Articol 4 A

Clinical Case Studies
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Killing Monsters : Combining a Novel Treatment Approach With Psychoeducational Counseling

Susan K. Williams and Lauren M. Hutto
Clinical Case Studies 2006 5: 161
DOI: 10.1177/1534650103261224
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CLINICAL
10.1177/1534650103261224
Williams, Hutto
CASE / KILLING
STUDIESMONSTERS
/ April 2006
Killing Monsters
Combining a Novel Treatment Approach
With Psychoeducational Counseling
SUSAN K. WILLIAMS
Yale University
LAUREN M. HUTTO
Florida State University
Abstract: The following case study examines a novel treatment strategy used to address one
boy’s fears, employed in the context of an 8-week psychoeducational counseling experi-
ence. As the focus of this article is a specific intervention strategy that occurred during the
counseling process, brief information on the theoretical underpinnings, organization, and
constituency of the counseling group is provided, although the authors emphasized a sin-
gle critical incident during which the strategy was implemented. This article emphasizes
(a) the flexibility required in conducting this type of group work and the need to adapt
group structure to the needs of the members; (b) the need to sometimes develop novel, and
often spontaneous, treatment strategies; (c) the related convergence of multiple disciplines
(e.g., psychology, religion, medicine); and (d) empathy when working with childhood
fears. Related to these factors, specific recommendations for practice and training are out-
lined.
Keywords: psychoeducational counseling; mood disorders; children; treatment; child-

hood fears
1 THEORETICAL AND RESEARCH BASIS
As the specific treatment strategy, which will be discussed later, is novel and neither
theoretically nor empirically grounded, such a discussion is not considered feasible or
applicable. However, the following summary of the theoretical and empirical basis for
the counseling group, in which the approach was developed, may provide the reader
with some helpful contextualization. The theory and motivation behind the group rep-
resents a convergence of three broad areas: cognitive-behavioral theory (CBT; Dobson,
AUTHORS’ NOTE: Correspondence and requests related to this article should be addressed to Susan K. Williams,
Ph.D., Child Study Center, 230 South Frontage Rd., P.O. Box 207900, New Haven CT 06520-7900; e-mail: susan.williams@
yale.edu
CLINICAL CASE STUDIES, Vol. 5 No. 2, April 2006 161-185
DOI: 10.1177/1534650103261224
© 2006 Sage Publications
161

162 CLINICAL CASE STUDIES / April 2006
TABLE 1
General Format of the Eight Sessions
Session Content Outline
1 Getting to know each other; learning about mood disorders; affective education;
confidentiality discussion; and group rules
2 Review goals; discussion of psychopharmacology for kids; suicidality; school issues;
externalization of the disorder
3 Teaching CBT basics (the relationship among thoughts, feelings, and behaviors); relaxation
and guided imagery
4 Review CBT; social skills training; using I statements; stop and think
5 Revisit social skills training; discussion of the importance of activity; scheduling
6 Tracking moods; biosocial rhythms
7 Review mood tracking and activity scheduling; practicing social skills
8 Review goals and develop new goals; saying good-bye
NOTE: CBT = cognitive-behavioral theory.
2001), group work with children and adolescents (McGinnis & Goldstein, 2000; Stark,
Napolitano, Swearer, Schmidt, Jaramillo, & Hoyle, 1996), and family based
psychoeducational treatment of children’s mood disorders (Fristad, 1999). The group
was designed to meet three primary goals: (a) to increase the perceived social support
among the group members, (b) to increase the children’s awareness of mood disorders
and their understanding and symptom management abilities, and (c) to improve the
children’s social skills. The group consisted of eight sessions, each lasting approximately
75 minutes. The broad focus of each of the sessions is provided in Table 1.
The group drew objectives and strategies from the related areas of CBT, group
counseling with children, and psychoeducational treatment of children’s mood disor-
ders. To address the underlying distorted thoughts and negative behaviors that are very
often associated with depression and mood disorders, the group employed a cognitive-
behavioral approach (Stark et al., 1996). The cognitions of depressed youth are domi-
nated by a preponderance of negative automatic thoughts. One goal of CBT is to replace
such negative thoughts with more adaptive and fewer self-evaluative cognitions.
Although much is yet to be learned about the etiological and treatment factors
associated with childhood mood disorders, current literature indicates success with
using CBT modalities in therapeutic work with children and adolescents (Kahn, Kehle,
Jenson, & Clark, 1990; Lerner & Clum, 1990; Lewinsohn, Clarke, Hops, & Andrews,
1990; Reynolds & Coats, 1986; Stark, Reynolds, & Kaslow, 1987; Stark, Rouse, &
Livingston, 1991). There are many well-known and successful cognitive-behavioral
models for the treatment of child and adolescent depression (Finch, Nelson, & Ott,
1993). Stark’s (1990) program, for example, stresses the importance of teaching children
to connect feelings of depression to depressive thoughts and includes aspects such as
affective education, cognitive restructuring, problem solving, event scheduling, and
assertiveness training.
According to a statement issued by the National Institute of Mental Health
(NIMH, 2000), recent research has shown that short-term psychotherapy, CBT in par-

Williams, Hutto / KILLING MONSTERS 163
ticular, is effective when treating children and adolescents with depression. In an

NIMH-funded study comparing different therapeutic modalities in the treatment of
childhood and adolescent depression, 65% of those treated with CBT showed signifi-
cant improvement. This was a notably higher rate of improvement in comparison to
children who received supportive therapy or family therapy. The NIMH also reported a
more rapid treatment response, indicating that CBT is often the current treatment of
choice when working with depressed children and adolescents.
Given the theoretical and empirical evidence supporting CBT, this group
employed a strong CBT component. The relationships between thoughts, feelings, and
behaviors and how negative interpretations and distorted thoughts can affect one’s emo-
tions and resulting behaviors were discussed. Such topics were discussed using language
appropriately geared for middle childhood (e.g., “no-good thinking”), figures and dia-
grams that made the concepts more concrete (e.g., interlocking gears, pictures), and
role-play scenarios. Related to this, the group discussed techniques to manage and cope
with each of the three primary psychological domains—mood, behavior, and thinking.
By teaching skills such as relaxation (e.g., deep breathing, imagery, and progressive mus-
cle relaxation), reframing and restructuring, and by talking about the importance of
monitoring moods and labeling emotions, the abstract relationship among the three
constructs was made more concrete and understandable, and the children gained tools
for their psychological toolbox in the process.
As Stark et al. (1996) have concluded, childhood depression is most effectively
treated holistically with intervention targeted at multiple levels, including biological
causes (with tricyclic antidepressants or selective serotonin reuptake inhibitors [SSRIs]),
psychosocial influences (with parent training and family counseling), and the children’s
behaviors and emotions (with strategies such as affective education, skills training, and
cognitive restructuring). Additionally, combining individual child therapy with group
counseling can often be especially effective in helping the child to feel safe enough to
disclose in and learn from a group experience (Stark et al., 1996). Individual therapy
with the child can help the child become engaged in treatment and be more compliant.
Adjunct group work for the therapeutic treatment of childhood mood disorders can be
especially useful for several reasons. Specifically, groups provide a supportive environ-
ment for children who often feel socially incompetent, a safe place to learn and practice
new skills (including social skills), and a fertile ground for developing and hearing multi-
ple viewpoints, thus offering more divergent opportunities for new learning (Stark et al.,
1996).
It is well documented that children with psychiatric concerns, including mood dis-
orders, often either fail to develop appropriate prosocial skills or do not use their skills to
the best of their abilities (McGinnis & Goldstein, 2000; Stark et al., 1996). Mood-disor-
dered youth often do not fully develop age-expected social skills because of their disabili-
ties (Fristad, Gavazzi, & Soldano, 1998). Children who are depressed tend to interact
with others in characteristically angry and withdrawn ways and often elicit negative or

even avoidant reactions from others (Stark et al., 1996). The ability to engage in mutu-
ally beneficial interactions with peers and others, termed social competence, is an impor-
tant developmental marker and is predictive of long-term healthy adjustment (Beelman,
Pfingsten, & Losel, 1994; Gresham, 1995). Children can be formally taught appropriate
social skills, which are the behaviors that reflect one’s social competence.
Reed (1994) concluded that using a specific social skills program can help alleviate
depressive symptomatology, especially with males. Such findings support the conten-
tion that social skills training should be an integral part of any work with children and
adolescents. One of the most effective ways to formally teach social skills to children who
have deficits in social skills acquisition is in a group format, via modeling, coaching, and
behavioral rehearsal (Gresham, 1995). A manualized social skills training approach that
incorporates modeling, role-play, and feedback is the Skillstreaming Model (Goldstein,
Sprafkin, & Gershaw, 1995). This was the model employed by the current group. Skills
such as making I statements, labeling emotions, and dealing with negative emotions
were reviewed and practiced.
Finally, this group incorporated some aspects of Fristad’s (1999) group work with
families of children with mood disorders. The multifamily group psychoeducational
(MFPG) treatment approach was developed in part to address the caretaker burden asso-
ciated with raising children with mood disorders. MFPG is an empirically validated,
manual-driven psychosocial intervention model for children diagnosed with bipolar dis-
order and their families (Fristad, Goldberg-Arnold, & Gavazzi, 2002). This approach
incorporates concurrent group treatment for children with mood disorders and for the
parents of children with mood disorders (Goldberg-Arnold, Fristad, & Gavazzi, 1999).
Treatment studies have supported the efficacy of the MFPG treatment approach as
adjunctive treatment for childhood mood disorders (Goldberg-Arnold et al., 1999). The
MFPG treatment approach has been found to help increase parents’ perceived social
support and their acquisition of information about mood disorders and their treatments.
Parental attitudes have also been found to shift during the course of treatment to a more
positive approach toward their children and the symptoms. Clinically, the opportunity to
meet and interact with other families who have children with mood disorders may result
in an interesting social-comparison phenomenon in which parents begin to view their
child more positively and see themselves as more capable of handling the stress associ-
ated with raising their child (Fristad et al., 2002).
Although Fristad’s (1999) MFPG treatment targets both parents and the identified
children, the counseling intervention described in this article focuses only on the mood-
disordered children. Because of time limitations and recruitment complications in
working with clinic-referred children, it was unfortunately not feasible to include care-
givers in the treatment. Despite this fundamental deviation in structure and targeted
participants, our group’s format, as well as many of its strategies and objectives (Fristad,
Gavazzi, & Soldano, 1999), were adopted and adapted from the MFPG model.

Objectives and strategies were also adopted from other treatment paradigms. An
activity and mood tracking system was adapted from studies that have reported on the
importance of biological and psychosocial daily rhythms and daily routines (e.g., sleep
and wake cycles, mealtimes, daily activities). This approach stresses the importance of
establishing and maintaining regular biological rhythms (Ehlers, Frank, & Kupfer,
1988; Monk, Flaherty, Frank, Hoskinson, & Kupfer, 1990; Monk, Reynolds, Machen,
& Kupfer, 1992). Upsets in daily social cycles may influence dysfunctional circadian
rhythms, which have been linked to the psychopathology of depression (Monk et al.,
1990). For the purposes of the present group, a modified daily activity log was developed
for the children to track their activities, moods, thoughts, and behaviors. Activities such
as waking up, eating breakfast, and the first interaction of the day with someone else were
listed on the log. The children were instructed on how to record the time, mood, behav-
ior, thoughts, and overall rating of mood for each listed behavior. These charts were used
to help establish and identify rhythms for the children and to pinpoint relationships
among activities (e.g., waiting for lunch, watching TV), thoughts (being bored), moods
(feeling irritable), and behaviors (fighting with sibling).
In summary, the present intervention program combined aspects from several
related approaches and models. The program is best described as a children’s counseling
group that is didactic in nature and that incorporates many psychoeducational compo-
nents. Its material and purpose were drawn from many sources, including CBT, normal
developmental issues such as navigating family relationships and opposite sex relation-
ships, social skills training, structured treatment programs for children with mood disor-
ders, family systems dynamics, and biosocial rhythm research. The children received
information about their moods and mood disorders, management tools for coping with
their disorders, and social survival skills.
2 CASE PRESENTATION
The following case is divided into two related sections. The first section discusses
the general format and processes of the previously described group intervention, includ-
ing mostly qualitative accounts, supplemented by some quantitative data, on its efficacy.
Additionally, some of the limitations and difficulties involved in developing and con-
ducting such a group are reviewed. The purpose of this section is to provide the reader
with a broad overview of some of the caveats, limitations, and procedural issues in devel-
oping and conducting such a group as well as to give information regarding specific tech-
niques and their clinically observed efficacy. The second section, which is the primary
topic of the article, focuses on one of the participants and a critical incident that
occurred during one of the group sessions. We chose to focus on this particular session
because it highlights some rather unusual characteristics and therapeutic strategies. It is

hoped that this format will lend credence to a fuller understanding of the use of novel
approaches when working in such a group context.
Part 1 of the Case Conceptualization section (discussed below) first presents a brief
review of the group participants, including their age, presenting concerns, and diagnos-
tic histories. Issues related to group dynamics and the structure of the session are also
reviewed. Part 2 of the Case Conceptualization section discusses an intervention with
one of the participants, Jeremy (pseudonym). During Week 6 of the treatment group, the
group’s coleaders happened to stumble on a rather unusual treatment strategy that has
not been previously described in the treatment literature. This case study describes an
in-group intervention involving Jeremy and some of his most scary monsters. It is our
hope that this information will be useful to others, both fledgling and more seasoned
practitioners, in their work with children who show fears that border on hallucinations,
in which the guides of best practice in treatment are oftentimes blurry at best and
nonexistent at worst.
3 PRESENTING COMPLAINTS
PART ONE
This group was initiated as a response to a need seen in the community for a tar-
geted group designed for children with mood disorders. The clinic where the group was
held reported having several potential clients with suspected or diagnosed mood prob-
lems who could benefit from participation in such a group. Several children were ini-
tially referred for the group. The families of referred children were contacted, and chil-
dren who met group inclusion criteria (ages 9.0 to 12.11 and have a diagnosed or
suspected Axis I mood disorder) were invited to participate.
At the start of the group, the group’s membership consisted of three elementary
school boys. The children presented some varied concerns, including family relation-
ship problems, peer relationship difficulties, some social isolation, and affective con-
cerns (e.g., sleep difficulties, coping strategies, anger).
Mark (pseudonym), age 10, was a White fourth-grade student referred primarily
for problems with aggression. He had been formally diagnosed with ADHD (combined
type) and had secondary diagnoses of anxiety and depression. At the start of the group,
Mark was prescribed Zoloft, Ritalin, and Metadate CD.
After the first two sessions, Mark decided that he did not want to be in the group and
subsequently dropped out. Mark’s most obvious concerns were behavioral in nature. He
had received multiple school referrals for aggression and fighting, and his social prob-
lem-solving deficits were clear. For example, when asked about options he had for han-
dling the stress of social difficulties, his only coping mechanism was to “beat someone
up.” Mark’s reasons for leaving the group were unfortunately never clearly understood;

his mother indicated to us that he decided he did not want to be in it any longer. How-
ever, it was quite clear in the first two sessions that Mark enjoyed talking about aggressive
themes and issues. Because this was not the focus of the group, he may have felt that the
group did not really apply to him or see any benefit in participating. Further information
and insight regarding his reasons for leaving the group would likely be useful in making
either the group more targeted in terms of member recruitment (e.g., excluding youth
with primarily social or peer aggression problems) or, conversely, in making the group
more applicable and relevant for a broader range of children. The two remaining boys,
Jeremy and Thomas (pseudonym), continued in the group until its conclusion.
Thomas, age 11, was a White fifth-grade student who had previously been diag-
nosed with ADHD and Tourette’s disorder. He was a precocious, talkative boy with supe-
rior intellectual abilities. There was some documented concern about a possible mood
disorder, although this had not been formally diagnosed. He presented symptoms of
depression, anger control difficulty, and oppositional tendencies in the home as well as
at school. Individually, Thomas also self-reported sleep disturbances (i.e., not being able
to fall asleep at night and being too sleepy during the school day). At the onset of the
group, Thomas was taking Adderall, Ritalin, and Clonodine. Thomas lived with his
mother, a single parent, and was close to his maternal grandparents. His father was not
present in the home or involved in Thomas’s life.
Jeremy, age 9, was an African American, third-grade boy who was referred for prob-
lems with depression. Depression was believed to be secondary to his mother’s death.
His caretaker (aunt) also reported concerns with deficient social skills, school failure,
and poor family relationships. Jeremy had a Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-IV-TR; 4th ed. text revision, American Psychiatric Association,
2000) primary diagnosis of ADHD, with secondary depression and associated concerns
related to anxiety. Jeremy’s mother had died of a heart attack the day after the 9/11 trag-
edy. Jeremy had significant academic difficulties, and his intellectual ability was esti-
mated to fall in the low average range. At the start of the group, Jeremy was prescribed
Zoloft.
PART TWO
Jeremy was small for his age and presented as a very friendly boy with an endearing
personality and a loving heart. At the beginning and the end of sessions, he would often
hug the leaders and was obviously eager to please adults. Jeremy was the prototypical
ideal client in some ways, given his eagerness, motivation, and cooperative demeanor. In
other ways, however, he displayed some very difficult and challenging clinical
symptoms.
As previously noted, Jeremy had experienced a very difficult year. The day after the
9/11 attack in New York City, his mother died of a heart attack. She was his sole care-
giver, and he subsequently was cared for by his aunt. According to reports provided by his

aunt and his caseworker, he understandably had great difficulty coping with the loss of
his mother and was prescribed an antidepressant (Zoloft). Unfortunately, he was mistak-
enly given too much of the medication and was reported to experience visual hallucina-
tions and delusional thinking as a result. After his medication was stabilized, these symp-
toms abated, and he began doing somewhat better. However, he was still very much
bothered by thoughts of his deceased mother, death, monsters, suicide, and other
themes of threat and loss of those around him. He had been formally diagnosed with
depression and was not receiving any individual counseling at the beginning of this
group.
In working with children in counseling, especially in a social service setting, two
issues often come up rather quickly that are not always formally or thoroughly addressed
in many applied training programs. These are (a) the multifaceted role that the coun-
selor is called on to take and (b) the blurry distinction between the real and imagined
monsters that children face. The first issue is related to how the mental health practitioner
should form the center pillar in a web of support systems that often includes several inter-
disciplinary professionals and involved people, such as the physician and/or psychiatrist,
teachers, parents, caseworkers, and extended family and siblings. The counselor is not
an island unto herself or himself, but instead must be in close communication with other
professionals and family members as part of a comprehensive treatment team.
The second issue is more directly linked to the modern challenges that many chil-
dren face. Included in this category are the old standards like premarital sex, peer pres-
sure, and the lure of alcohol and street drugs. However, newer issues often come to bear
as well, such as the interactions and potential side effects of prescription psychotropic
medications, the plethora of true as well as fictional information easily accessible via the
Web and television media by which kids and families are often bombarded, and the ever
increasing demands motivated by high academic standards and social pressures. Perhaps
the one challenge that is not new, per se, but unfortunately is not often addressed in the
literature, is the problem of how to discern the monsters that all children face at some
point in their lives and those that reflect pathological, disordered thinking. There are
those normal fears that arise out of the active, unbridled childhood imaginations (e.g.,
the boogie man and the scary monster under the bed), and then there are those that are
more pathological in nature, which may reflect true childhood psychosis (e.g.,
hallucinating that the monster really is there).
4 HISTORY
Potential participants for the group were contacted by the two group leaders and/or
by their caseworkers at a local children’s medical agency. Referrals were taken from pre-
vious clients of a university-based consultation and evaluation center for children and
from a community mental health clinic. Participant selection was determined according

to two basic criteria: (a) children between the ages of 9 and 12 years at the start of the
group and (b) either be diagnosed with a DSM-IV-TR Axis I mood disorder or display
characteristics of potentially having such a diagnosis. Interested families were sent infor-
mation describing the group, and informed parental consent and child assent was
collected from all attendees.
Briefly, the psychiatric histories of the two boys, Jeremy and Thomas, were quite
different. Jeremy’s mood disturbance and behavioral difficulties were readily associated
with a discrete identifiable event, his mother’s death. At the time of his mother’s death,
he was already diagnosed with ADHD. His depressive mood was triggered by this event,
and he subsequently received the secondary diagnosis of depression. Jeremy was started
on Zoloft approximately 1 year following his mother’s passing. As previously mentioned,
there was a miscommunication regarding his medication dosage, and Jeremy was acci-
dentally given the maximum dosage of Zoloft, as opposed to the lowest dosage and titrat-
ing up, which was the intention. As a result, Jeremy was admitted to the emergency room
with seizure-like symptoms and signs characteristic of a drug overdose, as well as visual
hallucinations of his dead mother. Following this incident, Jeremy began receiving indi-
vidual counseling, but it was intermittent because of scheduling and logistic difficulties
(arranging transportation) and was eventually discontinued entirely.
Onset of Thomas’s mood disturbance and associated behavioral problems was
more chronic and insidious than was that of Jeremy. His family history was positive for
mood disorders, specifically bipolar disorder. Thomas was diagnosed with ADHD at 5
years old and was prescribed Ritalin. One year later, he was switched from Ritalin to
Adderall but had a negative reaction to the Adderall, and it was discontinued. In the sum-
mer of his second-grade year, he was diagnosed with Tourette’s syndrome and was placed
on Clonodine and Risperadol. Despite Thomas’s superior intellectual abilities, he was
retained in kindergarten because of difficulties with emotional readiness and motor
skills. He was subsequently placed in an exceptional student education classroom, classi-
fied as emotionally handicapped, and received occupational therapy. Since this initial
placement, he was being gradually mainstreamed into a regular education classroom.
However, he continued to exhibit multiple behavioral difficulties such as work refusal,
sleeping in class, off-task behavior, and defiance. At the start of the group, Thomas had
been receiving individual counseling consistently.
5 ASSESSMENT
Several objective and subjective measures were used to assess change during group
counseling. However, as only two children completed the designed intervention, it was
not feasible to analyze change quantitatively. Therefore, the measures were used to
gauge individual change. The children in the group were administered two self-report
scales: the Reynolds Child Depression Scale (RCDS; Reynolds, 1989a) and a question-

naire designed to gauge knowledge of mood disorders, based on the Understanding

Mood Disorders Questionnaire (UMDQ; Gavazzi, Fristad, & Law, 1997). The caretak-
ers were asked to complete the Achenbach Child Behavior Checklist (CBCL;
Achenbach & Rescorla, 2001). Subjective indices of change included goal statements,
verbal self-reports from the children, and parental feedback.
The RCDS (Reynolds, 1989a) is a criterion-referenced, self-report measure of
depressive symptomology developed for children ages 8 through 12. It consists of 29
Likert-type items and 1 item consisting of faces that depict emotion. Higher scores indi-
cate higher levels of depressive symptomology. Raw scores above 74 correspond to clini-
cally relevant levels of symptom endorsement associated with depression; children who
score above 80 are likely experiencing severe depression (Poznanski et al., 1984). In
terms of internal consistency, alpha coefficients for the scale range from .87 to .90 for
children (grades 2 through 7). Test-retest reliability has been found to be relatively high
at 2-week (.82) and 4-week (.85) intervals (Reynolds, 1989b). There is also consistently
strong evidence for the convergent validity of the scale (e.g., correlations of .68 to .72
with the Children’s Depression Inventory; Kovacs, 1979, 1981; .76 with the Children’s
Depression Rating Scale–Revised; Poznanski et al., 1984). The RCDS was administered
three times during the group intervention.
An additional inventory was used to assess the group members’ knowledge and
understanding of mood disorders, as well as their ability to identify symptoms indicated
for depression and mania. The questionnaire used to gauge the participants’ understand-
ing of mood disorders and treatment was modeled from a self-report questionnaire: the
UMDQ (Gavazzi et al., 1997). The first 20 items on the UMDQ assess one’s attributions
about mood disorders, symptom knowledge, course, and treatment. The scale also
includes a 19-item checklist useful in gauging awareness of key manic and depressive
symptoms. Higher scores on each section reflect a better knowledge base or stronger
understanding of mood disorders and their treatment. The UMDQ has been found to be
psychometrically sound. The scale has an internal consistency (alpha) of .73 (Gavazzi
et al., 1997). Although preliminary data look promising for the scale, further analysis of
its psychometric properties using larger sample sizes has been recommended (Gavazzi
et al., 1997). A revised scale was employed because not all of the content covered by the
UMDQ was reviewed in the present group. The adapted instrument was administered
three times during the course of the group intervention to gauge change incrementally.
The Achenbach CBCL (ages 6 to 18; Achenbach & Rescorla, 2001) is a complex,
norm-referenced instrument designed to assess child competence, school issues, and
behavior. It is a multistep form that requires the parent to provide demographic informa-
tion, competence ratings, free-response narrative, school history and placement issues
(including current grades and standardized test scores), and a Likert scale system assess-
ing the degree to which a child displays a range of behaviors. For the syndrome scales, T

scores (which have a mean of 50 and a standard deviation of 10) that fall between 65 and
70 are considered borderline clinical; scores above 70 are clinically high. The syndrome
scales, which assess maladaptive behaviors, are further grouped into internalizing and
externalizing domains. The internalizing scale includes the anxious and depressed,
withdrawn and depressed, and somatic complaints scales; the externalizing scale
includes rule-breaking behaviors and aggression. The social problems, thought prob-
lems, and attention problems scales are not incorporated into the internalizing or
externalizing scales. The DSM-oriented scales were constructed using descriptive crite-
ria from the DSM-IV-TR. Individual items were rated by experienced psychiatrists and
retained based on their diagnostic value. Children are rated in accordance with the
number of symptoms displayed. Again, scores are T scores and are set up similar to the
syndrome scales in terms of clinical significance cutoffs.
The CBCL has been found to be a psychometrically sound instrument in terms of
reliability and validity (Achenbach & Rescorla, 2001). According to Achenbach and
Rescorla, the internal consistency of the syndrome scales range from a low of .78
(somatic complaints and thought problems) to a high of .94 (aggressive behaviors). With
regard to the DSM-oriented scales, coefficient alphas ranged from a low of .72 (anxiety
problems) to a high of .91 (conduct problems). Syndrome scales demonstrate high test-
retest reliability ranging from .82 to .94 (M r = .90). Similarly, the DSM-oriented scales
ranged from a low of .84 to a high of .93, with a mean r of .88.
Frequent subjective assessments of positive change in behavior, mood, and social-
ization were taken from the boys as well as from their caretakers during the process of the
group. This method of assessment was relatively simple and provided both the boys and
their caretakers with an open forum for expressing concerns related to their affective dif-
ficulties that occurred between sessions. As previously mentioned, mood tracking forms
were provided to the boys as a means of providing information about their daily function-
ing. However, implementation of this instrument was somewhat difficult (this is dis-
cussed further in the limitations section). Additionally, the boys were asked to write goal
statements at the beginning of group and to review and evaluate the extent to which they
had reached these goals at the conclusion of the group. Sample goals included making
new friends and learning about negative thoughts. Finally, the therapists kept weekly
group notes as well as individual case notes documenting their behavioral observations.
Throughout the course of the group, increased cohesion and application of the social
skills that were taught were apparent. Also, the boys seemed to improve their coping
skills, a result that was corroborated by their self-reports. A summary of the quantitative
data and descriptions of the qualitative information are provided in the Treatment
Implications section of this study.

6 CASE CONCEPTUALIZATION
This section provides a brief conceptualization of the dynamics in the group and
provides the context for the development of the treatment strategy discussed in the next
section. As previously discussed, Thomas and Jeremy were quite different from each
other in many ways, including intellectual ability, presenting behavioral issues, ethnic-
ity, and age. Thomas was an older White boy who was intellectually gifted yet socially
awkward. Jeremy was a small, African American boy with low average abilities who had
witnessed a great deal of trauma and subsequently gained a fair degree of street sense.
However, the boys shared qualities that made for the development of a cohesive and
cooperative bond. They were both quite sensitive and emotionally introspective. They
enjoyed talking about their emotions in the group and seemed to like learning about
how to manage social and emotional difficulties. They were also both victims of bullying
and some degree of social isolation at school. By the 3rd to 4th week, the boys were genu-
inely supportive of each other, and the group was feeling quite cohesive.
Suicide was a topic that was repeatedly brought up in the context of the group.
Both boys admitted to having experienced suicidal ideation in the past and to having
contemplated how they would carry it out. At one point during the group, Jeremy
seemed to be at high risk for possible suicide. Suicide precautions were taken, including
contacting his caregiver, caseworker, previous counselor, and closely monitoring his
behaviors and emotional state. After consultation with his treatment team and receiving
supervision, it was determined that hospitalization was not required. The therapists fol-
lowed up with his caregiver at home and stayed in close contact with his team of care
providers. Jeremy stabilized and was later able to discuss his feelings. He agreed to a no-
suicide pact and was able to talk about his feelings with the group. Suicide was touched
on at several times during the course of group, as it was obviously a highly relevant and
serious concern.
Thomas and Jeremy seemed to benefit from working together in the group con-
text. Although there were differences between the two of them that seemed rather large
at first, it was later apparent that these differences in some ways helped them learn how to
adapt to others and to help each other in novel ways. For instance, on several occasions,
Thomas noticed when Jeremy was having difficulty following what he was saying. When
this happened, Thomas would adjust his vocabulary or slow down and wait for Jeremy to
catch up. Jeremy, on the other hand, began using less vulgar speech (e.g., swearing) in
the group, as he realized that neither of the leaders nor Thomas used this language. The
boys modeled appropriate problem solving for each other at times and were able to pro-
vide constructive feedback and possible solutions to problems the other was having. The
cohesion between the boys and the closeness of the group as a whole were evident dur-
ing the session in which the critical incident occurred. As reviewed in the next section,
the boys were able to both give guidance and take help from each other. Likewise, the
therapists benefited from allowing themselves to take the back seat and be guided in the
natural course of the intervention.

7 COURSE OF TREATMENT
PART 1
The following summarizes the group experience and the interactions within the
group. Sessions were structured around central themes that built on and reinforced pre-
viously taught skills (see Figure 1). In the first meeting, we used warm-up exercises and
activities to get to know each other and feel more comfortable in the group. Issues such
as confidentiality, group rules, goals of the group, and the importance of regular atten-
dance were discussed. Much of the first session was also devoted to providing informa-
tion about mood disorders, their symptoms, and their treatment. This component also
included a section on medication side effects and the importance of adhering to
prescribed medication dosage schedules.
The second meeting included a review of many of the concepts addressed in the
first week, such as goals and group rules. In the second session, the issue of suicidality was
also initially addressed. The group discussed suicidal feelings, and risky behaviors, and
the boys’ suicide risk potential was assessed. Also, in the second session, time was devoted
to strategies designed to “externalize the disorder” (Fristad et al., 1999). This is a thera-
peutic technique useful in working with children who have mood disorders to help them
understand the separation between themselves as individuals and the symptoms of the
disorder or disorders they have. It involves having the children develop a list of character-
istics or qualities they like about themselves as well as a list of negative qualities associ-
ated with their disorder. For our exercise, we used a picture of a sun partially covered by a
cloud. On the sun, the child listed his positive characteristics and the negative qualities
of the disorder on the cloud. This exercise led to a discussion of how disorders can affect a
person without altering their fundamental character. This exercise seemed to be highly
valuable, and both boys exhibited obvious enjoyment in sharing both their positive and
negative lists with each other.
Sessions 3 and 4 were largely devoted to teaching the fundamental aspects of CBT.
Using teaching, didactic discussion, pictures, and role-play, the group reviewed how
thoughts influence one’s emotions and behaviors, and the importance of challenging
one’s thinking when it is faulty (Stark et al., 1996). We also taught specific relaxation
strategies (guided imagery, deep breathing, and progressive muscle relaxation) and
began discussing the problem-solving process (stop and think) and the importance of
identifying and labeling feelings directly and accurately (making I statements).
The following session (Session 5), we continued to teach and practice specific
social skills using teaching, modeling, role-play, and feedback (Goldstein et al., 1995).
The boys especially enjoyed this highly interactive and theatrical experience, as by this
time they were quite comfortable with each other and the group process. Session 6 was
devoted to learning about biosocial rhythms and the importance of tracking one’s
moods, behaviors, and thought patterns (Monk et al., 1990). It was also during the sixth
meeting that the specific strategy discussed in Part 2 occurred.

Figure 1. Jeremy’s Assessed Changes in Self-Reported Depressive Symptoms and Knowledge of Mood
Disorders
NOTE: Solid line = depressive symptoms, assessed with the Reynolds Child Depression Scale (RCDS); broken line =
knowledge of mood disorders, assessed with the Understanding Mood Disorders Questionnaire.
In Session 7, we reviewed the importance of mood tracking and talking to others

(parents, doctor) about one’s moods and looking for any patterns. At this point, Thomas
identified a daily pattern that had not occurred to him before. He realized that he felt
most sleepy and irritable shortly before school got out every day, and this was when he
was likely to get into the most trouble (for talking back and defiance). We had an open
discussion about possible influences of his mood fluctuation and learned that he often
got hungry and would subsequently eat his lunch well before lunchtime or would have
simple carbohydrates without much protein for lunch, leaving little energy to sustain
him through the rest of the afternoon at school. We discussed the importance of moni-
toring one’s diet and recommended some changes to Thomas’s diet. His mother agreed,
and Thomas began eating more protein and packing larger lunches as well as a mid-
morning snack. He continued to have some difficulty with sleepiness during the school
day, but it was not as problematic as it had been prior to this minor change in his diet. We
also practiced social skills during the Session 7 and talked about activity scheduling and
noticing the positives.
In Session 8, the boys’ goals from the beginning of the group were revisited, and a
discussion of the progress that they had made ensued. The group ended with a relaxation
exercise followed by the opportunity to say good-bye to each other. The boys enjoyed the
opportunity to share their thoughts and feelings with us and with each other. Thomas

even commented that he thought he might want to be a counselor when he grows up, to
which Jeremy responded that he thought Thomas would make a fine counselor.
PART 2
Jeremy was very tired, to the point that he could barely keep his eyes open, at the
beginning of Session 6. When asked why he was so groggy, he informed us that he had
not been sleeping well at night. We proceeded with the day’s scheduled activities, which
began with an introduction to biosocial rhythm tracking. As we started to explain how to
monitor one’s moods and behaviors at various times of the day, Jeremy abruptly inter-
ceded that he had felt “scared and mad” that morning and said that he wanted to tell the
group why. However, when Jeremy tried to verbalize what was bothering him that morn-
ing, he had great difficulty getting the words out.
Instead, he closed his eyes, covered his face with his hands, and asked the rest of the
group to do the same. We did. Jeremy then began to describe his vision of running
through the woods with something chasing after him and not being able to get out. He
said that he could not get this scary vision out of his mind. At about this point, Jeremy
quickly stopped talking, in midsentence, and said that he had to stop because the mon-
ster was now standing right behind him. Behind Jeremy’s seat was a large picture window
overlooking the parking area. Jeremy’s fear was palpable, as evidenced by his facial
expression and voice. He was extremely frightened.
By this time, it was clear that the planned agenda for the day’s group had to be
altered, if not altogether abandoned, to address Jeremy’s concerns. This brings up the
importance of flexibility. With any group, and perhaps especially in a group comprised
of children who have significant psychiatric concerns, the group leaders often have to be
extremely flexible with the structure of the group’s agenda. Although it is advisable to
have some activities and discussions preplanned and structured for the group, one has to
address the issues that the group members may present on any given day.
Jeremy continued to describe his fear in vivid detail. He spoke quietly, as the mon-
ster was still standing nearby. At this point in the session, it was unclear if Jeremy was
experiencing a visual hallucination or was lost in a private fantasy that he had been carry-
ing with him for some time. His caseworker and guardian had reported to us that he had
previously experienced visual hallucinations after accidentally being given too much of
his antidepressant medication (Zoloft). Prior to this session, Jeremy had not evidenced
any delusional thinking or hallucinations with us in session. Regardless of whether
Jeremy’s monster was a result of a normal childhood fantasy or an actual hallucination,
we knew that he needed to talk about it.
The other boy in the group, Thomas, then interjected. He had been listening
intently to Jeremy’s story and was obviously concerned. He told us how he used to get
scared at night by a monster but had been able to get over his fear. Thomas explained that
he imagined the pile of clothes at the end of his bed would transform at night into a mon-

ster and that it frightened him terribly and repeatedly. One night, Thomas continued, he
finally summoned the courage to look right at his monster and say out loud, “You’re
nothing.” With this simple yet powerful statement, Thomas learned that he could con-
trol his fear. In effect, he killed his monster by taking away its power over him. It seemed
that this was the first time that Thomas had spoken of this very private experience with
others. We all had the same idea: We could help Jeremy kill his monster too. Jeremy lis-
tened intently to Thomas’s story of his monster and how he had killed it. SW asked
Jeremy if he would like to kill his monster. He immediately and solemnly said, “Yes . . .
How should we do it?” Jeremy was not yet sure how to successfully rid himself of the
monster that had haunted him for so long. It was suggested that he first draw a picture of
the monster so that the rest of the group could visualize it. This helped to externalize the
fear and, therefore, make it something that could indeed be conquered. Jeremy drew the
monster quickly, and we all examined it and agreed that it did indeed seem very scary.
At this point, Jeremy clearly was leading the group and directing the activity. We
were his allies and were all on his side. He told us where to stand and what to do. Thomas
stood next to him, and SW sat at about an arm’s length in front of where Jeremy was
seated. LH was placed on the other side of him, across from Thomas. From our small cir-
cle, we counted to three in unison on Jeremy’s lead. Jeremy then turned around quickly
to face his monster (he was actually facing the window, but seemed to be looking past it).
A surprising slew of profanity gushed from him that truly reflected the depth of his hate,
fear, and loathing. His voice was low and steady. It was obvious from his words that he felt
that the monster had killed his mother and that now the monster wanted him too. As
soon as he finished his verbal assault on the monster, he directed Thomas to punch it.
Thomas obliged and pummeled the monster with wild punches thrown into the air.
When it was done, Jeremy said with a sigh that he felt better but indicated that the
monster was not completely dead. He whispered into SW's ear that he wanted to kill it
with soap and water, which seemed to represent holy water to him. SW asked him if she
should tell the rest of the group what he wanted to do, and he consented.
As a group, we each immediately filled our hands with soapy water and again, on
the count of three, following Jeremy’s lead, threw the water onto the wall behind us
where the image of the monster, according to Jeremy, was projected. We looked at each
other, and Jeremy was actually smiling. He said, “The monster is gone.” It was clear that
Jeremy had just experienced a very cathartic and unburdening event.
8 COMPLICATING FACTORS
There are two general factors that made the conduct of this group difficult. First,
there was some difficulty with participant recruitment and attendance. The group began
as a way to meet a need that we saw in the community. Mood-disordered children were
being seen individually in counseling and treated with medications, but there was no

easily accessible group available for adjunctive treatment. This group ideally should be
the beginning of an ongoing community-based group. The need for such a group
undoubtedly exists in many communities, but the primary obstacle appears to be getting
the word out to those families in need of services. Unfortunately, the families are often
already under a great deal of pressure and time stress. There are issues such as arranging
for transportation and childcare for siblings, juggling multiple jobs and schedules, and
simply not having any extra time. We recommend trying to alleviate some of these prob-
lems by holding the groups at a convenient location, providing as much advance notice
as possible for families to make necessary arrangements, and making the group at a con-
venient time. For example, our group was held immediately after school at a local child
care mental health clinic, but parents had to provide transportation to and from the
group meetings.
The second, broad class of complicating factors involves the need for clear com-
munication with the treatment team and family. Many factors must be addressed that are
often considered outside the scope of treatment by any one professional. This can unfor-
tunately result in redundant efforts, good intentions that often are not ever realized, and
frustration on the part of the family and child. Treatment should be, as much as possible,
holistic, focused, and consistent.
Other complicating factors include small group size, breadth of the curriculum,
and difficulties with the implementation of certain interventions. Specifically, there was
difficulty in identifying children whose primary diagnosis was affective in nature. More
often than not, potential participants had been identified with externalizing problems to
which depression was a secondary concern. As such, our original age range and more
strict criteria (of having been formally diagnosed with a mood disorder) had to be relaxed
to include a broader age range and presence of mood disorder symptomology prior to the
start of the group. As there is some hesitancy to diagnose mood disorders in children as
well as some difficulty with differential diagnosis, identification of this subgroup was par-
ticularly problematic. Consequently, the issues surrounding comorbidity and
differential diagnosis often presented themselves during group.
This group was implemented with the intent of teaching a great deal of informa-
tion to children with a broad range of learning abilities. However, in the interest of both
flexibility and therapeutic gains, the goals of each group session often had to be modified
or scaled down, leaving the counselors with the task of conveying a great deal of knowl-
edge in a short period of time. This may have compromised some of the
psychoeducational aims of the group, as the participants had to digest a rather large
amount of information in a short period of time. Finally, there was some resistance to the
mood tracking intervention. Specifically, the boys found it both difficult and cumber-
some to consistently track their interactions during the day, especially at school. There-
fore, a less invasive and time-intensive strategy is recommended for future tracking activ-
ities. Also, it would be most efficacious to include a parenting group component into the
treatment, as was done with the MFPG treatment (Fristad, 1999).

9 FOLLOW-UP
At follow-up after cessation of the group, two approaches were taken. First, there
was a need for some follow-up and closure for the group participants. The coleaders
shared and explained results of the CBCLs with caretakers who had completed them for
the boys. Each caretaker completed CBCLs at two points during the group: the begin-
ning and end of the group. Additionally, because Jeremy was not receiving individual
counseling during the group, his caretaker was given a referral for two community-based
service agencies that would accept his case.
Also, to address the problems seen in the group related to the systemic nature of the
children’s problems, we developed and led a parent training workshop hosted at the
community agency. The workshop focused on behavioral discipline methods. This met
a more general need in the community for formal parent training. The group went well,
and the parents asked for subsequent booster sessions, which were provided. As this issue
demonstrates, it is important to bear in mind the need for prevention and primary care in
addition to treatment of existing concerns in the community.
Regarding Part 2 (Jeremy’s issue), the week following the incident, Jeremy came
into the group in a pleasant mood. He seemed to be well-rested and quickly commented
that things had been better with his monster gone, as he looked hesitatingly out of the
window. Jeremy was certainly not cured of all his fears and still had many issues to tackle
therapeutically. However, we can say without any hesitation that he had a successful
experience that day in group. The group acted as one, for one. He felt supported and
empowered. Hopefully, he can recall those feelings when faced with other fears,
whether real or imagined, in the future. Approximately 2 months after the group, his
caretaker was recontacted, and it was reported that he seemed to be doing better
behaviorally at home and that he was indeed receiving individual counseling.
10 TREATMENT IMPLICATIONS OF THE CASE
This case study summarized a psychoeducational counseling group designed for

school-age children with mood disturbances. Over 8 weeks, eight 75-minute sessions
were completed. Each session covered a specific content area, and the group was struc-
tured so that subsequent sessions capitalized on the information and skills taught in prior
sessions. The goals of the group were threefold: (a) to provide social support to the chil-
dren in the group; (b) to increase the children’s awareness and knowledge of mood disor-
ders and their symptoms and to improve their coping skills and treatment adherence;
and (c) to improve the children’s social competence.
These therapeutic goals were based on the theoretical underpinnings of the group.
The theoretical base of the group was cognitive-behavioral in nature (Dobson, 2001).
We focused on the relationship between thoughts, feelings, and actions, and we webbed
aspects of CBT into many of the activities and strategies. The group also drew on previ-

TABLE 2
Changes on Measures for Each Child
Pretest Midpoint Posttest
Change scores for Jeremy

RCDSa 99 (99) 87 (89) 69 (72)
UMDQb 62 56 59
Change scores for Thomas
RCDS 4 (5) 19 (20) 22 (24)
UMDQ 79 87 92
NOTE: RCDS = Reynolds Child Depression Scale (1989); UMDQ = Understanding Mood Disorders Questionnaire.
a. Scores are reported as percentiles. First score compared to total population; second score compared to males.
b. Scores are reported as percentage correct.
ous empirical and clinical work with children and adolescents in group formats, focus-
ing on enhancing social competence in the children by formally teaching social skills
(McGinnis & Goldstein, 2000; Stark et al., 1996). Many of the objectives, strategies, and
therapeutic techniques were also adapted from work on family-based mood disorder
treatment (Fristad, 1999; Fristad et al., 2002).
Because of the small size of the group (two boys), statistical analyses of change and
efficacy are unfortunately not possible. However, individual data for each child on the
two self-report measures used are presented in Table 2. Both the RCDS (Reynolds,
1989a) and a questionnaire designed to measure one’s knowledge of mood disorders
were given at three points during the group: (a) at the onset of the group prior to the first
session, (b) midway through the group, and (c) at the completion of group immediately
after Session 8. Each of the boy’s caregivers was also given the CBCL (Achenbach &
Rescorla, 2001) at the beginning and completion of the group to gain some semiobjec-
tive measure of change. As can be seen in the tables and pictorially in Figures 1 and 2,
both boys exhibited change during the course of treatment.
Jeremy showed a steady decline in self-reported depressive symptomatology. He
began the group in the 99th percentile, in terms of depressive symptoms, compared to
other children his age. At the end of the group, he scored in the 69th percentile. This
means that his reported depressive affect decreased from a clinically severe level to a
nonclinical level over the course of the treatment. However, in terms of his knowledge of
mood disorders, from pretest to posttest, he actually showed a decline in reported knowl-
edge on the self-report questionnaire. Although the reasons for this change cannot be
known for certain, there are many plausible explanations. First, the decrease in Jeremy’s
depressive symptoms was corroborated by behavioral observations of him in the group as
well as by information reported by his caretaker on the CBCL (Table 3). His aunt
reported decreases in multiple problem areas from pretest to posttest, including anxious
and depressed, withdrawn and depressed, somatic complaints, social problems, and
attention problems. In terms of DSM-IV-TR concerns, decreases are seen in the follow-
ing areas: affective problems, anxiety problems, somatic complaints, and oppositional
defiant disorder.

Subjectively, Jeremy seemed to enjoy the group and to learn from it. However,
objectively, it appears that he did not retain a great deal of the specific information on
mood disorders that was taught. The reason for this can only be speculated but may be
related to multiple factors. His low average intellectual ability and ADHD may have
played a role, and he may not have been attentive or engaged during some of the more
traditional teaching components of the group, when much of this type of information
was conveyed. Future groups should ensure that all members are actively engaged in
this educational component. This may be more difficult as it often resembles a teacher-
student type of atmosphere. It may be especially helpful to make such a component as
didactic in nature as possible to encourage active discussion along with role-play or
question and answer.
Anecdotally, on reviewing his goals for the group, Jeremy seemed satisfied with his
progress in working toward his goals and appeared pleased at having addressed particular
concerns related to visual hallucinations. In reviewing group notes, Jeremy appeared to
become increasingly open with other group members and appeared comfortable shar-
ing his experiences, despite an occasional lack of shared experiences among the group
members (i.e., having witnessed intense interpersonal violence in his neighborhood).
His tendency to use obscene language decreased somewhat; however, more issues with
violence and aggression slowly emerged. Although his caretaker consistently reported
improvement during the group, she also became increasingly concerned with his
externalizing behaviors as well as his need to continue individual therapy.
Thomas showed a steady increase in self-reported depressive symptomatology on
the RCDS, from a score falling in the 5th percentile at pretest to the 24th percentile at
the end of group. In contrast to Jeremy’s profile, Thomas’s scores on the questionnaire
assessing knowledge of mood disorders steadily increased from pretest to posttest. It is
important to note that, although Thomas showed an increase in depressive symptoms,
he never reached clinical significance (a raw score above 74). It may be the case that his
increased scores actually represented his increased knowledge of, sensitivity to, and
acceptance of (or decrease in denial of) symptoms of depression. At the onset of group,
Thomas actively denied experiencing any feelings related to sadness, withdrawal, or
depression. He identified with feelings of frustration, anger, and irritation, as well as pre-
vious suicidal ideation, but did not report any mood disturbances. The CBCL com-
pleted by Thomas’s mother indicated that he remained fairly consistent across most of
the problem and DSM-IV-TR-related areas, with the exception of decreases in anxious
and depressed behavior, social problems, and attention problems (Table 4). Similar to
Jeremy, Thomas reported feeling that he had met his goals set forth at the beginning of
group. Furthermore, according to case notes, Thomas demonstrated increased skills in
his ability to use role-play as a therapeutic modality. The group leaders took this as an
indicator of Thomas’s increased social knowledge and application of social skills.
Although group change analyses are not feasible with the present study, it is felt
that the group was effective on an individual level. Behavioral observations as well as

Figure 2. Thomas’s Assessed Changes in Self-Reported Depressive Symptoms and Knowledge of Mood
Disorders
NOTE: Solid line = Depressive symptoms, assessed with the Reynolds Child Depression Scale (RCDS); broken line =
Knowledge of mood disorders, assessed with the Understanding Mood Disorders Questionnaire.
TABLE 3
Child Behavior Checklist Scores for Jeremy
Pretest Posttest
Syndrome scales
Anxious or depressed 72a 59
b
a b
Withdrawn or depressed 73 66
a a
Somatic complaints 74 72
a a
Social problems 83 73
a a
Thought problems 79 79
a a
Attention problems 83 79
Rule-breaking behavior 74a 78a
a a
Aggressive behavior 89 91
DSM scales
Affective problems 73a 63b
a b
Anxiety problems 73 65
a a
Somatic problems 73 70
ADHD 80a 80a
a a
ODD 80 73
a a
CD 83 87
NOTE: DSM = Diagnostic and Statistical Manual of Mental Disorders; ODD = oppositional defiant disorder; CD =
conduct disorder
a. Represents T scores in the clinical range.
b. Represents T scores in the borderline clinical range.

TABLE 4
Child Behavior Checklist Scores for Thomas
Pretest Posttest
Syndrome scales
Anxious or depressed 59 53
Withdrawn or depressed 54 58
Somatic complaints 72a 72
a
b
Social problems 65 58
Thought problems 73a 71
a
b
Attention problems 67 59
Rule-breaking behavior 64 64
Aggressive behavior 70a 69b
DSM scales
Affective problems 72a 72
a
Anxiety problems 55 55
Somatic problems 70a 70a
ADHD 69b 66b
a a
ODD 73 77
CD 67b 65b
NOTE: DSM = Diagnostic and Statistical Manual of Mental Disorders; ODD = oppositional defiant disorder; CD =
conduct disorder.
a. Represents T scores in the clinical range.
b. Represents T scores in the borderline clinical range.
group and individual case notes reflect positive changes in mood, affect, and behaviors
during the course of the group. Each boy seemed to reap his own unique benefits. One
unexpected finding was how two children with such diverse presenting concerns and
therapeutic needs could mutually benefit. We believe that the structure and content of
the group was useful. However, it is also believed that the chemistry and cohesion of the
group, the flexibility and openness to change, and the importance of being willing to try
novel strategies when the opportunity and need arises were helpful determinants.
11 RECOMMENDATIONS TO CLINICIANS AND STUDENTS

This article highlights many aspects of group treatment with children in general
and one technique in particular. Based on this case report, several recommendations
can be made to fellow clinicians and students. First, we treated the experience seriously.
Although throwing soapy water onto a wall to help a child overcome debilitating fears
and anxieties is not likely to be found in any treatment manual, in our group on that day,
it represented a real ritual with a real purpose. A strategy such as this represents, in some
ways, a crossover among religion and spirituality, childhood developmental issues, and
psychotherapy.
Firm distinctions are often drawn between these areas; however, in practice, the
separating lines are often much less clear. Counselors should be open to the possibility of
such disciplines influencing each other and take guidance from other areas when appro-

priate. Related to this, when working with children who may be taking multiple power-
ful medications, it is sometimes very difficult to determine the etiology of symptoms. Are
a child’s fears a reflection of a drug interaction, a true psychotic episode, or simply attrib-
utable to excessive childhood fears and anxieties? These questions must be asked and all
alternatives ruled out to come to a firm conclusion regarding a child’s behavioral
symptoms.
Second, as was previously discussed, flexibility is required in leading any counsel-
ing group, especially in group work with children. Structure and agendas are useful, but
only as a framework. The agenda should never inhibit the growth that can happen from
truly listening to the needs of the group members, as those needs often do not arise
within the neat confines of the scheduled day’s topics to be covered. Related to this are
the roles that the members take on in the group. Every recipient, or “helpee,” should also
be given the opportunity to be the helper. Similarly, the best group leaders also know
how to follow.
Finally, this case report highlights the special nature of working with childhood
fears. This issue gets at the core of empathy in counseling children. When we step out-
side of our adult shoes and into the shoes of a child with debilitating fears, we step into a
frighteningly familiar yet distant world. Most, if not all, adults can vividly recall their
most traumatic childhood fear—for some it was a certain toy, a Halloween costume, or a
shadow that lurked in your bedroom when you were alone at night. How nice would it
have been, still from the child's vantage point, to have someone who would not just
assure you that the monster did not exist or who would stay with you until you fell asleep
but to have someone actually show you that you had the power all along to kill the mon-
ster yourself? How nice would that have been?
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Susan K. Williams, Ph.D., is a graduate of Florida State University, where she specialized in school and
counseling psychology. She now works as a postdoctoral associate at the Yale Child Study Center in New
Haven, Connecticut. Her primary research and clinical interests are in the areas of assessment and treat-
ment of chronic childhood disorders, primarily autistic disorder.
Lauren M. Hutto obtained her bachelor’s of science in psychology at Florida State University (FSU) in
May 1999. She is currently a doctoral candidate in the combined doctoral program in counseling psychol-
ogy and school psychology at Florida State University, specializing in school psychology. She is in the pro-
cess of completing her internship at the FSU Regional Multidisciplinary Evaluation and Consulting Cen-
ter and is currently engaged in evaluation and research in the area of autism. Her current research interests
are in the areas of autism spectrum disorder and adult learning disability.

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Clinical Case Studies

Killing Monsters : Combining a Novel Treatment Approach With Psychoeducational Counseling

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>> Version of Record - Mar 3, 2006

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Keywords: psychoeducational counseling; mood disorders; children; treatment; child-

1 THEORETICAL AND RESEARCH BASIS

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NOTE: CBT = cognitive-behavioral theory.

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ticular, is effective when treating children and adolescents with depression. In an

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naire designed to gauge knowledge of mood disorders, based on the Understanding

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In Session 7, we reviewed the importance of mood tracking and talking to others

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10 TREATMENT IMPLICATIONS OF THE CASE

This case study summarized a psychoeducational counseling group designed for

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Change scores for Jeremy

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11 RECOMMENDATIONS TO CLINICIANS AND STUDENTS

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