Psychodrama and Treatment Planning

Psychodrama and Treatment Planning
© Copyright 1990, 2005, Rob Pramann, Ph.D., TEP
Christian Counseling Centers of Utah

Samuel C. Klagsbrun, M.D. (personal communication, May 13, 1989), at the Moreno Centennial (47th Annual) Meeting of the American Society of Group Psychotherapy and Psychodrama spoke on "Psychodrama: A Most Precious Though Neglected Tool for In-Patient Psychiatry." He noted that though psychodrama is known to shorten the length of in-patient stays it is little recognized by non-practitioners of psychodrama and this is most painfully apparent in the lack of articles on it outside of the organs of the Society. One particular need is to identify the ways in which psychodrama is relevant to the treatment of psychiatric patients, and specifically how it is relevant to the treatment planning process. This article will identify the wide variety of problems psychodrama can address for psychiatric patients in general and the chemically addicted in particular.

Psychodrama and the Psychiatric Patient

Psychodrama effectively addresses a wide range of problems and issues including those rooted in the past, present, or future; those occurring within a person, between persons, or between a person and a group; those involving intuition, feelings, thinking, or behavior; and spiritual, artistic, playful, and political aspects. It can function to provide education, support, insight, a test of reality, or as a spur to creativity where other modes of intervention have failed or "bogged down". It can play an important role in prevention, diagnosis, treatment, and relapse prevention. In a way unique among other psychotherapies, it addresses the importance of warming-up to an issue or action, setting the scene, choosing roles, and being flexible and creative (Blatner, 1988, p. vii).

Perhaps the easiest way to describe how psychodrama addresses an identified treatment problem is to consider common scenes or vignettes that are frequently the focus of psychodrama enactments. Blatner (1988, pp.3-6) has suggested a similar approach but for a different purpose. His examples are adapted here.

1) Psychodrama may be used to clarify the meaning of a complex family interaction. A child's misbehavior in the presence of his parents' conflicted marriage could be explored with either a parent or child in such a situation with benefit. A spouse, through a well set scene, role reversal, and consciously attempting to experience the feelings, thoughts and behaviors of the other, may become aware of what his/hers spouse is reacting to in him/her and how the child's misbehavior arises out of such a conflict. On the other hand, the child (depending on the age of the child), through role reversal, may learn that he is not responsible for the marital conflict and keeping his parents together and that better options for getting his needs met rather than misbehaving are available.

2) The unconscious needs operating in a relationship can be uncovered. The child in terms of having an ideal parent or parents could unfold the above situation. Through role reversal and acting out the roles of the ideal and his own role, the deep needs of the child could be identified and addressed.

3) The enactment may provide the context for a corrective emotional experience. The child in the above scenes could experience profound joy observing his parents dancing together after they have resolved their disagreement and he thereby has receive confirmation that he is not the cause of their problems. Or the child may feel a deep sense of being worthwhile, belonging, and acceptance as he is held by the parent(s) of his choice. Thus a traumatic experience can be transformed into a positive or happy one through mastery, experiencing empathy from another, being held, comforted, encouraged, and appreciated. Such an experience may be a first step in giving what is needed to one's self.

4) The enactment could use future projection to explore and move beyond what has inhibited or been evaded. The child in the above scenarios knows what it means to be worthwhile, to belong, and to be accepted but may discover by playing the barrier what is preventing him/herself from giving to the other part of him/herself. He/she may find he/she is afraid to outgrow his/her parents or that if he/she self-nurtured he/she would lose his/her toxic bond and identity with them.

5) The psychodrama enactment could serve to explore an alternate strategy and provide opportunity for rehearsal. Thus the child identified above could rehearse various ways of letting his parents know that he no longer chooses to misbehave to keep their marriage together. Such a use of psychodrama, “role training,” is appropriate for any feared event including confrontations, revelations, or one's first job interview. The success experienced in the enactment through creativity and reality testing can result in confidence, positive anticipation, and hopefulness instead of fear, dread, and a self-fulfilling prophecy of a negative experience.

6) Psychodrama can facilitate progress in resolving a grief through a "goodbye" encounter. Through role-reversal the bereaved can talk with the one lost saying those things time and circumstance did not allow, hearing the desire of the deceased for the living, and allowing the living to have control over the letting go by symbolically closing the eyes or pulling up the sheet. This process will result in the bereaved person's understanding of his own and the deceased's feelings, thoughts, actions, and their relationship. It will assist the bereaved in accepting the reality of the loss (facts, meaning, and irreversibility); to work through the pain of grief; to adjust to an environment without the deceased; and to emotionally relocate the deceased and move on with life (Worden, 2002).

7) Psychodrama can facilitate the exploration and understanding of recurrent dreams. The protagonist is allowed to play the part and fully experience each aspect of the dream and then to view it unfolding again before his/her eyes through the use of auxiliaries. This will serve the purpose of increasing self-awareness and in insight into hidden assumptions.

8) Psychodrama can be used to cope with or understand a hallucination or other symptom. The way such a symptom is approached must be based on one's clinical judgment. A hallucination could be concretized verbally and nonverbally or the patient could play the role of the hallucination and interact and negotiate with it thereby gaining a sense of voluntary control.

Psychodrama and the Substance Abusing

Psychodrama can be used with the substance-abusing patient in almost a programmatic way with the regularity of occurrence of various themes. Many programs rely on the Minnesota 12 - Step (AA) Model, which in part accounts for some of this regularity.

1) Psychodrama facilitates the acceptance of group support. Most addicts have difficulties relying on others and believing others like them. Discovering the support as trustworthy may come through the experience of having a good double, the support of the group through the warm-up, action, and sharing phases, or, through having each group member address the protagonist face to face as the other and express honestly their desire to help.

2) Psychodrama can help galvanize commitment to treatment. An action sociogram that illustrates where one is in regards to commitment to the treatment, the treatment program, or “their (12 step) program” as compared to where one would like to be is almost always effective. Each group member positions themselves between opposite walls in the room representing the extremes and at some level becomes aware of the effect of their choices about treatment. This warm-up could be followed by action concretizing and focusing on "what keeps you from moving where you are to where you want to be?" Specifically identifying and responding to the barrier along with role reversing with the barrier can be quite valuable.

3) Psychodrama can assist patients in facing their addiction. Patients can be led along by a rope or chased by an auxiliary representing their substance of choice. Usually tension will build until they literally face their addiction and address it. Such symbolic action readily facilitates into concrete action when an individual is confronted in the patient setting. Because of the power of this scenario, much care should be taken in an out patient setting because of the powerful urges it can elicit. Role training in which the protagonist rehearses and practices strategies for addressing their addiction on an ongoing basis should follow such an intervention. This intervention then can be valuable earlier in treatment to help the patient understand and own their vulnerability, their powerlessness and unmanageability.

4) Anger and other intense emotions can be dealt with psychodramatically. The person can role-reverse with their emotion and give it words or action through role reversal. They can learn to accept and understand this part of themselves instead of denying or hiding from it. Following this role training can be used to identify, explore, and practice various ways to respond to a particular situation. The adequacy of the enacted possibilities can be evaluated in terms of both the protagonist and the auxiliaries involved in the scene.

5) Psychodrama can provide the context for dealing with guilt and practicing making amends. In addition to providing the opportunity for emotional release, such action creates positive expectations for the future. Frequently the practice and role-playing will serve to warm up the protagonist to needed action.

6) Psychodrama can assist patients in clarifying the nature of their higher power and how he/she can be helpful to them. Frequently patients come with negatively tinged associations to God from experiences from the past. Higher power work helps them to develop a more benevolent and personal higher power and facilitates their development of trust. For many, their higher power is an extremely important resource in the work of recovery and in maintaining sobriety.

7) Psychodramatic enactment provides a choice modality for practicing fire drills of patient defined difficult situations. As the patient sets the scene and role-reverses with the substance of choice, frequently feelings of intoxication occur. The exact attraction or "come on" of the drug becomes apparent. The effectiveness of specific strategies can be tested and any necessary modifications can be made in the safety of the treatment environment. Used later in treatment this scenario can serve as a test of the adequacy of what the patient has learned and their readiness for discharge

8) Psychodrama facilitates discharge planning and preparation for life outside of the treatment. When the protagonist or star of the psychodrama resists or fails to resist in the scenario described above the action can be stopped and the substance auxiliary can make the round, becoming the substance of choice for each group member and seeing how many can be seduced. Thus the star patient and each group member can see how well they have learned to use the "tools" of the program (12-step groups, sponsors, therapists, higher power, 12 step literature, friends and family members, meditation/relaxation, recreation). If the star succumbs unwillingly the group can assist him/her in identifying the resources and reenact the scenarios with a successful outcome.

References

Blatner, H. A. (1988). Foundations of psychodrama: History, theory and practice (3rd ed.). New York: Springer

Worden, J. William (2002). Grief Counseling and Grief Therapy (3rd. ed.). New York: Springer.


	Psychodrama and Treatment Planning © Copyright 1990, 2005, Rob Pramann, Ph.D., TEP Christian Counseling Centers of Utah Samuel C. Klagsbrun, M.D. (personal communication, May 13, 1989), at the Moreno Centennial (47th Annual) Meeting of the American Society of Group Psychotherapy and Psychodrama spoke on "Psychodrama: A Most Precious Though Neglected Tool for In-Patient Psychiatry." He noted that though psychodrama is known to shorten the length of in-patient stays it is little recognized by non-practitioners of psychodrama and this is most painfully apparent in the lack of articles on it outside of the organs of the Society. One particular need is to identify the ways in which psychodrama is relevant to the treatment of psychiatric patients, and specifically how it is relevant to the treatment planning process. This article will identify the wide variety of problems psychodrama can address for psychiatric patients in general and the chemically addicted in particular. Psychodrama and the Psychiatric Patient Psychodrama effectively addresses a wide range of problems and issues including those rooted in the past, present, or future; those occurring within a person, between persons, or between a person and a group; those involving intuition, feelings, thinking, or behavior; and spiritual, artistic, playful, and political aspects. It can function to provide education, support, insight, a test of reality, or as a spur to creativity where other modes of intervention have failed or "bogged down". It can play an important role in prevention, diagnosis, treatment, and relapse prevention. In a way unique among other psychotherapies, it addresses the importance of warming-up to an issue or action, setting the scene, choosing roles, and being flexible and creative (Blatner, 1988, p. vii). Perhaps the easiest way to describe how psychodrama addresses an identified treatment problem is to consider common scenes or vignettes that are frequently the focus of psychodrama enactments. Blatner (1988, pp.3-6) has suggested a similar approach but for a different purpose. His examples are adapted here. 1) Psychodrama may be used to clarify the meaning of a complex family interaction. A child's misbehavior in the presence of his parents' conflicted marriage could be explored with either a parent or child in such a situation with benefit. A spouse, through a well set scene, role reversal, and consciously attempting to experience the feelings, thoughts and behaviors of the other, may become aware of what his/hers spouse is reacting to in him/her and how the child's misbehavior arises out of such a conflict. On the other hand, the child (depending on the age of the child), through role reversal, may learn that he is not responsible for the marital conflict and keeping his parents together and that better options for getting his needs met rather than misbehaving are available. 2) The unconscious needs operating in a relationship can be uncovered. The child in terms of having an ideal parent or parents could unfold the above situation. Through role reversal and acting out the roles of the ideal and his own role, the deep needs of the child could be identified and addressed. 3) The enactment may provide the context for a corrective emotional experience. The child in the above scenes could experience profound joy observing his parents dancing together after they have resolved their disagreement and he thereby has receive confirmation that he is not the cause of their problems. Or the child may feel a deep sense of being worthwhile, belonging, and acceptance as he is held by the parent(s) of his choice. Thus a traumatic experience can be transformed into a positive or happy one through mastery, experiencing empathy from another, being held, comforted, encouraged, and appreciated. Such an experience may be a first step in giving what is needed to one's self. 4) The enactment could use future projection to explore and move beyond what has inhibited or been evaded. The child in the above scenarios knows what it means to be worthwhile, to belong, and to be accepted but may discover by playing the barrier what is preventing him/herself from giving to the other part of him/herself. He/she may find he/she is afraid to outgrow his/her parents or that if he/she self-nurtured he/she would lose his/her toxic bond and identity with them. 5) The psychodrama enactment could serve to explore an alternate strategy and provide opportunity for rehearsal. Thus the child identified above could rehearse various ways of letting his parents know that he no longer chooses to misbehave to keep their marriage together. Such a use of psychodrama, “role training,” is appropriate for any feared event including confrontations, revelations, or one's first job interview. The success experienced in the enactment through creativity and reality testing can result in confidence, positive anticipation, and hopefulness instead of fear, dread, and a self-fulfilling prophecy of a negative experience. 6) Psychodrama can facilitate progress in resolving a grief through a "goodbye" encounter. Through role-reversal the bereaved can talk with the one lost saying those things time and circumstance did not allow, hearing the desire of the deceased for the living, and allowing the living to have control over the letting go by symbolically closing the eyes or pulling up the sheet. This process will result in the bereaved person's understanding of his own and the deceased's feelings, thoughts, actions, and their relationship. It will assist the bereaved in accepting the reality of the loss (facts, meaning, and irreversibility); to work through the pain of grief; to adjust to an environment without the deceased; and to emotionally relocate the deceased and move on with life (Worden, 2002). 7) Psychodrama can facilitate the exploration and understanding of recurrent dreams. The protagonist is allowed to play the part and fully experience each aspect of the dream and then to view it unfolding again before his/her eyes through the use of auxiliaries. This will serve the purpose of increasing self-awareness and in insight into hidden assumptions. 8) Psychodrama can be used to cope with or understand a hallucination or other symptom. The way such a symptom is approached must be based on one's clinical judgment. A hallucination could be concretized verbally and nonverbally or the patient could play the role of the hallucination and interact and negotiate with it thereby gaining a sense of voluntary control. Psychodrama and the Substance Abusing Psychodrama can be used with the substance-abusing patient in almost a programmatic way with the regularity of occurrence of various themes. Many programs rely on the Minnesota 12 - Step (AA) Model, which in part accounts for some of this regularity. 1) Psychodrama facilitates the acceptance of group support. Most addicts have difficulties relying on others and believing others like them. Discovering the support as trustworthy may come through the experience of having a good double, the support of the group through the warm-up, action, and sharing phases, or, through having each group member address the protagonist face to face as the other and express honestly their desire to help. 2) Psychodrama can help galvanize commitment to treatment. An action sociogram that illustrates where one is in regards to commitment to the treatment, the treatment program, or “their (12 step) program” as compared to where one would like to be is almost always effective. Each group member positions themselves between opposite walls in the room representing the extremes and at some level becomes aware of the effect of their choices about treatment. This warm-up could be followed by action concretizing and focusing on "what keeps you from moving where you are to where you want to be?" Specifically identifying and responding to the barrier along with role reversing with the barrier can be quite valuable. 3) Psychodrama can assist patients in facing their addiction. Patients can be led along by a rope or chased by an auxiliary representing their substance of choice. Usually tension will build until they literally face their addiction and address it. Such symbolic action readily facilitates into concrete action when an individual is confronted in the patient setting. Because of the power of this scenario, much care should be taken in an out patient setting because of the powerful urges it can elicit. Role training in which the protagonist rehearses and practices strategies for addressing their addiction on an ongoing basis should follow such an intervention. This intervention then can be valuable earlier in treatment to help the patient understand and own their vulnerability, their powerlessness and unmanageability. 4) Anger and other intense emotions can be dealt with psychodramatically. The person can role-reverse with their emotion and give it words or action through role reversal. They can learn to accept and understand this part of themselves instead of denying or hiding from it. Following this role training can be used to identify, explore, and practice various ways to respond to a particular situation. The adequacy of the enacted possibilities can be evaluated in terms of both the protagonist and the auxiliaries involved in the scene. 5) Psychodrama can provide the context for dealing with guilt and practicing making amends. In addition to providing the opportunity for emotional release, such action creates positive expectations for the future. Frequently the practice and role-playing will serve to warm up the protagonist to needed action. 6) Psychodrama can assist patients in clarifying the nature of their higher power and how he/she can be helpful to them. Frequently patients come with negatively tinged associations to God from experiences from the past. Higher power work helps them to develop a more benevolent and personal higher power and facilitates their development of trust. For many, their higher power is an extremely important resource in the work of recovery and in maintaining sobriety. 7) Psychodramatic enactment provides a choice modality for practicing fire drills of patient defined difficult situations. As the patient sets the scene and role-reverses with the substance of choice, frequently feelings of intoxication occur. The exact attraction or "come on" of the drug becomes apparent. The effectiveness of specific strategies can be tested and any necessary modifications can be made in the safety of the treatment environment. Used later in treatment this scenario can serve as a test of the adequacy of what the patient has learned and their readiness for discharge 8) Psychodrama facilitates discharge planning and preparation for life outside of the treatment. When the protagonist or star of the psychodrama resists or fails to resist in the scenario described above the action can be stopped and the substance auxiliary can make the round, becoming the substance of choice for each group member and seeing how many can be seduced. Thus the star patient and each group member can see how well they have learned to use the "tools" of the program (12-step groups, sponsors, therapists, higher power, 12 step literature, friends and family members, meditation/relaxation, recreation). If the star succumbs unwillingly the group can assist him/her in identifying the resources and reenact the scenarios with a successful outcome. References Blatner, H. A. (1988). Foundations of psychodrama: History, theory and practice (3rd ed.). New York: Springer Worden, J. William (2002). Grief Counseling and Grief Therapy (3rd. ed.). New York: Springer.
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