Running head: PSYCHODRAMA IN GROUP THERAPY WITH DEAF



















The Use of Psychodrama in Group Therapy

With Patients who are Deaf



















Robert L. Baldwin

Gallaudet University, Washington, D.C.

 Life's but a walking shadow, a poor player

That struts and frets his hour upon the stage.

		Shakespeare (Macbeth, Act 5, Scene 5)



	One of the most critical tasks during group therapy is to help patients understand the nature of their pathology. Under the right circumstances and with an appropriate group environment, patients will "strut" and display their maladaptive behaviors that need to be identified and treated (Yalom, 1995). One method, or theoretical approach, of group therapy that helps patients to display their problem behaviors is the technique and theory of psychodrama. Psychodrama requires patients to act out interpersonal interactions on a stage (Moreno, 1945).  Acting out social situations in a spontaneous fashion can help patients to identify and discuss their maladaptive behaviors that require treatment. 

The techniques of psychodrama are effective in helping clients to efficiently and accurately display their maladaptive behaviors. Consequently, as will be discussed later, much of the current theories on group therapy come from the theory upon which psychodrama is based. Further, psychodrama is still considered an appropriate method for some populations (Swink, 1985). Individuals who are deaf and are part of American Deaf Culture use American Sign Language (ASL) to communicate. Since ASL uses acting during story telling, the techniques used in psychodrama are well suited for treating patients who are deaf ASL users (Swink, 1985).

The founder of psychodrama, Jacob L. Moreno, stated that this therapeutic method had its beginning on April 1, 1921 (Kipper, 1996). Psychodrama originated in Vienna and was brought to the United States by Moreno in 1921 (Swink, 1985). In 1923, MorenoÕs Stegreif, or Theatre for Spontaneity, was published (Moreno, 1945). This paper became the most influential piece in the spread of psychodrama in the United States and ultimately lead to the development of several psychodramatic institutes. The most well know of these institutes was/is the Theatre for the Psychodrama at St. Elizabeths Hospital in Washington, D.C. At St. Elizabeths, psychodrama was frequently used in the treatment of military personnel.

According to Moreno (1945), the most important and difficult aspect of therapy is getting the patient to start expressing himself. The theory of psychodrama suggests that expression of self should be spontaneous. MorenoÕs use of the word spontaneity was very specific (Kipper, 1996). For him, "spontaneity may be define as (1) an adequate response to a new situation or a new response to an old situation, and (2) a response of varying degrees of adequacy to situations of varying degrees of novelty" (Moreno & Elefthery, 1975, p. 74). In other words, being spontaneous requires behaving in a creative way that is appropriate for the current situation. Further, spontaneity can be conceptualized as a form of energy and cannot be stored or accumulated and thus must be immediately expended in the present (Kipper, 1996). 

 Moreno believed that pathology occurs when individuals fail to behave spontaneously in what he called the "here and now", or current moment (Kipper, 1996). During interpersonal interactions, failing to act spontaneously leads to restrained or interrupted sequences of self-expression. Individuals become fixated on these interrupted sequences and inappropriately apply them to current situations in an attempt to resolve the previously restrained self-expression. According to this theory, when people are mentally ill they have become fixed, addicted, or habitual/compulsive in the way that they approach many of lifeÕs situations (Blatner, 1995). This means that they are continuously applying behavior to interpersonal situations in ways that are maladaptive. The goal of group psychotherapy, from this perspective, is to resolve previous interrupted incidents of self expression and to train patients to approach current situations spontaneously (Kipper, 1996).

The curative element of psychodrama comes from catharsis and training (Kipper, 1996). Since mental disorders arise from reenacting stifled emotions from the past, Moreno believed that therapy should be focused on helping people to live in the here and now. Catharsis occurs when an individualÕs restrained self-expression is displayed in the here and now situation. Displaying maladaptive behaviors and identifying them as such can be therapeutic and healing. However, training focused on replacing problematic behaviors is also therapeutic.

Training can involve spontaneity training or role expansion (Kipper, 1996). Spontaneity training involves teaching the patient how to respond to situations creatively instead of by relying on maladaptive templates for behavior. Role expansion includes role-playing new ways of responding to situations that have not been previously tried.

The method of psychodrama that is used to display maladaptive behaviors, cause catharsis, and train new behaviors is acting. "Aristotle expected the catharsis to take place in the spectator" while in psychodrama "the place of catharsis has moved from the spectators to the stage" (Moreno, 1945, pg. 5). Moreno used five elements in the staged enactment of a patientÕs problem area: the director (therapist), the protagonist (client), the auxiliary (supporting roles), the stage (physical location of all role-playing), and the audience (the other patients) (Blatner, 1995). While the protagonist, or patient, is acting, it is close to impossible for the actor to hide his true emotions and maladaptive behaviors (Moreno, 1945). As the client is acting, the audience may give feedback and encouragement, thus helping produce and identify problem behaviors (Blatner, 1995). Once the acting session is complete, the performance is analyzed by the therapist and audience in collaboration with the patient (Moreno, 1945).

The group therapy techniques that are used today are strongly influenced by MorenoÕs theories. Spontaneity is still considered an important part of the curative process. Yalom believes that "honesty and spontaneity of expression must be encouraged in the group" (Yalom, 1995, p. 110). Further, he basis his theory on the work of Sullivan who defines maladaptive behaviors, or any form of mental illness, as interpersonal interactions that are not appropriate to a situation. These inappropriate interpersonal interactions are caused by distorted perceptions, or parataxic distortions, of other people in the environment (Sullivan, 1954). Parataxic distortions are created in order to meet intrapersonal needs by projecting characteristics of significant individuals or situations from their past onto individuals or situations in the present (Yalom, 1995). This tenet is similar to MorenoÕs theory on spontaneity in that maladapted individuals are responding inappropriately in current situations because of unresolved past interactions or conflicts. These distortions can either lead to the procurement of security and satisfaction or, in the case of maladaptive behaviors, the barrier to security and satisfaction (Karon & Widener, 1995). Sullivan eloquently summarizes the relevance of this tenet: 

Crucial to understanding a human being is an understanding of the nature of his or her relations with others now and in the past, as well as the fantasies, conscious and unconscious, about those relations (Sullivan, 1964, in Karon & Widener, 1995, p. 38).



In order for individuals to get to the point where they can actively work on their maladaptive behaviors, the group must develop cohesiveness (Yalom, 1995). "It is cohesiveness that causes members to cathect the group and take seriously what happens in it" (Lonergan, 1994, pg. 207). Group cohesiveness, as defined by Yalom (1995), is the level of allure that members feel towards the group. It pertains to how comfortable and accepted members feel and how strongly they believe that they fit in as a group member. To make sure that members have a since of belonging, as in psychodrama, it is important for the therapist to promote an atmosphere where the members are honest with each other and provide feedback in a way that is supportive and caring. 

When group members feels safe and value honest feedback, they are more likely to start interacting with the other members of the group (Yalom, 1995).  As members freely interact with each other, a social microcosm will develop where members will view the group in the same ways that they are accustomed to viewing social interactions. Members will begin to interact with each other based upon their parataxic distortions, which is in essence the root of their pathology. Recognizing parataxic distortions requires members of the group to provide honest feedback and to analyze how and why they are interacting with each other at the present time. Yalom (1995) describes this as the here and now focus.  It should be noted that the end result of a cohesive group that has developed into a social microcosm has the same end result of role playing in psychodrama. In both forms of therapy the individualÕs maladaptive behaviors become recognized.	

	The members of a cohesive group that has developed into a social microcosm, will often act out past "conflictual relationships in the present" (Lonergan, 1994, pg. 207). The here and now focus involves members inspecting these parataxic distortions as they are occurring. Providing honest feedback on how current behaviors are being perceived helps the individual to learn how his behaviors make others feel. The here and now is important to both psychodrama and current forms of group therapy. Ultimately, healthy living requires attending to here and now interpersonal interactions to reduce pathology. In YalomÕs form of group therapy, present parataxic distortions are attended to in an attempt to increase undistorted interactions. In MorenoÕs psychodrama, present fixed patterns of responding are examined in order to increase spontaneous interactions.

According to Yalom (1995), the factors that make group therapy effective become possible when patients display their pathology. As the group develops into a social microcosm and maladaptive behaviors start to be displayed, catharsis begins to occur. As with psychodrama, catharsis, or the expression of strong emotion, is one of the most powerful therapeutic factors that can occur during this type of counseling (Ballinger & Yalom, 1995).  

As patients display their pathological behaviors, strong emotions in the group are often times expressed.  For example, a man whoÕs maladaptive behavior is to be over-controlling, may find that this behavior does not lead to submission as it had in his everyday social interactions.  Since the group has become cohesive and values honest feedback on behavior, someone may tell him how his behavior is annoying her and thus will hopefully help him to realize what he is doing that is not appropriate. This type of interaction is often times cathartic and can result in the expression and feeling of strong emotions. It is important to note how both of the forms of group therapy discussed involve the client acting out past unresolved interpersonal interactions.  The only difference between the two is that one method covertly helps the client to act out these unresolved interactions while the other is more overt in its approach.

American Sign Language (ASL) has been shown to be a fully functional language that is separate from English.

Beginning in the 1960s and developing in the decades that followed, linguists and psychologists provided an avalanche of evidence that the worldÕs manual languages were natural languages with autonomous vocabularies, grammars, and art forms all their own (Lane, 1993, pg. 46).



One aspect of ASL that is different from English is the way in which a speaker/signer or storyteller indicates what different characters/people said and did. In English, a person may change voice inflection to signal a change in who is being described (Lane, Hoffmeister, Bahan, 1996). Written English uses quotations to indicate that what a character said is being repeated. The equivalent to the English use of "she said, he said" in ASL involves the use of body movements and facial expressions to act out each individual in the story or dialogue (Glickman, 1996). Although psychodrama is not as popular as it once was, it is still a valid method for use with individuals who are deaf. Since deaf people utilize role-playing during the use of ASL, this therapeutic approach is inherently well suited for use with ASL using patients (Glickman, 1996; Swink, 1985).

	It has been reported that deaf patients will more readily adapt to the use of psychodrama than will hearing patients (Swink, 1985). It is as if they have already been using the techniques of psychodrama in everyday life. When deaf children tell stories, they do so in a fashion that is similar to the role-playing that happens in psychodrama. 

They become very emotionally involved in the story and use every sensory modality available to convey the message.  They take all of the roles of the characters in the story. They may become objects or animals, miming and gesturing to add clarity. As they use their voices to mimic explosions from bombs and hums of airplane engines, they leave the viewer no doubt as to every detail of the story (Swink, 1985, pg. 273).

	

From this description of ASL story telling, it is not surprising to find that deaf patients naturally accept the techniques of psychodrama.

	The theories and methods of psychodrama, as described by Moreno, have proven to be influential in the development of current forms of group therapy. Many of the tenets of YalomÕs approach to group work, such as the here and now focus, were developed based on the ideas of Moreno. Although psychodrama is not taught or mentioned often in mainstream classrooms of group therapy, its methods are still useful for some clinical populations. 

It has been noted that deaf patients are often time more accepting of the methods used in psychodrama than hearing patients (Glickman, 1996; Swink, 1985). This has been attributed to the fact that many properties of ASL are similar to the techniques that are utilized in this approach. It appears that the use of psychodrama is fading from mainstream use. This is unfortunate as it still has potential for helping patients who are deaf ASL users. Increased awareness and mention of this approach, at universities that train service provides to work with this population, may be beneficial for patients who are deaf. Increased knowledge of psychodrama and its techniques in service providers would likely expand its use with this group of people. This might improve the therapeutic potential of the services that are currently being provided. Further, it would, at least, increase the number of available therapeutic approaches that deaf people have to choose from.

 References

Blatner, A. (1995). Psychodrama. In R. J. Corsini & D. Wedding (Eds.), Current Psychotherapies (pp. 399-408). Itasca, IL: F. E. Peacock Publishers, Inc.

Glickman, N. S. (1996). Culturally Affirmative Psychotherapy with Deaf Persons. In N. S. Glickman & M. A. Harvey (Eds.), Culturally Affirmative Psychotherapy with Deaf Persons (pp. 1-55). Mahawah, NJ: Lawrence Erlbaum Associates, Publishers.

Karon, B. P. & Widener, A. J.  (1995). Psychodynamic therapies in historical perspective: "Nothing human do I consider alien to me."  In B. Bongar & L. E. Beutler (Eds.), Comprehensive Textbook of Psychotherapy (pp. 24-47). New York: Oxford University Press.

Kipper, D. A. (1996). The emergence of role playing as a form of psychotherapy. Journal of Group Psychotherapy, Psychodrama and Sociometry, 6, 99-119.

Lane, H. (1993). The Mask of Benevolence. New York: Vintage Books.

Lane, H., Hoffmeister, R., Bahan, B. (1996). A Journey into the Deaf-World. San Diego, CA: Dawn Sign Press.

Lonergan, E. C. (1994). Using theories of group therapy. In H. S. Bernard & K. R. MacKenzie (Editors), Basics of Group Psychotherapy (189-216).

Moreno, J. L.  (1945).  Psychodrama and the psychopathology of inter-personal relations.  Psychodrama Monographs, 16.

Moreno, J. L. & Elefthery, D. G. (1975). An introduction to group psychodrama. In G. M. Gazda (Editor), Basic Approaches to Group Psychotherapy and Group Counseling (69-100).

Sullivan, H. S. (1954). The psychiatric interview. New York: W. W. Norton & Company.

Swink, D. F. (1985). Psychodramatic treatment for deaf people.  American Annals of the Deaf, 130(4), 172-177.

Yalom, I. D. (1995). The  theory and practice of group psychotherapy. New York, NY: BasicBooks.