Psychodrama: Social Networking for Healing

One of my favorite psychotherapeutic methods has not even been widely recognized as strictly “psychotherapy” at all. It is called psychodrama, which, conceived and developed by Jacob L. Moreno, MD, employs guided dramatic action to examine problems or issues raised by an individual (psychodrama) or a group (sociodrama). It is considered a hybrid between mind exploration (Greek: psycho = “mind”) and theater (“drama”). So what is this psychodrama and how can it be applied to therapy?

Sigmund Freud believed that our unconscious processes contained, at deep, unaware levels, the seeds of our earlier repressed memories and emotions. Freud’s method of psychoanalysis works wonderfully at sometimes accessing those trapped or hidden past traumas, memories or feelings, after often many years of painstaking analysis of memory traces and reflections by the psychoanalyst. The father of cognitive therapy, Aaron Beck M.D., who developed the Beck Institute for Cognitive Therapy in Philadelphia, where I received my post-doctoral Cognitive Therapy training and certification, was a psychoanalyst. Beck discovered that after many years of traditional psychoanalysis, patients may have found some or even much relief, but often persisted with often unaddressed distorted thought systems, causing great psychic pain. His development of cognitive therapy was an active, experimental approach to addressing these distortions, by teaching patients to participate in their dismantling of unrealistic thoughts and adopting new more realistic beliefs and subsequent actions (see other links and blogs on this webpage for more on cognitive therapy).

Psychodrama is not a technique that I use to replace these other forms of psychotherapy. Like traditional analysis of past wounds and relationships, and the dismantling of cognitive errors, psychodrama is another tool in the properly trained therapist’s tool box for accessing deep and potent (painful or joyous) emotions, perhaps long-severed from the individual’s conscious awareness. How does psychodrama work, and how is a different “tool?”

Psychodrama was founded circa 1920’s by Jacob L. Moreno, M.D., a psychiatrist who believed in using the social network to reinact particular roles or incidents from the past, using a ‘stage’ and typical ‘acting’ components of protaganist (the patient), director (usually the therapist), and auxillary egos (people in the drama). By coaching the client into the full-blown active, realistically re-created “scene” of an unresolved issue or relationship, people are able to virtually re-experience the past within the setting, with a safe network of supporters. Techniques used in psychodrama include role-play, role reversals, imagining other’s feelings and roles, and even imagining outcomes in the future. This very active relationship with the director/therapist and auxillaries enables a full ‘mind-body,’ in-the-moment re-engagement of sometimes long-buried memories. The action of psychodrama with patients acting as protagonists enables them to access very potent memories through the action, that would not often be accessible to them through talk therapy.

I have been able to utilize psychodrama techniques with most types of clients, in individual and group settings. Many re-enact painful encounters with others, and others even take on their “disorders” (e.g., role reversing with their OCD, anxiety, depression, or addiction “monsters”). Following successful psychodrama experiences, after which a catharsis often occurs, sharing takes place with other group members,  and integration on cognitive, affective, behavioral and spiritual levels can follow (Farmer, 1996). Unique to psychodrama is the active, spontaneous and creative enterprise of reenacting the drama, both positive and negative, which authenitically accesses, for the client, the core who he is. The honor of a client allowing a social network to gain a glimpse of this very personal space and his self-growth journey, is special and powerful. Protagonists who share their story with the social network often feel a renewed sense of inclusion and belonging, because of the group’s sensitivity and compassion. The healing that takes place through psychodrama is wonderful and it is my hope that more people learn the benefits of this special but little-known technique.

Please see my membership group, American Society of Group Psychotherapy & Psychodrama, to learn more:




Social Anxiety: Changing your brain with psychotherapy

Medication and psychotherapy have both been demonstrated to help people with an anxiety disorder. But research on the effects of psychotherapy on nerve cells has lagged far behind that on medication-induced changes in the brain. There have been preliminary studies which have demonstrated superior effects (from patient’s reports) from cognitive therapy over medication, in quelling unpleasant anxiety (and depressive) symptoms, and these improvements have lasted in research follow-ups. But did you know that scientists are now discovering physical evidence for these improved changes in research with social anxiety disorder?

Social anxiety is a syndrome whereby people experience overwhelming fears of interacting with others and describe high expectations of being harshly judged.Vladimir Miskovic, doctoral candidate, wanted to understand if it would be possible to ascertain physical changes in the brain following psychotherapy, within people with SAD. ‘We wanted to track the brain changes while people were going through psychotherapy,’ says McMaster University doctoral candidate and study co-author Miskovic.

Miskovic was part of a research team, led by David Moscovitch, Ph.D., of the University of Waterloo, collaborated with McMaster’s Louis Schmidt, Ph.D. and Diane Santesso, Ph.D. The researchers used electroencephalograms or EEGs, which measure brain electrical interactions in real time, to assess brain activity and change. The researchers focused on the amount of ‘delta-beta coupling’, which has been found to elevate with rising anxiety. They recruited a group of adults with social anxiety disorder for their study, and divide the groups into those who received treatment, and those who did not (two sets of controls).

The patients participated in twelve weeks of group cognitive behavior therapy, a structured method that helps people identify and challenge the thinking patterns that perpetuate their painful and self-destructive behaviours. For more information on cognitive therapy, please search my website for related links. Two control groups – students who tested extremely high or low for symptoms of social anxiety – underwent no psychotherapy.The patients were given four EEGs — two before treatment, one halfway through, and one two weeks after the final session. When the patients’ pre and post-therapy EEGs were compared with the control groups’, the results were revealing.Before therapy, the clinical group’s delta-beta correlations were similar to those of the high-anxiety control group and far higher than the low-anxiety groups. Midway through treatment, improvements in the patients’ brains of those receiving the cognitive therapy paralleled clinicians’ and patients’ own self-reports of easing symptoms. And at the completion of therapy and at the two week follow-up, the patients’ tests resembled those of the low-anxiety control group!

So now we have bonafide physical proof : cognitive therapy does produce positive, enduring (at least in the short-term), brain changes at the neural/physical level. I’m sure this is just the start of what’s to come, and what we therapists and our clients have known all along – psychotherapy works! More exciting research is sure to follow, that will enable us  to truly not only visualize or imagine, expect or believe, but actually “see” our improvements in our brains, as we move towards self-growth.

Using Mindfulness and Cognitive Therapy for Treating Self-Doubts

To the outside world, you are successful, attractive or popular. You have a good marriage, your kids are doing well, or you get good reviews at work. But you feel like a worthless fraud on the inside. How could your own perception be so disparate from reality?

“Most people are struggling with difficult thoughts and feelings. But the show we put on for others says ‘I’ve got it handled,'” says Steven C. Hayes, a professor of psychology at University of Nevada-Reno. In reality, however, “there’s a big difference between what’s on the outside and what’s on the inside.”

Cognitive-behavioral therapy aims to help patients identify and dismantle their self doubts in several ways. Identifying the underlying cognitive distortion that may often be unconscious to the person is key. Most people make the mistake of utilizing one or more of several common cognitive distortions in appraising their life situations. Once these distortions are understood and made conscious, labeling the situation and thought error is often a big relief, besides extremely valuable (e.g., “I get all A’s and B’s in my accounting class, but I worry or dream I’m going to fail the class. What catastrophization! How ridiculous.”)

The next step is dismantling, which requires action steps learned with a cognitive therapist. These steps include utilizing the Socratic method (“What is the likelihood that your distortion is real? If so, what will happen next? What is the worst thing that will happen? What else can I do about when I have this thought?”) until the distortion becomes clear to the conscious mind, and renders itself faulty, exaggerated, or better yet, replaced.

Now, a third-wave of cognitive-behavioral therapy movement centers on mindfulness—paying attention to the present moment. One way I have found it useful to apply with clients is to help them imagine their thoughts as fluid, just passing through their minds, rather than sticking or having legitimate power or meaning (like “passing clouds.”) This technique can diffuse their emotional power (“Here’s that old ‘stupid’ feeling again. You know, this happens every time I compare myself to George in my class. But wait, my grades are good! I am sure mean to myself. I’m just going to let that thought pass and take a deep breath. Then, I’m going to get back to studying, or take a break. Or I could remind myself/focus upon when I did well on my tests or reports.”)

Here’s an example summary of how to address the thoughts of being a fraud:

Worried about being a fraud: Resolve to try to remember that you are valuable or capable, and have come by successes honestly.

Deny: Remember past decent exam scores and/or praise from a teacher/colleague.

Accept: Understand that everyone feels this way from time to time and ask yourself if worrying is worth it.

“Part of what mindfulness does is get to you to recognize that these critical thoughts are really stories you have created about yourself. They are not necessarily true, but they can have self-fulfilling consequences,” says Zindel V. Segal, a professor of psychiatry at the University of Toronto who devised Mindfulness-Based Cognitive Therapy to help depressed patients. “If you can get some distance from them, you can see that there are choices about how to respond.”

Mindfulness also involves paying attention to your breathing and other physical sensations while observing your thoughts so you have a tapestry of information to consider, says Dr. Segal. In fact, neuro-imaging studies have shown that when people consider problems mindfully, they use additional brain circuits beyond those that simply involve problem-solving. Randomized-controlled trials within the past ten years have shown extremely effective responses for people using the techniques for treating depression, anxiety, and even the personality disorders. I use many of these techniques also for addressing cravings for alcohol or drugs, or for addressing fears about change while undertaking sobriety.

My colleague Marsha Linehan, Ph.D., a professor of psychology at the University of Washington, summed up nicely the negative power behind such cognitive distortions: “It’s the nonjudgmental part that trips most people up,” says Dr. Linehan. “Most of us think that if we are judgmental enough, things will change. But judgment makes it harder to change.” She adds: “What happens in mindfulness over the long haul is that you finally accept that you’ve seen this soap opera before and you can turn off the TV.”