ISSUE 107 DECEMBER 2007 BACK

the group

The inpatient basketball group as an alternative to group therapy: Helping the “bad boys” feel good about themselves

Paul Elias and Nancy Britton Soth

ABSTRACT: Not every hospitalized adolescent can immediately benefit from verbal, insight-oriented group psychotherapy. A group for aggressive adolescent boys was designed in a long-term psychiatric hospital, with the purpose of identifying, exploring and releasing aggression by team sports. The basketball group enabled patients to form relationships, receive immediate feedback without too much threat, and to “find a place” or belong. The group also became a tool for analyzing each adolescent’s means for achieving his own power within the group. Group cohesion was achieved, vividly demonstrated when a new member was added to the group and when the group challenged another basketball team. Group rituals developed, which allowed patients to mark the group as a special place “separate from the hospital “and thus promoted cohesion. Authors believe that a cohesive sports group could proceed to a verbal group, but caution that the opportunity to release aggression in a sports group had no impact on the adolescent’s aggressive behavior in the hospital milieu.

Not every adolescent in the psychiatric hospital will respond to group psychotherapy. Adolescents who cannot function in a verbal group tend also to disrupt the group process and deny other members the opportunity to work effectively. In response to this problem and with a real desire to explore whether some of the benefits of group psychotherapy could be achieved in an alternate group format, we designed a sports group of aggressive adolescent boys in our long-term psychiatric hospital. The purpose of the group was to identify, explore, and release aggression by using team sports, confrontation, and discussion as the major tools of therapy.

The membership of the group was established following much discussion and debate within the group psychotherapy department. Members selected were in their second phase of treatment, had been explosive or acted out their aggression physically, verbally, or covertly, and also had some skill, interest, or capacity for active team sports. Six patients were chosen. The first day of the group was scheduled for approximately one week after the names of the group members were announced. During that week, there were feelings of both enthusiasm and skepticism from both staff and patients, in one group. “You must be looking for them to kill each other in the first week.” What began to be called the Bad Boys Group generated a lot of enthusiasm from the members selected. Some vowed to make life miserable for the leader, some seemed to be pessimistic, and others seemed to be worried about what would happen. The week of speculation and anticipation seemed to stimulate the group’s identity to the point that, without ever having to set foot in the gym, the group had already begun the process of cohesion.

Group membership
The original members of the group were; Swen, Lloyd, Jerry, Cowens, Bingo, and Rudy. They were later joined by Greg, Danny, Artis, Jim, and Joe.

Group development

The First Week. The “tough-guy” attitude and aggression were evident from the start of the first game. When they were asked whether they wanted to play half-court or full-court, they looked at the leaders as if they were crazy and said, “What do you think we are, a bunch of babies?” There was a scramble by each member to find a place where he felt comfortable fitting into the group. At the end of the group, we discussed the fact that the boys had switched from full-court to half-court in the middle of the game, and the leader called their attention to their “tough-guy” attitudes. Their response was that they were out of shape because they smoked cigarettes, and there was a unanimous acceptance that it was “cool” and you had to be tough to smoke, so it was okay to change their minds about playing half-court. The members” roles took shape very quickly in the first week. There was not one dominant member, but a definite display of power, which was achieved by reputation, verbal and physical aggression, basketball skill, and the ability to handle other group members” aggression. If a player lacked power in one area, he overcompensated in another.

Four Weeks. By this time, cohesion had emerged among four group members: Swen, Lloyd, Cowens, and Jerry, with Bingo and Rudy excluded. The core group seemed to feel comfortable coming out to the gym everyday and simply being together.

Five Weeks. Group cohesion was maintained following the transfer of Bingo and Rudy to another hospital. When it was announced several days before that a new member, Greg, would enter the group, the boys responded negatively and with anger. Each member knew Greg, and each had an opinion “that he was a jerk, could not play basketball, and would probably ruin the group. Greg was thrown into the lion's den... was scapegoated, ridiculed, and ostracized by the group. During processing his first day, he was able to say; “I’m not the best player, but I–ll try if you give me a chance”. The group listened to Greg and vowed to give him a chance.

However, they did not apologize and warned him that he had better not “blow it.” He was treated somewhat better but still as an outsider the next day, but was then transferred to a locked facility because of other disruptive behavior in the hospital.

Six Weeks. The core group became more cohesive and proud of their group and challenged the hospital teachers to a basketball game. They were excited and bragged about how the teachers were going to be beaten. Cowens was ill on the day of the game, the group did not win, but vowed to beat the teachers the next time they played.

Seven Weeks. Prior to Greg’s return from the locked unit, another new member was added to the group. Danny showed up before his coming was announced. The floodgates were opened and each member expressed his dissatisfaction with Danny, each in his own individual style. Cowens said: “He’ll ruin our group.” Swen looked for someone to blame, and said; “You–ll let anyone in this group, and you didn’t even ask us if it was all right.” Lloyd, in his usual passive-aggressive way, made the classic statement: “If he comes, I–ll quit.” Danny stayed in the gym just long enough to hear these statements. When he left, another barrage of aggressive statements followed. The rest of the game was very aggressive. Each member showed his we colors as he acted out his anger. Cowens was quiet but very physical. Swen was both verbally and physically aggressive, said he was angry, swung his elbows, played recklessly, and was hostile to the leaders. Lloyd displayed his anger in a physically aggressive way. For the first time there was the threat of someone trying to injure another in the group deliberately. After Lloyd pushed the leader as he was aiming for a shot, the game was stopped to talk about what was going on in the group. They talked about their anger and how they were expressing it, finished that game and left early. Each member expressed his anger in his own unique style. Yet cohesiveness seemed to be at its peak. They returned the following day and acted as if nothing had happened. The members seemed to be on the same wavelength emotionally and were relating to each other better than ever before. The previous day had been a cathartic experience for them and there seemed to be a sense of relief within the group. It was an enjoyable day, everyone was loose, and did not take the game too seriously. When asked about their behavior the previous day, they did not deny their actions or feelings, but did not want to talk about it. When asked what they thought about Danny’s joining they now seemed eerily comfortable with it.

Eight Weeks. Danny was still excited about the group, although he was smaller and younger than other members. He said he knew that they got rough, did not like him much, but he could handle it, and was looking forward to being with them. As expected, the other members of the team scapegoated Danny and made fun of him. The group leaders confronted them, and Danny did not back down and made it through the first group. When Greg returned on the the next day, the focus was removed from Danny, and transferred to him. When Greg made fun of Danny, the group stood up for him. So, in one day, the group had seemed to accept and protect Danny, but reject a member who had previously been in the group. During the next two weeks, Danny’s acceptance in the group was reinforced; he quietly participated and never missed a group session, and was very patient in waiting for the group’s acceptance. Greg, however, was very threatening and impatient with the group.

Ten Weeks. Group cohesion was once again achieved, so another game with the teachers was scheduled. Danny and Greg did not show up. Greg had been restricted to his unit, and Danny, knowing that his presence would add another strong player to the teacher’s team, did not show up to gain favor. The group beat the teachers in the second half.

Eleven Weeks. Cowens was discharged for behavior outside of the group; this was difficult for the boys because they had become dependent on him for leadership and support. This solidified Danny’s position within the group. Reaction to Cowens” leaving was expressed not in anger but in depression or a sense of loss. The group seemed just to be going through the motions. Danny appeared to take advantage of this situation by trying extra hard to gain attention and respect. This seemed to be exactly what the group needed to get back on the track. Danny had worked his way into being a powerful member of the group; he made himself attractive enough so that others wanted him on their team. He had impact on the group, not by basketball ability, but by his determination. He would get a nosebleed after being hit in the face and not stop playing, whereas Lloyd would fall down and fake an injury for attention.

Final Weeks. Another new member arrived, and the reaction was much milder than before. There were now three new members and three core members, and the group ran smoothly. After a few sessions, the group decided they did not want to play basketball anymore, and stickball was deemed to be their new activity. The stickball group seemed to be a regression because the objective for group members seemed to be one of trying to prove their “toughness” by war stories about growing up in the ghetto and playing stickball, while in reality none of them had experienced this life.

It was then a new term and time for a new group. The core members used the last week for reflection and separation, and began talking about “the good old days” in the group. The last days of group ended with much the same feelings as the first day. There was skepticism and enthusiasm about the new group. But what was different was that there was a feeling that the Group in the Gym “had not killed each other” and that the “Bad Boys” felt good about themselves.

Discussion
The goal of the group “to identify, explore, and release aggression “was achieved. It would have been possible, once cohesion was achieved, to take this group into a primarily verbal phase of group treatment. It was also helpful to view this group in terms of other therapeutic aspects “the development of identity and sources of self-esteem, as a laboratory for analyzing sources of power, and the development of group cohesion.

Identity and peer group acceptance
Developmentally, adolescence is a time when gaining approval and being accepted is very important. However, it seems that many adolescent psychiatric patients have either failed or have not had the opportunity to become a member of a group. The basketball group allowed these patients to form relationships, to receive immediate feedback without too much threat, and for most everyone to find a place. Danny was of special interest here “a small, young adolescent, who was able to face initial rejection and by determination find a place for himself within the group.

Liff (1981), in discussing the role of the group therapists in the treatment of learning disabled patients, stated that the central problem for the therapist is to help each patient identify with and internalize the positive climate and observational structure inherent in a cohesive group so that identity can eventually emerge in a mature and responsible way. Giovacchini (1979) indicates that the character-disordered patient could not construct a cohesive self because he was not responded to “and if there is not one around to respond “then there would no external reinforcement of his potential to achieve a stable sense of being.

Achieving power and dominance
For a social group to develop, two opposing adaptive processes must be reconciled: mechanisms for developing cohesion and mechanisms for establishing a dominance hierarchy (Kennedy & McKenzie, 1986). This was achieved in the group. This group was interesting, in fact, as a laboratory for studying dominance hierarchies and sources of power in a very raw form. Had we been merely a basketball team the leaders would not have been so attuned to this analytic attitude. Yalom (1984) has stressed the importance of the group as a social microcosm and notes that the way one behaves in a group resembles the way he/she behaves in the outside social environment. This was true even in a group devoted to basketball. Each member seemed to display his dynamics “his ways of controlling his environment “in a blatant fashion, the same dynamics he displayed in the psychiatric milieu. However, in the basketball group, these behaviors could be directly addressed by peer confrontation and by the leaders since all members did share the same ethic and the same task “whereas in the hospital corridors they did not share the goal of a therapeutic and peaceful milieu.
At the same time, most every member was able to achieve a source of esteem and power within the group, and for some the addition of basketball skills helped. They learned that each could have his own power and achievement and a place within the group, and usually not at the expense of another. Sources of power and dominance strongly resembled those displayed in the milieu.

Swen, the oldest and biggest of the members, liked to have things his way, and if he did not get them, he played the role of martyr. He was sarcastic and teased, but he could also receive it. He was a powerful member of the group because of his size and demeanor, and what he lacked in basketball skill, he made up for in a reckless style of play, which was intimidating. Yet he was a stabilizing force during the group, using his physical size to control the game and acting out aggression in a physical way.

Lloyd was an outstanding basketball player, seemed to know it, but needed to demonstrate this by bragging or showing off in a covert way. If the game was to go to 21 and his team had 20, he needed to be the one to make the final point. He showed little affect toward other members, but displayed some with the leaders. His power derived from basketball ability, but he acted out his anger in a covert fashion, calling fouls, delaying the game by throwing the ball at someone’s feet, dramatically stopping the game when he was hurt, and “play up” the injury.

Jerry had been athletic when young but had lost interest when he found newer, “cooler” things to do. He had the reputation as a “loser” and a “druggie” and enjoyed the reputation as a tough guy from the New York City ghetto although he was really from an upper-class Connecticut suburb. Other members wanted him on the team because he was a good team player. It was difficult to know if he was swearing and calling you names because he liked you or because he was angry. He expressed his anger verbally and was abusive at times, and gained power by verbally intimidating or belittling.

Cowens was a tough kid who had served time in what he called “jail” and was therefore seen as someone “not to mess with.” He seemed compelled to validate others” fears by intimidating them, which he could do simply by giving them the “evil eye.” He was respected by group members but also returned this respect. He played physically but fair. Group members liked to be on his team but hated to guard him. He expressed anger both physically and verbally but did not actually abuse or assault anyone. He gained power by his skills and intimidation without ever having to prove his toughness.

Bingo was discharged soon after the group’s formation. Although he was verbally and physically aggressive, he hardly ever displayed physical aggression in the group. Rudy, another short-term member, was the initial scapegoat for the group, and while there was passive and non-aggressive.

Greg, a new member, was not there long enough to achieve power within the group. This seemed to always affect his attendance. Danny, the other new member of the group, was a small, younger adolescent who wanted desperately to join the group. What he lacked in basketball skills, he made up for in hustle and determination. He expressed his anger verbally and sometimes covertly by throwing the ball at others” feet to delay the game. He gained powered and impact on the group by being the person who was protected. He did not seem to necessarily need protecting, but somehow manipulated other group members to stick up for him at times.

Artis came to the group after two and a half months after its formation and remained until the end, making the old member/new member ratio even. He had a reputation for being “crazy” and “out of control.” He expressed his anger through passive, verbal, and physical means. He would swear and threaten group members, find ways to delay the game and get somewhat physical with smaller group members. His power came through reputation and intimidation. Jim and Joe were not in the group long enough to be known.

What was also obvious in the group was also the shuffling for power. The first week of such groups is always interesting for its display. During the first week, Rudy was scapegoated and somewhat ostracized by Jerry and Bingo, seemingly to remove the focus from their insecure feelings about their basketball skill. Jerry aligned with Cowens to strengthen his feelings of power in the group, which, in turn, seemed to bolster Cowen's position. Swen aligned with Lloyd, seemingly to feel better about his basketball skills, and Lloyd received a sense of protection from this alignment. Rudy tried to align himself with the only remaining member, Bingo, but Bingo refused an alliance with the powerless Rudy. These two seemed to be left powerless without enough skill or capacity to deal with the other members; they were also the first to leave the group.

Group cohesion
Group cohesion has been seen as a major factor in group psychotherapy (Yalom, 1970). Cartwright and Zander (1960) define cohesiveness as 1) attraction to the group, including resistance to leaving; 2) motivation of the members to participate in group activities and coordination of the efforts of members. Cohesion was achieved in this group, a cohesion that could not have been achieved for these boys in a conventional group psychotherapy format. Cohesion developed and became evident through: 1) the development of group rituals; 2) the difficulties in assimilating new members, and 3) the heightening of cohesion which developed when the basketball group challenged the academy team.

Group rituals in the development of cohesion
Group rituals emerged early in the group’s formation. Members began coming to the gym early to “warm up” by shooting baskets. There seemed to be an evolutionary process with this “warming up.” It began with each person fending for himself. If one got the ball, he could shoot it, if he made it or missed it, he had to wait until he happened to catch the ball again. This practice, with some role modeling by the leaders, was changed to a more positive, organized ritual. One person would shoot, and if he made it, could shoot again and again until he missed. This seemed to benefit the person shooting by providing immediate feedback from the group. It also provided an opportunity for the group leaders to casually talk to group members waiting their turn, assess their moods, the kind of day they had had, process the previous day’s group, give them feedback, or listen to concerns. At 5:00, the leader would say; “Let’s shoot them up,” meaning that the first three people to make a free throw would be on one team, the others on the other team. Later, other members announced the game with this cry and the leader was no longer responsible for starting the group.

Another ritual which indicated a commitment to the group was begun by Cowens and Jerry, when they requested a locker for their basketball shoes. They established a ritual of coming into the gym, kicking off their boots, putting on their shoes, as if to say: “we’re here and ready to play.” Both of these rituals allowed members to express their commitment to the group, a task which was never easy for them.

Verbal interactions were also ritualistic, in that they seemed to feel most comfortable relating through sarcasm and name-calling, often with sexual undertones. This seemed to be a very non-threatening way to give each other positive or negative feedback. Positive feedback as a demonstration of affection, was usually negated by adding an insulting name at the end of a compliment. The sarcasm and name-calling allowed the group members to maintain their tough guy image but still communicate their feelings.

Cohesion was a major contributing factor to the success of this particular group. Cohesion was achieved, threatened, lost, and re-achieved through the group process.

Conclusions
We recommend a sports group as a helpful alternative for patients who cannot benefit or who are likely to disrupt insight-oriented verbal psychotherapy. Unfortunately, goals must be modest. Our hope that their release of aggression in the gym would decrease their aggressive incidents in the hospital now seems hopelessly naive. Many members dropped out of the group when their aggressive behaviors could not be contained in an open hospital.

They were able to learn from peer interaction in the group, and the development of cohesion allowed a higher sense of self-esteem by group members. They truly viewed the group as their own, personalized it, and regarded it as an amalgam of themselves. There was also an opportunity to work out their own issues of power and dominance in a more legitimate fashion, in a place where this need could be established, analyzed, and sometimes satisfied.

Achievements were modest, yet seemed momentous, when compared to the “Bad Boys” early progress in the conventional group psychotherapy program. Once group stability and cohesion is achieved, a next step might be conversion into a short verbal group, followed by basketball in the last thirty minutes as a rewarding finale for their work.

References

Cartwright, D., & Zander, A. (Eds). (1960). Group Dynamics Research and Theory. New York. Row, Peterson.

Giovacchini, P. (1973). Character disorders: with special reference to the borderline state. International Journal of Psychoanalytic Psychotherapy 2, pp.7-20.

Kennedy, J.L., & McKenzie, K.R. (1986). Dominance hierarchies in psychotherapy groups. British Journal of Psychiatry 148, pp.625-631.

Liff, Z.A., (1981). The role of the group therapist in the treatment of character disorder patients. In H. Kellerman (Ed). Group Cohesion: Theoretical and Clinical Perspectives. New York. Grune & Stratton, pp.289-289.

Yalom, I. (1975). Theory and Practice of Group Psychotherapy (2nd Ed.) New York. Basic Books.

Yalom, I. (1984). Inpatient Group Psychotherapy. New York. Basic Books.

This feature: Elias, P. and Soth, N.B. (1982). The inpatient basketball group as an alternative to group therapy: Helping the “bad boys” feel good about themselves. Journal of Child Care, 3, 4. pp.45-53.

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