Psychodrama in the Treatment of Addiction
Psychodrama in the Treatment of Addiction
‘Well, Dr. Freud, I start where you leave off….You analyse their dreams. I give them the courage to dream again. You analyse and tear them apart. I let them act out their conflicting roles and help them to put the parts back together again.'”
Psychodrama is a creative, action method of therapy developed by J.L. Moreno in turn of the century Vienna. Moreno is considered to be the father of group psychotherapy and his work with prostitutes in that city, the first attempt to treat people in groups. rather than exclusively in a one to one setting, as was developed by Freud during this period. Indeed he is thought to have coined the phrase “group therapy”
The basic elements of Psychodrama include :-
The Stage: The area where the enactment happens.
The Protagonist: The person whose issues are being explored
The Director: The facilitator or therapist; the director follows the lead of the protagonist as far as ‘work to be done’ is concerned.
The Auxiliary Egos: The players in the protagonist’s drama, chosen by the protagonist from group members who are willing to take on roles.
The Audience: The “group” who witnesses the action and from whom roles are selected
Each group follows roughly the same format.
Warm Up: When the group members consider which of their own issues they would like to work on and those issues present within the group as a whole.
Enactment: The physical role play or “action” part of the psychodramatic process
Sharing: The group sharing, processing, closure and identifying with elements of the enactment, both from “role” if they have been part of the action or from their own experience. This aspect of the group is extremely important with a great deal of attention being given to the sharing time. The concept being that this process is vital in order for the protagonist to gain identification and further insight from his or her group members but also that any work done by an individual will probably resonate very strongly within that group.
Techniques: These include, but are not limited to:-
Doubling: When the director or group members stand behind the protagonist in a scene being enacted and act as an “inner voice” articulating what they feel is not being said but may be being experienced unconsciously. So a group member who finds it difficult to express anger to a loved but dysfunctional parent may have a ‘double’ from the group who can state what is not being said. The protagonist will then agree and put the statement into their own words or disagree in which case the real feelings may come clearer, fear, sadness etc.
Role Reversal: Physically “reversing roles” and playing the part of another person, place or thing within the drama in order to gain a fuller, richer perspective on the self and the situation. Role reversal also allows the protagonist to gain insight into what might be driving the behaviour of another person.
Mirroring: When the client has the opportunity to watch a scene or situation that he or she has described being enacted from the “outside”. Literally having the chance to “take a step back” and watch themselves being played by a group member giving them a more objective view and chance to consider.
Catharsis: The expression of deep emotion be in grief, anger, sadness, confusion, laughter or joy.
Act Hunger: A desire for expression of action of some kind stimulated by the work. For example where a client may feel the need to talk to a significant person in there lives and this is enacted in
Action insight: Insight that occurs as a result of, or during, the psychodramatic enactment. This process is particularly valuable in light of what we now understand to be of value in trauma work and how being “in action” as opposed to just talking helps release deep seated traumatic feelings and experiences. Giving the protagonist the chance to reframe the situation and experience it in a more empowered memory state.
Concretisation: The act of externalising thoughts, feelings, fears or beliefs. Externalising the internal world of the protagonist. For example where we have someone play the “addictive voice” and the “recovery voice” of a client in order to examine the conflict between these two and by exposing it, strengthen their resolve and resources.
Role-playing: The acting out of an aspect of themselves, ‘surplus reality’ or a significant person in the protagonist’s life.
Surplus reality: The internal reality of an individual. Their hopes and dreams or “deeply held false beliefs”(Uram 2009). That which shapes, drives and defines their inner world and their thinking feeling and behaviour. Not necessarily external ‘facts’ but the significant internal emotional and psychological landscape.
Psychodrama allows difficulties and conflicts to be concretised by enlisting group members to play roles from the life of the protagonist. “It allows the protagonist to have a physical “encounter” with the self; to see and experience what he carries within his mind and body, so that it can be made explicit, concrete and can be dealt with in the here and now.” (Dayton) As Moreno used to say “Don’t tell me, show me!” A primary purpose of psychodramatic role play is for the client to gain insight into their issues and behaviours through action and mirroring rather than talk alone. Through role play, thinking, feeling and behaviour emerge clearly and at the same time. This allows for a fuller picture of what is in the psyche of our clients to come into view. The “double” acts as an inner voice putting words to interior thoughts, sensations and emotions that may be less than conscious. This “doubling” from others helps to enhance awareness of self and provide the protagonist with a feeling of being seen, supported and understood. “Role reversal” allows the protagonist to stand in the shoes of other people in his or her life in order to see the self from the position of the other and to actually experience being “in the skin” someone else.
Addicts are so used to living in their “false” selves, to showing very little, if anything, of their real feelings that it often becomes almost impossible for them to accurately identify which emotions they are having from moment to moment or even day to day. We are also notoriously self-focused so the value of being able to see our behaviour objectively and without attack is exceptionally useful if we are to implement change. It is important to promote an attitude of curiosity and consideration towards our thinking, feeling and behaviour rather than stultifying self-criticism.
The patients that we get in treatment are in crisis – no-one admits themselves into a psychiatric hospital or treatment centre without a good deal of distress and addicts have a particularly over blown sense that they should “be able to sort it out myself”. They usually end up at the door of a treatment facility when all else has failed. This includes attempts to solve what is a serious, difficult to manage illness, with the belief that if they only had enough “willpower”, that they should be able to cure themselves.
This idea that addicts are somehow to blame for their illness is rife. Not only, sadly, still in the medical profession, but also among sufferers themselves. Thus the level of defensiveness is high.
If you think that somehow you are at fault for not being able to get better or “behave well” or, as one patient stated, “I’m just a piece of shit” you are definitely going to struggle with self-acceptance!
This, alongside the messages from society and often family, means that the combination of self-hatred and desperate attachment to the addictive process, can create an extremely impenetrable wall of denial. After all how can one carry on doing something that feels as though it is saving ones life, whilst knowing that it is killing you, without that dissonance creating huge internal conflict and distress?
Traditional talking therapies certainly have value for anyone searching for an answer to their despair or confusion including addiction, but addicted patients have an extraordinary capacity for denial around their problems. In this case group therapy is absolutely the therapy of choice, as another addict is far more likely to be able to confront the deflections and distortions of a group member and get support in that from the group as a whole, than is an individual therapist – no matter how skilled.
It is also a real asset to be able to work with a group who, in the form of the Anonymous 12 Step fellowships and continuing attendance of those meetings, will remain as an integral part of each patient’s continued recovery and support once they have left the closer care of the hospital or treatment centre.
If group is good for addiction, psychodrama group is better. I remain convinced that psychodrama is one of the most useful tools that we have in dealing with the resistances, blocks and defences that are so common in working with addicted clients especially given the high level of addiction and trauma presented together in our patients.
The difficulty that addicts have in inhabiting their own emotional bodies authentically is immense. Not only have they dealt with their feelings with a constant attempt to anaesthetise, using drugs, food, sex or whatever other mood-altering substance or behaviour they find works best for them but there are also oftentimes the survivors of severe childhood developmental trauma. (Dayton 2001)
Addicts often report the sensation of being separate from their bodies, are often dissociated from their true emotions to a very high degree and exhibit a difficulty in even knowing what the feelings are that they are experiencing when they do get in touch with them. (Levine 1997)
They will almost always, in early days, automatically identify true feelings of sadness, fear or loneliness for example, simply as a craving, a desire to use their drug or compulsive behaviour of choice and find it difficult to move beyond that. It is simply too frightening or unfamiliar for them to be in congruence with what is really going on – the knee-jerk reaction to feeling “bad” or experiencing any kind of “difficult” emotion is to change it –preferably to kill it off completely by using something to alter their mood.
Therefore the ability to sit in a room and talk through their issues whether that is one-to-one or even in a group, without really feeling their emotions – sometimes telling the most painful or horrific stories without connecting emotionally with them at all, is most unhelpful to this client group. It merely strengthens both the belief that they are invulnerable emotionally or that they don’t have any feelings at all. This in turn means that when they do start to feel real emotions as a result of withdrawing from their addictive process or as they become increasingly in touch due to therapeutic work, they are ill-equipped to either identify or contain their new emotional state. (Carnes 1989)
Thus we are left, particularly in psychiatric and medicalised responses to distress, with the choice as to whether to merely change the addicted client’s drug or to support and teach him to manage and take responsibility for his difficult feelings.
Psychodrama has the power to support people to see, feel, re-experience and, most importantly, CHANGE their experiences of their stories in a safe and supportive fashion. The patient in an addiction treatment setting gets the opportunity to bring new tools and behaviours to situations that seemed impossible to understand let alone influence. Addiction is ultimately a statement of despair and disempowerment. As Moreno stated, psychodrama gives our patients the power to “dream again”.
In group I have watched people who have been almost completely shut down be able to accept and integrate their difficult experiences and emotions in a way that they have been completely unable to do in other therapeutic situations.
There is safety in literally and metaphorically being able to step back and watch one’s story being played out in a ”mirror” by other members of the group, even if that mirror is not quite accurate or sometimes deliberately distorted in order to provoke a response from the protagonist. (Moreno 2003) For example if a client is finding it difficult to accept the inappropriate meekness of his response to an abusive situation, they may well get in touch with it through correcting an overly quiet group member who might be playing his role.
This has often meant that a patient can reach out to themselves, albeit being played by another group member. impossible whilst they are sitting in their own seat and successfully and necessarily defending against feelings that could overwhelm them. We can, ironically, often allow ourselves to feel our feelings in watching them being ‘played out’ by someone else in a way that would be impossible otherwise.
It is always easier for addicted clients to respond emotionally and supportively to someone else as used to self-attack as they are. In the case of psychodrama that someone else is in fact them in role–reversal or mirror. (Karp 1998)
This reconnection, manifested sometimes in stepping in at “role training” to give advice to a younger or more vulnerable version of themselves in an authentic and emotionally alive fashion, sometimes simply by the protagonist giving or receiving a supportive hug or words, can be life changing for our patients.
To a great extent addiction and childhood trauma are effected by and result in, a massive schism in the client’s internal relationship and in his relationship between the self and others and we now have a much greater understanding of the connection between these two issues. There is often a requirement to treat patients in Addiction treatment with these co-existing issues and for our clients to be able to begin to repair that damage, however tentatively and slowly, is of great value to them in their experience of treatment.
I believe Psychodrama is unique in working with defences, unique in its ability to facilitate the client in meeting their authentic self, often for the first time. It is also unique in it’s power to unpick and heal childhood developmental trauma and the unhelpful symptoms of addiction developed by patients in an attempt to anaesthetise the commensurate pain.