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Psychodrama as an effective treatment for trauma and PTSD experience

Recent findings have challenged trauma therapists to consider alternative and adjunctive approaches to talk therapy and cognitive approaches. At the same time, these new findings serve to validate experiential philosophy, theories, and approaches that Jacob Moreno proposed decades prior.

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Giacomucci, S. (2021, June 28). Psychodrama as an effective treatment for trauma and PTSD experience. http://www.apadivisions.org/division-49/news-events/psychodrama-trauma-treatment

Psychodrama and PTSD

Jacob Moreno (1889-1974) created psychodrama over 100 years ago, long before PTSD was recognized as a diagnosis in the DSM in 1980. Most of Moreno’s early work was with trauma survivors, prior to the impacts of trauma and posttraumatic stress disorder (PTSD) were articulated or understood. At the climax of psychodrama’s popularity, it was employed regularly in psychiatric hospitals and Veteran Administration (VA) hospitals. One author suggests that in the 1950s, before widespread deinstitutionalization policies, psychodrama had been integrated into one third of all mental institutions (Borgatta, 1950). Psychodrama has been regularly used to treat trauma and its manifestations for an entire century. Unfortunately, very little research was conducted on the effectiveness of psychodrama, and it failed to stay integrated into university programs or mainstream mental health treatment in the United States. Over time, psychodrama seemed to have developed a negative reputation for retraumatizing clients when used by facilitators without adequate training in psychodrama or trauma-informed principles. These influences, along with the success of other action methods similar to psychodrama, collectively led to its decline in practice.

In the 1990s, a new wave of neuroscience research and trauma theory emerged and was absorbed into psychodrama practice while also sparking the development of new trauma-focused psychodrama models for treating PTSD. This influx of new neurobiology research highlights the impact of trauma on the body and parts of the brain below cognition, language, or talking. Brain scans show that when someone remembers a traumatic event, parts of the brain responsible for speech, language, and thinking are inactive or less active (Rauch et al., 1996). Furthermore, interpersonal neurobiologists agree that the most important finding of the century has been that experience has the power to change the brain throughout the entire lifespan (Cozolino, 2014; Siegel, 2012). This means new corrective experiences have the power to renegotiate the impacts of past trauma (Giacomucci & Stone, 2019). These findings have challenged trauma therapists to consider alternative and adjunctive approaches to talk therapy and cognitive approaches. At the same time, these new findings serve to validate experiential philosophy, theories, and approaches that Jacob Moreno proposed decades prior.

The relational emphasis of psychodrama and group therapy position it as uniquely effective in addressing attachment trauma or relational trauma. Psychodrama also often focuses on role training, which creates opportunities for group members to practice new social skills or approaches to triggering situations through simulations before facing them in real life. Aspects of Polyvagal theory have also been integrated in psychodrama practice which provides a guide for protagonists to get unstuck from the frozenness of their trauma responses, discharge somatic energy held in the nervous system from incomplete survival response, and restore social engagement (Giacomucci, 2018; Dayton, 2015).

Trauma and its impacts are often unspeakable or difficult to articulate in words; psychodrama’s action-based interventions provide trauma survivors with avenues for non-verbal or symbolic expression (van der Kolk, 2014). It is no secret that psychodrama has the power to help participants access strong catharses and release or express powerful emotions. In psychodrama theory however, there are multiple types of catharsis - abreactive catharsis and integrative catharsis. While psychodrama is often associated with catharsis of abreaction, psychodrama theory promotes catharsis of integration as the ultimate goal. Abreactions are more emotional based (releasing of emotion) while integrative catharsis has elements of emotion and cognitive restructuring (Giacomucci, 2021). Through psychodrama, participants can renegotiate physiological, emotional, cognitive, social, and existential impacts of trauma.

Psychodrama allows us to go places that would be impossible otherwise. The psychodrama stage becomes a portal to surplus reality where anything is possible. In psychodrama, we can enact scenes needed for closure, for healing, or for growth. A psychodrama protagonist can talk to God or deceased loved ones, comfort or protect themselves as a child victim, confront a perpetrator from the past, and embody a vision of post-traumatic growth for themselves in the future. A properly warmed-up group engages in these processes “as-if” they were occurring in the here-and-now. Though they are not “real” experiences, it appears that the body and mind are able to integrate the experience like any other real experience.

Interest in psychodrama has increased in various communities in the past few years, largely due to increased psychodrama publications, increased acceptance of experiential or creative arts therapies, and promotion by leading trauma expert Bessel van der Kolk. In the treatment of PTSD and trauma, research evidence continues to grow demonstrating the effectiveness of group therapy (Bisson et al., 2013; Burlingame, Strauss, & Joyce, 2012; Schwartze et al., 2019; Sloan et al., 2013), the creative arts therapies (Baker et al., 2018; Feniger-Shaal & Orkibi, 2020), experiential psychotherapies (Benish, Imel, & Wampold, 2008; Elliott, Greenberg, & Lietaer, 2004; Elliott et al., 2013), and body- and movement-oriented interventions (van de Kamp et al., 2019) – all of which are larger categories that include psychodrama.

The American Board of Examiners in Sociometry, Psychodrama, and Group Psychotherapy had a record number of applications for board-certification last year and the Social Work with Groups journal published a special issue on psychodrama for the first time ever this year. While interest in psychodrama has grown significantly, the research base continues to be lacking. Psychodrama’s disconnection from academia has severely limited the psychodrama community’s access to research expertise, IRB boards, funding, and other resources needed to execute high-quality research studies. The current evidence suggests that psychodrama may be effective as an additional treatment for PSTD and other mental health disorders, but more empirical research is needed. This is an area of study wide-open for group therapy and group psychology researchers to make meaningful contributions to the literature.

References

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Cozolino, L. J. (2014). The neuroscience of human relationships, (2nd Ed).  New York: W.W. Norton & Company.

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Giacomucci, S. (2018). The trauma survivor’s inner role atom: A clinical map for post-traumatic growth. Journal of Psychodrama, Sociometry, and Group Psychotherapy. 66(1): 115-129

Giacomucci, S. (2021). Social Work, Sociometry, and Psychodrama: Experiential Approaches for Group Therapists, Community Leaders, and Social Workers. Springer Nature. https://doi.org/10.1007/978-981-33-6342-7

Giacomucci, S., & Marquit, J. (2020). The Effectiveness of Trauma-Focused Psychodrama in the Treatment of PTSD in Inpatient Substance Abuse Treatment. Frontiers in Psychology11, 896. https://dx.doi.org/10.3389%2Ffpsyg.2020.00896

Giacomucci, S., & Stone, A. M. (2019). Being in two places at once: Renegotiating traumatic experience through the surplus reality of psychodrama. Social Work with Groups. 42(3), 184-196. https://doi.org/10.1080/01609513.2018.1533913

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Schwartze, D., Barkowski, S., Strauss, B., Knaevelsrud, C., & Rosendahl, J. (2019). Efficacy of group psychotherapy for posttraumatic stress disorder: Systematic review and meta-analysis of randomized controlled trials. Psychotherapy Research29(4), 415-431.


Sloan, D. M., Feinstein, B., Gallagher, M. W., Beck, J. G., & Keane, T. M. (2013). Efficacy of group treatment for posttraumatic stress disorder: A meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 176–183.

Siegel, D.J. (2012).  Developing mind:  How relationships and the brain interact to shape who we are. New York: Guilford Press.

van de Kamp, M. M., Scheffers, M., Hatzmann, J., Emck, C., Cuijpers, P., & Beek, P. J. (2019). Body‐and Movement‐Oriented Interventions for Posttraumatic Stress Disorder: A Systematic Review and Meta‐Analysis. Journal of traumatic stress32(6), 967-976.

van der Kolk, B. A. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. New York: Viking Press.