The Challenge for Group Psychotherapy

A Combination of Psychodrama and Group Psychotherapy, Part 2

Certain subjects show great flexibility in modifying their roles in conformance with the shifting balances between impulses and defense mechanisms, between satisfactions and frustrations. Such patients are susceptible to individual treatment, as in psychoanalysis. Others, however. show a marked difference between their roles and the character traits that come to light in private psychotherapeutic interviews. In our opinion. psychodramatic treatment is indicated for these patients because of the persistence of their ego defenses.

Psychodrama and Acting Out. In considering the therapeutic function of taking a role, one recalls Moreno’s position that role playing offers great possibilities in the realm of therapy. We have already expressed our disagreement with this hypothesis. We do not, however, reduce psychodrama to acting out, since in that case it would amount to a deliberate effort on the part of the patient to violate therapeutic guidelines and obtain satisfactions he feels are denied him by his analyst. The fact is that psychodrama offers other advantages. To begin with. it is clear that in psychodrama the contribution of gesture and mime is significantly greater than in other methods, since these adjuncts to language are an integral part of this new means of expression. Furthermore, acting in a psychodrama also involves the use of speech. The language is direct and forthright, while in classical psychoanalysis the patient usually describes what he says and does, and hence the material is more assimilated and controlled. In psychodrama, certain gestures are also eventually assimilated, evolving into conventional forms whose true meaning must be determined. Sitting, walking about, pretending to eat may take on different implications due to the make-believe nature of the action, while other gestures will keep their normal social value.

The gestures and attitudes of the psychotherapists must also be taken into consideration. The very fact that the therapists participate is of great importance since their actions affect the value of the patient’s gestures.

Psychodrama brings patients and therapists into a certain amount of physical contact. Some of these contacts are commonplace and at first glance would seem to pose no problem. When two persons pretend to meet, they shake hands, the accepted form of greeting in Western cultures. This social gesture might be considered as merely habitual. There are patients. however, even some who are only mildly disturbed, for whom this gesture is highly significant. Every psychoanalyst is familiar with patients who never shake hands either before or after sessions, while in a chance meeting these same patients perform this gesture easily and automatically. Hence we must weigh the significance behind the performance of even the most mundane type of physical contact.

Another problem arises from the apparent absence of any limits as to type of physical contact. Whereas certain types of contact occur routinely in public and are not out of place between doctor and patient, other types are debatable. Two possible lines of approach must be considered. On the one hand, certain gestures involving bodily contact—embraces, blows, etc.—are usually simulated. Some patients may make sport of such pantomime as a method of resistance. Many, however, find that a gesture is no easier to perform just because it is make-believe. All their fears intervene to prevent them from even imitating the gesture they want to make.
On the other hand, there exists a broad range of physical contacts which take on quite a different value when they occur between patients and psychotherapists. Often a therapist is induced to establish contact with a patient by putting a hand on his shoulder or taking his arm. The question here concerns gestures that are socially accepted and yet highly charged with affective significance. In many instances, certain patients derive real gratification from such contact. This satisfaction is counterbalanced, however, by the frustration arising from the fictitious nature of dramatic activity.

Generally speaking, it can indeed be said that while the action involved in psychodrama is never tantamount to acting in, it does quite often incur considerable difficulties in the performance of a succession of painful scenes, in spite of the annulment inherent in the make-believe quality of psychodramatic action.
This interweaving of denial of reality and intensely true-to-life experience that occurs in a dramatic performance is certainly one of the most distinctive characteristics of psychodrama.

It is for this reason that we do not believe this method can be used for individual reeducation. The truth of the matter is that playing out a situation one fears is not training oneself to be unafraid, contrary to what some patients may think. A man will not get a job more easily because he has gone through dialogues with a psychotherapist representing an employer; however, because a patient has been able to discover through psychodrama what his fantasized image of an employer represents in terms of displacement of his anxiety, he will be able to make progress toward recovery.

Psychodrama and Psychoanalysis
Being psychoanalysts, we have kept the dynamic perspectives taught us by analysis throughout all our psychotherapeutic activity. Furthermore, we have long since come to believe not only that there is no contradiction between the practice of psychodrama and the conduct of psychoanalytic treatment, but also that psychotherapy in terms of drama can be fully comprehended in all its aspects and implications only if one employs the theoretical concepts of psychoanalysis. This is why, in defining our techniques, we speak of psychoanalytic psychodrama and dramatic group psychoanalysis. Nevertheless, as we have stated before, we do not pretend that psychoanalysis makes it possible to understand all the processes at work in psychodrama. Consequently, psychoanalytic training—which to us seems so necessary, or at any rate highly desirable—is not alone sufficient to qualify psychotherapists to engage in psychodrama.

Transference in Psychodrama
Transference Toward the Director of the Psychodrama. This aspect of transference is similar to that observed in psychoanalysis, particularly in that the relations between patient and director are essentially verbal, albeit rather distinctive because of the manner in which psychodramatic treatment is conducted. The presence of a group of co-therapists, however, presents a rival image, which is inevitably reshaped by fantasies from the patient’s past and integrated either into the privileged relationship with the mother object or into the triangular relationship characteristic of the Oedipus complex.

Transference on Auxiliary Psychotherapists. This aspect of transference is unique in psychodrama. It is manifested in a great many ways, depending, of course, on the individual case. For example, inhibited adolescents frequently refuse to choose who should take this or that important role in a dramatization. After numerous sessions, they often do not know the names of psychotherapists whom they nevertheless ask time and again to play the role of such or such an imago. The most remarkable aspect is that an auxiliary therapist is usually assigned the same specific role to play at each succeeding session. Obviously, this is a very special situation in that transference on auxiliary psychotherapists is determined not only by the attitude of the patient but also by the way in which the therapist responds. Transference on assistant therapists may also be a significant reflection of the prevailing situation within the therapeutic group. Following a clearly recognizable dynamic pattern, a patient may use transference on an assistant therapist as a defense against a more guilt-laden transference toward the director of the psychodrama, whether the thrust of the transference is positive or negative. In such cases, it may prove particularly difficult to distinguish between what is transference and what is defense against transference.

Transference Relative to the Group Situation. In groups, each patient seeks to gain the individual attention of the director or his co-therapists; in other words, the patient’s transferential behavior tends to destroy the cohesion of the group as a whole. Numerous studies (Ezriel, 1951; Foulkes, 1957) have shown that one patient’s transference on another patient is, as a rule, primarily a consequence of the group situation. It has the attributes of transferential displacement and resistance. A clear awareness of this situation would avoid many a debate about acting out in group psychotherapy. It would also make it possible to understand group equilibrium, which is manifested to the extent that a group is held together by a true common denominator expressing the fantasies shared by the group vis-a-vis more or less conscious impulses (Ezriel, 1951), a common denominator to which each group member reacts according to his individual makeup.

This reciprocal equilibrium plays a part in psychodrama as well as in verbal types of group psychotherapy. It is often during the assignment of roles among group members that its dynamic effects become strikingly clear. One must beware of making facile judgments: the reciprocal effects of transference should always be kept in mind when attempting to interpret the behavior of patients.

Resolving Transference Neurosis
One knows how difficult it is in any type of psychotherapy to resolve transference neurosis and avoid situations that become very long and drawn out. In psychodrama such situations are potentially even more detrimental than in psychoanalysis. The abreactive effects of psychodramatic therapy and the ostensibly more active collaboration of the therapist have some secondary advantages, but they are liable to perpetuate transference neurosis. The problem is all the more complex in that the countertransference of an entire group of therapists must be taken into account. As might be expected, this is one of the reasons why adequate interpretations aimed at both transference and countertransference are essential in psychodrama, as they are in any therapy that is analytic in nature.

Interpretation of Transference
In the course of analytic psychodrama, it is not only possible but necessary to offer interpretations. Those concerning transference show the patient how and why he inevitably recognizes past situations in the therapeutic situation, rediscovering events he has forgotten or buried in his unconscious. In the type of psychodrama Moreno advocates, such interpretations are not offered. He stresses the importance of the patient’s actions in situ, his creativity, and hence holds that only his performance on the psychodramatic stage of past and present situations, real or fantasized, has any therapeutic value.

The fact is that the patient’s actions obviously depend on what he wants to do or is asked to do, but they also depend on developments that may well be determined by transference on the therapist who directs the psychodrama, on the auxiliary psychotherapists, and on the other patients.

In certain cases, interpretations are greatly facilitated by the fact that the concept of role offers a solid footing on which to approach a dynamic understanding of transference. As we have already seen, psychodramatic technique often provides an opportunity to comprehend dynamic patterns with greater clarity than is possible with verbal methods. All the activity which is externalized in the distribution of roles—which roles patients may or may not choose to take themselves and, especially, which roles they assign to the psychotherapists—affords deep insights into transferential mechanisms, for role distribution is, in a way, clinical proof of transference phenomena. This method of understanding transference by examining roles—roles assumed, roles assigned—has time and again proved to be as applicable to individual psychoanalysis as it is to interpersonal relations. Transference is in part determined by the fact that the psychoanalyst is able to assume any and all roles his patient assigns him; he can be identified with any imago the patient projects on him, and his neutral attitude is pivotal to the dynamics that constitute transference.

Resistance and Psychodrama
Freud’s basic law concerning the relationship between transference and resistance can be confirmed once again in psychodrama. If psychodrama is indeed a special means of expression, it is also inescapably true that for many patients it is a means of resistance. It represents, in effect, a compromise, which cannot be categorized as a compromise of either speech or action. In conformance with the rules of this therapeutic method, a psychodramatic performance will remain simulated and symbolic, and the activity on stage will remain within the confines of this framework. The fact is that this situation very often proves to be a source of resistance. When a patient treats a psychotherapist roughly, is overly familiar, or behaves insultingly, he is no doubt realizing, at least symbolically, one of his aggressive impulses, which in a man, for example, may be directed against the father image. What is undeniably distinctive in psychodrama is that the therapist who is the target of this aggressiveness acknowledges it and responds to it as if it were realized in actual fact. It is also true, however, that the patient knows that this situation is limited to the psychodramatic stage, and immediately afterwards he will again adopt the social conventions that normally govern a patient-doctor relationship. The pitfall is, then, that the patient may consider psychodrama the road to recovery, and he may shrink from any selfexpression outside the therapeutic setting.

In psychodrama, it can be useful to examine defense mechanisms as described by Anna Freud (1936). For example, subjects with an obsessional personality are seen to avoid forbidden compulsions through a pattern of displacement, isolation, and annulment. Such patients suggest themes that are exceptionally aggressive, relying on the fictional format of psychodrama to ward off compulsions and fantasies they are not facing up to. As it happens—and this is what should be pointed out to them—at the last moment they often back down from playing a particular role or confronting a certain person. It is easy to see—and to make them see—the inefficacy of ever more elaborate defenses. In such cases, the conditions in psychodrama are relatively more favorable for therapy than those found in classical psychoanalysis, where problems arise from. the fact that sometimes even a complete understanding of the motivations behind a patient’s behavior remains highly intellectual, leaving the ego defenses intact.

Countertransference in Psychodrama
Countertransference proper, in the director of the psychodrama and in the auxiliary psychotherapists, should be examined with regard to its various implications. The director, to be sure, has a very special function in psychodrama. The patient, or group of patients, attempts to establish a privileged relationship with him and he must accept this transference without taking advantage of it or seeking refuge in psychodramatic technique to avoid giving verbal interpretations.

Similarly, the group of co-therapists must beware of countertransferential reactions that might better be termed transferential vis-à-vis the director. When a team is well synchronized, many a problem can be avoided by varying the functions of the therapists as the team goes from one patient or group of patients to another, so that each therapist in turn may serve in the capacity of director.

In attempting to define the ideal attitude of the psychodramatist as therapist, two points must be noted: Like any therapist, the psychodramatist should identify himself with the situations that come to light and consequently he should be able to maintain an open attitude, similar to the psychoanalyst’s free-floating attention recommended by Freud; at the same time, the psychodramatist should take any role and accept any situation that the successive projections of the patients may call for. The exigencies of psychodramatic therapy are demanding and somewhat contradictory, requiring both presence and discreet effacement.

Psychotherapists may be acutely self-conscious due to their lack of experience or the difficult nature of certain cases. This can result in technical conduct detrimental to the patients, when therapists perform, no longer for their patients, but for their co-therapists, seeking their colleagues’ approval. Briefly, the ideal attitude of auxiliary psychotherapists could be summed up as follows: On the technical level, they should be capable of playing the diverse roles demanded of them as convincingly as possible; at the same time, they should be able to afford the patients a basis of identification for the various imagos that may be encompassed in a single person, so the patients’ fantasies and defense mechanisms can be brought to light.

In psychodrama, patients generally sense the underlying attitude of the therapists to a greater degree than in any other form of psychotherapy. The psychoanalyst is, after all, protected—or at any rate there is a chance he may seek protection—in his armchair, where his patient cannot see him. In any kind of group psychotherapy, however, the therapist is exposed to the patient’s view (Grotjahn, 1953). In psychodrama, the situation is intensified by the fact that the therapist is not passive, immobile, and silent; he must make his presence felt by participating in the performance.

We must now turn our attention to the effects of the therapists’ attitude on the progress of psychodrama tic treatment. Fenichel (1945) has stated that a psychoanalyst should never play the role of his patient. It so happens that in psychodrama the therapist must take part, and we might define his position by saying: play he must, but without playing the game of the patient. The function of the psychotherapists is not fulfilled by merely performing the scenes the patients request. Although they should always respect the patients’ wishes and the defenses activated by these wishes, the therapists’ primary concern should be to confront the patients with their resistances. Here the art of the psychotherapist lies in creating veritable shortcuts through dramatic activity, thus proving his intuition and opening up fertile ground for therapeutic progress. In fact, it is the conduct of the auxiliary therapists that enables the director to fulfill his interpretative function. They are not limited to either playing whatever the patients wish or refusing to do so; different situations and different circumstances lead the psychotherapists to adapt their attitude to the demands of their patients and to introduce new behavior patterns through the shortcut of psychodrama.

The make-believe aspect of psychodrama also intervenes to determine the psychotherapists’ conduct and thereby influence the evolution of the therapeutic process. There are, to be sure, situations that are easy to play, and their performance is not at all hindered by the therapeutic setting. For example, when a patient wants to reenact a game of tennis or some incident that takes place in a car, train, or plane, it is easily done despite the lack of props and scenery. On the other hand, as soon as one begins to deal with situations more deeply suffused with the fantasy life of patients—and this is often the case in group psychotherapy—problems concerning the attitude of the psychotherapists make it much more difficult to perform the proposed scenes. It is a fact that patients incorporate the most diverse behavior of psychotherapists into the portrayal of their fantasies. If one knows how importantly the imaginary representation of a scene from early experience, such as sexual relations between parents, figures in the fantasy life of the patients, one can understand that very often it is appropriate to introduce that theme, which involves guilt associated with sexual curiosity as well as frustration at being excluded from that privileged relationship. The transferential energy displaced onto psychotherapists is such that they need only appear to retire from the psychodramatic stage and stand side by side for patients to immediately incorporate this behavior into the context of their early experience; their reactions then express the effects of this fantasy on personality integration.