structure of both the children’s and caregiver’s
groups are presented. Group clinicians discuss confidentiality and empha-
size the importance of caregiver collaboration for maximizing therapeutic
 Structured Therapeutic Games 417

outcomes. The focus of the first session is on helping caregivers to get

to know one another and build an environment of open communication
and sharing. Caregivers participate in an engaging and structured icebreaker
game titled “Getting to Know You Stack,” designed to develop rapport, instill
group cohesion, and promote multicultural awareness among group mem-
bers. This structured game was designed to provide caregivers with a forum
to introduce and share information about themselves in a nonpressured,
comfortable, and naturalistic manner while learning about the other members
of the group.
“Getting to Know You Stack” utilizes game cards each with a one-
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

point question and a three-point question. One-point questions pull for

surface-level answers (e.g., What is your favorite dessert?), while three-point
questions require deeper more thoughtful answers (e.g., Tell us why you are
here). The game begins with a clinician rolling a die and passing the card
stack around the room until the number of spaces rolled is counted out.
The person who the card stack lands on is asked to pick the top card, read
both questions out loud, and decide whether he or she would like to answer
either or both questions. Points are awarded based on which question(s)
were answered. Play proceeds with that person rolling the die and the game
continuing in the same manner for the amount of time allotted. At the end
of the game, points for each caregiver are tallied and announced.

Session 2: Emotional Expression and Linking Feelings to Experience

This session is devoted to the topics of emotional expression and recognition
skills. These topics are covered in the children’s group, during sessions 3 and
4. By helping caregivers expand their emotional vocabularies, they are likely
to utilize a wider range of emotions around their children and recognize
when their children are doing the same. This is thought to support their
children’s development of these skills.
One of the structured games utilized with caregivers for building emo-
tional expression skills is titled “Don’t Say a Word” and utilizes cards that
contain two feeling words. A target feeling word appears at the top and the
words “don’t say” appear next to a second word, which is a synonym to the
word at the top. This game is played in teams of two, in which one caregiver
gives verbal clues to the other in order to try to get her or his teammate to
guess the target word on the card. Once the target word is guessed on one
card, the clue giver goes on to the next card. The only caveat is that the clue
giver cannot use any part of the target or the “don’t say” word while giving
clues. Teams work to successfully complete as many cards as possible during
a specified period of time (e.g., one minute) and are awarded one point per
card. At the end of the game, teams are provided with their final scores.
A second structured therapeutic game used during this session titled
“Feeling Swap” involves discussing emotional experiences (e.g., How did
 418 C. I. Springer et al.

you feel when you had your first child? Talk about a time you felt scared).
This game begins with caregivers each randomly picking numbers written
on slips of paper. The number drawn designates when each caregiver will
be able to pick a question, starting with the caregiver who drew number
1. Upon receiving their question, caregivers read it aloud and then decide
whether to keep the question or trade it with a previously read question.
After everyone has chosen their questions and all of the exchanges have
been completed, starting with the person who drew number 1, caregivers
answer the current questions in their possession.
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

Session 3: Dealing with Difficult Emotions and Parent Management

Training
Session 3 focuses on developing parent management strategies and skills
for dealing with difficult emotions. Difficult emotions arise at various points
throughout daily life and during treatment, particularly when caregivers
are thinking about and processing their children’s abuse experiences. This
session begins with a discussion of strategies that caregivers currently use to
deal with their difficult emotions. They are then taught additional techniques
that may be helpful (e.g., deep breathing, engaging in self-care activities,
etc.).
Difficult emotions are also discussed in relation to parenting, which
is another topic that can elicit strong emotions. This is particularly evi-
dent when children engage in disruptive and frustrating behaviors or when
caregivers must set limits. The importance of effective, consistent, and appro-
priate parenting is emphasized in light of the tendency of some caregivers to
overindulge their children following their abuse experience. This is a topical
area that may present particular resistance from caregivers since everyone
has at least some exposure to parenting and may believe that they have
expertise in this domain. For this reason, the STG utilized during this ses-
sion may be particularly useful. During this game, titled “What If My Child
Did . . . ?,” caregivers provide suggestions and brainstorm with one another
rather than having the group clinician provide this information didactically.
This appears to contribute to receptivity on the part of caregivers to con-
sider and integrate effective parenting into practice. This game involves the
group clinician reading out a theoretical scenario containing a behavior that
caregivers’ children could engage in. Scenarios involve positive or negative
behaviors or situations that can occur at school (e.g., your child pulls the fire
alarm), home (e.g., your child pays you a compliment), or in public (e.g.,
your child runs away from you in the mall). Caregivers are asked to anony-
mously write down a possible response to the scenario, which are collected
and then read aloud. Next, caregivers vote on the response they like best.
The response with the most votes wins the round and is discussed, at which
time the person who wrote the response is encouraged to identify himself
 Structured Therapeutic Games 419

or herself and is then awarded points based on the number of votes that his
or her response generated. The game continues with another scenario being
presented.

Session 4: Psychoeducation Part 1: Learning about Child Abuse

This session focuses on providing caregivers with information about child
abuse, incident rates, outcome research, treatment options, and potential
psychological consequences for victims and their families and demystifies
the legal process. This session attempts to help caregivers understand and
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

make sense of their child’s sexual abuse experiences. A STG is used to

correct caregivers’ misconceptions, promote accurate knowledge, and help
them to become more comfortable with this material. This game, titled the
“Crossword Puzzle Race,” involves working as quickly as possible with
a partner to complete a crossword puzzle on these topics prior to other
caregiver dyads.

Session 5: Psychoeducation Part 2: Talking to Children about Child

Abuse
In addition to the information presented during session 4, information pre-
sented and reviewed during session 5 focuses on understanding how to
educate and respond to questions that children may have about sexual
abuse, healthy sexuality, and personal safety skills. Caregivers participate
in a game in which they answer questions in each of these categories. This
game, titled “Abuse Card Game Competition,” involves rolling a die and
answering a question based on the number rolled on a die (numbers 2 and
5 are designated as personal safety skills, 1 and 4 as sexual abuse, and 3 and
6 as healthy sexuality). For each acceptable answer consistent with the psy-
choeducational information that was provided earlier in the session, a point
is awarded. At the conclusion of the time allotted for the game, the caregiver
with the highest number of points is declared the winner.

Session 6: Psychoeducation Part 3: Becoming Comfortable Talking

about Child Abuse
Recognizing that the topic of sexual abuse and healthy sexuality may not be
an easy one to discuss, a game titled “Knowledge by Letter” is utilized in
which caregivers are asked to come up with responses for child abuse and
healthy sexuality prompts beginning with a letter designated at the begin-
ning of each round. For instance, if the letter designated is B and one of
the prompts is female private part, a possible response would be “breasts.”
After a specified period of time (e.g., two minutes), the number of valid
 420 C. I. Springer et al.

responses that each person generated is totaled and the caregiver with the
largest number of responses wins the round.

Session 7: Exposure Therapy Level I

Psychoeducation about the rationale and techniques of exposure in therapy
is presented. Caregivers participate in a basic disclosure game titled “Who,
What, Where in a Hat.” During this game, caregivers are given three sheets
of paper and are asked to write “who” was the person that sexually abused
their child, “where” did the abuse take place, and “what” body parts were
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

touched. Responses are then folded and placed in a hat. Finally, they are
read aloud and caregivers are asked to raise their hands if the response
relates to their child’s abuse experience. At this lower level of basic disclo-
sure, caregivers are not asked to talk about their children’s abuse but to
nonverbally acknowledge various aspects of it.
Caregivers then play a second basic disclosure game titled “Exposure
Card Game” in which caregivers roll a die and then share aspects of their
children’s abuse scenarios based on the number they roll. This higher level of
basic disclosure involves minimal verbal responses, although group clinicians
may encourage caregivers to elaborate on their answers. The six questions
are:

1. Who abused your child?

2. Where were they when they were abused?
3. How was your child abused?
4. How did you first learn that your child was abused?
5. How did you feel when you found out that your child was abused?
6. What would you like to see happen for your child? For the perpetrator?

Session 8: Exposure Therapy Level II

For this next level of exposure, caregivers participate in a structured thera-
peutic game aimed at helping them share, listen, and recall aspects of another
caregiver’s child’s abuse experience. During this game, titled “What’s the
Scoop?” caregivers are paired in dyads and asked to interview each other
using active listening. Each dyad is called up to the front of the room, one
at a time, to answer questions about their partner’s child’s abuse experience
(e.g., using the same six questions discussed in the previous game). For each
question, one partner writes down her or his response and the other part-
ner tries to recall or infer that partner’s response. The dyad with the most
matches at the end of the game is declared the winner.
 Structured Therapeutic Games 421

Session 9: Exposure Therapy Level III

For the highest level of exposure, an activity titled “My Parent My Idol”
is utilized. During this game, caregivers role-play themselves providing a
supportive response to another group member or leader role-playing their
child making a full disclosure to them. The other group members then assess
caregivers on their ability to provide supportive and appropriate responses
and their ability to encourage openness using a yes or no response. For
each successful area one point is earned. Caregivers are then provided with
feedback from the other caregivers about the things that they did well and
areas needing improvement.
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

Session 10: Personal Safety and Child Abuse Awareness

This session focuses on educating caregivers of their role in protecting
children from future abuse as well as providing them with information to
reinforce their children’s current knowledge of personal safety skills. A STG
is utilized to review personal safety skills and address misconceptions about
child abuse. This game, titled “Personal Safety Trivia Competition,” involves
caregivers racing one another to provide a comprehensive answer to ques-
tions about child abuse, neglect, and how to keep children safe and healthy.
Teams are asked questions contained on personal safety Q&A sheets in
which there are multiple parts to the correct answer. They are awarded one
point for each component of the answer that they provide.

Session 11: Relaxation Training and Coping Skills

In order to help caregivers cope with the intense emotions that may have
been elicited by the previously mentioned exercises, relaxation and coping
strategies are taught and practiced. These skills help caregivers during treat-
ment but also serve to enhance their ability to deal with future stressful
experiences. After providing the rationale for the importance of relax-
ation and coping, caregivers are taught diaphragmatic breathing, progressive
muscle relaxation, guided visualization, and mindfulness. Next, caregivers
participate in “Stress Away Guess Away,” a game in which they come up with
a creative and unique activity that they could do to calm themselves when
they are stressed or anxious. Each caregiver has a turn to think about the
activity of his or her choosing, while the other caregivers have an opportu-
nity to ask one yes or no question in order to help them guess the technique
that the person was thinking about. For example, a caregiver attempting to
guess the technique may ask, “Is it something you do inside your home?”
By answering yes or no, the caregiver responsible for thinking of the tech-
nique will be helping the others systematically rule out various possibilities.
Caregivers take turns asking yes or no questions until someone in the group
 422 C. I. Springer et al.

guesses the technique correctly. The group has a predetermined maximum

number (e.g., 20) of yes or no questions that can be asked. If no one in the
group is able to guess the technique correctly within the specified maximum
number of questions, the group member thinking of the technique shares it
with the group and earns a point for the round. If a group member guesses
correctly, he or she earns a point and another group member thinks of a
different stress reducing activity. The caregiver with the most points at the
end of the game is the winner.

Session 12: Termination Processing

Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

The final caregiver group therapy session focuses on consolidation of skills

and processing feelings of termination. The game utilized during this session
is titled “Guess Who Card Shuffle,” which involves caregivers randomly and
silently picking one another’s names and writing an answer to the ques-
tion, “What did this person teach you over the course of group?” on a
sheet of paper. Caregiver responses are collected and read out loud to the
group while maintaining the anonymity of the author and subject. After each
response is read aloud, all caregivers attempt to identify whom they believe
the response was about. The author earns a point for each person that pro-
vided a correct guess. Guessers also earn a point for each correct guess that
they made. The person with the most points at the end of time allotted for
the game is declared the winner.

Graduation Session
The graduation session is a time that children and their caregivers come
together and celebrate their individual and joint achievements. During the
graduation ceremony, caregivers play a game, during which they are asked
to share their thoughts and feelings about the program, their child’s achieve-
ments, and their hopes and desires for their children’s futures. Caregivers are
provided with a card containing a question, a number, and a blank space
for them to include their names. Starting with the caregiver that has “card 1,”
caregivers are asked to say their name, their child’s name, read aloud and
answer their question. If they are willing and able to do so, caregivers are
asked to write their name on the card, which is entered into a raffle for a
pre-established prize (e.g., lottery ticket).

CASE STUDY: CYNTHIA WATTS

The following provides an example of a typical case treated by GB-CBT-GM

for nonoffending caregivers. Identifying information was altered in order to
 Structured Therapeutic Games 423

protect the confidentiality of the clients being discussed. In addition, material

presented in this case study represents a composite of multiple cases in order
to illustrate the utility of the model. In order to avoid repetition, games are
not described but only referred to by name in this section. For a description
of the games, readers are asked to refer to the previous sections.
Cynthia and Thomas Watts, the parents of Robert Watts, a 7-year-old
Caucasian male, were referred for GB-CBT-GM caregiver group following
an allegation that Robert’s maternal uncle, Steven Flynn, had forced Robert
to perform oral sex on him and had put his penis into Robert’s buttocks.
Ms. and Mr. Watts have been divorced for the past three years but maintain
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

a cordial relationship and have shared custody of Robert. They willingly

agreed to participate in the same caregiver group in order to support their
son.
The allegation emerged when Ms. Watts questioned Robert after he was
observed playing with action figures in a sexual manner. Robert reportedly
explained that his uncle, Mr. Flynn, had engaged him in sexual activities on
multiple occasions while he was babysitting him at Ms. Watts’s home. Robert
told her that Mr. Flynn had offered to buy him videogames in exchange
for complying with his requests and had later threatened to hurt him if he
told anyone about the incidents. Following Robert’s disclosure, Ms. Watts
contacted law enforcement and Mr. Watts to inform them of the allegations.
During the investigation, Ms. Watts indicated that she had relied on Mr.
Flynn to care for Robert while she was working evenings at a nursing home.
She reported feeling devastated and guilty since it was her brother who had
sexually abused her son. Mr. Watts indicated that he was equally upset and
angry with Mr. Flynn since Mr. Flynn had been a longtime friend and had
even introduced him to Ms. Watts.
Robert and his family were subsequently referred for a psychosocial mal-
treatment evaluation. During their evaluation, Robert reported experiencing
a number of trauma-related symptoms, including flashbacks, nightmares, and
intrusive thoughts associated with the abuse. Ms. Watts also indicated that in
addition to observing her son playing with action figures in a sexual manner,
she had observed him playing with his penis on numerous occasions in the
living room. While discussing the abuse, Ms. and Mr. Watts reported that they
had been having a difficult time coping with their son’s victimization and that
it has caused significant tension in their family. Ms. Watts stated that she has
frequently had images of her brother touching her son, which she has had
difficulty getting out of her head. She also reported that she has had a hard
time sleeping, lost her appetite, and has felt lethargic. Mr. Watts described
experiencing intense anger and resentment toward both Mr. Flynn for
abusing Robert and Ms. Watts for allowing Mr. Flynn to have access to him.
Following their evaluation, Ms. and Mr. Watts began attending a GB-
CBT-GM group for nonoffending caregivers. Robert concurrently attended a
GB-CBT-GM group for children between the ages of 5 and 7 years old who
 424 C. I. Springer et al.

have experienced sexual abuse. During the first group session, Ms. Watts was
tearful and frequently expressed shock and disbelief about her son’s sexual
abuse, while Mr. Watts appeared frustrated and was argumentative with Ms.
Watts whenever she spoke. For example, during the “Getting to Know You
Stack,” Ms. Watts answered the question “What was one of your biggest
regrets as a parent?” by indicating that it was leaving Robert in Mr. Flynn’s
care. In response, Mr. Watts verbally attacked her, stating, “You should have
known better,” and stormed out of the room. After a short period of time, Mr.
Watts reentered the room and continued playing the game. As the game
progressed and nonabuse topics were discussed, Mr. Watts appeared more
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

relaxed, sharing his interests and preferences in response to the questions

that were selected. At the end of the session, Mr. Watts told the group that
he enjoyed meeting everyone and apologized for his behavior, explaining
that he was having a difficult time coping with his son’s abuse.
When Ms. Watts and Mr. Watts arrived to session 2, they sat on opposite
sides of the room and avoided eye contact with each other. Mr. Watts indi-
cated that he had been thinking all week about Robert’s abuse and believes
that he will never be able to forgive Ms. Watts for what happened to their
son. Ms. Watts, with tears in her eyes, exclaimed, “It was all my fault. I don’t
blame you for not forgiving me.” Some of the other group members also
began to express guilt and self-blame for their children’s abuse, indicating
that they failed as parents in not protecting their children. After processing
these feelings, the group was directed to begin playing the games “Don’t
Say a Word” and “Feeling Swap,” after which the group members acknowl-
edged that in relation to any event, there are a host of feelings that can be
experienced. Ms. Watts related this to the earlier discussion of feeling guilty
about Robert’s abuse experience and indicated that she also felt fear and
helplessness when she found out. Furthermore, she expressed great sorrow
in its aftermath due to the resulting discord in her family.
During session 3, Ms. and Mr. Watts expressed drastic differences in
their approach to parenting Robert. During the “What If My Child Did . . .?”
game, Ms. Watts voted for responses that reflected a more permissive and
indulgent approach. Mr. Watts, on the other hand, expressed his belief that
obedience and respect are expected and do not need to be rewarded. None
of their early responses earned votes from the other caregivers. As the game
progressed, it appeared that Ms. and Mr. Watts recognized that in order
to earn votes their responses would need to be more balanced. As such,
their responses became similar to other group members and consequently to
each other. Mr. Watts even received the most votes for round 4, in which he
answered the question “What if my child pulled the fire alarm in school?” by
indicating that he would try to understand why his son had done this instead
of overreacting and providing a harsh consequence.
Sessions 4 and 5 involved playing the “Crossword Puzzle Race” and
“Abuse Card Game Competition” games covering psychoeducation about
 Structured Therapeutic Games 425

childhood sexual abuse. During the “Abuse Card Game Competition,” Ms.
Watts became tearful and expressed having a difficult time understanding
how so many children experience sexual abuse. Upon learning that sex-
ual abuse is often perpetrated by someone familiar to the child, Ms. Watts
reiterated her remorse and guilt for allow the perpetrator to have access
to Robert in light of her own victimization by her stepfather. Following
her disclosure, Mr. Watts became infuriated explaining that he could not
believe that Ms. Watts could have gone through this herself and still did not
have the wherewithal to recognize that Mr. Flynn was a “pedophile.” During
this exchange, another group member spoke up stating that she was also
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

abused as a child and had not been able to prevent her child from being
abused. Furthermore, she defended Ms. Watts stating that people who sexu-
ally abuse children are manipulative, deceitful, and difficult to detect. Other
group members also expressed their support for Ms. Watts and stated that Mr.
Watts was out of line. These sessions concluded with Ms. Watts stating that
she understands Mr. Watts’s frustration and that she wants him to know that
this was unintentional and that she loves Robert more than anything in the
world. Mr. Watts acknowledged Ms. Watts’s sentiment and suggested that
they continue to focus on getting Robert the help that he needs.
Mr. and Ms. Watts arrived to session 6 together and appeared to be talk-
ing to each other in a more casual and relaxed manner. During “Knowledge
by Letter,” Mr. Watts provided a number of entertaining answers to which
Ms. Watts and the other group members responded with laughter and com-
pliments. Similarly, Mr. Watts provided supportive statements to Ms. Watts
and the other caregivers playing the game. Both Ms. and Mr. Watts at differ-
ent times during the session indicated that they enjoyed the game and that
humor made it easier to discuss the topic of sexual abuse.
During session 7, while playing “Who, What, Where in a Hat,” Mr. Watts
indicated that he was emotionally impacted by the similarity of the chil-
dren’s abuse experiences and the profound effect that it has had on them.
He also expressed that while it is difficult to admit, he believes that the abuse
could have as easily occurred when Robert was in his care because he also
trusted Mr. Flynn and had no idea that he was capable of hurting his son.
Another group member responded to Mr. Watts by praising him for his brav-
ery and insight. Following the “Exposure Card Game,” Ms. Watts indicated
that she was beginning to feel better discussing her son’s victimization and
highlighted that Mr. Watts’s support has been critical in helping her heal.
During session 8, when playing “What’s the Scoop?” Mr. Watts became visi-
bly upset when Ms. Watts’s partner was retelling Robert’s story, as related by
Ms. Watts. He exclaimed that he is sorry for blaming Ms. Watts for the abuse
and for criticizing her in the past.
When group members were informed that they would be pairing up
for the advanced disclosure game “My Parent My Idol,” Ms. and Mr. Watts
 426 C. I. Springer et al.

indicated that they would like to work together. During this game, Ms.
and Mr. Watts realized that there were differences in the details that each of
them knew about what had occurred to Robert. They frequently made sup-
portive statements to one another and focused on their need to be united
in order to help their son. Moreover, they expressed their admiration for
each other for working through this difficult process. During their role-plays
in front of the group, they provided comfort and affection to each other as
each took turns acting as their son, giving hugs and making supportive state-
ments such as, “It’s not your fault.” Other group members observing these
role-plays applauded Ms. and Mr. Watts’s efforts and complimented them on
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

their progress.
Mr. Watts showed great enthusiasm during session 10’s “Personal Safety
Trivia Competition” indicating that he not only wanted to keep his son safe
in the future but that he was also interested in helping other parents min-
imize risk within their families. Similarly, Ms. Watts expressed an interest
in developing an ongoing parent support group after treatment termina-
tion, which the other group members said that they would be interested in
joining. During the final two sessions, in which they played “Stress Away
Guess Away” and the “Guess Who Card Shuffle,” Ms. and Mr. Watts indi-
cated that they felt increasingly comfortable co-parenting and expressed their
admiration and appreciation to each other and the group.
At the conclusion of group, Ms. Watts indicated that she was no longer
experiencing depressive symptoms, guilt, or intrusive images of Robert’s
abuse. She also reported that she feels more confident in her ability to help
him. Mr. Watts similarly reported feeling better, indicating that he was no
longer experiencing anger toward Ms. Watts and stated that he feels closer
to Robert and hopeful that his son will be able to achieve his full poten-
tial. In addition, Robert’s posttreatment assessment indicated that he was no
longer experiencing symptoms of trauma or sexually inappropriate behav-
ior. During the group graduation, Ms. and Mr. Watts gave heartfelt speeches
about their family’s ability to overcome the abuse and that how they will
always be there for Robert in the future.

CONCLUSION

GB-CBT-GM caregiver group is a promising model for working with

nonoffending caregivers of children who have experienced sexual abuse.
The use of structured therapeutic games provides a forum for increasing
engagement and motivation within treatment, facilitates comfort, and pro-
vides opportunities for skill development and posttraumatic growth. For
detailed instructions on how to conduct the STGs included in this article,
readers are referred to the GB-CBT manual (Springer & Misurell, 2015).
 Structured Therapeutic Games 427

REFERENCES

Alisic, E. Boeije, H. R. Jongmans, M. J., & Kieber, R. J. (2012). Supporting children

after single-incident trauma: Parents’ views. Clinical Pediatrics, 51, 274–282.
doi:10.1177/0009922811423309.
Barmish, A. J., & Kendall, P. C. (2005). Should parents be co-clients in cognitive-
behavioral therapy for anxious youth? Journal of Clinical Child and Adolescent
Psychology, 34(3), 569–581. doi:10.1207/s15374424jccp3403_12
Bratton, S. C., Ceballos, P. L., Landreth, G. L., & Costas, M. B. (2011). Child–
parent relationship therapy with nonoffending parents of sexually abused
children. In P. Goodyear-Brown (Ed.), Handbook of child sexual abuse:
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

Identification, assessment, and treatment (pp. 321–339), Hoboken, NJ: Wiley

doi:10.1002/9781118094822.ch14
Briggs, K., Runyon, M. K., & Deblinger, E. (2011). The use of play in trauma-
focused cognitive-behavioral therapy. In S. W. Russ & L. N. Niec (Eds.), Play
in clinical practice: Evidence-based approaches (pp. 168–200). New York, NY:
Guilford.
Burke, J. W., McNeill, M. D. J., Charles, D. K., Morrow, P. J., Crosbie, J. H., &
McDonough, S. M. (2009). Optimising engagement for stroke rehabilitation
using serious games. The Visual Computer, 25(12), 1085–1099.
Cavett, A. M., & Drewes, A. A. (2012). Play applications and trauma-specific com-
ponents. In J. A. Cohen, A. P. Mannarino, E. Deblinger (Eds.), Trauma-focused
CBT for children and adolescents: Treatment applications (pp. 124–148). New
York, NY: Guilford Press.
Dowell, K. A., & Ogles, B. M. (2010). The effects of parent participation on child
psychotherapy outcome: A meta-analytic review. Journal of Clinical Child &
Adolescent Psychology, 39(2), 151–162.
Goodyear-Brown, P., Fath, A., & Myers, L. (2012). Child sexual abuse: The scope
of the problem. In P. Goodyear-Brown (Ed.), Handbook of child sexual abuse:
Identification, assessment, and treatment (pp. 3–28). Hoboken, NJ: Wiley.
Lowenstein, L., & Hertlein, K. (2012). Engaging children in family sessions: Three cre-
ative interventions. Journal of Family Psychotherapy, 23(1), 62–66. doi:10.1080/
08975353.2012.654090
Manassis, K., Lee, T. C., Bennett, K., Zhao, X. Y., Mendlowitz, S., Duda, S., &
Wood, J. J. (2014). Types of parental involvement in CBT with anxious youth:
A preliminary meta-analysis. doi:10.1037/a0036969
Misurell, J., Springer, C., & Tryon, W. W. (2011). Game-based cognitive-behavioral
therapy (GB-CBT) group program for children who have experienced sexual
abuse: A preliminary investigation. Journal of Child Sexual Abuse, 20(1), 14–36.
doi:10.1080/10538712.2011.540000
Myrick A. M., & Green, E. J. (2013). A play-based treatment paradigm for
nonoffending caretakers: Evidence-informed secondary trauma treatment.
International Journal of Play Therapy, 22(4), 193–206. doi:10.1037/a0034560
Rego, P., Moreira, P. M., & Reis, L. P. (2010, June). Serious games for rehabilitation:
A survey and a classification towards a taxonomy. In Information Systems and
Technologies (CISTI), 2010 5th Iberian Conference on (pp. 1–6). IEEE.
Schaefer, C. E. (2003). Play therapy with adults. Hoboken, NJ: John Wiley & Sons.
 428 C. I. Springer et al.

Springer, C., & Misurell, J. R. (2010). Game-based cognitive-behavioral therapy

(GB-CBT): An innovative group treatment program for children who have
been sexually abused. Journal of Child and adolescent Trauma, 3(3), 163–180.
doi:10.1080/19361521.2010.491506
Springer, C., & Misurell, J. R. (2012). Game-based cognitive-behavioral therapy indi-
vidual model for child sexual abuse. International Journal of Play Therapy,
21(4), 188. doi:10.1037/a0030197.
Springer, C. I., & Misurell, J. R. (2015). Game-based cognitive-behavioral therapy for
child sexual abuse: An innovative treatment approach. New York, NY: Springer.
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 17:17 16 August 2015

AUTHOR NOTES

Craig I. Springer, PhD, was a supervising psychologist at Newark Beth Israel

Medical Center when this manuscript was written. He has since become
the director of the Psychological Services Clinic at Rutgers University. He
co-developed game-based cognitive-behavioral therapy, a therapeutic model
that integrates cognitive-behavioral therapy with structured play therapy. His
current research interests focus on evaluating and disseminating evidenced-
based practices for treating childhood problems and disorders.
Giselle Colorado, MS, is a doctoral candidate at the Ferkauf Graduate School
of Psychology at Yeshiva University and a psychology intern at Lincoln
Medical and Mental Health Center. She is currently completing her disserta-
tion research on supporting children’s social emotional skills and behavioral
development through teacher–child interaction training.
Justin R. Misurell is the clinical director of The Child Study Center at NYU
Langone Medical Center New Jersey Campus. He co-developed game-based
cognitive-behavioral therapy and is currently working to expand applications
of this transdiagnostic approach for addressing a wide range of childhood
disorders and difficulties.