Therapists Who Have Combined CBT and Psychodrama

Therapy schools each have their own specialized constructs and language; being able to read and understand those texts is important if sharing of ideas is to occur. The following selection illustrates some of the ways in which Psychodrama and CBT have been combined by focusing on multiple levels for comparison (e.g., technique, theory or philosophy). Many CBT writers have adopted Psychodrama methods such as role-play and family of origin imagery (see Jacobs, 2002, Flemming, 2000, and Hamamci, 2002, 2006). These methods are particularly likely to be suggested when the basic CBT strategies do not work. However, even when Psychodrama is mentioned (which is rarely), authors are unaware of or do not acknowledge its origins (See Padesky, 1994 and Edwards, 1990). Several Psychodrama practitioners bring CBT techniques and theory to Psychodrama. Treadwell, Kumar and Wright (2002) explain CBT theory, noting the utility of the goal-focused, problem solving, selfreflection and mood regulation aspects, and describe CBT techniques that can be used to enhance Psychodrama. Similarly, Kipper (2002) endorses the usefulness of identifying and exploring irrational beliefs and distorted thoughts, adapting and describing specific Psychodrama techniques to facilitate this. Additionally, both Fisher (2007) and Baim (2007) write how CBT and Psychodrama theory can enrich each other, each observing the ways in which Psychodrama could be considered a form of cognitive therapy.

Several researchers and practitioners have all considered it useful to combine techniques from CBT and Psychodrama. However, many (with the exception of Baim, Fisher and Griffith) detail only one theoretical perspective and none provide more than hints about the philosophy behind CBT or Psychodrama. To address this omission, this paper will consider the theoretical and philosophical position of each before presenting a case vignette (to be discussed in the next issue of The Group Psychologist) where the methods are applied together.

Founders

J. L. Moreno J. D. Moreno, editing his father's writing in 1989 notes that J. L. Moreno was born in Bucarest, Romania, 1889, from parents of Sephardic Jewish decent. He was raised in Vienna and immigrated to the United States in 1925 to pursue sociometric group research (Moreno, 1989a,1989b). Beck was born in the United States in 1921, and was raised by Russian Jewish immigrant parents (Weishaar, 1993, p.3). Each man was exposed to a variety of political and social views. For example, Moreno lived in a "...mixed neighborhood" and was "exposed to a wide range of influences" (Moreno, 1989a, p.22) coupled with living in Vienna where "... Nazism, communism and existentialism had their underground beginnings..." (Moreno, 1989a, p.45). Beck's father was a "free thinker" who introduced his son to literature, theatre and poetry, and regularly hosted a group of men in his home to exchange philosophical, political and literary opinions (Weishaar, 1993, p.7).

Each had an early personal experience of life at the emotional extremes, and each explicitly brought this to his work. Beck had a childhood history of extreme anxiety and phobias, while Moreno experienced periods of grandiosity and heightened creativity during his teens and twenties. Interestingly, the style and confidence of each man appears to have moderated over time was integrated into their work. Both men had ideas that were initially seen as rebellious or novel compared with mainstream thought at the time. Each man developed the seeds of all subsequent ideas in early writings (Beck writing his seminal works in 1963 and 1964, and Moreno writing Words of the Father in 1923). These ideas continued to develop and mature with the men and were further developed by others.

A.T. Beck Beck met many individual patients who had entered psychoanalytic therapy. Moreno's experience was with groups of people "on the street and in their homes, in their natural surroundings" as well as psychiatric patients (Moreno, 1989b, p.61). It is likely that these different observation points influenced the development of their theory and methods for explaining and changing human experience. Beck has focused on the individual and the primacy of thought; Moreno has focused on the group and the primacy of action.

Moreno and Beck's own words open each of the following sections, with quotes chosen to offer a glimpse of the men before I introduce aspects from the philosophy, theory and practice of Psychodrama and Cognitive Behavioral Therapy.

Philosophy, Theory and Practice

Moreno: Two contradictory principles are operating in the therapeutic investigation. One is the utterly subjectivist and existentialistic situations of the subject; The other is the objective requirements of the scientific method (Moreno & Moreno, 1959/1975a, p.216).

Beck: The cognitive perspective is often misunderstood as taking only a "realist" perspective. However, the cognitive perspective posits at the same time the dual existence of objective reality and a personal, subjective, phenomenological reality (Alford & Beck, 1997, p.22).

Both Beck and Moreno recognized the tension between fully entering the client's world and the need for objectivity. Beck has a long association with mainstream academic institutions that tend to promote reductionism and rationalism at the expense of holistic and spiritual values. CBT has been the subject of many studies in these institutions, and, at times, has been reduced to structured treatment manuals and narrow outcome measures. Beck's own writing, however, indicates that he appreciates the complexity of human experience. Beck aligns himself with the constructivist perspective, which states that "human beings actively construct their personal realities and create their own representational models of the world" (Meichenbaum, 1993, p. 203, cited in Alford & Beck, 1997). Moreno's emphasis on the subjective nature of "psychological truth" places him philosophically alongside the phenomenologist's perspective (Blatner, 2000). Both writers reject determinism and see clients as meaning makers in their own world, providing a common footing in the foundations of these therapies.

Moreno had a strong existential and spiritual belief system, identifying with existentialists and religious figures from an early age (Moreno, 1989a, p. 45). The early existentialists emphasized existence itself as something sacred. Central to existential philosophy is the valuing of spontaneity, creativity and the "urgency of immediate experience" (Moreno, 1989a, p. 45). Moreno gives spontaneity and creativity a spiritual significance, linking them to the experience of God within. He saw psychodrama as an extension of the existentialist movement and a method that could grapple with the big questions: "… birth, death, sex, and the function of the Creator of the world" (Moreno & Moreno, 1969/1975b, p. 19). Moreno developed his existential ideas at a time when the eugenic perspective adopted by the Nazis was gaining momentum in Europe. It is easy to imagine Moreno and his fellows passionately seizing existentialist values as a counter to the empirical classification of humanity embraced by the Nazis.

No reference could be located in regards to Beck's spiritual beliefs or his views on existentialism. However, in notes that were recorded following a conversation with His Holiness the Dalai Lama, Beck stated, "I am struck with the notion that Buddhism is the philosophy and psychology closest to cognitive therapy and vice versa". He notes several similarities between Cognitive Behavioral Therapy and Buddhism, including a view on universality (that is also consistent with Moreno): "We are one with all humankind" (Beck, 2005a).

Therapy Goals

Moreno: A truly therapeutic procedure can not have less an objective than the whole of mankind (Moreno, 1953/1993, p.3).

Beck: The goals of cognitive therapy are to correct faulty information processing and to modify dysfunctional beliefs and assumptions that maintain maladaptive behaviors and emotions (Beck and Weishaar, 1989, p.28).

Moreno's expansive goals are concerned with all aspects of living and the maximizing of human potential: "Psychodrama enables the protagonist to build a bridge beyond the roles he plays in his daily existence, to surpass and transcend the reality of life as he lives it, to get into a deeper relationship with existence, to come as close as possible to the highest form of encounter of which he is capable" (Moreno 1975b, p. 29). The focus is wider than symptom relief, extending towards full experience and relish of life.

While this paper focuses on psychotherapy, psychodrama goes beyond the therapy room towards development and growth in every human and community sphere. Moreno has written about his methods in many contexts, including education, business, and communities. He developed a triadic system and considered Psychodrama, Sociometry and Group Psychotherapy to be inter-related and indispensable to one another (Moreno, 1970). He considered Sociometry (his study and measurement of society and relationships) as the foundation of his work, and formulated several laws and hypothesis on the basis of his research (see Moreno, 1943, for details). He developed the field of Sociodrama as a method of exploring, understanding and intervening in group settings.

Beck's initial goals were narrower in scope. Focused on the individual therapy of clients suffering from depression where he made observations based on clinical data. He tested and developed measures to systematize these observations and formulated guidelines for therapy. He applied this process to a sequence of disorders and problems including suicide, anxiety and phobias, panic, personality disorders, substance abuse, interpersonal problems, anger, hostility and violence (Beck, 2005a). Beck's theories arose in a clinical context and his tightly focused approach led to specific strategies for particular problems. Relief of symptoms and managing troubling emotions are key treatment targets.

Basic Description

Moreno: Drama is a transliteration of the Greek δραμα which means action, or a thing done. Psychodrama can be defined as the science which explores the "truth" by dramatic methods. It deals with inter-personal relations and private worlds (Moreno 1953/1993, p.53).

Beck: Cognitive therapy is an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders (Beck, 1967, cited in Beck et. al., 1979, p. 3).

Psychodrama originated as a group action method. Participants in psychodrama enact events from their lives using five main instruments. The stage provides a flexible space for freedom of experience and expression. The psychodrama director (a term used in preference to therapist) functions as counselor, producer and analyst, assisting the group to build an environment where the protagonist (main actor or client) can experiment freely with the assistance of auxiliaries (group members). Auxiliaries assist the director and protagonist in guiding and exploring the protagonist's world, portraying the actual or imagined people and aspects contained in it. The audience can be a sounding board of public opinion or subject of the drama. They may assist the protagonist or may be assisted by the drama portrayed (Moreno, 1953/1993).

Cognitive Behavioral Therapy was initially developed primarily as a talk therapy for individuals with psychiatric problems. It is a collaborative process between client and therapist that employs behavioral and verbal techniques to examine the client's cognitions, challenge unhelpful beliefs and provide skills that promote more adaptive cognitive processing (Beck and Weishaar, 1989).

Spontaneity, Creativity and Surplus Reality

Spontaneity, creativity and surplus reality are three intriguing constructs proposed by Moreno. I am unaware of any equivalent concepts in Beck's work. Unfamiliar to CBT therapists and full of promise and hope, these constructs have rich potential for enhancing CBT.

Moreno: The universe is filled with the products of spontaneity-creativity interaction (Moreno,1953/1993, p. 11). Surplus reality is ... an enrichment of reality by the investments and extensive use of imagination (Moreno 1965, cited in Moreno et. al., 2000, p. 2).

Crucial to Moreno's theoretical perspective is the principle of spontaneity. He emphasizes "The root of the word 'spontaneous' and its derivatives is the Latin sponte, meaning 'of free will'" (Moreno, 1946/1977, p. 81), clearly differentiating it from impulsivity, with which it is often confused. He defines spontaneity as the ability to meet each new situation with adequacy, and to develop new responses to old situations (Moreno, 1946/1977, p. 50). He noted, "Successful adjustment to a plurality of environments requires a flexible, spontaneous personality make-up" (Moreno, 1953/1993, p. 193). In a spontaneous state, similar to that experienced by children as they play, we are less self conscious, freer to try new things, able to see ourselves and others in new ways and to use our imagination. When spontaneity is high, anxiety lessens, and vice versa. Moreno believed that spontaneity can be developed by Psychodrama training (Moreno, 1953/1993, p. 195) and that spontaneity is the catalyst for human creativity. In Psychodrama, the spontaneity and creativity of director, protagonist and group make anything possible. Human imagination flows freely and the group can create anything or any situation. Surplus reality "is a world which may never have been nor may ever be, yet it is absolutely real" (Moreno et al., 2000, p. 5). Our capacity to dream, to create, to imagine is a quality that makes us human. This capacity has given rise to painting, sculpture, architecture, drama, dance, music and other arts. It is a quality that has enabled science and technology, and resulted in humankind successfully inhabiting the globe. The process of imagining and engaging in something that has never existed or happened before. It is highly valued in Psychodrama; termed "surplus reality," it is harnessed for its healing potential.

Warm up

Moreno: ...learning connected with highly warmed up states establishes special associations. Contents of learning which enter the mind connected with highly warmed up states recur more easily with the recurrence of similarly warmed up states ... learning becomes essentially connected and integrated with [his] acts, not apart from them (Moreno, 1953/1993, p. 199–200).

Beck: ...cognitive constellations underlying affect become accessible and modifiable only with affective arousal. In the language of cognitive therapy these are "hot cognitions" (Beck & Weisharr, 1989, p. 29).

The concept of warm up is used in Psychodrama, both in the context of warming up a group as well as warming up the individual protagonist. According to Moreno "the warming up process manifests itself in every expression of the living organism as it strives towards an act" (italics in the original, Moreno, 1946/1977, p. 56). Warm up gets us started in a particular direction and can be self initiated or activated by another (Taylor, 1998, p. 50). The Psychodrama director uses the group warm up to assist members to become aware of their current experiences and to develop trust and group cohesion. After a well conducted warm up there is a sense of common purpose and involvement with one another, and the group is able to move smoothly into enactment. By contrast, an inadequate group warm up may result in divided interests, breaches in rapport and a sense of reluctance by some to move into action.

Psychodrama techniques function to increase the warm up of the protagonist, increasing the ability to be present, intensifying thoughts and feelings and enabling them to act with spontaneity. Following Moreno's guidelines (Moreno & Moreno, 1969/1975b, p. 235) and facilitating a warm up from more superficial to most salient issues assists the group and individual work at deeper and deeper levels.

Considering warm up and developing warm-up skills is useful for the CBT therapist. Beck noted, "change can only occur if the patient is engaged in the problematic situation and experiences affective arousal" (Beck & Weishaar, 1989, p. 29, italics in the original). Adequate warm up assists the client in accessing the deeper thoughts, feelings and behavior related to the current concern as well as facilitating the accessibility of emotionally laden cognitions.

Roles, Schema Modes and Personality

Moreno: Role is the functioning form the individual assumes in the specific moment he responds to a specific situation in which other persons or objects are involved (Moreno, 1946/1977, p. IV). Roles do not emerge from the self but the self emerges from the roles (Moreno, 1946/1977, p. II).

Beck: Modes are conceived of as structural and operational units of personality that serve to adapt an individual to changing circumstances. The modes consist of a composite of cognitive, affective, motivational and behavioral systems (Beck, 1996, p. 19).

Reflecting and joining in with the play of children, Moreno noticed them trying out different ways of being and responding to one another and the adults around them. He planted the seeds for role theory, "a body of knowledge associated with the interactive functioning of human beings" (Clayton, 1994, p. 122), that others have since developed (see Clayton's 1994 review). Roles have an action, feeling and thinking component. Moreno makes them central to personality development; the self is a system of interacting roles (Clayton, 1975). According to Moreno, a healthy adult develops a wide repertoire of roles, has sufficient spontaneity to develop new roles or generalize old roles to new situations and is able to react flexibly in many different situations.

Roles described by Moreno sound similar to schema modes as described by Beck, who conceptualized schema modes as the "basic components of personality" (Beck, 1996, p. 27). The similarity between roles and schema modes is not coincidental. Influential theorist George Kelly borrowed ideas from Moreno (Stewart & Barry, 1991), and Beck was in turn influenced by Kelly (Alford & Beck, 1997).

More so than Beck, Moreno firmly places roles in a social context; roles arise in response to others and are thus inseparable from a social system. Moreno suggests that the person's internal psychological systems interlock with the "psychological geography" of a community, and that community is part of the "psychological totality of human society itself" (Moreno, 1937, p. 207 & p. 215). The specialized techniques Moreno developed to measure and address social issues (Sociometry and Sociodrama) create a method that can explicitly address the social context in which an individual's problems lie.

Psychopathology

Moreno: Without this function of spontaneity to facilitate the shift, the warming up process can produce a mental set in one track to the degree that it hampers or harms the relationship of the individual to real situations and real objects, or to imagined situations and imagined objects (Moreno, 1946/1977, p.72).

Beck: ...the cognitive model of psychopathology stipulates that the processing of external events or internal stimuli is biased and therefore systematically distorts the individual's construction of his or her experiences, leading to a variety of cognitive errors.... Underlying these distorted interpretations are dysfunctional beliefs incorporated into relatively enduring cognitive structures or schemas (Beck, 2005b, p. 954).

Writing extensively about social relationships and personality development, Moreno embraces the complexity and normality of human experience. His writing about psychopathology is in the form of case study and explanatory notes, from which some of his ideas about psychopathology can be gleaned. Moreno writes of the social atom as the "pattern of interpersonal relations which develop from the time of birth" (Moreno, 1939, p. 3). Although constantly changing, the social atom that develops in response to early social relationships (e.g., family of origin) is seen to be particularly influential in later development of relationships with others and with the picture a person has of himself. Moreno recognizes in normal development the relationship between self and experience of self (e.g., our ability to have feelings of acceptance, rejection, discord, or indifference to ourselves). According to Moreno, a person with an "abnormal social atom development may go through life without clinical manifestation of a mental disturbance but these can be rapidly activated as soon as a precipitating cause appears" (Moreno, 1939, p. 29). Precipitants can include physical illness, psychological states such as feelings of inferiority, or social conditions such as job loss or bereavement.

Moreno identified that lack of role flexibility can contribute to difficulties, and insufficient spontaneity results in limited responses. He notes that in complex personalities there may be multiple and contradictory relationships with self. In times of psychosis, there is a disturbance between all the relationships the patient has with himself and others, and the sense of time and space may also become blurred (Moreno, 1939, p. 4). Moreno postulated that a normal split between objective reality and fantasy or subjective reality occurs in early childhood and "the more deeply engraved these tracks are the harder it becomes to shift from one to the other on the spur of the moment" (Moreno, 1946/1977, p. 72).

Beck has written extensively about psychopathology and psychological problems. His theory, summarized from Beck and Weishaar (1989) is as follows:

Cognitive theory is based on the observation that "an organism needs to process information in an adaptive way in order to survive" (p.21). The processing is not always rational; in some circumstances (e.g., mate selection) it may have been an advantage to be extremely optimistic; in other circumstances (e.g., risky situations) exaggerating the potential for harm enabled the survival of the individual and contribution to the gene pool. Evolution has thus shaped our information coding systems to have a tendency to bias.

Each individual's learning history will contribute to the development of rules, assumptions and attitudes as we appraise our environment and experiences. Negative childhood experiences such as neglectful parents, major losses and trauma may predispose an individual to psychopathology by activating a less flexible, negatively biased and "more primitive" (p. 22) coding system, particularly in times of stress. Note that the cognitions do not cause psychopathology but are "an intrinsic part of it" (p. 23). As more "primitive information-processing systems" (p. 23) are activated, systematic errors in thinking called "cognitive distortions" (p. 23) become apparent. Examples of cognitive distortions include a tendency toward dichotomous thinking (classifying experiences as one or two extremes, e.g., "I must be the best student in the class or I am a failure") and personalization (blaming oneself for external events in the absence of any evidence of connection, e.g., "My boss must be grumpy because of something I have done"). Beck noted and described specific patterns of cognitive distortions in several psychiatric disorders. According to Beck "each person has a set of idiosyncratic vulnerabilities that may predispose one to psychological distress." These vulnerabilities are related to "personality structure and one's fundamental beliefs, values and attitudes about the self and world" (p. 24). The cognitive structures that contain these beliefs are termed schemata. The schemata develop during childhood in response to personal experiences, particularly interaction and identification with significant others. They are reinforced and shaped by further learning experiences. In his later writing, Beck (1996) formulates his theory of schema modes, integrating cognitive schemata with structures from the affective, behavioral, motivational and physiological systems.

Although influenced by the medical model of health and illness, Beck attributes psychopathology to the over-activation of normal information coding systems rather than qualitatively different process, noting that "cognitive theory considers personality to be grounded in the coordinated operations of complex systems that have been selected or adapted to insure biological survival" (Alford & Beck, 1997, p. 29).

Beck has a focused commitment to researching and understanding psychological problems. Collaborating with academic psychologists, he has created a well-developed and comprehensive theory of psychopathology. The patterns he has observed and written about have assisted me in understanding why people become unwell, and CBT research contributes to specific and detailed recommendations about effective therapy strategies.

Therapeutic Relationship and Encounter

Moreno: The fundamental principle underlying all forms of psychotherapy is the encounter (Moreno & Moreno, 1959/1975a, p. 234). ... let us consider the encounter in its various forms. On the lowest level are the millions of simple, drab encounters of daily life which everyone shares. At the highest level is the rare, penetrating "high" encounter which happens once or twice in a lifetime, a flash, an encounter with nature, a love relationship or an intense friendship, or a religious experience ... Psychodrama enables the protagonist to ... come as close as possible to the highest form of encounter of which he is capable (Moreno & Moreno, 1969/1975b, p. 29).

Beck: The general characteristics of the therapist which facilitate the application of cognitive therapy ... include warmth, accurate empathy and genuineness (Beck, 1979, p. 45). The therapist accurately communicates an understanding of the patient's thoughts and feelings. 'Understanding' refers to how well the therapist can step into the patient's world, see and experience life the way the patient does, and convey this understanding to the patient (Young & Beck, 1980, p. 5).

It is difficult to express the difference between a Psychodrama encounter and a CBT relationship by just referring to the literature. Both Psychodrama and CBT writers state that the therapeutic relationship is important. In CBT, a satisfactory working relationship is the vehicle by which CBT (and CBT supervision and training) can be delivered. In Psychodrama, the relationship (with director, group members and trainers) is a major, if not the major, component of the method.

Moreno puts relationship at the heart of the therapy process and is talking about something that is qualitatively different from the "understanding" or "stepping into the patient's world" which occurs during CBT. In psychodrama, group members are trained or coached in the moment to be assistants to the client (protagonist) by becoming the people in the client's world and inner experiences. In such therapeutic assistance, an auxiliary will not just "step" into the patient's world. If the protagonist is weeping and crawling on the ground, the auxiliary will weep and crawl on the ground. The skilled auxiliary will be the protagonist. This true role reversal is qualitatively different from empathy in a talking therapy. Psychodrama teaches the auxiliary to fully and completely enter into the experience of the protagonist with all their being. Extensive personal development is one of the reasons Psychodrama training is so lengthy and includes hundreds of hours of group interactions including dramas, sharing, interpersonal conflicts, discussions and personal work.

Beck emphasizes that a good working alliance and collaboration is necessary for a good outcome, and makes concrete suggestions about how to achieve this, including operational definitions (Young & Beck, 1980). However, CBT therapists could maximize the impact of their work by placing much more emphasis on relationship and relationship training. Attending closely to the therapeutic relationship while delivering CBT enhances the potency of the content and tasks of CBT; it potentially makes therapy easier and more satisfying for both the client and therapist. For complex clients, the relationship may be the essential ingredient that keeps the client engaged in therapy.

Group Considerations

Moreno: ....psychodrama represents the chief turning point away from the treatment of the individual in isolation to the treatment of the individual in groups (Moreno, 1946/1977, p. 10).

Moreno (1953/1993, p. 61) noted that modern psychiatry developed out of somatic medicine, where the locus of a physical ailment is within the individual. As psychiatry developed, this same premise was automatically applied to mental disorders. Changing the locus of therapy from the individual to the group is one of Moreno's major contributions to psychotherapy. Problems are seen as arising in a social context and in relation to others, and the creation of a therapeutic environment, including auxiliaries who interact with the patient, is a crucial aspect of Psychodrama. Group members in psychodrama become agents of therapy themselves (i.e., they are both clients and healers/therapists). The therapist/group leader is also seen as a group member. Although he or she has more expertise in the method, he or she is not seen as "expert" in offering a solution to difficulties in the same way as CBT therapists tend to be. CBT is frequently delivered in groups, but the groups tend to focus on content rather than process, with some leaders actively discouraging extensive discussion of emotional experiences, instead focusing on the acquisition of technical skills. (e.g., Free, 2007, p. 40). Moreno's method teaches group leaders to focus on both content and process, giving clients an opportunity to learn new skills, as well as the opportunity to learn about human relationships and the effect of interpersonal interactions on their difficulties.

In individual therapy situations, the psychodramatist is aware of group principles. The social context of the issue at hand is highly relevant. Typically the individual Psychodrama therapy room becomes populated with people from the client's life, represented by objects or dolls or in imagery (Hirschfeld & McVea, 1998). Psychodrama literature can provide a model for the CBT therapist to work with the social context even in one-to-one therapy.

Catharsis

Moreno: Mental catharsis is here defined as a process which accompanies every type of learning, not only release and relief but also a catharsis of integration (Moreno,1953/1993, p. 206).

Beck: ... it has been found efficacious to produce an affective experience through inducing imagery regarding traumatic childhood experiences, revivifying early memories, and role playing crucial past episodes (Beck, 1991, p. 195).

The term "catharsis" originally applied to physical purging, and was first used by Aristotle who related it to the emotional reaction of the audience in Greek theatre (Langley, 1998, p. 263). Moreno was more interested in the experience of the protagonist, although he also recognized the therapeutic effects on the audience. Moreno differentiated between catharsis of abreaction—a release or expression of feeling, and catharsis of integration—"a cognitive and emotional shift in perception" (Dayton, 1994, p. 15).

Catharsis of abreaction with emotional and physical expression is a characteristic feature of psychodramas. Each catharsis of abreaction is accompanied by catharsis of integration to "ground the learning on a cognitive level" (Dayton, 1994, p. 16). Catharsis of abreaction does not necessarily involve a noisy outburst of emotion; quiet and delicate expressions can be full and valuable and can also be followed by a reflective catharsis of integration. Psychodrama enactments enable corrective and helpful learning to occur in an emotionally charged state.

In contrast, many CBT techniques focus on the management of emotions, and Beck is dismissive of catharsis, particularly when it is simply a release of "dammed-up feelings" (Beck et al., 1979, p. 42). Beck does, however, support the use of experiential and emotive techniques, such as role play and imagery, combined with a highly organized "realitytest" of the associated cognitions (Beck and Weishaar, 1989, p. 29).

Action

Moreno: Because of the universality of the act and its primordial nature it engulfs all other forms of expression. They flow naturally out of it or can be encouraged to emerge, verbal associations, musical associations, visual associations, color associations, rhythmic and dance associations (Moreno & Moreno, 1977, p. 18).

Beck: ...behavioral methods can be regarded as a series of small experiments designed to test the validity of the patient's ideas or hypothesis about himself (Beck, Rush, Shaw & Emery, 1979, p. 118).

For Moreno, action is primary and psychodrama represented a movement away from treatment by talking therapies to treatment by action methods (Moreno & Moreno, 1977, p. 10). Before each of us developed spoken language we could act, and, according to Moreno, it is through action that we learn, change and develop. Moreno developed a wealth of action methods in many different spheres. Moreno believed that knowledge and insight in itself does not cure. To Moreno, it is important to change behavior, and to change behavior it is necessary to access spontaneity and creativity (Moreno et al., 2000, p. 13). Psychodrama utilizes many forms of creative expression in order to develop new perceptions and change behavior. "Drama" is only one aspect of this; music, song, color, and dance are frequently expressed on the psychodrama stage.

Beck advises that the ultimate aim of including behavioral tasks in CBT is "to produce change in the negative attitudes" (Beck et al., 1979, p. 119). Psychodrama action provides ample opportunities for behavioral rehearsal, behavioral experiments and graded exposure to previously avoided situations. These action strategies, with appropriate catharsis and integration, can impact the client's attitudes.

Thoughts

Moreno: I had two teachers, Jesus and Socrates; Jesus the improvising saint, and Socrates, in a curious sort of way the closest to being a pioneer of the psychodramatic format (Moreno,1953, p. xxii).

Beck: Cognitive therapy ... is based on an underlying theoretical rationale that an individual's affect and behavior are largely determined by the way in which he structures the world (Beck, 1967, cited in Beck et al. 1979, p. 3). Alterations in the content of the person's underlying cognitive structures affect his or her affective state and behavioral pattern ... correction of faulty dysfunctional constructs can lead to clinical improvement (Beck et al., 1979, p. 8).

Moreno was impressed with Socrates, seeing him as unconsciously using the technique of role reversal during his dialogues. Interviewing for a role is an opportunity for the director to explorer thoughts and cognitive processes in Psychodrama. Using Socratic questioning, the director questions the protagonist during a drama either as him/herself or (in role reversal) as a significant other. This process illuminates the thinking process of the protagonist and his insight into the thoughts and values of others. Moreno also identified with Jesus, seeing Jesus as being able to enter in the "totality and essence" of a situation. Moreno saw Psychodrama as a synthesis of the approaches of these two great healers (Moreno, 1953, p. xxii).

Beck examines thought processes separately and in much greater detail than other aspects of human functioning. For Beck, cognition is primary – not because it necessarily comes first, but because he found it most amenable to change. According to Beck, the cognitive biases that are present when a person is distressed or psychologically unwell can be identified by the client and therapist and systematically challenged. Shifts in cognition lead to shifts in affect and behavior. If more adaptive patterns of cognition are constructed and maintained, then the person is less vulnerable to recurrence of problems such as anxiety and depression (Beck, 1991). The competent CBT therapist approaches the client open-mindedly using Socratic questioning to guide the collection of data, identifying and exploring themes and patterns collaboratively so that the client "learns to identify these assumptions and to consider whether they are valid or logical" (Beck, 1979, p. 55).

Socratic questioning is a fundamental component of both CBT and Psychodrama and an effective intervention to assist clients in identifying, monitoring and changing their thinking. Using Socratic questioning in action situations (interviewing for role) provides immediate access to emotionally relevant cognitions in "totality and essence".

Therapy Content and Therapist Stance

Moreno: The objective of psychodrama was, from its inception, to construct a therapeutic setting which uses life as a model, to integrate into it all the modalities of living, beginning with these universals – time, space, reality and cosmos – down to all the details and nuances of life and reality practice (Moreno & Moreno, 1969/1975b, p. 11).

Beck: ...symptom relief, distortions in logic and problem behaviors ... ultimately ... to modify underlying assumptions and systematic bias in thinking (Beck & Weishaar, 1989, p. 28).

Moreno identified what he called the four universalia of psychotherapy: time, space, reality and cosmos. Consideration of all these dimensions contributes to the rich, multi-layered experience of Psychodrama moving far beyond the concerns of standard CBT.

Moreno was interested in the relationship humans have with time, noting: "Man lives in time—past, present and future. He may suffer from a pathology related to each" (Moreno & Moreno, 1969/1975b, p. 11). He was concerned about space, including perception of physical space, physical distance and movement. He recognized different aspects of reality including what is happening in the therapy office, what is happening in the client's day-to-day life, and surplus reality (Moreno & Moreno, 1969/1975b). Moreno saw man as a "cosmic being" and psychodrama as a method which can address "the dilemma of the existentialist ... how to tie his personal existence into the rest of the world" (Moreno & Moreno, 1969/1975b, p. 19).

A skilled director enables the protagonist to see an issue or a relationship in many dimensions. Past, present and future can all be present, and abstract ideas can be made concrete. When fully immersed in a drama, the protagonist may be in an altered state similar to light hypnosis. The shift in perspective by reversing roles or standing outside the action as an observer brings new insights, new possibilities and new behaviors and results in a very full experience which may remain strongly in memory for many years.

The psychodramatist is directive about the process of the session (e.g., giving instruction to move from discussion to enactment or from physical gesture to verbal expression). He or she attends to the spatial aspect of the situation, including action and staging, but is entirely flexible about content, noticing subtle clues in the protagonist that guide the flow of the drama. The Psychodrama director learns to value "not knowing" what will happen next. The situation could be explored at the level of: the individual, society or the universe; past, present or future; or from any perspective on reality (e.g., dream or fantasy).

CBT's content and therapist stance is very different. CBT is focused on current day problems. "Little attention is paid to childhood recollections except to clarify present observations" (Beck, 1979, p. 7). The focus is on everyday thoughts, feelings and behavior. Goals are established for the course of therapy and within the session. The therapist is directive about the content of the session and will prioritize key activities, thoughts or behaviors that Beck has demonstrated as likely to be effective points for intervention and change. This parameter is both CBT's strength and its weakness. When CBT works well, behavior change and symptom relief can be rapid. However, there are many cases when consideration of a much broader content area such childhood experiences, dreams and existential concerns are highly relevant.

Techniques

Moreno: Psychodrama ... includes all previous technical approaches (Moreno, 1975a, p. 236).

Beck: With the theory of cognitive therapy in place, we can turn to other systems of psychotherapy as a rich source of therapeutic procedures (Beck, 1991, p. 191).

Psychodrama has a number of unique techniques (e.g., see Moreno, 1959, 1969 and Blatner, 1996). However, it is debatable whether any technique applied in isolation is Psychodrama. Similarly, although CBT has a proud tradition of specialized techniques (see Leahy, 2003); CBT therapists would argue that it is the cognitive conceptualization rather than techniques that make it true CBT. As indicated previously in this paper, CBT and Psychodrama therapists are already borrowing techniques from one another. Psychodramatists willingly adopt any technique that might seem useful in a specific situation, many of whom could readily and creatively adopt the techniques of CBT. CBT practitioners are also great borrowers of new ideas. Beck and Moreno would support this, but probably each would think his was the integrative therapy.

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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, Leann Terry, & Tom Treadwell.