Psychodrama as a Therapeutic Tool: Uses and Techniques

Introduction: The Brain, Trauma, and Psychotherapy

The ways in which the mind processes and stores information, and how it works with the human body as a whole, remains a mystery not yet completely solved. Science does have an informed understanding of the brain, but its intimate relationship in protecting the body from the psychological damage of traumatic experience is only in the process of being unraveled. The human brain remains one of the great mysteries, like the unexplored regions of the ocean depths or the universe around us. What science does understand is that the brain responds to physical and environmental stimuli, especially psychological disasters or traumatic events. Those kinds of human experiences are often hidden within the subconscious, so that the person who experienced the event can function without it in the forefront of their thoughts. This is not to say that the events do not inhibit or pose a problem for the individual who experienced them.

Psychotherapy is about the process of working with patients whose lives have been adversely impacted in some way that prevents them from achieving their fullest potential in their own lives, work, community, and social relationships. In order for psychotherapy to be successful, Danie Beaulieu, PhD (2006) writes, the therapist must be able to change the patient's thought perceptions, patterns, and behaviors in exchange for healthier ones that facilitate the client's life and goals. While this may seem a straightforward exercise, there is no prescribed formula between client and therapist for success, because the therapist and client are dealing with issues that may be locked deep within the client's subconscious memory. This can take long periods of time — bringing memories to a point where the client can work through them in a way that is no more harmful than keeping them repressed.

Employing the tool of psychodrama is not something easily accomplished in a one-hour session or within the confines of a therapist's office. Beaulieu explains:

"To incorporate the concepts underlying these specialized approaches into a more accessible and readily applicable method, Impact Techniques were developed. Recognizing that a primary goal of psychotherapy is to generate and reinforce new insights and life-skills that can stand up to the challenges of the rich, stimulating, multisensory experiences of daily life, Impact Techniques aim to make the experience in the therapist's office an equally rich, stimulating, and multisensory experience."

Psychodrama, or "drama therapy," proves especially useful when working through issues of childhood trauma or military personnel's post-traumatic stress disorders.

Psychodrama as a Therapeutic Tool

Chris Farmer (1995), author of Psychodrama and Systemic Therapy, argues that psychodrama is useful with psychotic patients who cannot bridge the present with past events in their lives. "Action methods," Farmer says, allow the patient to depart from the question-and-answer intake method. The patient can then use action methods to bring to the surface experiences and memories that are buried in the subconscious and which are preventing him or her from achieving the highest quality of life medically possible. It is worth considering how this visualization of events — and the acting out of those events — might facilitate the patient's goals by putting those events into an expression that informs the therapist of what issues need to be worked through. Farmer goes on to provide case histories that demonstrate the usefulness of psychodrama as a tool in therapeutic treatment.

Farmer cites the case of a schizophrenic patient whose life was altered when her younger brother died as a young child. There was a history of events that, in the era when Farmer's patient was raised — the World War II era — were subjects people did not discuss publicly. Horrific events such as suicide and illegitimacy were kept as closely guarded family secrets. Today, of course, we understand that such events, tragic as they may be, occur in the lives of many families. People are not alone in those experiences, and no shame should be attached to them. The birth of a child, regardless of whether the parent is married, is a celebration of new life. While suicide is tragic, it is to be understood in terms of the individual, and not necessarily the family — although arriving at such an understanding may itself require therapy, even psychodrama, to demonstrate the relationship between the patient and the suicide victim.

That is precisely what Farmer's patient's therapist did: employed psychodrama as a tool by which the patient could link the timeline and events to their proper perspectives. This is consistent with what Beaulieu described — providing the patient with the means to make the necessary connections and to express the events. As Beaulieu stated, it helps produce change in the patient's perception, thinking process, and behavioral response to memory.

Farmer's schizophrenic patient had lapsed into a state of muted, catatonic unresponsiveness. The clinical team working with her made observations about the patient's relationships and physical responses when her family members — two sisters — visited, often together.

"In family sessions, the sisters and their husbands attended (but never both husbands at the same time; legitimate reasons were given, but it was postulated that there might have been some conflict between them). Some of their own separate anxieties were addressed, but there was great resistance to this; they wanted to focus upon Edith's illness. When it was perceived that the more they did this, the more intense Edith's ambivalence over being 'ill' would become, a structural/strategic intervention was made: the sisters' visiting Edith on the ward was restricted, and they were to visit Edith only when she was at her own home (to which the community psychiatric nurse was taking her for increasing periods of time during the day)."

This constituted a form of psychodrama, and the patient's clinical team was able to take this dynamic and make changes that allowed the patient to relate to her sisters differently. In doing so, they changed the patient's perceptions, her way of thinking, and — by altering her reaction to family members based on the new relational dynamics — changed the physical response that had caused her to enter the muted, catatonic state.

Farmer provides other case scenarios, but the one cited here is particularly poignant, as the patient was a schizophrenic suffering the worst possible manifestations of psychosis. It demonstrates the usefulness of psychodrama and shows that it can prevail even in cases of the most severe patient suffering.

Psychodrama with Children and Trauma Survivors

Therapeutic psychodrama has also been used in work with children. In Creative Therapies with Traumatized Children, Anne Bannister (2003) discusses the use of psychodrama in working with children who have had traumatic childhood experiences. Bannister notes that in her work using creative therapy with children, the clinical creative team includes both a dramatherapist and a psychodramatist. She refers to the work as "interactive therapy" — a self-explanatory term in today's technological world, though it specifically means that the therapist, the patient, and the treatment interact with one another in a dynamic way. Bannister cites a creative bonding between the team members and between the team and the patient, suggesting that this bond differs from the one formed in psychotherapy that does not rely on the creative skills of team members.

Bannister argues that the creative element of therapeutic skills extends beyond what is available to the therapist who does not utilize psychodrama. This is not to suggest that psychotherapy without psychodrama is less effective — only that the skill of psychodrama represents an additional tool the therapist can employ to achieve a fuller integration of skill, therapy, patient, and therapist interaction. Bannister also cites observable changes in behavior in the children that result from the interactive psychodrama process.

Psychodrama is particularly well suited to work with children because of this interactive element and because it provides a way to help children — whose ability to express their thoughts is inherently limited — externalize and process difficult experiences. By bringing the past into the present and helping to rearrange the timeline of events versus current reality, psychodrama puts those concepts in terms the child can relate to. Without psychodrama, grasping such concepts could take a child much longer in therapy.

For sexually abused children, Bannister provides the following clinical model:

The Regenerative Model

Phase One — Assessment
Development, Attachment, Coping, Safety
Embodiment play / Interaction child-carer / strategies / Home situation
Projected play / Sociograms / Internal self-protection
Role play / External / Locus of control / Dissociation

Phase Two — Action
Building Attachment, Creativity
Acceptance / Interactive play
Boundaries / Child-centered
Body-mind connections / Drama (role play and rehearsal)
Balance of power / Art, music, poetry, dance, story
Confirming feelings and identity / Doubling, mirroring, and role reversal / Witnessing

Phase Three — Resolution
Self-redevelopment
Ability to understand and express feelings
Awareness of self-identity
Ability to make, maintain, or terminate relationships

It should not be taken for granted that psychodrama is the complete solution to every suffering child's problems. Bannister readily acknowledges that the creative group noticed some children did not respond to the therapy in ways that indicated it was a productive approach for those particular individuals. The team's initial response was to reassess how they were interacting with those children. Their final assessment was that they, as an outside source, could not provide the complete or total stimuli needed for those children to react in therapeutically useful ways, and that participation from family members was required.

It is also worth noting that even within a psychodrama framework, the therapists recognized it as one tool among many in the repertoire of psychoanalysis and psychotherapeutic practice. Their work with children was challenging, and there was no quick fix for the problems those children faced. Psychodrama did, however, prove useful in bringing those problems to the surface so that patient and therapist could work through them together. Continual assessment and reassessment of psychodrama's progress is integral to its success. Recognizing the need for a different approach, or bringing additional participants into the interactive process, is essential — as is always keeping sight of the child's life and the supporting players within it.

Conclusion

In conclusion, psychodrama has been examined here for its meaning, its different uses, its images, and the ability to keep the tool current so as to be effective in today's therapeutic environments. More recently, the use of phototherapy has been positioned as a subcategory of psychodrama. Rosy Martin (2001) argues that re-enactment therapy makes visible the performative body. This approach is particularly suited to patients who do not respond to other forms of psychodrama — it is new, inventive, and useful in just the way Martin describes. By its nature, psychodrama allows the therapist and patient to make choices about treatment that take them away from the confines of space and time that might otherwise hold the patient in the present moment and prevent or inhibit him or her from going back in time or confronting irrational fears of the future. The different modes of psychodrama serve to establish a relevant relationship between space and time, and allow the client's subconscious to be explored in ways that question-and-answer therapy does not.

Perhaps calling it relationship therapy or any of its numerous other names is simply a renaming of what, in any form, psychodrama does: a re-enactment of events or emotions that have become buried, surrendered to the patient's traumatic experience. It is what Salvo Pitruzzella calls "person and threshold." The application, Pitruzzella says, is numerous — appropriate for understanding the attachment style of drug addiction, for the traumatized young person or child, for the person whose life has brought them into confrontation with death and disaster, and for any number of other emotional and psychological events that can psychologically maim an individual. Even those individuals whose condition cannot be accurately or fully diagnosed by the clinical team can receive the benefit of attempted understanding and interpretation through psychodrama.

That psychodrama serves to improve mental, physical, and emotional health and well-being is perhaps its primary and most important application. It has become a widely used tool, one that — if we rely on the research and writings of the experts — proves more useful as time moves forward in therapeutic history. Moreno would probably not be surprised, but would surely be amazed at the progress made in broadening the concept of psychodrama and keeping it current as an effective and valuable therapeutic tool.

Works Cited

Bannister, Anne. Creative Therapies with Traumatized Children. London: Jessica Kingsley, 2003.

Beaulieu, Danie. "Impact Techniques: Applying Our Knowledge of Human Memory Systems to Psychotherapy." Annals of the American Psychotherapy Association 9, no. 4 (2006): 23+.

Farmer, Chris. Psychodrama and Systemic Therapy. London: Karnac Books, 1995.

Fonseca, Jose. Contemporary Psychodrama: New Approaches to Theory and Technique. New York: Brunner-Routledge, 2004.

Hudgins, M. Katherine. Experiential Treatment for PTSD: The Therapeutic Spiral Model. New York: Springer, 2002.

Martin, Rosy. "The Performative Body: Phototherapy and Re-enactment." Afterimage 29, no. 3 (2001): 17+.

Pitruzzella, Salvo. Introduction to Dramatherapy: Person and Threshold. New York: Brunner-Routledge, 2004.

Scategni, Wilma. Psychodrama, Group Processes, and Dreams: Archetypal Images of Individuation. New York: Brunner-Routledge, 2002.