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Psychodrama and Cognitive Behavioral Therapy: Complementary companions (part 2)

This is part 2 of an article focusing on the developmental history and comparisons between Cognitive Behavioral Therapy and psychodrama

By Jenny Wilson

This article is part 2 of a piece that was published in the June, 2011 issue of The Group Psychologist. Part 1 focused on the developmental history and comparisons between concepts utilized in Cognitive Behavioral Therapy (CBT) and Psychodrama. Part 2 focuses on a specific example integrating the two treatment modalities.

The following section describes an example of my integration of CBT and Psychodrama through the course of several therapy sessions. The uses of techniques from both therapies are illustrated, followed by a discussion regarding underlying theory and philosophy.

CBT Enriched With Psychodrama

Background
This work occurred at the Psychology Centre, a clinic at which clinical psychology students gain practical experience and clients access psychological assessment and therapy at a reasonable cost. The main therapy model used at the clinic is CBT. As a senior clinical psychologist staffing the Centre, I supervise students and conduct assessment and therapy sessions. The client and student trainee consented to me using this material; their names have been changed.

Margaret is a 28-year-old woman who has been suffering from depressive symptoms and body image concerns. She referred herself to therapy and was aware that she had a student trainee and supervising clinical psychologist working with her. Lisa, the student, has a Bachelor’s degree in psychology and is studying for a PhD. At the time of these sessions, she was in her second year of postgraduate clinical psychology training. Lisa and I decided to work as co-therapists, with Lisa taking on as much of the therapy process as she could manage. I was in the room and assisted Lisa when necessary.

CBT in the Treatment Sessions
Lisa prepared and conducted the majority of three CBT sessions with our client. She formed a warm and attentive relationship with Margaret, teaching and assisting her to explore her world using effective CBT techniques (e.g., Socratic questioning). I was impressed with her ability to listen and attend to Margaret, her willingness to enter the client's reality and to be flexible in the therapy session. Lisa was still learning about CBT; she struggled and faltered at times but managed to maintain a strong relationship with Margaret. She did a substantial portion of the work on her own, but I assisted her at various choice points.

Margaret's depressive symptoms lifted quickly; she was bright, motivated and learned easily. She had a potential for healthy psychological functioning (including a good range of roles and cognitive flexibility) that was readily revived with a warm and empathic therapeutic relationship and well-targeted CBT interventions. She enjoyed the structure of CBT, including making an agenda at the beginning of each session, checking progress, setting goals, responding to didactic teaching of new skills and selecting and checking homework to be done between sessions. She readily brought up relevant items for the agenda, and worked on homework tasks such as pleasant event scheduling (bringing back “me time” into her diary). She was particularly excited about a homework reading that we assigned her from Self Esteem (McKay & Fanning, 2000), through which she identified in herself a critical voice and a more compassionate coaching voice.

Lisa taught Margaret to identify and record her negative automatic thoughts: habitual, involuntary and unhelpful thoughts about herself, the world and others that have a negative impact on her mood. She questioned and dis- cussed Margaret's thoughts, encouraging her to notice their impact and evaluate them, rather than accept them. Evidence for and against unhelpful thinking patterns were systematically gathered with Margaret and formed the basis for thought challenges. Additionally, structured exercises assisted her to develop alternative thinking patterns. For homework, Margaret filled-out thought challenge worksheets, practicing and developing skills to independently record and challenge her negative automatic thoughts.

Incorporation of Psychodrama
At this point, we reached a point in the therapy familiar to many CBT therapists. Margaret could identify thoughts that were unhelpful and probably untrue, but they “still felt true” to her. Experiential learning can be very useful to facilitate an emotional shift, and in supervision we discussed using a Psychodrama approach to enhance CBT. I talked with Lisa about using experiential work within a CBT framework, and recommended some CBT articles related to this. We planned that I would direct if the opportunity arose in the next session.

At the start of the fourth session, Margaret put on the agenda her concern about negative thoughts about herself and her body and stated her desire to change these cognitions. Lisa was warm and gentle with the client. She was quite directive, wrote key points on the whiteboard during the session and followed a standard CBT format. She used Socratic questioning to assist Margaret in identifying her negative automatic thoughts, found evidence that supported and challenges these negative thoughts and developed alternative thoughts based on the presented evidence. Margaret was actively engaged in this process–thoughtful, humorous and able to access a range of thoughts and beliefs about her with supporting examples. Margaret's automatic thoughts included concerns that she was too fat and “blobby” and that her boyfriend would find her unattractive. Evidence to challenge these thoughts included many positive remarks made to her by her friends and her boyfriend. At the end of the exercise, she was able to clearly state that, “Sexiness is a state of mind, not a body size”. She also stated that, although she knew this intellectually, it still did not feel true.

As planned, I invited Margaret to try a different sort of thought challenge–a type of “role play”. She agreed. I indicated the “stage” area where I had placed two chairs. I suggested she take up the role of "Young Blobby Margaret" who had been cruelly teased by catty girls at her school. She sat in one of the chairs and took up this role, moving into it quite quickly and requiring minimal prompting to talk in the present tense: “I'm fat and blobby”, “No one likes me”, “I am ugly and pathetic”. She was uncomfortable in her body, sitting on the edge of the seat, moving her hands over her hips and thighs in an agitated way. She was very conscious of her body and her stomach as she repeated the names she had been taunted with as a young girl. She was focused inward, experiencing an earlier child- hood time. Her constricted voice, small movements of her mouth and eyes holding back tears were evidence of her distress. She did not make eye-contact with me. Her level of immersion and arousal suggested that she had moved through the warm-up phase quickly and was ready for the interactive role-play phase. I stood up, asking her to move out of her chair and take the other. I then directed Lisa to take Margaret's seat and the role of Blobby Margaret.

Lisa was initially self-conscious, so I first demonstrated the role to her. She took up the role strongly, maximizing the agitated hand squeezing and pinching and talking in a self-deprecating way. The client looked at Blobby Margaret, silent for a minute; her face was set and a little uncertain. Suddenly her face changed and softened. She moved forward in her seat saying, “Oh I want to hug her! You poor thing.” I asked the auxiliary (Lisa) if it was okay for Margaret to hug her, to which she consented. Margaret moved her chair towards Blobby Margaret. She did not hug her but sat close. She talked kindly to her, gently and softly reassuring her. She firmly stated some of the things we had identified in the early cognitive challenge: “Those girls were really mean”; “You look okay”; “You are fine just the way you are”; “You are plump, but your parents were plump too, it’s okay”. We had several role reversals like this one in which Blobby Margaret heard the reassurance but had to check out whether Margaret really meant it. It took some time before Lisa could make eye-contact. There was a deep level of connection in eye and voice but there was still no physical contact. I invited Margaret to let Blobby Margaret know that she would stay in contact. She did this wholeheartedly and we ended the enactment on a positive note.

We returned to our original chairs, and I explained to Lisa the purpose of Psychodrama sharing. When a person has done an enactment such as this they often feel vulnerable. Making a human rather than a "professional" connection with the client helps her feel less exposed and helps with the transition back into ordinary life. (I was aware that Margaret was listening and that she understood the rationale behind the role play; she nodded when I talked to Lisa.)

In sharing, I let Margaret know that I felt moved by the gentle relationship she was developing towards herself. Lisa and I normalized Margaret’s feelings of dissatisfaction with her body, indicating that it was often difficult to keep liking our bodies when there were so many pressures to look a particular way. Margaret expressed her appreciation for the session. She was bright and animated, stating that she was “amazed” at this way of working and that she felt very different from the start of the session.

In three later sessions we continued with a standard CBT format, but the psychodrama experience of a “conversation with yourself” was frequently used. The client maintained her gains and was consistently more compassionate and gentle with herself. She finished therapy six weeks after the described session.

Philosophy and Theory behind the Techniques
The session described used aspects of CBT and Psychodrama. Both therapies influenced the techniques used, my stance and my thinking. Psychodrama influences are most salient in my attention to therapy and supervision relationship and in my stance of being directive about the process but relatively open about the content of the session. I find that nearly every topic of discussion provides ample opportunities to work with cognitive distortions, schema and behavioral patterns, as well as with roles and role relationships. I am not bound by the limitations of spoken word, Whiteboard or two column thought challenges; I can work with whatever material emerges, including multiple clusters of cognitions and feelings and multiple time-frames. I set therapy goals and focus on symptom reduction but hold these goals lightly. I recognize that client-led “detours” sometimes lead to the heart of an issue and those problematic inflexible roles or cognitive patterns that need to be addressed will show themselves repeatedly. The more I become aware of the social context of mental health issues, the more I value the theoretical and technical contribution Psychodrama offers for addressing this.

In preparing students such as Lisa to use Psychodrama techniques in session, I am attentive to the relationship between us. Guided by the philosophy and theory of Psychodrama, I attended to Lisa's warm-up and focused on her healthy functioning prior to the start of therapy with Margaret. Psychodrama experience and theory informs me that having the student use her body in action will greatly assist her. I am aware that playfulness is a glimpse of spontaneity and creativity that Lisa was capable of accessing within herself. Thanks to psychodrama training, I am a spontaneous and creative supervisor!

As a co-therapist with the student trainee, I recreated the supervised experiential learning style of Psychodrama as opposed to a CBT supervision style that may rely more on student report or review of recordings. Within Psychodrama's culture of lifelong personal development, I have been both a student and a “client” in the recent past. This assisted me to position myself alongside Lisa and Margaret physically and emotionally during some of the sessions. Doubling each of them in this way provided a strong experience of empathic attunement that they both responded to positively.

Moving from CBT into Psychodrama
The structured CBT thought challenge on the whiteboard strongly engaged the client's ability to think and reason, making the most of her intellectual capacities. However, it did not convincingly shift her emotions since it still did not feel true. This is a common issue identified in CBT and is traditionally addressed by ensuring that the client also engages in changes in behavior. For CBT homework, the client in this example had been engaging in pleasant events, planning breaks from her work schedule and eating regular healthy meals. Other specific CBT homework behavioral tasks for body image issues included: exercises such as observing her body in front of a mirror and developing neutral descriptors (e.g. “rounded hips” instead of “fat and ugly hips”), engaging in moderate physical exercise and abstaining from checking behaviors (such as pinching and measuring).

A CBT approach may recommend experiential techniques such as imagery or rational-emotive role-play to restructure childhood beliefs. However, it seems as though many psychologists (including myself) have received little or no CBT training in how to do this. Psychodrama training focuses primarily on experiential techniques, so training in this technique can provide opportunity to practice a large repertoire of experiential methods.

Considering the use of Psychodrama in the fourth session, I had thought about staging beforehand and had brought in extra chairs for the session in the event that this opportunity arose (which, in this case, it did). Placing the action on a stage or distinct allocated space is characteristic of Psychodrama. This assists the protagonist by defining the boundary between current day experience and surplus reality and moving from audience to stage is a physical marker of degree of warm-up. Unlike CBT's rational-emotive role-play, concrete positions are available for different roles. Body positions and spatial relationships between roles (e.g., near or far, higher or lower) provide another layer of information about the quality of relationships.

Consistent with CBT and Psychodrama's role training, the enactment had a clear goal and content in mind: to shift feelings about a particular issue. The Psychodrama director, however, primarily directs the process rather than content. In the sessions described above, for example, we were keen for the client to develop feelings congruent with rational thinking. Psychodrama training has prepared me to hold such goals lightly. If the enactment had taken a different direction (perhaps moving the client towards more unhappiness or arousing feelings of rage), my Psychodrama training would provide me ample preparation for working with such client experience rather than pushing it in a preconceived direction. Psychodrama theory and experience informed me that the spontaneity and creativity of the client, the student and myself would have risen to the occasion and found a progressive direction. I think that those without Psychodrama training would find this difficult.

Psychodrama sharing assists the client to transition from the intense internal experience of enactment of childhood experiences to the present day and current relationships before returning to her working day. Coupled with this, sharing some of our own human experience with the client is consistent with Psychodrama theory as we are all “group members”. It is also consistent with CBT in that it may counter beliefs that her concerns make her abnormal. In this example, the enactment was simple and effective and the production was adequate. True to CBT, it focused on the area with most potential for symptom relief (concerns about body image). By focusing on two main roles that were congruent with CBT theory, there was a clear framework for the student to follow that assisted her learning about CBT and use of experiential methods within a CBT framework.

In asking the client to be herself as a blobby teenager, I was picking up on her terminology, accepting and fully entering into her experience of reality. This is a stance consistent with both CBT and Psychodrama. Drawing attention to body sensations, posture and movement (e.g., coaching the auxiliary to maximize the agitated hands) facilitated the visual and spatial experience for the client, heightening warm-up, deepening emotional experience and accessing CBT's “hot cognitions”. By standing up rather than sitting, I warmed myself up to being a director of action rather than a talking therapist.

The most obvious strength of the enactment was that we had the blobby and bullied child present with herself as an encouraging, caring companion. We were able to engage the client with herself in such a way that she responded well to the negativity and her own harsh criticism. We did not address the thoughts, feelings and behaviors of the bullying children.

In demonstrating the role of Blobby Margaret I was coaching Lisa to become a spontaneous auxiliary for Margaret. I also facilitated two mirrors for Margaret. She saw an aspect of herself reflected in me (the supervisor/teacher) and then by Lisa (the auxiliary). Multiple views of herself and at least three perspectives (the first from “within” the role, the second as she “eavesdropped” on my demonstration to Lisa and the third as she interacted with it) deepened her experience of herself and assisted the shift in affect.

Stemming from role theory, appreciation of role concepts is crucial to Psychodrama theory. Reversing roles is a powerful technique; physically moving to another position changes one's perspective emotionally and intellectually. Viewing herself as an unhappy teenager markedly shifted the client's experience. This was not just a cognitive shift but a complete shift in role. Compassionate feelings, thoughts and actions were aroused and utilized to good effect as a result.

During the main psychodrama session, a potent action cue was stated: “I want to hug her”. Encouraged to move closer to the blobby teenager, the client willing shifted her chair closer but hesitated to actually make body contact. At this point I experienced a role conflict within myself. In Psychodrama, ethical physical contact is valued for its healing potential and ability to maximize the experience for the client. Psychodrama practitioners do not necessarily use physical touch in individual sessions; however, as a Psychodrama director, it could have been appropriate for me to gently assist the client to make physical contact with the auxiliary by coaching her or modeling the action for her. As a clinical psychologist, I have been discouraged from having physical contact with clients. In this situation, the auxiliary had consented and the action cue had been given by the client rather than by me (the director). Cautious and recognizing the good work that was occurring by sitting close together, I did not amplify the action at this point. I believe it was a good decision, as I have not yet found a way to integrate physical touch in my CBT practice.

Psychodrama training has taught me to attend to the quality of the role—not just the words—during role reversals. I was aware of tone of voice, softening of timbre and softening and moistening of eyes. These and other clues indicated that the client was fully engaged in the enactment with heightened emotions and cognitions. I also was conscious of the client occasionally shifting roles and time frames during her interactions with me. No longer immersed in the enactment, she would thoughtfully and calmly ask a question before returning to the action of being fully present and emotionally expressive towards herself as a teenager. We were in existential time where multiple layers of experience, past and present, were happening in the Here and Now. The client was also demonstrating and practicing schema mode flexibility, moving easily from one mode to the next and having access to a rational appraisal of the situation.

For those readers who are interested in integrating CBT and psycho- drama in their clinical work, the self-help book from McKay and Fanning (2000) is a user-friendly guide to CBT that is compatible with Psychodrama techniques. McKay and Fanning illustrate thought challenging using two characters – the “Pathological Critic” and the “Encouraging Coach”. It is a short step to role enactment. The session described above exemplifies many dimensions of this book; it used Psychodrama elements within a CBT structure. However, it was professional Psychodrama training that informed my genuine openness to the content of the session and the quality of relationship that enabled production with sensitivity and depth. The CBT agenda and the initial cognitive challenge exercise served as warm- up for the enactment. The Psychodrama action was integrated into the body of the CBT session in order to attend to material in the client’s past.

Implications
I have investigated the goals, philosophy, theory and practice of Beck and Moreno, and have compared and contrasted their work (Part I). I have then taken these findings and applied them to a supervised therapy situation (Part II). This work has implications for clinical practice, research and future directions.

Clinical practice
Although CBT is the predominant therapy model in many mainstream organizations, research and clinical experience confirms that many clients will not make full and sustained recovery with CBT alone. One possibility for enhancing the delivery of CBT is to borrow methods from other therapy schools. I have demonstrated that many aspects of Psychodrama enrich CBT. Psychodrama training enables the CBT therapist to maximize use of the therapeutic relationship. Psychodrama techniques can ease the tasks of CBT for many clients, facilitating access to emotionally charged cognitions and providing opportunities for change. Psychodrama could also be a sequel to CBT. With its focus on experiential learning in a group context, Psychodrama may be particularly useful for clients who have long standing interpersonal difficulties that inhibit progress or contribute to relapse in traditional CBT.

For CBT supervision and training, Psychodrama offers a complementary training model that is based on health rather than illness and encourages lifelong learning and personal development. Psychodrama normalizes the difficulties faced by therapists and provides opportunities to develop intimate and supportive peer relationships where personal and professional development occur side by side.

The full potential of combining the therapies will only be realized with training, experiential learning and supervision. For example, lack of training in the therapeutic use of space and physical touch will prevent a CBT practitioner from ever using the full range of Psychodrama action methods. Additionally, use of any technique will be limited unless the clinician has an appreciation of its theoretical underpinnings.

Although there are some similarities, there are significant and possibly irreconcilable differences between Psychodrama and CBT at the level of philosophy. Both therapies value the subjective and objective experience of the client and both see human beings as meaning makers of their own world. However, there is likely to be tension between the spiritual and existential values of psychodrama and the tight focus on predetermined goals, specific outcomes and measurable symptom reduction endorsed by CBT and its academic psychology roots.

In clinical settings, Psychodrama therapists are referred clients with a psychiatric diagnosis and are expected to assist with symptom relief in short time frames. CBT's focus on psychological problems may provide a useful adjunct to Psychodrama's health-focused model:

  1. CBT shares some common ground with Psychodrama, has widespread mainstream acceptance and its language is familiar to many mental health practitioners. Use of CBT language may facilitate acceptance of Psychodrama concepts.
  2. All psychodramas involve cognitions and cognitive change.
    Consideration of CBT theory could raise awareness of the cognitive aspect of role and sharpen focus particularly in groups in clinical settings and during catharsis of integration.
  3. CBT offers a wide range of specifically tailored strategies for clinical problems many of which can be adapted and used in action.

Research and future directions
Psychodrama's contrasting but largely complementary perspective has the potential to stimulate CBT theory and research. Psychodrama has the potential to increase the effectiveness of CBT with individuals, enhance the effective delivery of CBT in groups and reduce risk of relapse. Promising areas for further exploration and research include:

  1. Investigating role theory and its relation to schema mode theory.
    This may be particularly useful for CBT practitioners and re- searchers considering the impact of schema modes in group and social contexts.
  2. Enhancing delivery of CBT in groups by drawing on Psychodrama theory related to group process.
  3. Considering Psychodrama's extensive repertoire of methods that do not rely on spoken or written work for clients with language and literacy problems.
  4. Developing CBT's repertoire of experiential techniques to include use of spatial relationships, movement, color, body sensations, physical objects and ethical use of touch.
  5. Developing CBT theory and practice by considering Psycho- drama's capacity for dealing with multiple time-frames and multiple clusters of experience (including several streams of cognition) simultaneously. 
  6. Considering spontaneity and surplus reality in the development of theory, practice and training, particularly in regard to anxiety reduction and motivation to experiment and “play” with new behaviors.
  7. Exploring alternative styles of CBT training and supervision, including the supervised clinical practice model of Psychodrama (as an adjunct to recordings, student report, or one-way mirror observations).

Further exploration and research into the area of combining CBT and Psychodrama is warranted. This is likely to initially involve more individual case studies and therapist observations, but may eventually result in more controlled trials being conducted. Robust discussion is needed to determine whether this method of research is appropriate for Psychodrama and whether there are better means to explore this complex method.

The similarities in the work of Beck and Moreno are intriguing and warrant further investigation. It is heartening that these two men with such different approaches have findings in common. It gives me hope that it may be eventually possible for people of diverse opinions to have a greater degree of shared understanding of the human condition.

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About The Author

Jenny Wilson is a Senior Clinical Psychologist currently working at the University of Canterbury as a Clinical Educator. She is particularly interested in psychotherapy and the thoughtful integration of different psychotherapies.

This paper was edited for The Group Psychologist by Letitia Travaglini & Tom Treadwell.