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Psychodrama as a social work modality.

Developed in the early years of the 20th century by Viennese psychiatrist Jacob L. Moreno, psychodrama is an experiential method of group psychotherapy that uses action techniques to explore the root of psychological and social problems (Moreno & Moreno, 1969). Psychodrama is the process of enacting and reenacting past concerns and imagining the situation reoccurring in a present form, allowing patients to uncover thoughts and feelings that may not be accessed solely through talk therapy. Psychodrama enhances problem-solving insight and facilitates personal growth on cognitive, affective, and behavioral levels (Avrahami, 2003). The acting method aims to encourage communication, clarify issues, enhance physical and emotional well-being, and foster skill development. As an action-oriented technique or a clinical role-play, psychodrama provides a context in which individuals examine habitual patterns of reacting to certain problems and discover alternative ways to respond in a safe, supportive environment.

Psychodrama is applied to diverse age and treatment groups, from children to older adults, and from chronically mentally ill or cognitively impaired people to those who desire improved functioning with their families or in work settings. Psychodrama should not be viewed as a separate school of thought; rather, it represents an integrative approach to treatment, incorporating methods from various theoretical approaches such as cognitive, behavioral, gestalt, empowerment, psychoanalysis, and other individual and group treatment modalities. Because of psychodrama's experiential nature, clinicians can use it as an educational method to observe and practice clinical skills. It appeals to social workers because of its utility in a variety of settings; its strengths-based, transtheoretical approach to practice; and its application of a contextualized framework through consideration of the client's perspective. Although research on psychodrama tends to validate specific techniques through case demonstrations (Kipper, 2005), there is a body of empirical studies with data to support the technique applications of psychodrama and its outcome-based effectiveness, utility in social work, and educational function.

APPLICATIONS OF STRENGTHS-BASED TECHNIQUES

Psychodrama techniques are person focused, aiming at bringing out the client's positive outlook on life. A meta-analysis conducted by Kipper and Ritchie (2003) found four reviews of psychodrama research over a span of 23 years. These four reviews served as the initial research on doubling (that is, another group member imitating the role and actions of the protagonist) and role reversal (that is, the protagonist playing the role of the person of concern) as techniques in psychodrama. In another analysis, Kipper and Hundal (2003) studied 34 case illustrations of psychodrama to demonstrate its client-focused nature. A third empirical study, conducted by Rademaker, Vermetten, and Kleber (2009), highlighted the value of psychodrama as a group technique to help 22 veterans release somatic, depressive, and other posttraumatic stress disorder symptoms. A more recent study on six psychiatric adolescent patients (mean age, 16.67 years) found that qualitative and quantitative data could be captured in the observatory process to identify symptom reduction after a weekly 12-session analytical group psychodrama program (Gatta et al., 2010). These studies identified the strengths of psychodrama as a method for aiding clients in the discovery of their issues and the subsequent identification of solutions.

A major component of psychodrama is the use of the here-and-now technique that focuses on the current feeling in the present moment, aiming to express unpleasant emotions that were stuck in the past. One study on the resolution of interpersonal situations among 16 female undergraduate students found that psychodramatic doubling helped break client "resistances," yielding "revealingness" as an outcome of moving forward after revealing past feelings (Hudgins & Kiesler, 1987, p. 253). When psychodrama was used with the Bowenian family systems approach, Farmer and Geller (2005) found that the use of the here-and-now technique and the exploration of emotional processes were helpful for clients, enabling them to detach from triangulated struggles before reexamining their concepts of the meaning of life. The use of improvisational acting activities in family therapy enabled clients to interact in a creative and authentic manner with the goal of finding their strengths (Cheung & Leung, 2008).

OUTCOME-BASED EFFECTIVENESS

An overview of research studies found positive outcomes regarding the stabilizing of clients' emotions. Through therapeutic enactment, clients who were engaged in interpersonal and action-oriented processes successfully addressed a wide range of problems, including personal and group trauma, grief and loss, interpersonal conflict, family of origin issues, institutional violence, and work- or employment-related issues (Westwood, Keats, & Wilensky, 2003). Similarly, Blacker, Watson, and Beech (2008) provided empirical data from a combined drama-based and cognitive-behavioral therapy program in the United Kingdom indicating that psychodrama helped clients explore the root causes of anger and aggression. The 62 clients in this study, who were violent offenders from six prisons, also acquired skills through dramatic enactment. The pre- and postcourse assessments revealed significant reductions in anger, suggesting that a drama-based approach may be a favorable addition to anger management programs for violent offenders.

Effectiveness was also reported in sexual abuse research, especially with regard to the rebuilding of self-concept. Avinger and Jones (2007) found that two out of 10 empirical studies from 1985 to 2005 specifically addressed the effectiveness of psychodrama therapy for reducing depressive symptoms in sexually abused gifts (ages 11 to 18). In another psychodrama treatment program in a middle school, effectiveness was shown when 12 girls used their five senses to reenact and process their past trauma (Carbonell & Parteleno-Barehmi, 1999). In these reenactment experiences, the therapists refrained the traumatic events in adaptive ways, empowering the clients to alter and replay the ending of their story as a positive experience. The evaluative outcome was measured by a sense of self-control, not by any predetermined instrument.

Another outcome of psychodrama is the enhancement of social involvement. Fong (2006) described the effect of psychodrama on 19 high school gifts as they overcame anxieties about violence, unlearned fear, and gender stereotypes that weakened their psychological strengths. After a weekly six-month psychodrama program, these teenagers reported an increase in confidence when attending social activities. Empirical evidence also supports the use of drama activities with older clients. Martin and Stepath (1993) compared the use of an interview approach to a psychodrama therapy approach with 53 inpatients in a geriatric psychiatric unit. Before the psychodrama session, the clients had withdrawn from their social roles, resulting in isolation; however, after taking on various roles in psychodrama activities, they became active social participants at a higher functioning level. More recently, a process analysis of seven adults in group psychotherapy found that the visual analysis of a patient's social atom (that is, diagram of human relationships) was associated with the healing of unresolved emotional pain and the repair of fragmentation in interpersonal relationships (McVea, Gow, & Lowe, 2011). When patients participate in enactment activities, they are empowered to sense the importance of feeling useful and active. The positive outcomes reported in these studies were primarily related to the rebuilding of self-image.

UTILITY IN SOCIAL WORK

In an article written over 60 years ago, Treudley (1944), a social worker, shared her experiences at the Psychodramatic Institute in Beacon, New York, where she observed the application of psychodramatic methods in treatment with psychotic patients. She wrote about how psychodrama was significantly different from traditional casework because the treatment technique of interviewing was not used. As the earliest social work advocate of psychodrama, Treudley envisioned a social work role for psychodramatic techniques that would help clients acquire therapeutic insight and relieve tension through reenacting emotions. She also implied that psychodrama could be used as a way for student interns to directly observe various types of case scenarios in action. Since then, however, most studies related to the application of psychodrama in social work group therapy have used college student participants to test the outcomes of clinical treatment (Boury, Treadwell, & Kumar, 2001; Morran & Stockton, 1991).

In a recent article coauthored by a social worker, the benefits of therapeutic enactment in a college counseling services setting were described (Keats & Sabharwal, 2008). The authors combined two intervention modes, an open group counseling format and a process-oriented therapeutic enactment model (as described in Westwood & Wilensky, 2005), to create a brief counseling approach. Their findings demonstrated that using enactment in group therapy could provide a venue for college students to reflect on their issues without fear. The benefits included the working through of issues by interacting with others, the receipt of social support, and the opportunity to observe the commitments and struggles of other group members.

Avrahami (2003) designed another integrated treatment program for social workers to use that illustrated the effect of incorporating cognitive-behavioral treatment into psychodrama. The study outlined a clinical process to help drug addicts work through their losses and feelings of rejection and accept things that could not have been changed. Using the published transcripts in treatment with these clients, the author provided information on how social work treatment programs could apply psychodrama to help clients create a new perspective for processing life issues.

EDUCATIONAL FUNCTION

Because psychodrama enhances the opportunity for an "aha" experience through modeling, rehearsal, differentiation, and actualization, it can also be used as a process- and action-oriented method to facilitate skill practice for clinicians. However, critics of psychodrama have raised the issue of the lack of empirical research that supports claims of its effectiveness in clinical learning and observations (Kim, 2003). Kipper and Ritchie (2003) found that most work on psychodrama published in the past 30 years consists of anecdotal clinical experiences and case illustrations. This lack of connection between education and practice stems from the fact that psychodramatists tend to use their clinical notes, not for scientific research but, rather, for supervisory use or oral presentations in professional conferences (Gershoni, 2008; Villiotou, 2006). Because the social work profession increasingly demands empirical evidence as a prerequisite for incorporating methods into practice, it is critical that research studies of psychodrama provide empirical validation of its success in both practice and education. Such studies could potentially lead to a systematic use of psychodrama in social work practice and education.

The purpose of the exploratory study described in this article was to examine the applications of psychodrama in clinical learning and practice through a social worker's direct participation in 13 psychodrama sessions in a partial hospitalization program. The data on therapeutic outcomes are based on the direct observations and reactions of 13 patients acting as protagonists, follow-up interviews with the psychodrama director, and a consultation interview with an expert. The article also describes the process and observable outcomes of psychodrama as a treatment modality, through qualitative analyses, to support its use in clinical skill enhancement.

METHOD

In a mental health and chemical dependency partial hospitalization program (day hospital) in a suburban area of a major city in Texas, 13 patients participated in group psychodrama sessions with a certified psychodrama therapist, "PD," referred to as the "director" of the psychodrama, and the social worker (first author of this article) responsible for the group formation and process. The director provided guidance in each psychodrama session, and the social worker recorded data during the entire process, including warm-up, enactment, group sharing, observations of the patients' participation in different roles, and the director's debriefing session with each protagonist. The data analysis method is based on Berelson's (1952) communication content analysis using a three-phase process: (1) participation, (2) categorization into themes of the words used, and (3) analysis of communication streams through patterns of recurrence. This method focuses on describing attitudinal and behavioral responses and on determining the trends or patterns in psychological feedback from people or groups (Berelson, 1952). In this study, four people were involved in the analysis process. The social worker started by recording the word use and behavioral indicators of participant disclosures throughout the entire process. After grouping patterns of words and indicators, the social worker and her field supervisor (second author of this article) chose themes to represent these patterns with input from the director. Clarification of these themes as they pertained to psychodrama outcomes was also obtained through follow-up interviews with the director and further confirmed in consultation with a psychodrama expert, Adam Blatner (see Blatner, 1996, 2007).

RESULTS

Thirteen patients participated in the biweekly open group psychodrama sessions over the course of their psychotherapeutic treatment. The duration of each psychodrama session was approximately two hours. Because of its open nature, the group size in each session varied from four to 12 patients, averaging eight patients; each patient participated in four to six sessions. The average age of these 13 patients was 40 years (range, 19 to 62). The male-to-female ratio was approximately equal. Most patients (85 percent) were white; others were African American (8 percent) or Latino American (8 percent). Most (85 percent) were previously employed before hospitalization, and many indicated in the sessions that they had received postsecondary education. Mental health diagnoses consisted of major depressive disorder, bipolar disorder, anxiety disorders, substance dependency, borderline personality disorder, schizoaffective disorder, and possible dissociative identity disorder. The majority (77 percent) of these participants reported a history of mental illness in their families.

The social worker was selected as the auxiliary (that is, representative of someone in the situation) by the protagonist in 11 sessions and as a member of the audience in two sessions. After each session, the director debriefed (that is, reviewed the experience and insights gained) with the protagonist, followed by a debriefing between the director and the social worker. These debriefings were based on the principle that every participant in a psychodrama has an effect on and is affected by the group process. In this experience, three patients either failed to attend all of the psychodrama sessions or left the sessions prematurely; reasons cited for leaving were a physical problem, emotional ailments, and a need to tend to other obligations because the session ran over the allotted time. One patient left before the enactment began, expressing anger that he was not selected to be the protagonist. Another patient left quietly during the warm-up without offering a reason for departure. This individual appeared withdrawn and disengaged before the session began. Of those who attended the complete sessions, only one declined to participate as protagonist, stating she felt anxious and uncomfortable. The findings discussed in this article were obtained from 13 patients' disclosures during the sessions and from observations of these patients' behaviors.

STRUCTURE AND PROCESS OF PSYCHODRAMA

With a leveled stage set up and variable lighting in place, the psychodrama sessions adhered to a structured format consisting of five stages--warm-up, enactment preparation, enactment, group sharing, and individual processing. The psychodrama process applied to this day hospital population followed the general principles of classical psychodrama with some modifications due to the type of setting. The typical "action warm-up" of classical psychodrama (for example, standing in a line indicating one's position on an issue) was replaced with a warm-up procedure in which patients sat in chairs arranged in a circle, explained process and results to new members, and shared what issue they desired to work on. The director made the decision not to use action warm-ups in this setting because of the possibility that they could provoke anxiety because of the constant influx of new patients to the day hospital group. The director was concerned that immersing the patients in action exercises with strangers could make them feel uneasy.

Stage 1: Warm-Up

Existing group members were encouraged to explain the process and rules to new members. If no one volunteered, the director provided the explanation. In each session, the participants were reminded that participation was voluntary and that they were not expected to have special skills or to know what to do beforehand. The director guided the process and asked group members to withhold their personal beliefs as if they were attending a play. The warm-up continued with members verbalizing what issue they would like to work on that day. Once everyone had shared, the director asked for volunteers to play the role of protagonist. Group members could volunteer themselves or encourage others, who had the right to decline. If more than one person volunteered, the director asked the individuals to pick a number between 1 and 10. The director covertly wrote a number on a piece of paper, and the person who selected the number closest to it was allowed to be the protagonist. In the case of a tie, the two people were given an opportunity to work it out between themselves. If one did not concede, the process was repeated. The director pointed out that all group members would benefit in some way from participation, regardless of whether they were chosen to be protagonists. He encouraged the patients to look for themes and similarities between their situation and the protagonist's, as this close examination could lead to increased insight and the development of new cognitions, feelings, and behaviors.

Stage 2: Enactment Preparation

The enactment preparation portion began with group members arranging their chairs as if they were an audience watching a play. The director placed a single chair in front of the audience for the protagonist. He then asked the protagonist to describe in detail the issue he or she wanted to work on. He asked for background information and a specific situation recall. He emphasized that he was not asking how the situation actually was or how other people would say it was, but how it felt to him or her. He asked the protagonist to identify a goal for expressing the feeling and to pick a double and auxiliaries. He also emphasized that group members had the right to refuse a role and that their refusal would not be a reflection on how they felt about the protagonist.

Stage 3: Enactment (Action)

The director then set up the stage for the first scene of the enactment according to the cues provided by the protagonist. The enactment began, and characters assumed their roles. Chairs, pillows, and sheets were used as props throughout the drama. The director addressed the protagonist and auxiliaries in their roles, as if they were in the place and time enacted. The first scene usually began with the present-day problem or issue, such as a strained relationship with a spouse or family member or a conflict with a supervisor. The scene was enacted in the way it felt to the protagonist, with the director guiding the process. The physical space, position of characters, and verbalizations and behaviors of auxiliaries were largely determined by the director on the basis of the description provided by the protagonist before the enactment. Some spontaneity on the part of auxiliaries was permitted and encouraged. Unlike the auxiliaries, the protagonist's words and behaviors throughout the enactment were largely spontaneous and often not guided by the director.

After the present-day scene was enacted, the stage was cleared, and chairs and props were rearranged to represent the protagonist's childhood. The protagonist, double, and auxiliaries assumed their assigned roles in positions dictated by the director. Parents and other key figures in the protagonist's childhood were usually enacted. The auxiliaries who assumed these roles were guided to speak in the way it felt to the protagonist as a child. The director guided the process, facilitating interactions between the characters and the protagonist. The director instructed the auxiliaries to play their assigned role and say something to the protagonist, weaving role reversal and doubling into the interaction. The auxiliaries verbalized new responses and engaged in new behaviors that were not formerly experienced by the protagonist, representing what had been missing in the protagonist's life. Spontaneity was evident as the protagonist and auxiliaries acted and reacted to the new situations as they occurred. Whereas the auxiliaries' words and behaviors were mostly guided by the director, the protagonist's verbalizations, actions, and reactions were largely spontaneous. New feelings, thoughts, and behaviors emerged as the director created alterations in the situation and prompted new verbal and nonverbal communication among auxiliaries. In addition, the protagonist viewed his or her inner sells psychological experience through observation of the double. The characters became immersed in their roles as if they were in real situations.

The final scene took place in the present. The stage was again cleared, and original roles were assumed. The current situation was reenacted. This time, the protagonist performed the role again but using the acquired skills and insight gained to approach the situation in a different manner. The director checked with the protagonist about what attributes and abilities were uncovered during the course of the enactment or after hidden feelings had been expressed. For closure, the director asked the protagonist to provide a title for the psychodrama and recite the title to the group. The psychodrama session came to an end after the protagonist released the roles of all auxiliaries by stating their real names.

Stage 4: Group Sharing

Immediately following the enactment, group members arranged chairs in a circle as they did in the beginning of the session, and a process called sharing back began. Each group member briefly shared how the experience affected him or her. The protagonist described insights gained that could be applied to real-life situations. Auxiliaries commented on their in-role experiences. The director cautioned against giving advice to the protagonist; the purpose of sharing back was for each participant to process how the drama affected him or her. After everyone had an opportunity to share, the session was adjourned. The protagonist was asked to stay to debrief the session with the director.

Stage 5: Individual Therapeutic Processing

During the final debriefing stage, the director met with each patient individually, starting with the question, "What did this session say to you?" The director wrote the responses or insights on a sheet of paper titled "Considerations." The notes taken during the session were also included on this paper to demonstrate learning about the self as a result of engaging in the psychodrama process. The purpose of this paper was to help each client put some thoughts together about the enactments and reflect on them as a concrete tool for gaining additional therapeutic insight. Citing the patient's own words, the director typically ended the session with an encouraging comment that aimed to leave the patient with an optimistic feeling about his or her positive qualities that were discovered in the session.

The director advised the patient to do additional processing with a family member, friend, or another therapist at least a few hours after leaving the session. The director stressed the importance of exploring the issues further in individual therapy. He acknowledged that not all issues could be addressed and resolved in a single psychodrama session but that psychodrama had opened the door for further exploration and resolution. He also cautioned against analyzing the drama, instructing the patient to simply visualize the process and articulate it in words before sharing it with someone. As a result of the experience, 11 patients (85 percent) expressed feeling "lighter," or as if something had been lifted off the shoulders. If the patient did not feel lighter, he or she was encouraged to talk about other feelings generated from this experience. With guidance, all patients could talk about their issues individually with their therapist or relate their feelings to an observable fact that this experience opened up some unresolved issues that needed further examination.

During &briefings, it was evident that all patients experienced benefits from their roles as the protagonists. Each could verbalize his or her learned insight and ability to take a new perspective on an unresolved issue. Because the purpose of the sessions was to help these patients open up a new perspective, no formal measure was used to identify change after treatment. Instead, the change for each patient was individualized on the basis of his or her ability to verbalize feelings. Through the experience, these patients took the opportunity to experience love (that is, care or concern) in a concrete manner and to feel the support that was lacking from an important person in their lives. The enactment provided them with a sense of control over the situation and the ability to connect feelings to a concern that had negatively affected their self-worth. They also learned alternative ways of handling situations and expressing the accompanying emotions to a person (or people) with whom they had not been able to closely communicate before this experience.

LINKING CONCERNS TO THERAPEUTIC OUTCOMES

A strengths-based orientation was present throughout the sessions, with an emphasis on the innate possession of positive attributes, self-efficacy, and hope for the future. Through enactment, 22 concerns emerged during the sessions. Beginning with the most frequently expressed, they included relationship problems (personal and professional), low self-esteem, self-loathing, emotional neglect or abuse by parents, trauma (physical or sexual abuse, murder of mother and grandmother), suicide attempt, substance abuse, anger outbursts, feelings of isolation, feelings of hopelessness, lack of (or perceived lack of) emotional support, loss of control, boundary issues, trust issues, issues with authority, inability to accept love, grief and loss, abandonment, feelings of rejection, multigenerational patterns of maladaptive thoughts and behaviors, avoidance of intimacy, and questioning of faith. Typically, several concerns emerged within a single psychodrama session, and many interpersonal concerns recurred throughout different sessions.

At the end of the psychodrama, a treatment outcome was considered positive when a patient was able to connect current feelings to a previously unspoken concern and the social worker was also able to witness these connections through each patient's actions. These actions were translated into words that best described the patients' behavioral changes. First, the social worker used direct observations and notes to identify outcome-related words and phrases that were connected to the behavioral and psychological responses of the patients. Second, the social worker worked jointly with her field supervisor to further identify patterns and themes from the observation notes and the director's comments. Through this processing of the patients' actions exhibited during the psychodrama process, the authors found word and behavioral patterns that were linked to therapeutic outcomes and categorized them into eight themes. The following sections list quotes that were echoed by more than one patient in representing their experiences and achievements throughout their psychodrama experience. To protect patient confidentiality, no individual demographics are included after these quotes.

Change in Emotions

* "Even when anger, hurt, and resentment are justified, I still need to examine how it affects my life and decide to keep it or let it go. I need to let it go because I deserve to live without it."

* "The past should remain in the past; one episode of your life should not control your entire life. A wall can keep things in and keep things out--I need a gate."

Family of Origin Issues

* "I feel cheated for not having a sister. Underneath the anger [at not having a sister], there's a lot of love. I miss a relationship with my sister, of sharing my life with her. I feel alone and vulnerable."

* "My [abusive] father wasn't the only one who molded me. I have loved and still have resources to love."

Impact of Group Work

* "I don't have to go through this alone."

* "I am not crazy. I should free her [the double]."

* "I am really lovable and loving, but I have been hiding it, so no one can see it."

* "I have to recognize that people have boundaries. I can be happy without the forced affection."

Relationships with Others

* "I realize now that I portray myself to others as angry and that this is a veneer."

* "I can fulfill those needs within myself."

* "I need to focus more on my job and less on people's thoughts about me."

* "I'm always thinking about what others think about me and how I do my job."

Impact of the Past

* "I'm carrying how I felt in school into my adult life."

* "I may benefit from exploring some past events that I thought didn't bother me."

* "The withdrawing perpetuates the feeling of abandonment, so it wasn't doing any good. It was actually doing harm."

Self-Awareness

* "My self-criticism was a learned way of thinking."

* "I know what advice to give, but I don't give it to myself."

* "I need to separate the past from the present. The past can influence me but not dictate who I am."

* "I think I beg for criticism so that I can learn what not to do. My self-criticism tells me I should always do it the right way. I need to learn to check in."

* "I'm assuming people don't like me, that I won't measure up. I recognize that I can change that by changing the child part of me. I can stop it."

Self-Worth * "I do have worth and value."

* "I do know how to love myself."

* "I have to remind myself of the positive things about myself."

* "I need to uncover the true essence I was born with."

* "The pillows [prop used for concretizing the patient's positive traits] strengthened me."

Shift of Personal Views

* "These qualities come forth in me. This gives me confidence and hope."

* "Helping others helps me, and that's OK."

* "It helps them as well if they help [love] me. It's OK to accept help [love] from others."

Summary of the Outcome Themes

The eight outcome themes show evidence that participation in psychodrama had a profound impact, providing these psychiatric patients with a new perspective. As previously mentioned, most patients (85 percent) described feeling lighter after at least one psychodrama session as the protagonist. Insights gained from the psychodrama provided them with explanations for feelings they had not previously understood. All patients expressed that concretizing through the use of props (pillows or sheets) enhanced their involvement in the process, whether the props were used to represent love or specific traits held by a person or to delineate physical boundaries or relationship connections. The props allowed the patients to physically feel and hold onto intangible feelings by connecting with something concrete. They learned that once their past responses were enacted in the here-and-now environment, they could gain control of their feelings. Individual protagonists discovered hidden personal strengths, leading to a perception of improved self-esteem. As a group, the enactments helped these patients learn how past issues influenced current functioning and enabled them to make a connection between the two. Through their increased insight, the patients were able to view their interpersonal conflict through a new perspective.

CLINICAL LEARNING: PROCESS, OUTCOMES, AND LIMITATIONS

To gain additional knowledge about the process, outcomes, and limitations of psychodrama, the authors interviewed two psychodrama therapists: (1) PD, the director of the 13 psychodrama sessions, who is a certified practitioner licensed by the American Board of Examiners in Psychodrama, Sociometry, and Group Psychotherapy (ABEPSGP), and (2) Adam Blatner, MD, who is the author of Acting-In (Blatner, 1996) and Foundations of Psychodrama (Blatner, 2000). The interview with PD was in person and via written correspondence (August 16, 2010), and the interview with Dr. Blatner was via written correspondence (August 5, 2010). In addition, the social worker's observations were used in describing the limitations of this study.

Patients Served

Because psychodrama can be used in a wide variety of clinical settings, PD conveyed that patients who have the greatest difficulty with this technique are "paranoid, psychotic, or dissociative [and] may have not been in individual therapy for at least a year." However, he indicated that this population should not be entirely excluded. He has successfully directed psychodrama sessions with psychotic patients (but only with select group members, and only in an inpatient setting). Dr. Blatner agreed that patients who are acutely psychotic may not be appropriate for psychodrama because of their mental state but felt that some can still receive benefit from being members of the audience. He pointed out that the director of the psychodrama sessions must assess who is appropriate for this type of treatment.

Contributions

Dr. Blatner stressed the importance of concretizing patients' ideas because it "gets past tendencies to distance oneself through narration." Similarly, PD added that concretization provides integration of thought and affect, stimulates all of the senses, identifies experiential memories, provides cognitive insight into esoteric or intangible concepts, and opens an opportunity for behavioral rehearsal. In terms of incorporating specific psychological theories in psychodrama, Dr. Blatner noted that "almost any theory" can be used, but he asserted that "most theories could benefit from being fertilized with concepts from role therapy and other Morenean ideas." A similarity between psychodrama and social work strengths-based practice was evident in his remark that "just the idea of helping people to frame their challenge as creative rather than focusing on problem solving makes psychodrama more open ended."

Efficacy

PD pointed out that he received positive patient feedback during his tenure as a psychodrama director in an inpatient setting over a 48-month period. His monthly reports showed that on a rating scale completed on exit from the facility, patients consistently rated psychodrama as their top choice as the most helpful treatment during their hospital stay. Dr. Blatner conveyed the following thoughts about efficacy studies pertaining to psychodrama:
   I don't see the method as pure or as a single
   therapy. Indeed, I don't see any therapy as
   sufficient in itself. I think the era of competing
   schools of thought is or should be past. So
   much depends on the clinical judgment, the
   authenticity, the wisdom, and other qualities
   of the director, and also the quality, norms,
   and consciousness level of the group.


Limitations

Through observations and interviews with the two experts, the social worker found that psychodrama was used effectively as an adjunct to help the patients open up about their concerns. However, it was difficult to identify the effective outcomes that could be attributed solely to psychodrama because it was combined with other treatment modalities offered in the hospital. The effectiveness of this psychodrama treatment could be supported only by the qualitative data gathered during the assessment step, which took place once it was clear that patients had increased their levels of insight.

Nevertheless, the social worker also gained insight from being an active participant, observing the entire process, and recording the outcome words used by each patient. The social worker documented the patients' change to use of the present feel from the past felt, indicating that they were in touch with present feelings that were initially too abstract for these patients to even describe. The social worker's participation became a living proof of each patient's positive changes resulting from his or her protagonist role, stay-in-the-moment action, and debriefing feedback. Throughout the entire process, the social worker recorded data summarizing how the present-moment capturing of the experiencing or reexperiencing resulted in the patient's feeling hopeful. All of these experiences support the use of psychodrama in clinical learning and practice.

DISCUSSION

Not all psychiatric patients reveal in psychodrama what they typically do not reveal in other types of psychotherapy. However, when they visualize and feel the effect of the drama, they may internally analyze their situation and then share this outcome individually with their therapists without the pressure of group sharing. Although this study examined the outcomes from only one day hospital program, its qualitative results provide four hints for building a learning base that can inform further investigations.

First, it is essential to plan a positive ending from the beginning of each drama session. At the end of the four- to six-week treatment, these patients could find meaning in their lives and talk positively about their futures. They felt that they became more open about their issues and, therefore, achieved positive outcomes. From the patients' perspectives, psychodrama was perceived as an educational means to help them shift their personal views so that positivity could be highlighted in each session and maintained throughout the course of treatment.

Second, the experiential outcome data must be individualized. This study focused on the thematic analysis of therapeutic insights verbally expressed by these patients instead of recording their responses on a standardized outcome measure. Except for the analysis of their use of positive words, no fixed measures were used in this process because the direction of the dramatic content was individually connected to each patient.

Third, psychodramatic practice can also be used as an educational tool when working with social work interns or as a continuing educational tool for practitioners. This educational opportunity, unfortunately, has not been promoted because of a lack of qualified field supervisors. In 2006 to 2007, 32 percent of psychodramatists certified by the ABEPSGP were licensed social workers (128 of 403) (Gershoni, 2008); however, in 2011, this percentage had dropped to 11 percent (42 of 381) (ABEPSGP, 2011). Psychodrama can be prepared for through many facets of dramatic learning, such as focusing on an issue through sociodrama in a classroom setting (Blatner& Glass Collins, 2008). In field education or continuing education, through the observatory process and from the client's perspective, interns and clinicians can practice the enactment skills needed to empower patients to face uncovered situations that need further therapeutic attention. The strong emphasis of psychodrama on creativity and strengths focused dialogue is consistent with the person-centered values of social work. The enhancement of this practice and learning method requires special attention.

Fourth, psychodrama is a clinical experience of openness and acceptance. Many psychodramatic elements, for example, family sculpture in which group members post as the protagonist and the protagonist's family members to enact interactions and feelings for the protagonist to observe, have been incorporated into clinical social work practice, as documented in social work sessions such as those conducted by Satir (1989). The psychodrama stage allows social workers to address the multiple psychosocial forces affecting their clients' lives through a series of enactments. It helps social workers appreciate the conjoint effort of multiple treatment approaches and interdisciplinary efforts in creating a safe environment for clients to express concerns and find solutions.

IMPLICATIONS FOR SOCIAL WORK PRACTICE

Psychodrama is used in a variety of settings, both in individual and group contexts, including mental health programs, business, education, community development, and clinical supervision (Scholl & Smith-Adcock, 2006-2007). Although there has been a decline in the number of certified practitioners, social workers can practice psychodrama with their clinical training and make contributions to clinical skill enhancement in three major areas:

1. As a treatment modality, psychodrama is viewed as helpful in group therapy when conducted within a safe and familiar environment, including day or inpatient settings and therapist-led programs (Dogan, 2010; Kipper, 1997).

2. As a training tool, psychodrama promotes the clinician's active participation in the client's treatment process. With its action-oriented procedures, a clinician can play various roles that empower patients to disclose concerns and find solutions. By reporting this "visual" process in clinical supervision, the clinician can link a client's actions with observable changes (Hinkle, 2008).

3. As a psychoeducational medium, psychodrama provides an environment for clinicians to observe and manage transference and countertransference issues with their patients (Jenkyns, 2008).

This study provides evidence to support the use of action-oriented methods and psychodramatic techniques in clinical practice to enhance the social worker's role in a therapeutic process. In this observatory study, the social worker (an author of this article) affirmed that psychodrama is a clinical tool that can generate positive outcomes such as being open and thinking of hope. The results and outcome analysis from this process should encourage clinicians to use psychodrama as a resource-oriented modality that promotes immediate feedback from clients and other therapists. Because every patient is unique, the strength of psychodrama is in its creativity and individualization to bring about positive therapeutic outcomes in the here-and-now moment.

doi: 10.1093/sw/sws054

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Debra A. Konopik, MSW LMSW, is clinical social worker, Texas Children's Hospital, Houston. Monit Cheung, PhD, LCSW, is professor and chair of clinical practice concentration, Graduate College of Social Work, University of Houston, 110HA, Social Work Building, Houston, TX 77204; e-mail: mcheung@uk.edu.

Original manuscript received September 5, 2011

Final revision received October 14, 2011

Accepted November 2, 2011

Advance Access Publication December 6, 2012
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Date:Jan 1, 2013
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