The Challenge for Group Psychotherapy

A Combination of Psychodrama and Group Psychotherapy, Part 3

One can see that in our view psychodrama should go far beyond the confines of realism. The crux of the matter lies in making different patients actually live and relive emotional situations. From this stand point, the physical aspects of a therapist are less important than his ability to directly influence the situation, not only by performing the proposed scenes realistically, but also by systematically refusing to follow paths of regression and resistance, and, ultimately, by maintaining the appropriate underlying attitude that makes it possible to reconstruct past experiences, to bring into play the fantasies and also the defense mechanisms that express the character structure of each of the patients.

Psychodrama and Regression
One might think that psychodrama would create almost insurmountable problems in regression. In fact, many psychotherapists who do not practice psychodrama or who criticize it categorically consider such acting to be regressive per se. They think of it as a strictly infantile activity, located on a very primitive level as compared with more highly developed verbal activity; consequently, in their opinion, all psychodrama falls within the realm of acting out and any psychodramatic activity is but resistance vis-à-vis verbal activity . We have shown that psychodrama is nothing of the sort and that acting is by no means a regressive mode of expression. It would become so only if the therapists’ attitude were to encourage regression. It is not hard to imagine such a situation arising when therapists with little aptitude for psychodrama see in it merely action without meaning.

Psychodrama, like any psychoanalytic therapy, does, however, permit controlled regressions within the therapeutic setting and sanctions their examination and interpretation. The fact is that in many cases psychodramatic activity seems to enable patients to express their regressive desires and actions more easily and clearly. The more freely and fully these regressions are expressed, the better they are gratified. This perspective is necessary in order to understand a good many of the positive effects of all sorts of physical contact, which we have already discussed in terms of variations, limits, and significance.

Regression occurring in psychodrama may, however, also be a manifestation of resistance. Quite frequently, in fact, one observes that patients propose regressive activities in order to avoid, by virtue of the obstacles created by transference, other more mature types of interpersonal relations with the therapists. It is particularly striking to see how often patients, even adolescents and adults, suggest themes that entail eating together. They are thereby not only expressing their fantasized conception of the privileged relations between adults, they are also evading other, more anxiety-provoking contacts with the attending therapists. In view of this, it is interesting to note that maladapted transference on the part of certain therapists is also translated into activities that are regressive in nature.

With allowance made for those regressions that are expressed in any type of therapy, psychodrama included, it can be said that the psychodramatic method permits the therapist to treat regression as resistance and refuse to satisfy it, in the manner of the psychoanalyst who refuses to go along with regression as his patient would have him do. The truth of the matter is that acting is by no means inherently regressive and, as we observed in the first section, one cannot help but be impressed by the intensity with which patients enter into the make-believe of psychodrama. They participate in it without resorting to jest or mockery, which they would be bound to do if they thought of themselves as spectators at the theater or indulgent adults watching children play games that they themselves would not venture to join.

Notes on Techniques in Dramatic Group Psychoanalysis
We use the term dramatic group psychoanalysis to designate a specific type of group therapy in which the treatment of a group of patients usually entails the participation of a group of psychotherapists. Experience has led us to limit the number of participants to five or six patients, whatever their age, and two or three psychotherapists, both sexes being represented. One of the psychotherapists acts as director, getting the session under way, bringing the performance to a halt, and offering interpretations. In many of our experiments, these therapeutic functions were handled by a team of two psychotherapists, one male and one female.

The patients are first asked what they would like to act out. Children always enter into a psychodramatic session as if it were a real game. With older adolescents and adults, however, it takes longer to develop a theme of departure. The story that emerges should be general enough to concern everyone and yet remain sufficiently concrete so that none of its meaning is lost.

At times it is not easy for the patients to come up with a theme. In certain cases no one will say a word, while in others one particular patient will monopolize the floor at the beginning of every session, not without causing a most characteristic group reaction. In seizing the initiative, this individual evokes apparent complaisance on the part of the other patients; they are obviously uninterested in his proposals, and yet they profess complete agreement with what they have scarcely heard. This passive attitude is a typical manifestation of group resistance and may be viewed as acting in. It would be a mistake to follow the lead of the deviant patient on the pretext that he is making a contribution, for to do so would utterly destroy the group’s cohesion. Rather, when such a phenomenon of group resistance is observed, the proper course is to regard that very resistance as the implicitly proposed theme and to suggest dramatizing it. Psychodramatic portrayal of group resistance usually provides very fertile material.

A striking example of group dynamics is found in the dramatic presentation of dreams. This approach may be particularly useful in the early stages of treatment.

Once the theme has been settled upon, each of the patients is asked to choose a role to his own liking, and then the group as a whole is asked to decide which roles the psychotherapists should take. In this distribution of roles, one can perceive different behavior patterns, which vary according to the age of the patients. Child therapy groups usually include a passively acknowledged leader; it is he who suggests the theme and his proposal is accepted with enthusiasm. Among adolescents, the group structure is more complex, the interaction is more highly organized. This is especially evident during the distribution of roles, when certain subjects may choose roles that others do not wish to allot to them. In particular, a patient may take a role that the others obviously intended to assign to a psychotherapist. This same phenomenon occurs among adults, and one can see in it an expression of the group situation and the specific transference developing therein.

When the casting has been completed, the play begins. It is then that the task of the psychotherapists becomes complex. They should serve as a catalyst to the session, while refraining from joining as one with the patients. The therapists’ acting must be convincing, as we have already stated, if only so that acting may become the group’s mode of expression. They must take careful note of all that happens and yet be most circumspect in their observation; any attitude that hints of a researcher in quest of material is strictly taboo. And all the while the psychotherapists must pay close attention to the group’s cohesion, for during a session a group may develop a tendency to split up. Such a division must be considered significant material and should be handled accordingly.

We have cautioned against psychotherapists “playing the game” of their patients, as we say in psychodramatic parlance. Patients, however, may act as psychotherapists in order to give other patients gratification that has been denied. Such substitution has a special import and leads to reorganization of the group.

The psychotherapist directing the treatment is responsible for bringing the performance to a halt, and it is he who has the option of offering interpretations.
Certain attitudes taken by patients require an immediate reaction. The acting in peculiar to psychodrama can often be reduced by the response of the director, who may even go so far as to deliberately ignore the patient; thus, the patient drops out of the performance and his own behavior should bring awareness of the anxiety eliciting this particular mode of defense. Besides, the group itself stands in the way of a fellow patient taking an aloof attitude: each group member reacts so as to prevent any other member from breaking the conventions agreed upon by the group as a whole.

By and large, however, interpretations tend to reduce this kind of behavior. They are usually offered at the end of a session. The crux of this matter lies in observance of the following rule: never give an interpretation that does not apply to the group as a whole. In developing and performing the group drama, each individual has taken part in a way that can be fully explained only with reference to the behavior of the other group members. In those fairly frequent instances when one of the patients polarizes the group, it is appropriate to address that individual directly, clarifying his conduct to him and at the same time showing the others how and why they contributed to his behavior. We should point out here the dilemma involved in utilizing one’s knowledge of a patient’s past life. It would be absurd to pretend ignorance of such information inasmuch as patients are prone to bring up their life histories in an effort to capture the attention of the therapists and other group members. Therefore, while alluding to a patient’s past, it is nonetheless essential to give strictly here-and-now interpretations. In psychodrama, recovery from infantile amnesia does not occur in the classical sense; rather, that process is replaced by working through fantasies shared in common by the group. Reference to the past often arises only tangentially through associations volunteered spontaneously by the patients.

As for the general course of psychodramatic treatment, the progress made by individual group members is very similar to that observed in classical psychoanalytic therapy. There are a certain number of special characteristics, however, that should be noted. In the artificially created social situation of psychodrama, the material is bound to focus on oedipal conflict, while fantasies of a pregenital nature prove to be much more difficult to explore.

One of the problems of group therapy lies in the fact that group members must usually show uniform progress. In psychodrama, however, where the fantasies presented in common are stripped down to basic essentials, it is possible to change the composition of a group if due consideration is given to the frustration reactions that may result from such modification. Contrary to the general rule adhered to in verbal groups, it is not necessary for all the patients in a psychodramatic group to improve at the same rate and be released at the same time. The departure of a patient who has recovered does not disrupt the group. The introduction of new patients, however, can be undertaken only in circumstances that have been very carefully reviewed with the aim of avoiding major reactions of rejection and exclusion.

These observations enable us to clarify the specific therapeutic applicability of group psychodrama. This method makes it possible to deal with the social reactions of individuals insofar as these reactions reflect object-related anxiety. The presentation of fantasies shared by the group in common, that is, the social elaboration of unconscious fantasies held by each member individually, serves a very useful purpose in the psychotherapeutic process.

The requisite research into case histories indicates that dramatic group psychotherapy has yielded beneficial results with respect to children, adolescents, and adults. It is not possible, however, to give a detailed analysis of those results here.

Beyond strictly therapeutic groups, psychodramatic techniques can also be applied to closed groups, or even to institutional or natural groups, particularly when treatment of the audience is contemplated.

The Psychotherapeutic Effect of Psychodrama on the Audience
Every psychodramatic performance has an effect upon the group—on the group of patients and on the group of doctors as well. In closed group psychotherapy it would be impossible to ignore the group dynamics that converge through the channel of mutual identification to a state of group cohesion. Elsewhere, however, psychodrama can have repercussions on the audience, that is, on the more or less structured group of seemingly passive spectators who are present as the play unfolds. This happens frequently in certain exploratory forms of psychodrama undertaken for diagnostic purposes or in certain types of group therapy practiced in institutions. In such cases, identification in the true sense of the word has clear and undeniable effects upon the audience. This phenomenon has its root source in the emotional participation of the spectators. Psychodrama can produce still more striking effects of identification than other types of group therapy, because it evokes problems that are common to the entire group. This is obvious in institutional groups, where individual problems are lived out in common, that is, they are experienced through the reactions, vicissitudes, frustrations, and satisfactions arising from the life in common.

At the risk of being cursory, we would like to distinguish two ways in which psychodrama affects the audience: (1) Certain spectators feel moved to enter into the dramatic action; whether a member of the audience participates actively obviously depends on his imitative response and his reaction to the particular scene being portrayed, but it is also related to his capacity to identify himself with the characters and the situation. Spectators take roles and refrain from doing so according to a dialectical contradiction, which expresses the symptomatic com promise of the moment. (2) The audience as a whole participates in psychodrama emotionally, and a performance mayor may not be followed up with discussion.

This is why one can speak of the didactic effect of psychodrama, and it was with this in mind that we thought it useful to examine the techniques of role playing. As we have already stated, in no way does role playing constitute a learning procedure. However, self-expression through role is bound up with the difficulty one has in assuming a particular role, whether that difficulty is due to a real or fantasized situation; therefore, an individual’s relationship to the imago of another, made explicit in role, emerges as the real focal point of role playing. One can understand one’s own attitude vis-à-vis others only if one is able to identify oneself with others, whether through direct participation in the dramatic action or through indirect participation as a spectator. Every human situation perforce involves interpersonal relations, and learning to identify with others is a continuing necessity. Submission to others and identification with aggressors are but two sides of the same coin; they are both defensive attitudes, and everyone should recognize such behavior patterns in himself.

In this study we wished to place particular emphasis on the theoretical concepts and dynamic principles of psychodrama as it is conducted by psychoanalysts. Our discussion has focused primarily on techniques of group psychodrama; however, we often employ individual psychodrama for treatment of a single patient with the aid of a team of psychodramatists. In examining these various techniques, we have demonstrated their didactic value and, in addition, we have pointed out the advantageous emotional effects of psychodrama on the audience.

Throughout this study, the reader will have perceived that we feel, at least in certain cases, that psychodrama, a special means of expression, can be understood and handled in an adequate manner only by utilizing psychoanalytic concepts. To us it seems that psychoanalytic training is indispensable if the therapeutic process is to be fully comprehended and competently conducted.

One might well ask whether conversely the practice of psychodrama and group psychotherapy has enriched our clinical and theoretical conception of psychoanalysis. This could well be true beyond any doubt, for the scope of our activity has been enlarged to an extent not possible in classical psychoanalysis and we have thus been able to gain insights into the origins of psychosis.

To be more specific as to what we have learned from psychodrama, its extensive countertransferential effects put us on guard against the ways in which we may seek to manipulate our patients. There is no question that this prudence carries over into our psychoanalytic practice.

Finally, in community psychiatric services psychoanalysts are often called upon to contribute their expertise; their familiarity with group psychotherapy and experience in the sphere of psychodrama can be extremely useful in the task of teaching the professional or interprofessional groups assigned to them for training.

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