Resolving Painful Emotional Experience During Psychodrama Charmaine S. Mcvea. a Dissertation Submitted to the School of Psycholo
Resolving Painful Emotional Experience during Psychodrama
Charmaine S. McVea. B.A. Dip.Psych. M.Psych.(Applied) MAPS
A dissertation submitted to the School of Psychology and Counselling for the degree of Doctor of Philosophy.
Queensland University of Technology Brisbane, Queensland 2009
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Keywords
Brief Structured Recall Interpersonal process recall Catharsis Morenian role theory Change process research Psychodrama Comprehensive process analysis Painful emotional experience Emotion Multiple case studies Enactment Social atom In-session resolution Spontaneity theory
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Abstract
Unresolved painful emotional experiences such as bereavement, trauma and disturbances in core relationships, are common presenting problems for clients of psychodrama or psychotherapy more generally. Emotional pain is experienced as a shattering of the sense of self and disconnection from others and, when unresolved, produces avoidant responses which inhibit the healing process. There is agreement across therapeutic modalities that exposure to emotional experience can increase the efficacy of therapeutic interventions. Moreno proposes that the activation of spontaneity is the primary curative factor in psychodrama and that healing occurs when the protagonist (client) engages with his or her wider social system and develops greater flexibility in response to that system. An extensive case-report literature describes the application of the psychodrama method in healing unresolved painful emotional experiences, but there is limited empirical research to verify the efficacy of the method or to identify the processes that are linked to therapeutic change. The purpose of this current research was to construct a model of protagonist change processes that could extend psychodrama theory, inform practitioners’ therapeutic decisions and contribute to understanding the common factors in therapeutic change. Four studies investigated protagonist processes linked to in- session resolution of painful emotional experiences. Significant therapeutic events were analysed using recordings and transcripts of psychodrama enactments, protagonist and director recall interviews and a range of process and outcome measures. A preliminary study (3 cases) identified four themes that were associated with helpful therapeutic events: enactment, the working alliance with the director and with group members, emotional release or relief and social atom repair. The second study (7 cases) used Comprehensive Process Analysis (CPA) to construct a model of protagonists’ processes linked to in-session resolution. This model was then validated across four more cases in Study 3. Five meta-processes were identified: (i) a readiness to engage in the psychodrama process; (ii) re-experiencing and insight; (iii) activating resourcefulness; (iv) social atom repair with emotional release and (v) integration. Social atom repair with emotional release involved deeply iii experiencing a wished-for interpersonal experience accompanied by a free flowing release of previously restricted emotion and was most clearly linked to protagonists’ reports of reaching resolution and to post session improvements in interpersonal relationships and sense of self. Acceptance of self in the moment increased protagonists’ capacity to generate new responses within each meta-process and, in resolved cases, there was evidence of spontaneity developing over time. The fourth study tested Greenberg’s allowing and accepting painful emotional experience model as an alternative explanation of protagonist change. The findings of this study suggested that while the process of allowing emotional pain was present in resolved cases, Greenberg’s model was not sufficient to explain the processes that lead to in-session resolution. The protagonist’s readiness to engage and activation of resourcefulness appear to facilitate the transition from problem identification to emotional release. Furthermore, experiencing a reparative relationship was found to be central to the healing process. This research verifies that there can be in-session resolution of painful emotional experience during psychodrama and protagonists’ reports suggest that in-session resolution can heal the damage to the sense of self and the interpersonal disconnection that are associated with unresolved emotional pain. A model of protagonist change processes has been constructed that challenges the view of psychodrama as a primarily cathartic therapy, by locating the therapeutic experience of emotional release within the development of new role relationships. The five meta-processes which are described within the model suggest broad change principles which can assist practitioners to make sense of events as they unfold and guide their clinical decision making in the moment. Each meta-process was linked to specific post-session changes, so that the model can inform the development of therapeutic plans for individual clients and can aid communication for practitioners when a psychodrama intervention is used for a specific therapeutic purpose within a comprehensive program of therapy. iv
Statement of Original Authorship
I, Charmaine McVea, declare that this thesis has not previously been submitted, either complete or in part, to meet the requirements for an award to this or any other institution of higher education. This work results from original research and to the best of my knowledge or belief, contains no material previously published or written by another person except where due reference is made in the text of the thesis.
Signature …………………………………………… Date …………………………………………....
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Acknowledgments
Many people have assisted me in the creation of this body of work and the opportunity to work with each of them has made the often solitary journey of completing a PhD personally and professionally enriching. I am immensely grateful for the guidance and encouragement I received from my primary supervisor, Professor Kathryn Gow. She has a remarkable capacity to hold the big picture and still have an eye for details. Her steadying hand and confidence in the research have enabled me to see the project through. I would also like to thank my associate supervisor Dr Roger Lowe for his insights and suggestions and the QUT School of Psychology and Counselling for supporting this research. The openness and generosity of the workshop participants, sharing what were at times very painful experiences, made this project possible. It is inspiring to walk along side people who are on a journey of personal growth and I thank them for their willingness to make their experiences available for the benefit of others. Likewise, I would like to thank the psychodramatists who conducted the workshops, Chris Andrade, Brigid Hirschfeld, Kate Hudgins and Mary Anne Cox, for their willingness to reflect on their own practice with honesty and humility. I have gained enormously from working with such dynamic and skilled therapists. To my colleagues who contributed time and enthusiasm over a number of years – Jenelle Watson, Jan Patty, Brenda Lack, Melody Krok, Jane-Ellen Corkeron, Maria O’Leary and Kathy Uzsoki – I am very grateful. As well as their professional involvement reviewing transcripts, auditing or editing, they offered personal support and their continuing faith that this was a project worth completing. I thank my peers in the Australian and New Zealand Psychodrama Association for their warm response to the research, in particular Don Reekie, who has discussed psychodrama theory with me, and Elizabeth Synnot and Peter Howie for the use of their venue. Finally, my family have continued to provide me with love and encouragement throughout. My husband, Ralph Allan, gave me unwavering personal support and was also my principal editor, reading numerous drafts over the years. Our daughter, Kathryn, has helped to give me a balanced perspective. She rightly suggests that we should have lots of parties to celebrate being finished. vi
Table of Contents
Page Keywords i Abstract ii Statement of Original Authorship iv Acknowledgments v Table of contents vi List of Tables xii List of Figures xiv List of Abbreviations xviii Glossary of Psychodrama Terms xix
Chapter 1: Introduction 1 Purpose of the research 1 Background to the research 1 Overview of the thesis 5
Chapter 2: Theoretical Foundations of Psychodrama 7 A model of healthy functioning: spontaneity theory and role theory 7 Social atom repair: the psychodramatic construction of healing and personal development 11 The application of spontaneity theory and role theory within the structure of a classical psychodrama session 13 Summary 16
Chapter 3: Empirical Evidence for Psychodrama Theory and Practice 17 The current state of psychodrama outcome research 17 Psychodrama process research: Models of therapeutic agency 21 A need for research to build theory and inform psychotherapy practice 26
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Chapter 4: Emotion and Emotional Processing 28 Defining emotion 28 Emotion and healthy functioning 29 Emotional pain 30 Emotional processing 31 The relationship between emotion and spontaneity 32 Summary 33
Chapter 5: Overview of the Research 35 Rationale 35 Research plan and research questions 37
Chapter 6: Research Design and Methodological Approach 40 Multiple case study design 40 Psychotherapy change-process research as an approach to model building 41 Multiple sources of data 45 Team-based analysis and the consensus decision making approach 47 The participation of the investigator at all stages of the research 48 Ensuring credibility and coherence of the findings 50 The single-session psychodrama intervention design 52 Introduction to the reports of the four studies 54
Chapter 7: Protagonist and director recall of Protagonists’ Change Processes during psychodrama: A preliminary study 55 Overview of Study 1 55 Context for the preliminary study 55 Research questions 56 Method 57 Participants 57 Questionnaires and measures 58 Procedure 61 Analysis 65 Results 68 viii
In-session resolution and protagonists’ experiences of post-session change. 68 Interrater agreement on the DRS/PRP 68 Credibility of the ratings of in-session resolution 68 Case Study 1: Ella 69 Case Study 2: Karen 70 Case Study 3: Erin 70 General features of protagonists’ experiences of change. 71 Qualitative analysis of IPR responses. 72 Discussion of the findings of the Preliminary Study 87 In-session resolution 87 Unifying themes from protagonist and director recall 89 Relationship with the director 89 The impact of auxiliaries and role reversal 90 Emotional release 91 Contextual factors 91 Differences between the two resolved cases 91 Limitations of this preliminary study 92 Summary 93
Chapter 8: An investigation of Protagonist Processes leading to in-session resolution of painful emotional experiences during psychodrama: Building the model. 94 Overview of Study 2 94 Context for the second study 95 Research question 97 Method 97 Participants 97 Measures 100 Procedure 104 Analysis 108 Linear mixed methods design 108 Hermeneutic single case efficacy design (HSCED) 109 Rating in-session resolution 114 ix
Comprehensive Process Analysis (CPA) of significant change events 115
Chapter 9: Outcome and Efficacy Results (Study 2) 120 Evidence of post-intervention changes in general symptom distress and interpersonal distress 120 Efficacy of the psychodrama intervention 124 In-session resolution 124 Resolved cases 126 Case Study 4: Cheryl 127 Case Study 5: Julie 128 Case Study 6: Jane 129 Case Study 7: Ray 130 Summary of efficacy results for protagonists who achieved in- session resolution 132 Not-resolved cases 132 Case Study 8: Grant 133 Case Study 9: Geraldine 134 Case Study 10: Linda 135 Summary of efficacy results across the seven cases 135
Chapter 10: Results of the Comprehensive Process Analysis of Significant Events (Study 2) 137 Descriptive summary of protagonists’ responses 137 Five meta-processes linked to in-session resolution 143 General patterns across the four meta-events 166 Summary of the findings of the comprehensive process analysis of significant events 170 Implications for building a model of protagonists’ change processes 174
Chapter 11: Verifying the emerging model of protagonist change processes 175 Overview of Study 3 175 Hypothesised protagonist processes leading to in-session resolution 176 Research question 179 x
Method 179 Group participants 179 Protagonists 180 Psychodrama directors 180 Measures 182 Procedure 183 Analysis 184 Results 194 Limits to homogeneity between Study 2 and Study 3 cohorts 194 Evidence of protagonist change at two-week follow-up 195 In-session resolution 197 Occurrence of meta-processes in resolved and not-resolved cases 197 The four cases: Context, process and impact patterns 199 Case Study 11: Sue 200 Case Study 12: Angela 206 Case Study 13: Patricia 214 Case Study 14: Isabel 219 Summary of the results of Study 3 221
Chapter 12: Verifying the application of Greenberg’s ‘allowing and accepting painful emotional experience’ model to the psychodrama method 223 Greenberg’s Allowing and accepting painful emotional experience Model 223 Emotion or spontaneity as the catalyst for change 226 Rationale for Study 4 227 Verifying the model within the task-analytic research approach 227 Hypotheses 231 Research questions 231 Method 232 Protagonists 232 Process measures 232 Procedure 236 Results 242 xi
Interrater reliability for process measures 242 Occurrence of components of the allowing and accepting model in resolved and not-resolved cases 243 Performance patterns within resolved cases 245 Performance patterns within not-resolved cases 264 Summary of the findings of Study 4 264
Chapter 13: Discussion 269 A review of the aims and research questions 269 In-session resolution 270 Evidence for the efficacy of the classical psychodrama intervention 273 A proposed model of protagonist processes leading to in-session resolution of painful emotional experience during psychodrama 278 Implications of the model of protagonist change processes for Moreno’s (1961) Theory of Spontaneity 284 Further explication of the psychodrama construct of social atom repair 288 Implications of the findings for other therapeutic models of psychodrama 289 The fit between Greenberg’s allowing and accepting painful emotional experience model and protagonists’ experiences of resolution 294 Applications of the research 298 Strengths of the research 302 Limitations of the research 303 Areas for further research 305 A framework for building psychodrama practice-based research 306
Chapter 14: Conclusion 307
References 313
Appendices A. Personal History Questionnaire A1 B. Post Workshop Evaluation Form A4 C. Client change Interview Protocol A8 D. Statement of expectations and biases of the research team A10 xii
List of Tables
Table Title Page
7.1 Degree of Resolution Scale: Problematic Reaction Points 60
7.2 Protagonist and director recall of significant events within psychodrama: four domains and the core ideas within domains 74
8.1 Demographic characteristics of the Study 2 cohorts, compared with characteristics of all participants across the four studies. 99
8.2 Assessment points for outcome and process instruments 101
8.3 Data sources matched to Elliott’s efficacy criteria 111
8.4 Criteria for clinical dysfunction and reliable change indices 112
9.1 Comparison of mean pre-intervention SCL90-R(GSI) and IIP- 127(Total) scores for cohorts 2 and 3 120
9.2 SCL90-R(GSI) scores for protagonists compared to non-protagonists 121
9.3 IIP-127 Total scores for protagonists compared to non-protagonists 122
9.4 Participants’ SCL90 (GSI) at pre-intervention, 2 weeks & 3 months 123
9.5 Protagonists’ IIP-127 (Total) at pre-intervention, 2 weeks & 3 months 124
9.6 Degree of Resolution Ratings & Protagonist Helpfulness Ratings 125
9.7 Number of resolved and not-resolved cases per director 125
10.1 The representativeness of domains, categories and core ideas across the seven cases 138
10.2 Summary of Event 1: Re-experiencing and Insight 145
10.3 Summary of Event 2: Activating Resourcefulness 153 xiii
Table Title Page
10.4 Summary of Event 3: Social atom repair with emotional release 161
10.5 Summary of Event 4: Integration 165
11.1 Demographic characteristics for Cohort 4 compared to characteristics for all research participants. 181
11.2 Assessment points for outcome and process instruments 182
11.3 Checklist of significant protagonist processes 188
11.4 Participants (protagonists & other group members) SCL90-R Global Severity Indices (GSI) at pre-intervention and 2 week follow-up. 196
11.5 Participants (protagonists & other group members) IIP-127 (Total) scores at pre-intervention and 2 week follow-up. 196
11.6 In-session Resolution Ratings & Session Helpfulness Ratings 197
11.7 Representativeness of meta-processes in resolved and not-resolved cases 198
12.1 Interrater reliability coefficients for process measures 242
12.2 Occurrence of criteria of the allowing and accepting model across resolved and not-resolved cases 243
12.3 Occurrence of criteria of the allowing and accepting model in resolved and not resolved cases (Fisher’s exact test) 244
12.4 Occurrence of criteria of the allowing and accepting model in social atom repair events 245
13.1 Resolution ratings mapped to protagonists’ session impact reports 272 xiv
List of Figures
Figure Title Page
2.1 The Hollander Psychodrama Curve. (Source: Hollander, 1969). 15
5.1 Overview of the research plan 37
7.1 Preliminary study research plan 55
7.2 Steps in the procedure for Study 1 62
7.3 Extracts from the recall of Karen and her director: group participation reduces isolation and builds spontaneity 81
7.4 Extracts from the recall of Erin and her director: experiencing receiving an unmet need, with emotional catharsis and relief 82
7.5 Extracts from the recall of Karen and her director: experiencing receiving an unmet need in a surplus reality encounter 83
7.6 Extracts from the recall of Karen and her director: action insight arising from concretising an obsessive thinking pattern 84
7.7 Extract from Erin’s recall: action insight in role reversal 85
8.1 Study 2 research plan: Multiple case study investigation of significant change events using Comprehensive Process Analysis 94
8.2 Steps in the procedure for Study 2 105
8.3 Stages in the data analysis for Study 2 108
10.1 Five meta-processes linked to in-session resolution of painful emotional experiences during psychodrama. 143
10.2 Summary of Cheryl’s re-experiencing and insight event 149 xv
Figure Title Page
10.3 A partial re-experiencing and insight event from a not-resolved case 152
10.4 Summary of Ray’s boundary setting event 155
10.5 Boundary setting in a not-resolved case 157
10.6 Summary of Julie’s intimacy event 158
10.7 Intimacy in a not-resolved case 159
10.8 Jane’s social atom repair with emotional release event 163
10.9 Extract of Jane’s recall of an integration event 166
10.10 A case example of the dynamic development of action insight 168
11.1 Research plan for Study 3 175
11.2 Hypothesised protagonists’ processes for re-experiencing and insight event 176
11.3 Hypothesised protagonists’ processes for boundary setting event 177
11.4 Hypothesised protagonists’ processes for intimacy event 177
11.5 Hypothesised protagonists’ processes for social atom repair with emotional release event 178
11.6 Steps in the procedure for Study 3 183
11.7 Steps in the analysis of significant events 186
11.8 Extract from Sue’s transcript: Re-experiencing & Insight 202
11.9 Extract from Sue’s transcript: Activating resourcefulness 204
11.10 Extract from Sue’s transcript: Social atom repair with emotional release. 205 xvi
Figure Title Page
11.11 Extract from Angela’s transcript: Re-experiencing & Insight 209
11.12 Extract from Angela’s transcript: Activating resourcefulness 210
11.13 Extract from Angela’s transcript: Social atom repair with emotional release. 212
11.14 Extract from Patricia’s transcript: Re-experiencing & insight 216
12.1 The process of allowing and accepting painful emotional experience. (Source: Greenberg & Paivio, 1998, p. 55) 225
12.2 Criteria for the four components of the allowing and accepting painful emotional experience model, based on the work of Foerster & Greenberg (1995, in Greenberg, 1999) 230
12.3 Study 4 research plan 232
12.4 Steps in procedure for Study 4 236
12.5 Format of protagonists’ performance diagrams 246
12.6 Performance diagram of Erin’s first social atom repair event, with extract from her transcript 249
12.7 Karen’s performance diagram with extracts from her transcript 251
12.8 Jane’s performance diagram with extracts from her transcript 255
12.9 Julie’s performance diagram with extracts from her transcript 257
12.10 Cheryl’s performance diagram with extracts from her transcript 261
12.11 Ray’s performance diagram with extracts from his transcript 263
12.12 General performance patterns in resolved cases 266
13.1 A model of protagonists’ processes leading to in-session 279 xvii
Figure Title Page
resolution of painful emotional experience during psychodrama
13.2 The development of spontaneity when there is in-session 287 resolution of painful emotional experience, compared to Hollander’s (1969) emotional continuum
13.3 Allowing emotional pain (Source: Greenberg, 1999) 297
13.4 Modification of Greenberg’s (1999) Allowing Emotional Pain 297 model, to fit Psychodrama (McVea, 2009).
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List of Abbreviations
BSR Brief Structured Recall CBT Cognitive behavioural therapy CCRT Core Conflictual Relationship Theme Measure CPA Comprehensive Process Analysis EXP Experiencing Scale HSCED Hermeneutic Single Case Efficacy Design IIP Inventory of Interpersonal Problems IPR Interpersonal Process Recall RCI Reliable change indices SASB Structural Analysis of Social Behaviour. SCL90-R Symptom Checklist 90 (Revised)
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Glossary of Psychodrama Terms
Act hunger ‘The drive towards a fulfilment of the desires and impulses at the core of the self’ (Blatner, 1988, p. 77). Action insight ‘The integration of emotional, cognitive, imaginary, behavioural and interpersonal learning experiences ... achieved only in action.’ (Kellermann, 1992, p. 86). Auxiliary A group member who acts in the role of another person, intra- psychic role of the protagonist or role of an animal, object or meta- physical being to assist in the production of the protagonist’s drama. Concretisation Setting out on the stage, aspects of the protagonist’s subjective reality, using auxiliaries or props. Cultural Atom A person’s cultural atom consists of the roles and role relationships that are enacted between that person and significant others that make up his or her social atom. Director The psychodrama practitioner or therapist Double The intentional use of a group member “in the specialised role of playing the part of the inner self” to assist the client to be aware of and put words to their inner experience (Blatner, 1988, p.28). Encounter A meeting of two or more people involving an intuitive role reversal one with the other and immediate, direct and meaningful expression in the moment (Moreno, 1964/1946; 1970). Mirror ‘The technique of the mirror “portrays” the body image and the unconscious of (the protagonist) at a distance from him so that he can see himself. The portrayal is done by an auxiliary ego, who has made a close study of (the protagonist)’ (Moreno, 1975/1959). Protagonist The group participant who is the subject of the psychodrama enactment. Role The functioning form an individual takes when responding in the moment (Moreno, 1961). Role Reversal The technique whereby two people step out of their own roles and into the role of the other, so that they can experience and respond in xx
the moment ‘as-if’ they were the other. In its original construction, role reversal involved two people in a real-life encounter, and this process is sometimes used in family or relationship counselling. The more common use of role reversal in psychodrama is where the protagonist reverses roles with a group member who is acting as a significant other. Social Atom A person’s social atom consists of the central relationships within which he or she enacts the roles that produce the sense of self. The social atom takes into consideration strength of connections between the person and each significant other, and the quality of the relationship, if it is positive, negative or neutral, mutual or one- sided. Moreno (1953) considered that the smallest unit in society was not the individual but the social atom. Social atom repair ‘The development of new roles and role systems … any re- organisation or any development in the relationship of the person with the outside world’ (Clayton, 1993, p. 55), Spontaneity An inner state of ‘readiness of the subject to respond as required’ (Moreno, 1987/ 1975, p. 42). The definition of spontaneity has been refined by Carter (1994) as ‘a readiness for a free and vital response to the emerging moment' (p. 41). Spontaneous response The product of spontaneity, arising from free will and having the qualities of novelty, adequacy, purposefulness and direction. (Moreno, 1987/ 1975, pp. 42-43). Surplus reality Unexpressed hopes, dreams, fantasies, conversations or actions, which are considered reality because they are part of the person’s construction of reality, and are considered surplus because they have not been expressed, they are additional to what has been presented in the person’s relating to the world. Warm-up The ‘individualised manner of preparing to respond either emotionally, intellectually, physically or spiritually’ (Hollander, 1981). Warm-up was regarded by Moreno to activate spontaneity. Chapter 1 1
Chapter 1 Introduction
Purpose of the Research The central aim of this thesis is to build an explanatory model of protagonist (client) processes that lead to the in-session resolution of painful emotional experiences during psychodrama. This opens new ground in psychodrama research through an in-depth exploration of the processes that lead to therapeutic change, and responds to calls for the development of models or mini-theories that can assist practitioners to make effective therapeutic decisions (e.g. Bohart, 2000; Greenberg 1999; Mahrer & Boulet, 1999). Understanding the effective components of psychodrama will advance the practice of psychodrama and inform the training of psychodrama practitioners. It is hoped that this thesis will also contribute more generally to a better understanding of the underlying principles of therapeutic change and thus play a part in the movement towards integration across therapeutic modalities. This chapter introduces the reader to the key concepts and issues pertaining to the resolution of painful emotional experience during psychodrama and sets the scene for the studies that follow.
Background to the Research Unresolved painful emotional experiences such as bereavement, disturbance in core relationships and trauma are a common focus of concern when people present for psychological counselling. Such experiences impact on an individual’s sense of self and ability to relate to others (Bolger, 1999), and when they remain unresolved, have the potential for long term and serious impact on physical and psychological well-being (Felitti et al., 1998; Hayes, Wilson, Gifford, Follette & Strosahl, 1996). Greenberg and Paivio (1998) suggest that more research is required to develop a detailed understanding of how psychotherapy can assist people to resolve these experiences, and that such research would assist practitioners working across a range of therapeutic modalities. Psychodrama was introduced as a therapeutic group method by J.L. Moreno in the 1920s (refer to Moreno, 1946/1980; 1959/1975 & 1969/1975). Since that time, a rich case report literature has emerged supporting the efficacy of psychodrama in Chapter 1 2 working with people with unresolved painful emotional experiences associated with bereavement, childhood abuse and trauma (e.g. Holmes, Karp & Watson, 1994; Kellermann & Hudgins, 2000). However, empirical research and the development of theory within the psychodrama method have been limited. Given that painful emotional experience is a common focus of psychodramatic interventions, it would seem that this is an appropriate area of application in which to build psychodrama theory. Founded on existential philosophy and methodology of the theatre, psychodrama is concerned with the whole experience of what it means to be human. As a therapeutic method, it has been positioned within the experiential psychotherapy field by a number of authors (see Greenberg, Watson & Lietaer, 1998; Hudgins, 2002). However, psychodrama cannot be fully understood as an experiential psychotherapy alone. Moreno (1987a) referred to psychodrama as an interpersonal therapy and it has been further described as a broad methodology that employs a range of therapeutic techniques (Moreno, 1969/1975). Blatner (2002) describes psychodrama as an integrative method, noting that ‘intrinsic to healing are self- expression and self-affirmation through action and the attainment of a wholeness through the integration of imagination, emotion, action, and group relations’ (p. 1). Kellermann (1992) suggested that the method is best defined by a comprehensive description of its attributes, and proposed the following definition: “Psychodrama is a method of psychotherapy in which clients are encouraged to continue and complete their actions through dramatisation, role-playing and dramatic self-presentation. Both verbal and non-verbal communications are utilised. A number of scenes are enacted, depicting, for example, memories of specific happenings in the past, unfinished situations, inner dramas, fantasies, dreams, preparations for future risk-taking situations, or unrehearsed expressions of mental states in the here and now. These scenes either approximate real-life situations or are externalisations of inner mental processes. If required, other roles may be taken by group members or by inanimate objects. Many techniques are employed, such as role reversal, doubling, mirroring, concretising, maximising and soliloquy. Usually the phases of warm-up, action, working through, closure and sharing can be identified.” (p. 20). Chapter 1 3
This definition characterises psychodrama as being a group method with (i) an experiential, humanistic philosophy that emphasises the centrality of the client’s experience; (ii) an interpersonal systems orientation that considers the functioning of the individual within their social and cultural context and (iii) a learning orientation realised through spontaneity training and action experimentation. Thus, psychodrama engages not only the cognitive and affective functioning of the individual, but also physical action and the interplay of the individual within their interpersonal system and broader cultural context. All of these orientations have strong therapeutic application in working through previously unresolved painful emotional experiences. Classical psychodrama aims to assist people to develop their spontaneity which is considered to produce an increased ability to respond flexibly and appropriately to others and to the environment. Spontaneity is developed and expressed in the context of interpersonal relationships, and it will be argued that this emphasis on inner experience and interpersonal encounter as therapeutic tools makes the method well placed to attend to the personal and interpersonal difficulties that can arise from unresolved painful emotional experiences. Conceptual development of psychodrama theory has occurred through a tradition of experiential learning and reflective practice, and the publication of a number of modified approaches to psychodrama in the past 10 years suggests that the development of the method in this way is alive and well. Mahrer (2005) proposes that research that builds on the conceptual developments of expert practitioners is more likely to advance our understanding of the types of issues that confront practitioners and their clients. In his view, the genesis of new ideas occurs in the field, and one role of research is to further investigate and test out these ideas. There is little empirical research into the processes linked to positive outcomes from psychodrama (Kipper & Ritchie, 2003). A notable exception to this is the work of Kellermann (1989, reported in Kellermann, 1992) who built a model of the therapeutic aspects of psychodrama based on studying the reports of protagonists and of expert psychodrama practitioners. A number of other projects have investigated the process of change in psychodrama, and these studies can be seen to give further depth to some of the factors identified by Kellermann (see Brooks, 2000). At a micro-process level, investigations of the therapeutic impact of psychodramatic techniques such as doubling and role reversal have been encouraging. Nevertheless, Chapter 1 4 many of the claims found in the psychodrama literature have not been adequately tested (Kipper & Ritchie, 2003; Weiser, 2007). Although psychodrama research is limited, psychodrama practice adheres to many of the therapeutic principles that have been linked to positive therapeutic outcomes in other areas of psychotherapy research. Research in the areas of emotion processing and experiential psychotherapy process and outcome have contributed to an understanding of the common factors that contribute to effective psychotherapy outcomes across therapeutic modalities. Notably, there is an emerging consensus that some form of exposure to problematic experience produces positive therapeutic outcomes when the exposure activates emotions and is associated with a change in cognitions and/or behaviour (e.g. Foa and Kozac, 1986; van der Kolk et.al., 1996). Research in the field of one-to-one experiential psychotherapies has identified a number of processes that are linked to the resolution of painful emotional experience. In addition to evidence that activating emotional responses to problematic situations leads to increased efficacy of therapeutic interventions (Bolger, 1999; Greenberg & Pascual-Leone, 2006; Greenberg & Saffran, 1989; Magnavita, 2006), it has been proposed that activating corrective emotional experiences through an empathic relationship (Bridges, 2006) and the development of a sense of mastery through experiential tasks that enable the person to take action in response to the painful experience (van der Kolk, McFarlane & van der Hart, 1996), may assist the therapeutic process. It is suggested in this thesis that psychodrama interventions will at times intentionally generate all three of these conditions and that key psychodramatic principles are supported by experiential psychotherapy research. Enactment is the psychodramatic vehicle used for experiencing the problematic situation and for generating new responses, and the use of group members as auxiliaries enables the setting out and enactment of role relationships as a primary therapeutic tool. Greenberg and Paivio (1998) argue that allowing and accepting painful emotional experience is central to therapeutic change. They articulate a model of client processes leading to the resolution of painful emotional experience that they propose would apply across therapeutic approaches. It is proposed that the ‘allowing and accepting’ model is compatible with Moreno’s (1946/1980) spontaneity theory, and may provide an operational description of some of the tasks a protagonist undertakes during a psychodrama session where they reach in-session resolution. However, it is Chapter 1 5 also proposed that while the allowing and accepting model describes the experiential process of the individual, the additional orientations to interpersonal systems and behavioural learning that are part of the psychodramatic method may provide further illumination of processes that can contribute to resolution.
Overview of the Thesis This thesis reports on four studies that investigated protagonists’ processes leading to in-session resolution of painful emotional experience during psychodrama. The following three chapters establish the context for this current research, by exploring in more detail the ideas that have been presented in this introduction. Chapter 2 provides a theoretical background to the psychodrama method, with an introduction to Moreno’s concept of healthy functioning contained in his spontaneity theory and role theory. The current state of psychodrama outcome and process research is then considered in Chapter 3, where the need is established for further research to develop theory and practice, and the particular contribution psychodrama research could make to psychotherapy integration, is considered. Chapter 4 considers the phenomenon of emotional pain, defining emotion and emotional pain in relation to healthy functioning and discussing the therapeutic agency of activating emotions during exposure. This discussion highlights questions about the relationship between emotion and spontaneity, which are pertinent to understanding the process of change during psychodrama. The structure of the research is then outlined. Chapter 5 presents the rationale for the four studies of the thesis and an overview of the research plan. Chapter 6 introduces the multiple case study design and the methodological stance that has been taken in the research. Four studies are then reported. The preliminary study (Chapter 7) investigates protagonists’ experiences of change during psychodrama and examines the underlying premise of the research project, that psychodrama interventions can produce in-session resolution of painful emotional experience. The second study (Chapters 8, 9 & 10), which is the pivotal study of the research, builds an explanatory model of protagonist change processes, through the comprehensive analysis of significant change events. The emerging model is verified in Study 3 through the analysis of further cases (Chapter 11). Finally, Study 4 (Chapter 12) examines an alternative explanation of in-session change by testing the fit between Chapter 1 6 protagonists’ experiences and the experientially based allowing and accepting painful emotional experience model. The implications of the findings for psychodrama theory and practice are discussed in Chapter 13 and a model of protagonist change processes leading to in- session resolution of painful emotional experiences is proposed. Applications of the findings for general models of therapeutic change and for the integration of the psychodramatic method with other therapeutic modalities are considered. Strengths and limitations of this research are discussed and areas for further research are suggested. In particular, a strategy for undertaking future psychodrama research is proposed. Chapter 2 7
Chapter 2 Theoretical Foundations of Psychodrama
Psychodrama practice is based on the principle that the psychodramatic enactment of a person’s central concern can produce conditions that generate healthy functioning. In this chapter, Moreno’s spontaneity theory and role theory are introduced. These theories underpin his construct of psychological health and inform the practice of the psychodrama method.
A Model of Healthy Functioning: Spontaneity Theory and Role Theory Moreno (1946/1980) proposed that the two requirements for healthy functioning were spontaneity and encounter which enable people to respond with vitality, creativity, originality, flexibility and adequacy to one another and their environment. The psychodramatic method aims to generate spontaneity and encounter which are considered to be core curative factors as well as being therapeutic goals. These concepts are articulated in Moreno’s spontaneity theory and role theory.
Spontaneity Theory Moreno’s (1946/1980) theory of spontaneity is fundamental to the psychodramatic concept of healthy functioning. There has been some grappling with the psychodramatic meaning of spontaneity (e.g. Carter, 1994; Kipper, 2000, 2006; Kipper & Hundal, 2005), stemming in part from the different ways Moreno himself used the term. His original definition of spontaneity was as energy ‘that propels an individual towards an adequate response to a new situation or a new response to an old situation’ (Moreno, 1953, p. 42). In later writings, he spoke about spontaneity as the actual response or behaviour that emerged in the situation and this was readily picked up in the literature, where for some time the prevailing definition of spontaneity was reduced to ‘an adequate solution to a new situation or a new solution to an old situation’ (Kipper, 2006). When Moreno’s writings have reflected more fully on the nature of spontaneity, it is conceptualised in accordance with the initial definition, as an internal experience, present in the moment. The behaviour emerging from spontaneity, the spontaneous response, is more readily identified and described than spontaneity itself. Moreno identified a number of characteristics of a spontaneous response, beginning with the qualities of novelty and adequacy that are included in his definition. He related spontaneity to 'free will'
Chapter 2 8 and regarded it as directional and purposeful. He states: ‘warming up to a spontaneous state leads up to and is aimed at more or less highly organized patterns of conduct’ (1987/1975, p. 42). Carter (1994) offers the following definition that encapsulates these qualities: ‘Spontaneity is a readiness for a free and vital response to the emerging moment' (p. 41). Spontaneity has been further defined by delineating what it is not. Moreno stated that anxiety was the opposite of spontaneity, and that a person could not experience the two at the same time. He further delineated spontaneity from populist misconceptions of the term, namely, that it is commonly identified with the expression of emotion and action when it may equally produce cognitive processes and rest; and that it is often used to describe people who have diminished control of their own functioning. Moreno was emphatic that feelings, thoughts and actions were all important to spontaneity, while the inclination to behave impulsively and without conscious restraint was considered by Moreno to be pathological. Similarly, energetic behaviour that is habitual or reactive, sometimes termed stereotyped spontaneity, does not meet the criteria of a spontaneous response. Kipper (2000) believes that a lack of attention to conceptual development in spontaneity theory, has led to two major definitional difficulties with the classical theory: (1) spontaneity and non-spontaneity being defined as polar opposites, when non-spontaneity has been described as both a positive (e.g. the ability to perform routine tasks) and a negative (e.g. the inability to respond adequately in the moment) condition; and (2) defining as forms of spontaneity responses that do not meet any of the criteria for spontaneity, as with the use of terms such as pathological and stereotypical spontaneity. He proposed that a theoretical solution to these difficulties was to conceptualise spontaneity as a psychological quality that has only a positive meaning, independent of non-spontaneity. To test this hypothesis, Kipper and Hundal (2005) developed a measure of spontaneity and a measure of non-spontaneity. The resultant Spontaneity Assessment Inventory (SAI) and the Spontaneity Deficit Inventory (SDI) are in the early stages of development and validation. From their research to date, Kipper and Hundal have concluded that spontaneity and spontaneity deficit are two different continua, the first being the degree of ability to be spontaneous and the second the extent of spontaneity incapacity. While spontaneity was found to be negatively correlated with spontaneity deficit, the relationship between the two was only present
Chapter 2 9 for top SAI scorers. They concluded from their study that spontaneity and non- spontaneity cannot co-exist at any given time, but that they can exist in the same person.
“The phrase the spontaneous man or woman does not describe a personality dimension of an individual who is always spontaneous. Rather it characterises a person who is able to become spontaneous often, whenever appropriate, but who, in many situations, may act non-spontaneously” (Kipper & Hundal, 2005, p. 127).
The relationship between spontaneity and healthy functioning has been assumed in much of the psychodrama literature. A lack of spontaneity has been referred to in two contexts, firstly, in the management of routine functions and secondly, in relation to situations where spontaneity may be required but is not present. This second condition, what Kipper and Hundal have now termed spontaneity deficit, is seen to indicate a restriction in healthy psychological functioning. This is consistent with Moreno’s notion of spontaneity being blocked, which he considered produced disequilibrium and anxiety. Spontaneity, as it is operationalised by the SAI, SDI and by an earlier measure, the Personal Attitude Scale (PAS: Collins et al., 1997), has been found to correlate with measures of psychological functioning, consistent with Moreno’s theory. Kellar et al. (2002) found that spontaneity (measured by the PAS-II) was correlated positively with self-report measures of self-actualisation, extraversion, creative capacity and playfulness, and correlated negatively with measures of neuroticism and, for women, with depression. Christoforou and Kipper (2006) found that spontaneity was associated with temporal orientation to the here and now, while spontaneity deficit correlated only with the past, and not the present or future. They found that spontaneity deficit was associated with trait and state anxiety and with obsessive-compulsive tendency and concluded, firstly, that spontaneity could not co- exist with either trait or state anxiety, and secondly, that the SDI may be a scale of pathology. The work of researchers cited above has begun to examine the construct of spontaneity, but more than 60 years after Moreno first wrote of it, a coherent theory of spontaneity is still in the developmental stage. Given that spontaneity is conceived to be an inner experience of the individual in the moment, it would seem
Chapter 2 10 that theory development would benefit from investigating the moment to moment experience of individuals.
Role Theory and the Social Atom Moreno has been attributed as being “more clearly responsible for the move from individual therapy to the understanding of interpersonal components of psychological living than any other single psychiatrist in the field” (Whitaker, 1987, p. vii). He considered that understanding the structure of human society was essential to promoting the psychological health of the individual and he introduced the term ‘sociometry’ for the study of interpersonal relationships within and between groups (Moreno, 1987a). ‘Tele’ is a term coined by Moreno (1959/1975), to denote the underlying sociometric relationships between people, formed from mutual attractions and repulsions at an intuitive level. Moreno likened tele to a two-way empathy, where both people have a feeling connection to the experience of the other. This feeling may be positive or negative. People’s sensitivity to telic relationships varies, but deepening the awareness of tele builds group cohesion and assists people to differentiate their sense of self in relationship to others (Blatner, 1994). Central to sociometry is Moreno’s role theory. The Morenian concept of role is defined as the functioning form an individual takes when responding in the moment (Moreno, 1961). The sense of self emerges as the individual takes on roles in relation to others and to his or her environment (Moreno, 1953). Moreno considered that the smallest unit in society was not the individual but the social atom. A person’s social atom consists of the central relationships within which he or she enacts the roles that produce the sense of self. Within the social atom, relationships are defined by the strength of the connection and by the attitude of the connection, which might be mutually positive, negative or neutral, or a non-mutual combination of any two of these attitudes. The roles that are enacted between the person and those he or she relates to in the social atom, Moreno termed the cultural atom. L. Clayton (1982) proposed that roles constellate around pathological, coping and individuated gestalts, which can be used to guide psychodramatic interventions and record progress in therapy. The (pathological) gestalt represents the unresolved pathological aspects of the parents’ personalities together with the role responses of the child. The
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coping response represents the ‘best means of coping that the person learned in the family system (and) represents a partial separation from parent figures and early life experiences … The individuated gestalt represents a balanced set of roles unique to the individual. Progress can be assessed by emergence of roles and an identity belonging to the individuated gestalt (Clayton, 1982, p. 112-114).
The application of the social and cultural atom to psychodrama practice has been further developed, particularly by G. M. Clayton (see Clayton, 1992, 1993, 1994). Clayton (1993) suggests the terms ‘progressive’ and ‘fragmenting’ better represent the relational nature of roles, and uses these rather than the psychoanalytically oriented terms ‘individuated’ and ‘pathological’. In line with current usage, the terms ‘progressive’, ‘coping’ and ‘fragmenting’ are used here. G. M. Clayton considers that the individual’s constructs of the social world guide the organisation of roles. Progressive roles are those roles that ‘enhance the fulfilment of (the individual’s) purpose’ and where feelings, actions and constructs are congruent; whereas fragmenting roles create a sense of disconnection with self and isolation from others (1993, p. 30). Consistent with L. Clayton’s earlier proposition, a person’s role repertoire is considered to be influenced by the original social and cultural atom, that is, by the relationships within the family of origin or constellation of significant others from childhood, as well as being influenced by the capacity for spontaneity that has enabled the emergence of other roles and role relationships in adolescence and adult life. When spontaneity is high, progressive roles emerge and become part of the individual’s role repertoire. When spontaneity is inhibited, the person may revert to known responses that may not adequately relate to the specific situation, and coping or fragmenting roles are developed or reinforced. Spontaneity is required to produce a new and vital response to the situation.
Social Atom Repair: The Psychodramatic Construction of Healing and Personal Development Healing is a concept that resides somewhere between cure and personal growth. In the medical paradigm cure presupposes illness or disease separate from the identity of the individual. Personal development, a concept that has been embraced by the encounter movement and many experiential approaches, rests on a notion of human potential. Healing presupposes a functioning self that has been damaged or
Chapter 2 12 wounded and a process of reconnecting and reconstructing the self. Most models that embrace the concept of healing would propose that through healing, personal growth occurs, so that the person does not simply return to their pre-wound condition, but will have developed a deeper understanding and expression of self. Healing does not focus on symptom reduction or symptom management, but it would be anticipated that the self-harming aspects of symptoms would reduce with healing. Additionally, some symptoms may require management strategies to be put in place as a precursor to healing. The psychodramatic construct of healing is social atom repair, defined as ‘the development of new roles and role systems … any re-organisation or any development in the relationship of the person with the outside world’ (Clayton, 1993, p. 55). Therapeutic change is measured by movement in roles and role relationships from fragmenting and coping functioning to progressive functioning (Clayton, L., 1982; Clayton, G.M., 1993). Clayton (1993) identifies the core principles of social atom repair as being the development of a larger perspective of the social system and greater flexibility in response. This is achieved through being more conscious of the values of other people, so that this consciousness is integrated into the individual’s warm-up; producing a ‘catharsis of integration’ which he describes as ‘a sense of opening out and including other elements outside of oneself’ (Clayton & Carter, 2004, p. 337). This process brings ‘different aspects of (self) into harmony’, so that old warm ups move into the background, a corrective emotional experience is developed and progressive roles are strengthened. (p. 324). Fragmenting and coping functioning are seen to arise from restrictions or inadequacies in the individual’s original social atom, resulting in a dysfunctional warm-up in the individual to some situations. When the warm-up to an interpersonal relationship is maintained, encounter between two people is possible. Moreno (1946/1980; 1970) defined encounter as a meeting of two or more people involving an intuitive role reversal one with the other and immediate, direct and meaningful expression in the moment: ‘It is a meeting of the most intense level of communication. The participants are not put there by an external authority; they are there because they want to be. … It is an intuitive reversal of roles, a realisation of the self through the other. It is
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identity, the rare, unforgotten experience of total reciprocity’ (Moreno, 1970, p. 9). Social atom repair is achieved in encounter during general group sessions, in the interview with the psychodrama director and in the psychodramatic enactment. The use of role reversal techniques places encounter at the centre of psychodramatic enactment and it is through the experience of encounter that progressive functioning is both developed and expressed.
The Application of Spontaneity Theory and Role Theory within the Structure of a Classical Psychodrama Session The application of the psychodrama method rests on two claims: firstly, that spontaneity is a therapeutic agent, and secondly, that spontaneity can be trained and developed. Spontaneity is seen to be activated by a sustained warm-up, defined as the ‘individualised manner of preparing to respond either emotionally, intellectually, physically or spiritually’ (Hollander, S. 1981). A person’s ability to respond with vitality in the moment is dependant on an ability to maintain warm-up to a given situation at that moment in time. When the warm-up process is interrupted, spontaneity is inhibited and the person is unable to respond adequately. The incomplete warm-up to the moment produces an inner experience of incompleteness and dissatisfaction, referred to as ‘act-hunger’. Psychodramatic enactment of problematic situations is considered to assist people to sustain the previously interrupted warm-up so that actions can be completed. In this way, spontaneity is developed in the moment and the person is trained to sustain their warm-up, allowing an increased capacity for spontaneity in future situations. The purpose of a psychodrama session is to increase spontaneity so that creativity is enhanced and progressive roles can be produced and integrated into the person’s role repertoire. To achieve this purpose, classical psychodrama sessions are structured around three phases of warm-up, enactment and integration (Blatner, 2000; Hollander, 1978/2002; Kellermann, 1992; Moreno, 1972). Central conditions of these three phases are (a) the warm-up to spontaneity which is promoted by building the individual’s sense of purpose and connections with others and with the environment, and the development of a contract between the protagonist and the director to focus on a specific piece of work; (b) the enactment of the situation that deepens the warm-up to the specific situation or dynamic that the person is
Chapter 2 14 concerned with, further heightening spontaneity and producing a creative response to the situation; and (c) working through feelings, insights and action responses that have emerged during the enactment phase, consolidating new learning and integrating new roles (McVea & Reekie, 2007). The Hollander Psychodrama Curve (1969, 1978/2002), was an early attempt to give systematic form to the complex and dynamic process that occurs during a classical psychodrama session (See Figure 2.1). Hollander represents the three phases of warm-up, enactment and integration that are consistently described in contemporary applications of psychodrama. The warm-up and integration phases entail general group work and the enactment phase is the psychodramatic intervention. Hollander divided the enactment phase into two roughly symmetrical parts. The first part focussed on affective exploration and the diagnosis of the problem through active exploration, producing a point of resistance and a catharsis of abreaction. The second part focussed on developing cognitive functioning by working through issues, and included a catharsis of interaction linked to developing new interpersonal responses. Hollander placed the psychodrama session on an emotional continuum and in so doing, reinforced some of the confusion within the literature between the meaning of ‘spontaneity’ and ‘emotion’. As discussed earlier, Moreno proposed that spontaneity, operationalised through warm-up, is the core therapeutic agent in psychodrama. Warm-up refers to the readiness of the protagonist in many areas of functioning, and can be assisted by engaging cognitively and actively, as well as emotionally. By emphasising emotion, Hollander has contributed, perhaps unintentionally, to the view of psychodrama as a primarily cathartic method. (Catharsis is discussed in more detail in Chapter 3, when Kellermann’s therapeutic aspects of psychodrama are considered). The emotional continuum has been presented elsewhere as a ‘warm-up’ continuum, in which the early warm-up ‘phase’ relates to the specific focus of developing a unified warm-up within the group and the protagonist, in readiness to commence an enactment; and the warm-up of the protagonist continues to develop as he or she engages in the enactment (McVea & Reekie, 2007). The differentiation between spontaneity and emotion is of central concern to this thesis, and will be considered again in Chapter 4.
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Warm-up Psychodrama Enactment Integration
Catharsis x Of Point of resistance Abreaction Warm-up • Encounter Integration with audience • Phase Affective exploration • Self-disclosure (unnatural) Cognitive resolution & closure & exposure of problem • Dialogue • Sociometric Catharsis of interaction process • Summary (natural) Scene II Scene III Reality based Surplus reality diagnosis Positive ending Role training Scene I Emotional continuum Theme identification
Temporal continuum
Figure 2.1. The Hollander Psychodrama Curve. (Source: Hollander, 1969) Note: Hollander published simplified versions of this model in subsequent articles, and one such version is reproduced in the 2002 article that was published after his death.
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Summary Spontaneity theory holds that with training, people are able to develop more flexibility and vitality in response to themselves, others and their environment. Early research suggests that spontaneity deficiency may be linked to psychological dysfunction, supporting the proposition that increasing spontaneity where it was previously blocked, will improve psychological functioning. Moreno proposed that the smallest unit in a society was not the individual but the social atom, or core interpersonal networks through which the individual enacts and experiences the self. He considered psychodramatic enactment to be a therapy that most closely reflected this aspect of real life, and thus an effective vehicle for producing the conditions for spontaneity to develop. Two issues have been raised in this chapter that are relevant to the question of therapeutic change processes leading to the resolution of painful emotional experiences during psychodrama. Firstly, psychodrama is considered an integrative therapy that combines an experiential approach where the person’s experience in the moment is central, with an interpersonal-systems approach oriented to the social and cultural context of people’s role relationships, and a learning orientation realised through spontaneity training and action experimentation. These interrelated perspectives may contribute additional understanding to the process of change, beyond that offered by other experiential approaches. Secondly, further investigation of the expression of spontaneity and emotion during psychodrama and clarification of the therapeutic utility of each is required. The following chapter considers the current state of research as it pertains to the therapeutic application of the psychodrama method.
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Chapter 3 Empirical Evidence for Psychodrama Theory and Practice
Psychodrama theory is founded on the seminal work of J. L. Moreno which has been further developed through a tradition of practitioner reflection, action experimentation and published case discussions of expert practitioners. There is a need to follow up the claims in the professional psychodrama literature with rigorous research that will build psychodrama theory and that will contribute both to psychodrama practice and to understanding the common factors underlying therapeutic change. In this chapter, empirical evidence for the therapeutic effectiveness of psychodrama is considered, beginning with an overview of the current state of psychodrama outcome research and a review of the findings of available outcome studies. This is followed by a review of psychodrama process research, with a particular focus on Kellermann’s studies of the therapeutic aspects of psychodrama. Finally, the scope for psychodrama research to contribute both to the development of psychodrama theory and to general theories of change, is considered.
The Current State of Psychodrama Outcome Research There is some evidence that groups with a classical psychodrama component produce improvement in functioning (Carbonell & Parteleno-Barehmi, 1999; Ragsdale et al., 1996) and are at least as effective as other interventions (Ragsdale et al., 1996). However, the paucity of psychodrama research means there is limited validation of practitioners’ observations of psychodrama process and impact so that theory remains underdeveloped. Kipper and Ritchie (2003) located 25 experimental and quasi-experimental psychodrama outcome studies published in English language journals in the 30 years between 1970 and 2000. They restricted their review to studies with control groups and consequently omitted many other reported studies. The majority of these studies investigated specific psychodrama techniques, in particular role reversal and doubling, rather than classical psychodrama itself. From a meta-analysis of these studies, Kipper and Ritchie concluded that while there was strong support for the therapeutic effectiveness of role reversal and doubling, not enough studies
Chapter 3 18 investigated classical psychodrama to be able to draw conclusions about the effectiveness of the method as a whole. Weiser (2007) reviewed studies of psychodrama psychotherapy treatment effectiveness with mental and behavioural disorders, published in German and English language journals over a 50 year period from the 1950’s. He included studies with statistical analyses, that is, randomised clinical trials, controlled studies, and naturalistic studies, including some single case-studies where there was a component of statistical analysis. Of particular relevance to this thesis, he concluded that affective disorders were effectively treated with psychodrama therapy (three studies with statistically significant improvement) and that neurotic, stress-related and somatoform disorders are the best validated area for psychodrama therapy (23 with statistically significant improvement). Weiser noted that many of the studies that he reported did not meet contemporary standards of scientific rigour, that his review included a number of single-case study designs and that the lack of uniform approaches to measurement and reporting of results, limited the possibility of comparing results across studies. Both reviews suggested that while reported outcomes were encouraging, the small number of studies available and the lack of scientific rigour in many studies limited the inferences that could be drawn from the research to date. Kipper and Ritchie contend that the encouraging results from the 25 studies they reported are evidence that traditional quantitative research methods can be successfully applied to psychodrama. Yet their analysis has only really offered support for the application of these methods to the investigation of structured psychodramatic techniques or modified-for-research interventions, and not to classical psychodrama itself. It is proposed in this thesis that the lack of rigorous psychodrama research is in part due to the difficulties inherent in investigating psychodrama through traditional quantitative methods, and that not only is there a need for some consensus on what measurement instruments best apply to psychodrama, as Weiser proposes, but there is also a need for greater consideration to be given to the types of research that would provide both scientific rigour and construct integrity to psychodrama research. This issue is discussed further in Chapter 4. Findings of outcome studies that have investigated some of the central techniques of psychodrama, and two English- language outcome studies of classical psychodrama are reported here.
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Research Evidence for the Central Techniques of Psychodrama Empirical studies have investigated the impact of doubling and role reversal, two of the core techniques proposed by Moreno as promoting the development of spontaneity. Findings of the impact of these two techniques, and the implications for the process of resolution of painful emotional experiences during psychodramatic enactment, will be presented and discussed. Doubling. Doubling is the intentional use of a group member “in the specialised role of playing the part of the inner self” to assist the client to be aware of and put words to their inner experience (Blatner, 1988, p. 28). Hudgins and Kiesler (1987) concluded that the psychodramatic technique of doubling led to a deeper level of experiencing and a higher level of self-disclosure at intake interviews, than the use of a standard interview procedure. Greenberg and Safran (1989) noted that high levels of experiencing have been consistently related to good outcomes in psychotherapy. In a single-case pilot study, the containing double technique, a modified doubling technique designed to contain overwhelming affect, reduced dissociation in a client with PTSD symptoms (Drucker, 2000). This research is currently the subject of a more extensive follow up study. If this finding can be supported, it would validate Hudgin’s (2000) view that the containing double technique assists engagement with emotional pain while managing defensive avoidance. Role reversal. Role reversal is the technique whereby two people step out of their own role and into the role of the other, so that they can experience and respond in the moment ‘as-if’ they were the other. In its original construction, role reversal involved two people in a real-life encounter, and this process is sometimes used in family or relationship counselling. The more common use of role reversal in psychodrama is where the protagonist reverses roles with a group member who is acting in the role of a significant other. Moreno considered that the ability to reverse roles with another was fundamental to healthy childhood development, and required the capacity to experience the self as clearly separate from the other. The ability to role reverse is considered a cornerstone of encounter. Whereas the double technique is oriented to deepening inner experience, role reversal bridges the experiential and interpersonal orientations of psychodrama. Documented case studies consistently point to the importance of role reversal to assist the activation of emotion (Bouza & Barrio, 2000) and catharsis (Leutz, 2000). The impact of role reversal in conflict resolution was the focus of early research in
Chapter 3 20 this area and taking the role of the other was found to produce compromise solutions through improving empathy (Johnson, 1967, 1970). Bohart (1977) concluded that reversing roles with someone acting in the role of the person the conflict was with, led to a greater reduction in anger and hostility, than did the act of expressing anger alone. Kipper and Uspiz (1987) concluded that role reversal facilitated problem- solving by improving cognitive functioning. They proposed that when people reversed roles, their inhibitions against self-disclosure were reduced and consequently their cognitions were clearer.
Outcome Studies Investigating Classical Psychodrama A smaller number of outcome studies have investigated the impact of classical psychodrama. The participants in these studies and the focal concern of the groups varied widely. Two studies reported here were both concerned with painful emotional experience: adult males who had experienced war trauma in the first study, and girls who had experienced chronic and complex trauma in the second study. Ragsdale et al. (1996) analysed outcomes for war veterans with PTSD who participated in intensive treatments, comparing a program with a major psychodrama component with programs with a CBT exposure component, and a wait list group who received outpatient counselling. Participants of all intensive programs improved on measures of hopelessness, guilt, shame, loneliness and emotional expressiveness, while the wait list group showed no improvement in these areas. This research was not able to isolate the impact of the psychodrama component within the program, but the authors noted that the drop out rate for the psychodrama program was less than that for other intensive programs. They observed that following psychodrama sessions “veterans often appraise the traumatic event differently than they did prior to processing the event psychodramatically. There seems to be a greater sense of understanding and forgiveness of self” (p. 280). Carbonell and Parteleno-Barehmi (1999) investigated a 20 week psychodrama intervention for girls between the ages of 11-13 years, who each met criteria for having experienced 10 of a possible 15 traumatic childhood experiences. Compared to a wait-list control group, participants in the psychodrama group had reduced scores on withdrawal and anxiety/ depression at the end of the 20 weeks. Participants reported feeling less isolated and alienated. Interestingly, participants
Chapter 3 21 reported that the interaction with other group members and learning to trust others, were important factors in achieving this change. The two studies cited above, do not address whether client change can be attributed to the psychodrama enactment or is a result of general group processes. The psychodrama enactment cannot be extracted from general group process in a classical psychodrama intervention, without interfering with the integrity of the method. Nevertheless, if and how the psychodrama enactment contributes to client outcomes, remains an open question that needs to be addressed.
Implications of Outcome Research As Kipper and Ritchie noted, the most compelling outcome evidence with psychodrama has been in the investigation of two central techniques: role reversal and doubling. They argue that such findings indicate that traditional outcome methods can be usefully applied to psychodrama research. In this current research, however, it is argued that these findings support the case for micro-processes within the method, but not for the classical psychodrama method itself, and that classical psychodrama will only be effectively investigated where outcome research is combined with an analysis of the processes leading to the change. Outcome studies of classical psychodrama are difficult to locate. When studies are carried out, such as the two cited here, the results are encouraging, but do not isolate the impact of the psychodrama enactment from the impact of general group processes that are an intrinsic component of the intervention.
Psychodrama Process Research: Models of Therapeutic Agency Qualitative studies have progressed the understanding of the therapeutic agents operating during psychodrama, identifying some consistent themes.
Kellermann’s Seven Therapeutic Aspects of Psychodrama Kellermann (1989, reported in Kellermann, 1992) distilled seven general curative factors of psychodrama, from two studies of protagonists’ self report of their experience of psychodrama and an analysis of responses from leading psychodramatists. They are: (1) therapist skills; (2) emotional abreaction (catharsis); (3) cognitive reprocessing through action-insight; (4) learning through interpersonal relationships; (5) behavioural learning through enactment; (6)
Chapter 3 22 imaginary simulation through ‘as-if’ enactment of surplus reality and (7) non- specific global secondary factors, including therapeutic ritual. Kellermann’s work was based on surveys of protagonists some time after their psychodrama experience. It might be expected then, that the reports reflected generally recalled events and experiences, and that the recall may be affected by time and interceding events. Nevertheless, strong patterns emerged across the responses, suggesting a common experience of therapeutic helpfulness. Expert practitioners were questioned about their general experience of conducting psychodramas, rather than relating their responses to a specific context. Protagonists identified emotional abreaction, insight and interpersonal relationships, as the most helpful aspects of their psychodrama experience; and from the responses of expert practitioners, Kellermann added therapist skills, enactment and surplus reality (imaginary enactment of unexpressed experiences or desires ‘as- if’ an experience were happening in the here and now) and therapeutic ritual. Kellermann makes the point that while these factors are presented as discrete change processes, they are intrinsically interconnected. This interconnection was made explicit in the findings of a more recent study, where change processes were described as complex combinations of factors (Brooks, 2000). Brooks analysed protagonists’ in-session experiences, based on intensive post-session interviews and analysis of contextual information. Six of Kellermann’s seven therapeutic aspects of psychodrama are discussed in more detail below, drawing on Brooks’ findings. (The seventh aspect, ‘non-specific factors’, is potentially all-encompassing, and won’t be considered here). Therapist skills. Kellermann identified therapist skills rather than therapeutic relationship, as a curative factor, although the ability to form a particular type of therapeutic relationship is implicit in his writing. Brooks (2000) concluded from his study that “positive attachment to and exploration with the director in a collaborative spirit supports the protagonist’s sense of agency, control and commitment throughout the process” (p. 392). This is consistent with the experiential therapy position that the therapeutic relationship is a primary curative factor and positions the therapeutic relationship within a mutual and purposeful endeavour. Catharsis. Kellermann (1984) defines catharsis as “release of stored up content through affective expression … the particular experience of release that occurs when a longstanding state of inner mobilization (warming-up) finds its outlet in action” (p.
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3). Moreno viewed catharsis as an active process that was fundamental to creativity. In his view, when spontaneity is inhibited in a particular situation, disequilibrium is created in the person and an emotional and physical release is required to re-establish equilibrium, so that spontaneity is increased and creative responses can emerge. The greater the restriction to spontaneity, the greater is the disequilibrium, increasing the requirement for catharsis. When protagonists engage in an enactment of a problematic experience, they have a heightened realisation of the disequilibrium, experienced in emotional, cognitive and physical functioning, and this produces catharsis. While this has been referred to as ‘catharsis of abreaction’ (Moreno, 1975; Hollander, 1969), psychodramatic catharsis is seen to differ from Breuer and Freud’s (1953/1991), earlier description of abreaction, because of the active quality of the cathartic experience. Hollander (1978/2002) considered that catharsis occurred in psychodrama immediately preceding the peak of spontaneity, which brought with it the greatest expression of creativity. In his earlier writing, Hollander (1969) described two types of catharsis, a catharsis of abreaction and a catharsis of interaction (see figure 2.1, Chapter 2). The first occurred after a person had moved through a point of resistance, at the emotional peak of the psychodrama enactment. The second occurred as the psychodrama enactment moved to a close and the protagonist was making sense of the experience. In later representations of his model, he referred only to a ‘climax of catharsis’, in the place of his earlier ‘catharsis of abreaction’ (Hollander, 1978/2002). ‘Catharsis of interaction’ resonates with other references to ‘catharsis of integration’, both in Moreno’s original writings and the work of more recent practitioner/ theorists. Clayton has this to say about catharsis of integration: “It’s not just an emotional catharsis. It’s an expansion of the psyche that’s going on. The freeing up of different abilities so that those different abilities become much more available” (Clayton & Carter, 2004, p. 239). Moreno considered that group members could also experience catharsis, through their identification with and active participation in the protagonist’s drama. While catharsis has traditionally been associated with psychodrama, some writers have questioned the emphasis on catharsis as a curative factor (Kellermann, 1984, Moreno, Z., 1969/1975; Williams, 1989). Kellermann (1984) saw the function of catharsis in psychodrama as being secondary to conscious experiencing and that the
Chapter 3 24 more therapeutic aspect of psychodrama lay in its capacity to assist people to develop roles where thoughts, feelings and actions are congruent. This is consistent with current research into the relationship between emotional and therapeutic outcome, which suggests that it is the expression of productive emotion accompanied by cognitive processing of that emotional expression, rather than the degree of emotional expression itself, that is conducive to positive therapeutic outcomes (Greenberg, Auszra & Herrmann, 2007). (See Chapter 4: Emotion and Emotional Processing.) Williams (1989) observed that some protagonists became very skilled at cathartic expression and for these people catharsis was the repetition of a conserved response which provided only temporary relief, rather than a precursor to greater spontaneity. Zerka Moreno (1959/1975) considered that a misconception had developed among some psychodrama practitioners that catharsis was evidence of a successful psychodrama, and that this view led practitioners to increase emotional expression, rather than spontaneity, in the production of an enactment. She noted that spontaneity requires mindfulness as well as emotion. Brooks (2000) noted that, for the participants in his study, the function of catharsis in psychodrama was complex. He concluded that ‘people bring different goals to catharsis, and that novel interactions during and immediately after it are some of the most change producing moments of the entire process, in terms of facilitating rescripting of affective self and object representations.” (p. 416). This observation of the function of catharsis links catharsis with action insight, and the combination of these two factors is considered to be necessary for therapeutic change (Moreno, Z., 1969/1975; Kellermann, 1984). Action Insight. Kellermann (1992) defines action insight as ‘the integration of emotional, cognitive, imaginary, behavioural and interpersonal learning experiences ... achieved only in action’ and being concerned with ‘inner truth and awareness of self’ (pp. 86-87). Participating in action in a personally meaningful way, rather than thinking about experience, produces learning that is not consciously cognitive in its genesis, but appears to arise from emotional and intuitive processing. Moreno (1959/1987) considered that action was more curative than language, because action reinstated the context of the earlier experience in the here and now, giving access to different sources of information. Kellermann defines participating ‘in action’ broadly, noting that participation can include acting from a role within the
Chapter 3 25 enactment, or acting as a witness to the action, observing the re-enactment but from a position of personal involvement with the story that is being portrayed. Action insight is often reported following catharsis, and it has been proposed that the sensory stimulation created by the psychodrama along with emotional catharsis ‘cause a restructuring of the protagonist’s perceptual field’ (Greenberg, I., 1974, p. 19) that brings about new understanding. It has been proposed that the experience of catharsis with insight requires containment of expression as much as expansion of expression (Moreno, Z., 1965; Hudgins, 2002). Hudgins (2002) makes explicit claims for the need for containment of overwhelming affect and conscious experiencing, proposing that functions of containment, observation and restoration need to be operating within protagonists before they can manage the experiencing of traumatic material. She suggests that conscious re-experiencing can then produce a cathartic release with insight. Research in other therapeutic modalities has suggested that emotional engagement with traumatic experience, if not accompanied with the development of new cognitions, can produce increased anxiety (Jaycox et.al., 1998), and such findings support the view that re-experiencing alone is not therapeutic. Learning through Interpersonal Relationships and through Enactment. Two of Kellermann’s therapeutic aspects, ‘learning through interpersonal relationships’ and ‘learning through enactment’, are closely related, and will be considered together. Moreno (1959/1975) considered that group therapy shifted the emphasis of therapeutic agency away from being the sole territory of the therapist and towards group members generally. Auxiliaries (either trained professionals or group members who take up roles within a protagonist’s psychodrama) are viewed as serving as an extension of the director, with the therapeutic relationship occurring as much in the enactment of relationships with auxiliaries as in the director-protagonist relationship (Moreno, Z., 2006; McVea, in press). This is one facet of psychodrama which distinguishes it from most other therapies. Brooks identified three core change processes linked to the enactment of interpersonal interactions: (i) the differentiation of feelings and meanings through interaction with others; (ii) the development of new boundaries between self and other and (iii) the development and practice of new responses for dealing with social-emotional interactions. Surplus reality. Surplus reality is a broad construct that includes expressing previously unexpressed elements of interpersonal relationships and enacting fantasies and hopes that are part of the protagonist’s inner world. This is a vehicle for act
Chapter 3 26 hunger to be fulfilled through dramatic enactment. Brooks (2002) found that the ability to enter surplus reality generated hope which increased the desire of psychodrama participants to return to previously unworkable interactions. Furthermore, one form of surplus reality, the enactment of corrective emotional experiences addressing early interactional dynamics, were rated as highly important by protagonists.
A Need for Research to Build Theory and Inform Psychotherapy Practice
Establishing an empirical base for psychodrama theory and practice The qualitative research that has been cited above provides practitioners with a framework from which to understand the complexities of the psychodrama method, but a more comprehensive investigation of the change processes which operate during psychodrama is called for. Kellermann’s general factors give a broad view of the therapeutic process rather than a detailed analysis of protagonists’ experiences of change. Brooks undertook a more detailed study of protagonists’ experiences of change, but the therapeutic impact of the processes that were identified and the conditions under which they operate have not been specified. There is a need to extend and deepen this work, to establish an empirical base that will develop psychodrama theory and inform practitioners’ moment-by-moment decision making processes.
Contributing to understanding the common factors of effective psychotherapies Research that investigates the processes of change during psychodrama has the potential to inform psychotherapeutic practice more broadly. Schneider (2007) argues that the comprehensiveness and depth of existentially-oriented psychotherapies gives them the potential to be at the forefront of new developments in clinical practice. Psychodrama’s existential philosophy and its therapeutic orientation towards experiential, behavioural and interpersonal processes, offers possibilities to discover new dimensions to the common factors of therapeutic change. The argument in support of investigating effective therapeutic processes, rather than defending the claims of a particular therapeutic modality, is compelling. Meta- analytic studies of psychotherapy outcome research have concluded that
Chapter 3 27 psychotherapy is generally effective and that common factors operating across modalities, rather than the specific claims of any one therapeutic approach, explain most client change (Ahn & Wampold, 2001; Wampold et al., 1997). Attempts to identify common factors in psychotherapy focus on three areas: (i) common factors that are distinct from therapeutic interventions, such as client characteristics and the therapeutic relationship (e.g. Lambert & Barley, 2001; Orlinsky, Grawe & Parks, 1994); (ii) factors that are common to different therapy interventions (e.g. Stricker & Gold, 2008) and (iii) a subset of the second category, change processes which are common to successful therapy events (e.g. Greenberg, 2008). Lambert and Barley (2001) suggest that specific therapy techniques account for only 15% of client change, client expectations account for a further 15%, and extra-therapeutic factors and common factors across therapies account for most change (40% and 30% respectively). They consider common factors to be encapsulated in the therapeutic relationship, which is a confluence of client qualities, therapist qualities and relationship qualities; and that effective therapists facilitate clients’ natural healing processes. The relatively low influence of specific therapy techniques may be partially explained by the shared characteristics of the different approaches. Stricker and Gold (2008) claim that three factors that are common to effective psychotherapies can be identified in the research literature: (i) exposure to the problem, either through imagination or in situ; (ii) a corrective emotional experience and (iii) a coherent rationale for the problems that are being experienced. Psychodrama enactments potentially generate all three of these conditions. The third area of common factors research, the investigation of change processes underlying successful therapeutic events, can produce a detailed understanding of change mechanisms that has direct application to psychotherapy practice. Of particular relevance to this thesis is the work that has been done in the area of emotional processing, which informs our understanding of two of the factors identified by Stricker and Gold: exposure to the problem and the corrective emotional experience. The following chapter addresses emotion and emotional processing more fully, and considers the contribution spontaneity theory might make to understanding emotional processing.
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Chapter 4 Emotion & Emotional Processing
Psychodrama enactments are a form of exposure to the subjective experience of the protagonist. There is a growing consensus across therapeutic modalities that when a person has experienced trauma, overwhelming grief or disturbances in core developmental relationships, exposure to affective experience can facilitate healing (Beck & Davis, 2003; Foa, Rauthbaum & Hembree, 2006; Greenberg, 2008; van der Kolk, van der Hart & Burbidge, 2002). There are different theoretical explanations for the efficacy of exposure, but a common theme appears to be that experiencing emotional pain under certain conditions, promotes, and may even be essential to, healthy functioning. In this chapter, emotion and emotional pain is defined in the context of healthy functioning. Different theoretical perspectives on the place of emotional processing in the resolution of painful emotional experiences are considered and the relationship between emotion and Moreno’s spontaneity theory is reviewed.
Defining Emotion The term ‘emotion’ is used in the literature to refer to a range of experiences that have as a core component, a subjective experience of affect. Russell (2003) defines core affect as ‘a neurological state that is consciously accessible as a simple, non- reflective feeling that is an integral blend of hedonic (pleasure-displeasure) and arousal (sleepy-activated) values’ (p. 148). Emotion itself is most often described as a complex system having its origin in biological and/or mental processes, and incorporating physiological sensations, affective experiencing, motivational and attributional qualities (Damasio, 1998; Greenberg, 2008; Russell, 2003; Russell & Barrett, 1999). While emotions appear to be readily identifiable (Adolphs, 2002), suggesting that there is even some cross-cultural agreement about what constitutes particular emotions (Matsumoto, 2006), there have been many different views about the essential function of emotion. These differences are reflected in the treatment of emotional material in therapy.
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Emotion and Healthy Functioning Psychotherapists have traditionally been polarised in their approach to emotions, between the view that they are secondary to cognition and often problematic (Beck, 1976), and the view that they are primary processes, generated independently of cognition and essentially adaptive (Fijda, 1986, 2004; Greenberg, 2008). Nevertheless, Greenberg (2008) notes that there is a growing consensus among different theoretical orientations, and supported by empirical studies, that emotions can be (but are not always) adaptive, and promote goal oriented behaviour, social development and decision making. The argument that emotions are primary processes is supported by studies that have shown that emotional functioning operates in infants prior to the development of cognitive functioning (Greenspan & Shanker, 2007); and by advances in neurological research which have identified separate systems for generating emotional and cognitive functions (Le Doux, 1986, 1993; Damasio, 1998). Emotion is regarded as a motivating agent (Frijda, 2004; Greenberg, 2008). Pleasant affect is designed to enable constructive goal-oriented behaviour and support the development of social connections; while unpleasant affect enables a rapid appraisal and withdrawal from potentially threatening situations (Frijda, 2004; Frijda, Kruipers & ter Schure, 1989; Russell & Barrett, 1999). Emotional functioning has been linked with decision making, suggesting that emotion is crucial for the development of new ideas and responses (Weller, Lewin, Shiv & Bechara, 2007). Frijda (1986, 2004) observed that emotions emerged in response to the person’s environment, and that experiencing and expressing emotion has a regulating effect on self and other. Experiencing and expressing emotions may promote health, as is suggested by studies that have linked emotional inhibition with debilitating physiological functioning (Traue & Pennebaker, 1993). Inhibition of emotional experience and emotional expression has been linked to cardiovascular reactivity (Davidson, 1996) and to poor prognosis in cardiac treatment patients (Denollet, Pederson, Ong, et al., 2006). The centrality of emotions in healthy functioning is also supported in psychotherapy research that has linked depth of in-session experiencing with successful outcomes in therapy (Pos et al., 2003; Goldman, Greenberg & Pos, 2005; Greenberg & Watson, 2006; Watson & Greenberg, 1996).
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Greenberg and Saffran (1989) suggest that some emotions are more ‘healthy’ than others. They distinguish between four categories of emotion: biologically adaptive primary emotion, secondary reactive emotion, instrumental emotion and learned maladaptive primary emotion. Primary adaptive emotions operate prior to cognition, and are a biological response to the environment that motivates the person to take adaptive action. The other three categories are all considered maladaptive, in that they inhibit healthy functioning. Secondary emotions arise from cognitive processes in response to primary adaptive emotion and are an attempt to manage potentially intolerable experiences. According to Greenberg and Saffron, secondary emotions are maladaptive because they mask primary adaptive emotions. Instrumental emotions are learned behaviours, and may be an attempt to meet felt needs. Emotions are considered to be instrumental when they are used to elicit particular responses from others. The final category, learned maladaptive primary emotion, includes automatic emotional responses generated from traumatic experiences, which operate prior to cognition but hinder healthy functioning. Greenberg and Saffran suggest that differences in therapeutic orientations to emotion may reflect the category of emotion emphasised by different therapeutic modalities. They argue, however, that the activation of primary adaptive emotions promotes positive therapeutic change. This argument is supported by findings from a study by Greenberg, Auszra and Herrmann (2007), which compared the emotional arousal and emotional expression of the most successful and least successful clients who received emotion-focussed therapy for depression. The authors concluded that emotional expression per se did not differentiate between most and least successful, but that the emotional expression of primary adaptive emotion did.
Emotional Pain Emotional pain is defined as “a complex, bodily felt experience of damage or trauma to the self” (Greenberg & Paivio, 1998, p. 50). It can incorporate, but is not defined by, feelings of sadness, anger and hurt. As a primary adaptive emotion, its function is considered to be firstly, to teach people to avoid dangerous experiences and secondly, to motivate the person to withdraw from society to have time to experience the sadness, anger and hurt associated with loss or trauma, so that the experience can eventually be incorporated into their understanding of themselves and their environment (Greenberg and Bolger, 2001; Greenberg & Paivio, 1998).
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However, the avoidance that is engendered by the initial experience of emotional pain is often to the emotion itself, so that the healing function of emotional pain may not be experienced. An investigation of the experience of emotional pain in adult children of alcoholics identified that the affective experience of emotional pain was avoided (Bolger, 1999), and it has been proposed that such avoidance inhibits the healing process so that the harmful impact of the loss or trauma on sense of self and interpersonal relationships persists. Bolger concluded that emotional pain was experienced as a sense of personal shattering and of being disconnected from others, and that the most pervasive impact of the experience was the fear that re- experiencing the emotional pain would lead to a disintegration of the sense of self.
Emotional Processing There is compelling evidence across therapeutic modalities that activating emotional responses to problematic situations through some form of exposure is linked to increased efficacy of therapeutic interventions (e.g. Beck, Freeman & Davis, 2003; Foa & Kozak, 1986; Greenberg, Korman, Paivio & Cain, 2002; Greenberg, Warwar & Malcolm, 2008; van der Kolk et al., 2002). In a review of empirical studies, Greenberg and Saffran (1989) found support for the link between therapeutic change and emotional arousal and affective expression. Despite this apparent agreement, different explanations are offered for the therapeutic agency of exposure. This difference is exemplified in a comparison of the cognitive- behavioural based emotion processing theory (Foa and Kozac, 1986; Foa, Rauthbaum & Hembree, 2006; Foa, Riggs, Massie & Yarczower, 1995) and experiential therapy approaches to exposure (Watson, Greenberg & Lietaer, 1998). Both emotion processing theory and the experiential paradigm support the contention that some type of exposure that activates emotion assists healing. Emotion processing theory (Foa and Kozac, 1986) argues that the avoidance of fear inducing stimuli is reinforced by the relief produced by the avoidance. Foa and Kozac propose that prolonged exposure to the fear-inducing stimuli overrides this reinforcement effect and produces new information that the fearful response can be lived through. An analysis of fear expression during the first reliving of rape memories concluded that in-session activation of the fear response was correlated with post-treatment improvement (Foa, Riggs, Massie, & Yarczower, 1995). Further research found that exposure was most successful when it was combined with higher
Chapter 4 32 levels of engagement with the fearful material during the session, and habituation between sessions (Jaycox, Foa & Morral, 1998). The focus of prolonged exposure is on the external fear-inducing stimulus and the cognitive-behavioural position is that therapeutic agency occurs through a change in conditioning and through engaging in new behaviour. Proponents of the experiential paradigm, on the other hand, argue that the therapeutic agency of exposure lies in the exposure to previously avoided internal experience, which produces a change in the meaning of that experience (Greenberg & Paivio, 1998; Watson, Greenberg & Lietaer, 1998). Allowing and accepting painful emotional experience is considered to be central to therapeutic change (Greenberg, 1999; Greenberg, 2008; Greenberg & Bolger, 2001; Greenberg & Paivio, 1998). Therapeutic weeping is seen to be a transformative process that alters the person’s internal pain-inducing structure, producing affective and motivational change, change in perception of self and others and rejuvenation, experienced as relief and self-affirmation (Greenberg, 1999). Both emotion processing theory and the experiential approach agree that previously avoided emotion needs to be aroused, accepted and tolerated. Emotion processing theory holds that exposure and habituation produce new information; whereas experiential theorists consider that integration of cognitive and emotional functioning requires cognitive orientation to the experience, in order to reflect on and make sense of that experience (Greenberg, 2008; Greenberg & Pascuale-Leone, 2006). Recognition and soothing of the disturbing emotion, rather than control, are the focus of the experiential intervention (Greenberg & Pascuale-Leone, 2006). Both approaches acknowledge the importance of the therapeutic relationship, but emotion processing theory considers that the safe therapeutic relationship is the context in which prolonged exposure takes place (Foa & Kozac, 1989), whereas the healing nature of the therapeutic relationship is a central tenet of experiential therapy (Watson, Greenberg & Leitaer, 1998).
The relationship between emotion and spontaneity Psychodrama has been identified more often as an experiential therapy and the experientially-based explanation of therapeutic change described above seems intuitively compatible with Moreno’s concepts of encounter and spontaneity. However, a significant difference between this experiential explanation and the
Chapter 4 33 psychodrama paradigm is in the emphasis on emotion compared to spontaneity, as the therapeutic agent. Greenberg and Paivio (1998) define the goal of therapy as being to allow previously avoided painful emotional experience, so that new meaning is created in the allowing process. In contrast, the therapeutic goal during psychodrama is to complete unfinished warm-up processes, so that spontaneity is increased and new responses are developed and integrated (Moreno, 1987). Moreno was emphatic that spontaneity is neither an emotion nor a component of emotion, but considered that the production of feeling assists the development of spontaneity. To understand the difference between emotion and spontaneity it is instructive to consider how readiness is used to define both concepts. Emotion is defined as a motivating agent for action, so that accessing a primary emotion promotes the person’s readiness to respond in a particular way, consistent with the structure of that emotion. Spontaneity, on the other hand, is defined as a readiness to respond in the moment, as required by the situation and with the flexibility to create a new response as the situation changes. Emotion influences the spontaneous response by providing salient information about the significance to the person of their experience in the moment. The different emphasis on spontaneity or emotion may indicate complementary rather than competing approaches to understanding therapeutic change. However, it is proposed in this thesis that the psychodrama paradigm offers a comprehensive view of the interaction of emotion with other aspects of warm-up to spontaneity, and that this approach has the potential to extend our understanding of the therapeutic utility of exposure to affective experiencing.
Summary The emotion system is biologically designed to maximise our flexibility in responding to our environment; predisposing us to constructive goal oriented behaviour, while equipping us to identify and respond quickly to external threats. Painful emotional experience is proposed to be a primary adaptive emotion that motivates the individual to withdraw from others for a period of healing. However, the sense of shattering of the self that is associated with emotional pain can produce an avoidance response that inhibits the person from experiencing affect and thus leave the experience unresolved. An experience of damage to the sense of self and
Chapter 4 34 disconnection from others are the enduring effects of unresolved painful emotional experience. The activation of previously avoided emotions has been found to be beneficial in psychotherapy, although different therapeutic modalities offer different explanations for the therapeutic efficacy of exposure to affective experience. Moreno proposes that it is the activation of spontaneity rather than emotion that is the catalyst for change, but considers that engaging with feelings assists the development of spontaneity. The activation of emotion in psychodrama and the relationship between emotion and spontaneity warrants further investigation. Building a detailed picture of protagonist processes during psychodrama, may advance our understanding of the relationship between spontaneity and emotion in therapeutic change, and contribute to understanding the conditions under which exposure to affective experience is therapeutically helpful.
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Chapter 5 Overview of the Research
The purpose of this thesis is to build a model of protagonist processes leading to in-session resolution of painful emotional experience that would inform psychodrama theory and practice. This chapter articulates the rationale for the research and outlines the research plan. Chapter 6 will then discuss the methodological considerations that guided the research design.
Rationale The rationale for this research is based on two considerations: (i) A need for theory development within the psychodrama paradigm; and (ii) A contribution to understanding general principles of psychotherapeutic change. Both of these areas are considered in more detail below.
A need for theoretical development within psychodrama It has been suggested that new developments in therapeutic practice are more likely to emerge from the work of practitioners than from research and that, consequently, research would benefit from investigating the claims of practitioners as much as from following the lead of other researchers (Mahrer, 2005; Mahrer & Boulet, 1999). The psychodrama method has evolved primarily from a tradition of reflective practice, but empirical research has failed to match this development either by testing the claims in the professional literature or by extending the theory base that informs practice. Testing the claims that psychodrama assists healing of painful emotional experience would seem to be a fruitful area for building psychodrama theory. There is a rich case report literature in which expert practitioners present psychodrama as an effective intervention with people addressing painful emotional experiences such as loss, abuse and trauma (see for example Kellermann & Hudgins, 2000; Holmes, Karp & Watson, 1994); but the systematic investigation of individual cases has been limited and there has been little if any investigation of the processes that are common across cases. There has been a call for psychodrama research to build on this tradition of case reports by applying practice-based research methods to
Chapter 5 36 single case and multiple case study design, to enhance the understanding of how and when psychodrama works (McVea, 2004). Bohart (2000) suggests that examining what happens within effective therapy in relation to specific client issues and contexts is the most effective way to produce models of change that are relevant to the requirements of therapeutic practice. This thesis is essentially a practice-based body of work, in response to the need for the development of models or what Greenberg (1999) calls ‘mini-theories’ that can assist practitioners to make effective therapeutic decisions during the course of therapy.
Contributing to understanding the common factors of effective psychotherapies Evidence of the effectiveness of different therapeutic approaches, combined with trends towards integration in psychotherapy practice, has led to calls for psychotherapy research to pay greater attention to understanding effective change processes across therapy modalities (Norcross & Goldfried, 2005). Psychodrama may have a major contribution to make in this area because of its unique combination of experiential, behavioural and interpersonal systems perspectives. One of the consequences of a lack of rigorous research of psychodrama is that information about the effective components of psychodrama is not accessible to the wider psychotherapy profession. Consequently, the development of the method is not open to broad debate and the potential impact of psychodramatic theory on the development of the psychotherapy field has been restricted. The incorporation of psychodramatic techniques into other modalities, including cognitive-behaviour therapy (Beck, Freeman & Davis, 2003; Hamamci, 2002, 2006 ), schema-focussed therapy (Griffith, 2003) and brief solution focussed therapy (Anderson-Klontz, Dayton & Anderson-Klontz, 1999), suggests that in-depth and accessible information about the effective components of psychodrama would contribute to the development of general principles of client change that is central to the move towards integration of therapeutic modalities. Furthermore, psychodrama is a group method that is often applied as an intensive intervention in the course of ongoing individual-based therapies. Understanding the links between processes during psychodrama, as well as the in-session and post- session impacts of those processes, will inform decision making about when and how psychodrama interventions might be combined with other therapies.
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Research Plan and Research Questions The research plan is structured around the two phases of change-process research, a discovery-oriented phase and a verification phase (see Figure 5.1; Chapter 6 provides a fuller description of psychotherapy change-process research). The four studies that make up this research, and the questions around which the studies were formed, are presented here in the context of these two phases.
Discovery-oriented Phase
STUDY 1 (Chapter 7)
Preliminary Study: Protagonist & Director recall of protagonists’ change processes during psychodrama.
STUDY 2 (Chapters 8, 9, & 10)
Building the model: Investigating protagonists’ processes leading to in- session resolution of painful emotional experiences during psychodrama.
Verification Phase
STUDY 3 STUDY 4 (Chapter 11) (Chapter 12)
Verifying the model of Verifying Greenberg’s ‘allowing protagonists’ processes & accepting painful emotional leading to in-session experience’ model within resolution. psychodrama.
Figure 5.1. Overview of the research plan
Discovery-oriented phase The first two studies are discovery-oriented and aim to build a detailed description of protagonists’ experiences of change during psychodrama. This begins with a broad investigation of the phenomenon in the preliminary study, followed by a more focussed investigation in Study 2.
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Study 1. Study 1 (Chapter 7) is a preliminary study designed to clarify the types of in-session change processes that might occur during a psychodrama intervention. In doing this, the study also examines the underlying premise of the research project; that psychodrama interventions can produce in-session resolution of painful emotional experience. The research questions (RQs) for Study 1 are:
RQ1 What is the protagonist’s experience of change during a psychodrama enactment? RQ2 Can there be in-session resolution of painful emotional experiences during psychodrama?
The results of this preliminary study establish whether there are sufficient grounds for further investigation towards building a model of protagonist processes that are linked to in-session resolution during psychodrama.
Study 2. Study 2 aims to build an explanatory model of protagonist processes that are linked to in-session resolution of painful emotional experience during psychodrama. It is a more focussed investigation of significant therapeutic events within psychodrama enactments and is the central study of the thesis. The principal research question for Study 2 is:
RQ3 What protagonist processes are linked to in-session resolution of painful emotional experience during psychodrama?
A secondary consideration in investigating protagonist in-session change processes was the relationship between in-session change and post-session change. Thus the question posed of the data is:
RQ4 What is the post-session impact of protagonists’ in-session change processes?
Verification Phase The verification phase seeks to investigate the tentative conclusions drawn from the discovery phase. There were two possible explanations of change emerging from the first two studies, which warranted further investigation: (i) the tentative model of protagonist change processes which was constructed from the findings of Study 2 and (ii) the allowing and accepting painful emotional experience model (Greenberg,
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1999; Greenberg and Paivio, 1998; Greenberg & Saffran, 1989) which appeared to have some resonance with the findings of the first two studies. These alternative explanations are investigated further in Studies 3 and 4.
Study 3. Study 3 aims to verify the model of protagonist processes that was developed in Study 2. The principle research question for Study 3 is:
RQ5 Can the emerging model of protagonist change processes, identified in Study 2, be applied to additional cases in which protagonists address painful emotional experience?
Study 4: The findings of Study 2 raised the possibility of an alternative explanation of protagonist change processes, Greenberg’s allowing and accepting painful emotional experience model. The fourth study is designed to investigate this alternative explanation, by applying established criteria established by the authors of the model (Foerster & Greenberg, 1995, in Greenberg, 1999). The principle research questions for Study 4 are:
RQ6 Do psychodrama enactments where there is in-session resolution of painful emotional experience meet Foerster and Greenberg’s criteria for allowing and accepting emotional pain?
RQ7 Do Foerster and Greenberg’s criteria for allowing and accepting emotional pain differentiate between those psychodrama enactments where there is in- session resolution of painful emotional experience and those enactments where there is not in-session resolution?
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Chapter 6
Research Design and Methodological Approach
This chapter provides an overview of the research design and methodological approach of this thesis. Details of the methodology used in each study, are described in later chapters. This current research is concerned with investigating protagonists’ change processes in the context of general psychodrama practice. With this intention in mind, a multiple-case study design (Yin, 2003) was adopted and this will be discussed first. An overview of current trends in psychotherapy change process research then locates this body of work within the broader field of psychotherapy research, and the methodological considerations influencing the collection and analysis of data are discussed. Lastly, the design of the psychodrama intervention is described.
Multiple Case-Study Design Multiple case study design investigates ‘a contemporary phenomenon within its real life context, especially when the boundaries between phenomenon and context are not clearly evident’ (Yin, 2003, p. 13). The design allows a phenomenon to be investigated within its context so that an in-depth picture of the relationship between phenomenon and context can emerge rather than be controlled. Multiple case study design begins with the examination of individual cases using questions that are derived from tentative theoretical positions. When a small number of cases has been examined, patterns within those cases are identified, a tentative model is developed, and the initial questions are reviewed and, if necessary, refined. Further cases are then examined and the procedure is repeated until a compelling explanation of the phenomenon under investigation has been produced. Theory emerges from the data and is compared to the original theoretical position and to competing claims within the literature. The use of multiple case-study design is in line with trends in psychotherapy change process research (e.g. Bohart, 2000; Hill et al., 2005; Hill, Thompson and Williams, 1997; Elliott, 2008; Elliott, Packer & Addison, 1989; Greenberg, 1999). The study of individual cases enables the intensive investigation of significant
Chapter 6 41 therapy events to develop detailed descriptions of the events under study. Extending the investigation to multiple cases allows cross-case comparisons that can develop and test emerging models. This design is ideally suited to studying psychotherapy in its natural context because it is not restricted to treating therapeutic interventions and client change in linear terms, but can manage the complexities of psychotherapy processes. The number of cases that are required to build a compelling explanation is based on the principle of saturation; that is, more cases are added until the addition of further cases no longer contributes significant understanding to the phenomenon being investigated (Hill et al., 1997). Various authors have identified the number of cases that, in their experience, achieve this purpose. Hill et al. (1997) proposed that up to 15 cases might be necessary, and suggested that six or seven cases be used in the initial development of a model, with further cases being added to test the stability of findings. They suggest that fewer cases are required when more data are collected for each case. Greenberg has used multiple case study design to compare successful and unsuccessful therapy events and recommends 9 successful and 9 not-successful cases to draw confident conclusions about the differences between the two groups (L. Greenberg, personal communication, July 29, 2002). Even so, published studies comparing successful and not successful cases have been based on as little as three cases in each group (e.g. Foerster & Greenberg, 1995, in Greenberg, 1999). In this thesis, 15 cases were examined in the course of the four studies, nine resolved cases and six not-resolved cases.
Psychotherapy Change-Process Research as an Approach to Model Building Evidence of therapeutic effectiveness across different therapeutic approaches, combined with trends towards integration in psychotherapy practice, has led to calls for research to pay greater attention to understanding effective underlying change processes (Norcross & Goldfried, 2005). Bohart (2000) suggests that studying what happens within effective therapy cases in relation to specific client issues and contexts will produce empirically based models that are more relevant to the exigencies of psychotherapy practice than will global outcomes from treatment protocols. Psychotherapy change-process research (Greenberg, 1986; Greenberg & Newman, 1996; Greenberg & Watson, 2006) investigates the therapeutic processes
Chapter 6 42 linked to client change, through the detailed analysis of significant change events. It bridges process and outcome research, by identifying events linked to positive therapeutic outcomes, as the focus for analysis. Where traditional process research treats all processes in therapy as equally relevant or having the same meaning without reference to context, change-process research asserts that targeting identifiably significant events offers greater potential for discovering what makes therapy effective. Greenberg and Newman (1996) identify three stages in change-process research (i) intense observation and detailed description of a small number of cases, (ii) development of an explanatory model through systematic measurement and contextual analysis, and (iii) verification of the explanatory model. In order to develop models that are based on a deep understanding of the active ingredients of change, considerable attention must be given to the early discovery stage, before moving to the verification stage. The first two studies of this research are concerned with the discovery stage, the third study moves towards verification of the model that emerged from this research and the fourth study seeks to verify an alternative explanatory model. Change-process research explores the links between process and client change, and therefore questions of outcome (that is, identifying client change) and efficacy (that is, demonstrating that there is a link between the therapeutic processes and the client change) become relevant. The results of this type of research are influenced by how cases are selected and how client change and therapeutically significant events are identified.
Selecting cases Many change-process research projects are carried out as a component of larger research programs, where a collection of potential case material is available. Cases are selected on the basis of the occurrence of defined therapeutic events, such as problem clarification events (Rees et al., 2001), weeping events (Greenberg, 1999) and vague awareness events (Hardy et al., 1998). The phenomenon that was under investigation in this thesis was not a specific therapeutic event, but the process of in-session change when a protagonist addresses painful emotional experience during psychodrama. Cases were selected where there was potential for therapeutic change to occur, based on three criteria: (i) participants
Chapter 6 43 identified a painful emotional experience which, in their judgment, was continuing to have an adverse impact on their life; (ii) they expressed a desire to effect some change in their response to the experience and (ii) they chose to address that issue as a protagonist within a psychodrama workshop. An assumption of the investigator was that there would be a variation in the nature of in-session change experienced by different protagonists, but that at least some would experience in-session resolution of the painful emotional experience. An early part of the analysis of protagonist change processes involved identifying resolved and not-resolved cases embedded within the studies. In-session resolution provides a framework for classifying psychodrama sessions so that cases where similar therapeutic tasks have been completed can be compared. Furthermore, it is a framework that has been used in other change process research, including the investigation of emotional pain in experiential therapy (Greenberg, Rice & Elliott, 1993; Greenberg 1999) and therefore offers the opportunity to compare the results of this study to other work in the field.
Identifying in-session change In-session change has been found to be a predictor of positive outcomes for clients (Elliott, 2008; Watson & Greenberg, 1996) and therefore it is argued that understanding in-session change will contribute to developing effective therapeutic practice. In-session resolution of painful emotional experience is defined, as a starting position in this current research, by the Degree of Resolution Scale: Problematic Reaction Points (DRS/PRP; Greenberg, Rice & Elliott, 1993)1. The DRS/PRP describes a range of possible in-session outcomes, culminating in ‘reaching resolution’ when the protagonist “gets a whole new view of important aspects of his or her own mode of functioning and what self-changes he/she wants to make and is beginning to feel empowered to make the change” (Greenberg, Rice & Elliott, 1993, p. 148). The DRS/PRP is one of a series of resolution scales developed by Greenberg, Rice and Elliott for specific change-process research purposes, and has not been validated elsewhere. The reliability of the measure, and whether or not the definition of resolution used in this measure is meaningful in the context of psychodrama with painful emotional experience, had to be established in the course of this current
1 The DRS/PRP is described in Study 1 (Chapter 7).
Chapter 6 44 research. Reliability of the measure was established by using multiple independent raters, and validity of the measure was investigated by checking ratings on the DRS/PRP against protagonists’ self reports of resolution and post-session impact data. These procedures are described in some detail in the relevant studies.
Identifying therapeutically significant events A fundamental principle behind change-process research is that some processes that occur within therapy are more therapeutically significant than others (Greenberg, 1986). Identifying what constitutes a significant event worthy of analysis is of central concern. Two interrelated questions that needed to be addressed in this current research are (i) what constitutes a significant event and (ii) who is best able to identify significant change events. Elliott, Packer and Addison (1989) note that significant therapy events can range from a brief event of two to three speaking turns, to as much as 10 minutes or more. Most change-process studies have targeted specific types of therapeutic tasks for investigation, for example, the resolution of unfinished business (Paivio & Greenberg, 1995) or therapeutic weeping (Greenberg, 1999), and have analysed brief events. This current research has chosen longer events, more often around 10 minutes in duration, as the key unit for analysis. The decision to do this was influenced by the exploratory nature of this research and assumptions about the structure of a psychodramatic intervention. Firstly, this research is not built on predefined types of events for analysis, as has been the position in other change- process research. Rather, it is interested in the basic question of what types of significant events can be linked to what types of in-session changes, without being predisposed to particular types of events or to the belief that all cases would contain the same events. Secondly, a classical psychodrama session often consists of more than one scene and each scene could be considered a specific intervention containing a number of micro-interventions. It was assumed that the combination of a number of micro-interventions within the scene might influence the impact of any one event, and that for a first study of this kind, the interrelationships of such micro-events was of interest. Greenberg (1999) suggests that events which both the client and the therapist agree are therapeutically significant are most likely to reveal important information about change processes. However, in practice, decisions are made based on the
Chapter 6 45 nature of the question under review and the pragmatics dictated by the nature of the data that are available to investigators. Elliott, Packer and Addison (1989) had clients identify in-session events that they consider were helpful and unhelpful, immediately after the session, or while reviewing a recording of the session, and then gather information from the therapist and other sources, to support or challenge the therapeutic significance of the identified event. This approach has been used in the comprehensive process analysis (CPA) of weeping events (Labott, Elliott & Eason, 1992) insight events (Elliott, Shapiro, et al., 1994), vague awareness events (Hardy, Rees, et al., 1998) and problem-clarification events (Rees, Hardy, et al., 2001). Mahrer and Boulet (1999) on the other hand, suggest that a team of investigators review video-recordings of sessions and reach consensus as to what were the significant moments of change. This approach has been used in a number of task- analysis studies, which have had access to a collection of recordings of therapy sessions to investigate events such as alliance ruptures (Watson & Greenberg, 2000) and allowing emotional pain (Greenberg & Foerster, 1996). The procedure for selecting significant events is described in each of the studies (see Chapters 8, 9, 10 and 11). In essence, Elliott’s approach was applied, whereby protagonists identify significant events and therapists later reflect on those events and indicate their own assessment of the therapeutic significance of the events. However, the investigator determined how much contextual material from the scene leading up to and following the protagonist-identified event, was viewed. The protagonist was later able to identify event peaks or specific sub-events within each scene that they considered significant, ensuring that there was clear and specific information about the particular experience that was relevant to the protagonist. In this way, the protagonist remained the authority on what was significant for them, while the investigator ensured that contextual information that was theoretically relevant was considered.
Multiple sources of data Data were collected from multiple sources, including the use of qualitative and quantitative measures, protagonist and director recall and independent observers. The use of video-recordings of interventions was an essential component of data collection.
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Video based research. The use of audio and video-recordings of therapy sessions for research purposes has enhanced psychotherapy research by making it possible to investigate actual events during therapy, rather than reports of therapeutic events. Tape-based research is advocated to assist clients’ and therapists’ recall of their in-session experiences (Elliott & Shapiro, 1988; Greenberg, 1999) and to enable researchers to observe the detailed performances of clients and therapists (Greenberg, 1999; Mahrer & Boulet, 1999). Transcripts of sessions have been used effectively to analyse interpersonal dynamics during psychotherapy, but information about voice quality and intensity that is available through recordings, can add significantly to the understanding of the dynamic interaction of the session (Luborsky & Crits-Cristoph, 1990). Many research projects have been based on the analysis of audio recordings of sessions (e.g. Greenberg, 1999), while various interpersonal process recall methods use video- recordings to reinstate the context for therapists and clients as they recall their in- session experiences (see below). In this current research, it was considered that video-recordings would be the most effective way to record the active and interactive components of psychodrama sessions. Taped based research enhances the possibilities for studying non-manualised therapy interventions. When large research projects produce a collection of taped therapy sessions, investigators are able to identify specific events worthy of further investigation and select cases where these events occur. This has enabled therapeutic phenomena to be investigated when and as they emerge in therapy, rather than requiring the therapist to produce a certain type of experience within the therapy session. Studies that have targeted very specific in-session performances have generally selected their sample cases from a pool of taped sessions, gathered as part of a larger project (Greenberg, 1999; Mahrer & Boulet, 1999). One of the restrictions confronting this current research was the lack of availability of such a pool of recorded psychodrama sessions. Consequently, the research questions were framed around broader questions of what are the types of significant events that are common or idiosyncratic across these cases, rather than targeting a specific type of event.
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Interpersonal Process Recall (IPR) method. Interpersonal process recall (IPR: Kagan, 1980; Kagan & Kagan, 1991) is a method of eliciting participant information about interpersonal interactions, through video-assisted recall. The method is based on two principles: (i) reviewing a video- recording of an interaction reinstates the context of the interaction, enabling the person to recall thoughts and feelings in depth and detail; and (ii) a recall interviewer acting as an encouraging inquirer, reduces the interviewee’s tendency to give socially appropriate responses, and assists the person to describe underlying thoughts and feelings (Kagan & Kagan, 1997). In the classical design of the IPR method, clients or counsellors review a video- recording of their counselling session to assist recall, stopping the recording at their own discretion to reflect on their experience in the moment. Open-ended questions are used to encourage a deeper exploration of that experience. The method was developed for counsellor training and supervision, but has been found to be an effective tool for investigating and developing models of interpersonal interactions and has been adopted as a tool for psychotherapy process research (Elliott, 1986; Kagan & Kagan, 1997). Researchers have developed modifications of the IPR method, structured around specific theoretical or research considerations (e.g. Elliott & Shapiro, 1988; Greenberg, 1999; Sheehan, Fromm & Nash, 1992; Toukmanian & Rennie, 1992). In this current research, two forms of interpersonal process recall have been adopted. The preliminary study uses the classical, minimally structured IPR method, to identify the range of significant in-session events. Unstructured enquiry increases the likelihood that themes emerge from the experience of participants, rather than from the questions that are being asked (Dick, 2005). The results of this study help to formulate the theoretical position for further studies, so that in the second study, Brief Structured Recall method (Elliott, 1986; Elliott & Shapiro, 1988) is used to focus more strategically on significant in-session events. These two approaches are considered in more detail in Chapters 7 and 8.
Team Based Analysis and the Consensus Decision Making Approach In the central study of this current research (Study 2), sessions are analysed by a team of observers using a consensus decision making approach. Similar approaches are used in a number of current psychotherapy research methodologies (e.g. Elliott, Shapiro, Firth-Cozens, et al., 2001; Hill, Knox, Thompson, et al., 2005;
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Knox, Hess, Williams & Hill, 2003; Mahrer &; Boulet, 1999; Rees, Hardy, Barkham, et al., 2001). The consensual team approach is based on the principle that vigorous discussion of a range of observations and interpretations enables more perspectives to be included and a fuller understanding of phenomena to be achieved (Hill et al., 1997; Hill et al., 2005; Elliott, 1983a; Elliott et al., 1994). The analysis involves three phases that are repeated throughout the analysis. (i) The material is reviewed by individual team members who make tentative decisions, which are then collated for the team to review. (ii) The team considers all individual decisions and discusses differences until consensus is reached. Principles of group decision-making expounded by Dick (1991) were used to guide the discussion of differences. Dick proposes that differences result from (a) deficiencies in information available to all or some group members, (b) the impact of team members’ feelings in response to the material being discussed or (c) entrenched beliefs about the nature of the phenomenon being discussed. The team decision making process used in this research assumed initially, that differences were a product of assumptions or limited information, and questions were asked to clarify individual team member’s decisions, or further information was gathered about the case or the concept being discussed. For remaining differences, feelings or beliefs that individual team members held about the material being reviewed, were discussed. (iii) Team decisions are reviewed through an auditing process. Auditing is a core component of establish the credibility and coherence of the findings, and is discussed in more detail later in this chapter. This three-phase procedure maximises the potential for all members of the team to influence decision making, because all initial findings are considered in the discussion. It also allows for interpretations and misunderstandings to become apparent. Hill et al. (1997) note that effective consensual decision making requires ‘mutual respect, equal involvement and shared power’ (p. 523). The possibility that some team members will have undue influence over the decision making process, or that the group may become blind to the impact of ‘group-think’, is reduced by periodically reviewing the decision making process and subjecting findings to the review of auditors.
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The Participation of the Investigator at all Stages of the Research. The principal investigator was engaged with every level of the research, including participating as a psychodramatist to direct a number of the psychodrama interventions. This level of engagement is strongly advocated by some researchers who regard involvement in the intervention phase as assisting the investigator to ‘draw on his or her tacit understanding of change to help explicate change phenomena’ (Greenberg, 1999, p. 1468). The involvement of the investigator as a therapist in the research is, however, controversial, with three potential risks to the integrity of the results: researcher bias (i) in the implementation of the intervention and (ii) in the interpretation of the results; and (iii) the impact of the investigator’s multiple roles on clients’ interview responses during and after the intervention. These risks are considered here and the strategies that were implemented to ameliorate potential problems are discussed.
Potential researcher bias in the intervention phase The investigator is highly likely to be influenced by prior knowledge of the research hypotheses, to intervene in particular ways during the intervention phase. As noted earlier, all participating psychodramatists were asked to intervene on the basis of their professional judgement, and it would realistically be expected that the research hypotheses reflect the professional judgement of the investigator at different stages of the research project. However, this does not necessarily constitute a limitation in the research design. Multiple case study design assumes that learning will be progressively integrated into the research so that, over the course of time, tentative theories are developed, modified and tested out with further cases. Mahrer and Boulet (1999) argue that when therapists discover something interesting through the research process and adopt this learning into their practice, there is an opportunity to more clearly identify effective therapeutic processes. Potential researcher bias in the interpretation of case material A more cogent area of risk to the integrity of the findings is the impact of researcher bias in the interpretation of case material. The investigator may have an attachment to interpreting events in a particular light, or have a reaction to a client which impacts on her ability to objectively consider the case material. While expectations and biases impact on all analysts, the impact is arguably more complex when the investigator is examining her own work. On the other hand, as noted
Chapter 6 50 earlier, the investigator’s direct participation with the case may elicit a deeper understanding of the material. Mechanisms were put in place in the analysis phase, to attempt to achieve an optimum balance between these two possible impacts. Firstly, the principal investigator was one of four psychodrama directors and directed only four of the 14 enactments that were examined. Secondly, cases directed by other psychodramatists were analysed first, so that early modelling was based on cases where the investigator did not have direct client involvement. Thirdly, multiple qualitative analysts and the use of auditors to review results provided a check on the influence of the investigator.
The impact on participants of the investigator’s dual role as therapist and researcher The involvement of the principal investigator as both therapist and researcher may influence participants’ responses to questionnaires and interviews during and after the intervention. This research sought to reduce the impact of dual roles by ensuring that the principal investigator did not carry out post-intervention interviews with participants where she was also the director of the session. In these instances, recall interviews and post-session change interviews were carried out by other members of the research team. The impact of the therapeutic relationship on participants’ reports of helpful and unhelpful aspects of therapy was considered as a general factor in all cases.
Ensuring Credibility and Coherence of the Findings Where validity and reliability are the cornerstones of quantitative research, qualitative research is concerned with establishing that the emerging findings present a credible and coherent picture of the phenomenon under investigation (Elliott, Fischer & Rennie, 1998). Credibility checks were provided at various points during the research, via an articulation of the expectations and biases of the research team at the outset, the use of multiple qualitative analysts, comparison of resolved and not- resolved cases, the provision of detailed examples to illustrate findings and the use of auditors throughout.
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Identifying expectations and biases The expectations and biases of the investigator can influence how information is gathered and interpreted. Articulating the expectations and biases that investigators took into the project gives the reader a context within which to consider the findings. The introductory chapters of this thesis articulate many of the expectations that the primary researcher held, entering into the research. As the research progressed, expectations were at times modified, in response to emerging results, and these are articulated as hypotheses within each study. Findings that differed from expectations are of particular interest, because they more clearly emerge from the data rather than from preconceptions. On the other hand, findings that support the working hypotheses of the investigator are not necessarily less valid, but need to be supported by clear evidence. This is done in part by providing examples from the data to illustrate the findings, allowing readers to draw their own conclusions about the fit between the data and the interpretation. Biases include demographic characteristics, experiences and beliefs that may make it difficult for the researcher to consider some information dispassionately. Demographic and other characteristics of the research team are presented in the method section of Study 2 (Chapter 8) and summary statements of the expectations and biases of team members can be found in Appendix D.
Multiple qualitative analysts The use of multiple analysts, as in the team approach described earlier, mitigates the impact of the expectations and biases of a single qualitative judge. This is a key argument in favour of using the team approach. Multiple analysts were used for all qualitative decisions that were made in this research. To provide different perspectives, qualitative judges had varying degrees of prior exposure to psychodrama but were not themselves psychodramatists, with the exception of the primary investigator and in those specified instances where psychodramatists were asked to make judgements about the sessions they directed.
Internal comparison group: analysing resolved and not-resolved cases This research investigated both successful and unsuccessful case examples of in- session resolution, in line with the approach described by Greenberg (1999). This provides an internal control comparison, so that a stronger argument can be presented for the link between specific processes and the experience of in-session resolution.
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Processes that differentiate resolved and not-resolved cases can be identified and processes that were experienced as therapeutically helpful across all cases, but which do not on their own lead to in-session resolution, can be identified.
The use of auditors Auditors were used to review data analyses, to check that all data were considered, that categories made sense and that data were allocated accurately. Auditors made recommendations regarding allocation of data to categories and these recommendations were taken into consideration by the researcher in the ongoing analysis. Different people were used for the auditing role, depending on the requirements at each point for the person to have an understanding of the information they were reviewing. Auditors typically had some psychodrama experience but were not certified psychodramatists. It was considered that some understanding of the logistics of a psychodrama session was necessary for auditors to be able to concentrate their energies on their job as auditors, rather than on trying to understand the psychodrama context. In addition, emerging models were reviewed by psychodrama practitioners, to test whether they provided a coherent explanation of the protagonists’ processes.
The single-session psychodrama intervention design Decisions about the design of the psychodrama intervention used in this research have implications for the scope of enquiry and the generalisability of the findings. Intervention design considerations are discussed here.
Psychodrama as an intensive single-session intervention This research was practice-based, that is, the focus was on investigating change processes as they occur in the field. Kipper and Hundal (2005) propose that the psychodrama method can be conceived of as a series of single session interventions. There are three general ways in which these single-session interventions are structured in therapeutic practice: (i) psychodrama techniques are applied in conjunction with other therapeutic methods, either from a predominantly psychodramatic orientation (e.g. Hamamci, 2006) or incorporated into a different theoretical orientation (e.g. Beck, Freeman & Davis, 2003); (ii) an ongoing psychodrama group runs for a series of regular sessions, where one or more psychodramas are conducted at each session (e.g. Kim, 2003), or (iii) an intensive
Chapter 6 53 workshop is conducted over consecutive days, focussed on a specific theme or concern (e.g. Clayton & Carter, 2004; Hudgins, 2002). The intensive workshop approach was selected for this research, because it is the form of practice more commonly used by the investigator, was consistent with the general practice of the majority of psychodrama practitioners who participated in the research and was an efficient way of producing a series of cases for change-process analysis. In the clinical setting, this psychodrama format is typically chosen as an intensive group intervention within the context of ongoing individual therapy. In these cases, the psychodrama session does not constitute the complete therapeutic process with a client, but rather is a point in time within his or her therapeutic process.
The general structure of the psychodrama intervention The psychodrama intervention was a two-and-a-half-days (Studies 1 & 2) or two days (Study 3) workshop, which incorporated a number of discrete psychodrama sessions, with a different protagonist for each session. The workshop structures are described in more detail within each of the studies (see Chapters 8, 9 & 10). All workshops included the three general phases of a psychodrama session: warm-up, enactment and sharing. Four conditions were considered necessary for the session to be considered a psychodrama (refer to Kellermann’s definition of psychodrama in Chapter 1): (i) there was one protagonist for the session, whose enactment of a core concern was the focus of the session; (ii) there was the enactment of at least one scene which either approximated a real-life situation or was an externalisation of the protagonist’s inner mental processes; (iii) group members took up roles within the protagonist’s enactment and (iv) there was the use of at least one of the central psychodramatic techniques of role reversal, doubling, mirroring and concretisation. All psychodrama enactments that were included in this research met these four conditions. The published focus of the workshop was the resolution of painful emotional experiences. Within this general frame of reference, psychodrama practitioners were asked to direct psychodrama sessions in accordance with their own professional judgment.
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A non-clinical participant pool Participation in the studies was targeted at a non-clinical rather than a clinical population. That is, people were recruited on the basis of being able to identify a particular issue that was affecting them in their lives, rather than on the basis of a clinical diagnosis. This recruitment decision was made for two reasons. Firstly, it was assumed that a high-functioning group offered a greater likelihood of reaching in-session resolution in at least some cases, and this was a necessary condition for the research to be completed. Secondly, the logistics of the intervention were complex. To be able to record the moment-by-moment process of the protagonists and significant auxiliaries in an enactment, it was necessary that audio-visual equipment and technicians were, to some extent, in the therapeutic space. Participants had to be equipped with microphones as they took up roles in a psychodrama and the video camera, while remaining on the outer edge of the group space, had to move with the action to stay in contact with the protagonist. This may have created an additional layer of anxiety for participants and directors alike. This was the first time that psychotherapy research methods that have essentially been designed to investigate individual therapy, have been applied in a group context and it was assumed that targeting a non-clinical population was one way to contain the complexity.
Introduction to the reports of the four studies The following six chapters present the four studies that make up this research. The approach is fundamentally hermeneutic in that it seeks to make meaning of the phenomenon under investigation – protagonists’ change processes. Each study is presented in its entirety, with tentative conclusions, so that the unfolding of ideas over the course of the studies is revealed.
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Chapter 7 Protagonist and Director Recall of Protagonists’ Change Processes during psychodrama A Preliminary Study
Workshop 1: Cases 1,2 & 3
Base-line data
Intervention
Rate resolution
Post-workshop change interviews
Interpersonal Process Recall
Identify and describe protagonist change processes
Figure 7.1. Preliminary Study Research Plan
Overview of Study 1
The preliminary study that is reported here was designed to investigate the underlying premise of the research project, that psychodrama interventions can produce in-session resolution of painful emotional experience. In order to do this, a small number of cases were examined for evidence of in-session resolution, and protagonist and director recall of the protagonists’ experiences of in-session resolution was examined. The results of this study would establish whether there were sufficient grounds for further investigation towards building a model of protagonist processes that lead to in-session resolution during psychodrama.
Context for the Preliminary Study
There is a gap in the literature between practitioner reports of in-session resolution of painful emotional experience during psychodrama and empirical evidence to verify these observations. The work of Kellermann (1992) has been the
Chapter 7 56 most comprehensive attempt to address this gap. Drawing on survey responses from protagonists and leading psychodramatists, Kellermann described seven general curative factors of psychodrama. Protagonists identified (1) emotional catharsis, (2) action-insight and (3) interpersonal relationships as therapeutically significant, and from the responses of practitioners Kellermann added (4) therapist skills, (5) enactment, (6) surplus reality (imaginary enactment as-if an experience were happening in the here and now) and (7) non-specific factors including therapeutic ritual. These factors are generally consistent with published case reports and with Moreno’s writing. While Kellermann’s work provided a unifying framework for the practice of psychodrama, he relied on survey information at some distance from the psychodrama experience that was being recalled and did not establish that therapeutic change had occurred in the situations respondents were relating to. More focussed change process research is required to establish and specify links between psychodrama interventions and protagonist change processes.
Research Questions
This preliminary study aimed to establish the grounds for further investigation of the process of change during psychodrama, by broadly identifying the types of changes that can occur during a psychodrama enactment. The first question pertained to general change processes:
RQ1: What is the protagonist’s experience of change during a psychodrama enactment?
The second question examined evidence of a specific type of change, namely the experience of in-session resolution, to investigate the premise that psychodrama enactment can produce in-session resolution of painful emotional experience:
RQ2 Can there be in-session resolution of painful emotional experiences during psychodrama?
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Method
Three psychodrama sessions were rated for in-session resolution of painful emotional experiences, and protagonists’ and director’s recall of the protagonists’ experiences during the session were investigated using the Interpersonal Process Recall method. A qualitative analysis of recall responses compared responses across the three cases.
Participants
Group members
Expressions of interest were invited through university and professional development seminars, for mental health practitioners and post-graduate mental health students to participate in a psychodrama workshop focussed on addressing painful emotional experiences. The first eight people to express interest in the workshop were assessed to be suitable and were accepted. Suitability for participation was assessed prior to the workshop on the basis of participants being able to identify a painful emotional experience from their past that continued to affect them in their lives, and having adequate ego strength to participate in the workshop. Ego strength was assessed in pre-workshop interviews from clinical observations of the participant’s functioning, identifying social supports outside of the workshop setting and having realistic strategies for managing the possible emotional distress that could arise through participating in the workshop. There were six female and two male participants, ranging in age from 35 to 58 years with a median age of 49 years. Most had little or no previous experience of psychodrama. Four participants had no previous psychodrama experience, three had attended an introductory psychodrama workshop and one participant had previously participated in more than one psychodrama workshop.
Protagonists
During the workshop, three participants volunteered to be protagonists and to work with their specific unresolved painful emotional experience in a psychodrama session. The three protagonists, Ella1, Karen and Erin, were all female, currently working and aged from 35 to 50 years. Karen and Erin had attended a one day
1 The names of group participants and identifying information have been changed throughout this thesis.
Chapter 7 58 introductory psychodrama training session in the past 12 months, and Erin had trained in other experiential therapies, but not psychodrama. Ella had no previous exposure to psychodrama. All three had sought some counselling in the past and two had received some counselling within the 3 months prior to the workshop.
The director
The director of the three psychodrama sessions was Dr Kate Hudgins, an internationally recognized practitioner and trainer in the field of psychodrama and trauma. Dr Hudgins has written and edited a number of books and journal articles in this field, is a past editor of the Journal of Group Psychotherapy, Psychodrama and Sociometry, and was the guest editor for that journal when it published a special edition on the use of psychodrama with trauma. The work of an expert practitioner was targeted for this study in order to maximise the possibility of producing some cases where there was in-session resolution of painful emotional experience. This decision reflected an assumption at the outset of the research that full in-session resolution would not occur often and was more likely to occur with a highly skilled practitioner. Greenberg (1999) and Mahrer (1996, 2005) recommend studying the work of expert practitioners because this provides the opportunity to discover what can happen in therapy when it works well. Perceptions of the director as an expert may influence participant perceptions of the therapeutic helpfulness of the session and of the director’s interventions, and attention would need to be paid to evidence of this in the protagonist and director recall. One safeguard against this type of bias lies in a comparison of resolved and non-resolved cases.
Questionnaires and Measures
Three self report questionnaires were administered to participants – a Personal History Questionnaire prior to the workshop, a Post-Workshop Evaluation at completion of the workshop and a Client change Interview at two week follow-up and three month follow-up. An observer rating scale, the Degree of Resolution Scale: Problematic Reaction Points (DRS/PRP; Greenberg, Rice & Elliott, 1993) was used to rate protagonist in-session resolution. These measures are described below.
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Personal History Questionnaire. The Personal History Questionnaire is a self- report questionnaire developed for this study (See Appendix A). The purpose of this questionnaire was to establish a profile of each participant in areas that may be relevant to their participation in the workshop. It has two sections: (i) Biographical information including occupational and health status, previous counselling and group work experience; and (ii) Workshop goals, where participants identify current areas of concern in relation to a painful emotional experience, describe their perception of current functioning in relation to the identified issue and identify areas of desired change. This information is checked against reported changes at two week and three month follow-up. Post-Workshop Evaluation Form (See Appendix B). The Post-workshop Evaluation Form is a self-report reaction questionnaire, developed for this study. The purpose of the questionnaire was to collect quantitative and qualitative information about a protagonist’s perceptions of the relative impact of the session in which he or she was a protagonist compared with other workshop events, so that alternative explanations for any changes arising from the workshop could be considered. The questionnaire asks participants to (i) rate the helpfulness of the workshop and of individual sessions, on a nine-point likert scale; (ii) describe the impact of each session and (iii) identify helpful and unhelpful aspects of each session. Client Change Interview (Modified with permission from R. Elliott, 1999; see Appendix C). The Client Change Interview is a semi-structured interview that asks participants to report on post-therapy changes and attribution of cause. Participants are asked to describe all changes they have experienced since the workshop and rate each change on three five point likert scales: the degree to which the change is important or unimportant to them; the degree to which the change was a surprise to them or had been expected and the degree to which they consider the change was unlikely or likely to have happened if they had not participated in the workshop. The Client Change Interview was developed by Elliott for use in individual ongoing therapy. Minor changes have been made to his protocol, for use in a single- intervention group context.
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The Degree of Resolution Scale: Unfolding Problematic Reaction Points (DRS/PRP; Greenberg, Rice and Elliott, 1993). The DRS/PRP was developed as a tool to differentiate resolved and not-resolved cases in change-process research (see Table 7.1). It is one of a series of six scales that describes stages in the resolution of specific therapeutic tasks that have been identified in process-experiential therapy. The DRS/PRP is concerned with therapeutic resolution of experiences where the client considers that his or her response to particular situations is ‘unexpected, unreasonable or otherwise problematic’ (p. 143).
Table 7.1. Degree of Resolution Scale: Unfolding Problematic Reaction Points. (Source: Greenberg, Elliott & Rice, 1993, p. 148.)
Stage 1. Protagonist describes problematic reaction of his/her own.
Stage 2. Protagonist has “re-entered” the scene and is recalling and re-experiencing the time when the reaction was triggered.
Stage 3. Protagonist recalls salient aspects of the stimulus situation. Explores both own internal affective reaction to situation and own subjective construal of potential impact of the stimulus situation.
Stage 4. Protagonist reaches the ‘meaning bridge’. Has discovered the link between his/her problematic reaction and own construal of potential impact of stimulus situation.
Stage 5. Protagonist recognises this as an example of a broader aspect of own mode of functioning that is interfering with own needs and wants.
Stage 6. Protagonist reaches “resolution”; gets a whole new view of important aspects of own mode of functioning and what self-changes he/she wants to make. Is beginning to feel empowered to make the change.
Note: The term ‘client’ in the original scale, has been replaced by the term ‘protagonist’
The DRS/PRP is based on an experiential model of resolution that begins with an in-session marker that exploration of a problematic reaction is therapeutically indicated. The marker, which constitutes Stage 1 on the DRS/PRP, has been defined as meeting three conditions:
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‘(i) The client recounts a particular instance of a reaction in a particular situation; (ii) The reaction that is felt as problematic is the client’s own, not that of someone else. (iii) There is some indication that the client views his or her reaction as problematic, not simply as an unfortunate consequence of someone else’s behaviour.’ (Greenberg, Rice & Elliott, 1993, p. 144).
Stage 4 (‘Reaches meaning bridge’) is considered a partial resolution. The client has experienced their problematic response in its situational context and consciously linked the problematic response with their emotional and cognitive functioning. At Stage 6, the client reaches a more complete resolution, with a new sense of self, a sense of direction and an impetus to change. The DRS/PRP was developed to measure resolution in individual therapy and there are no available research data on its reliability or validity in that context, nor has it been applied in a group intervention context. Its application in this study was, therefore, exploratory. Multiple observers were used for purposes of reliability, and ratings were compared to protagonist reports of in-session and post-session impact, to develop a case for the plausible acceptance of the ratings as a measure of in- session resolution.
Procedure
Three psychodrama sessions were conducted in the course of a two-and-a-half day workshop. The sessions were rated for degree of in-session resolution of painful emotional experience and the protagonists’ and director’s recall of significant change events was investigated using the Interpersonal Process Recall method. Details of the procedure are outlined in Figure 7.2 and described below.
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1. Pre-intervention participant interviews
2. Intervention: Psychodrama workshop
3. Immediate post-intervention follow-up.
4. Rate resolution
5. 2-week follow-up
6. Interpersonal Process Recall interviews
7. Three-month Follow-up Figure 7.2: Steps in the Procedure for Study 1
Pre-intervention participant interviews
A week prior to the workshop, participants attended a pre-intervention interview, where they completed a Personal History Questionnaire and were asked to specify a painful emotional experience they wanted to address, to describe the current impact of that experience on their personal, interpersonal, social and spiritual well-being, and to identify goals for the workshop.
Intervention A psychodrama workshop was conducted over two and a half consecutive days. The workshop was structured around five sessions, each of approximately three hours duration. In the introductory session general group work techniques were used that focused on inclusion and goal setting. Three psychodrama sessions were then conducted, following the classical psychodrama phases of warm-up, enactment and sharing. In each of these sessions, a group participant volunteered to be a protagonist and to address her specific painful emotional experience. The fifth and final session once again used general group work techniques, this time with a focus on group closure.
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Immediate post-intervention follow-up
At the immediate conclusion of the workshop, participants completed a post- workshop evaluation form, rating each session on a nine point helpfulness scale, and reporting helpful and unhelpful aspects of each session.
Rating in-session-resolution
Immediately after each psychodrama session, the director rated the degree of in- session resolution of painful emotional experience using the DRS/PRP. In the week after the workshop, two independent observers reviewed a video recording of each session and rated the in-session resolution of painful emotional experience using the DRS/PRP.
Two-week follow-up interviews
At two week and three month follow-up interviews, protagonists were asked the following questions modelled on Elliott’s (1999) Client Change Interview protocol: a. What changes, if any, have you noticed since the workshop? (For example, are you doing, feeling or thinking differently from the way you did before? What specific ideas, if any, have you got from the workshop, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) b. Has anything changed for the worse for you since the workshop? c. Is there anything that you wanted to change that hasn’t changed since the workshop? d. In relation to each change i. How likely do you think it is that this change would have happened if you hadn’t participated in the workshop? ii. What other counselling, groups, have you participated in since the workshop? What other significant events have occurred in your life since the workshop? iii. In general, what do you think has caused these various changes or brought them about? (Include things both outside of the workshop; to do with the workshop in general and to do with your psychodrama in particular).
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Interpersonal Process Recall (IPR) interviews.
Immediately following the change interview described above, protagonists reviewed a video recording of their session using Interpersonal Process Recall Method (IPR: Kagan, 1975). The director reviewed each session independently of the protagonist. As was discussed in Chapter 6, Kagan’s original approach to IPR was minimally structured and allowed the interviewee to determine where the focus of his or her recall would be. Modifications of the method have introduced more structure to focus on specific theoretical or research objectives. The intention of this study was to arrive at a general understanding of the protagonists’ experiences of resolution, from which more focused investigations could be designed in the studies that followed. Mahrer and Boulet (1999) advocate that research should begin from a position of naïve enquiry, to reveal what is happening during a session. In line with this exploratory orientation, the classical open-ended application of IPR was adopted. It was anticipated that the results of this study would inform a more focused IPR process in the later studies of this research. Video recordings of the session were reviewed to reinstate the context for the interviewee and assist her to have a fuller and more accurate recall of her experiences. Kagan’s original method, where interviewees recalled their own experiences of sessions, was modified for the purpose of the study, with both the director and the protagonist being asked to reflect on the protagonist’s process. The instructions for the protagonist were: I want to review with you what was going on for you during the psychodrama session, in relation to addressing and working through your issue. We’re going to look at the video of the session, as a way of reminding you of the experience and re- entering into what was happening at the time. Stop the video at any point where you think there is potential to review what was going on for you, and what helped and hindered your process. You can stop the video as often as you like. When the video was stopped the interviewer prompted the protagonist, where necessary, with questions such as “What was happening for you in this moment?”, “What enabled that to happen/got in the way?” and “What did you do in response to this?” The instructions for the director were:
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I want to review with you what you think was happening for the protagonist during the psychodrama session, in relation to addressing and working through the issue she presented. We’re going to look at the video of the session, as a way of reminding you of the experience and re-entering into what was happening at the time. Stop the video at any point where you think there is potential to review what was happening for the protagonist, and what helped and hindered the process. You can stop the video as often as you like. When the video was stopped, the interviewer prompted the director where necessary, with questions such as “What did you notice happening for the protagonist at this moment?”, “What enabled that to happen/got in the way?”, “What decisions did you make?” and “How did this affect the protagonist?”
Three Month Follow-up interviews
At three month follow-up protagonists were again asked to report on post workshop changes and to review the status of the changes that they had reported at two weeks. Other life events that may have impacted on these changes were recorded.
Analysis
Ratings of in-session resolution were mapped against protagonists’ reports of resolution and a qualitative analysis of IPR responses was carried out. The steps in the analysis are outlined here.
Determining Degree of In-session Resolution
Sessions were judged to be resolved or not resolved based on criteria that were established prior to the workshop. Where the director and two independent observers all rated a session at “6: reaches resolution” on the DRS/PRP, and the protagonist reported experiencing resolution of their issue, the session was accepted as having in- session resolution. Where there was disagreement between the three judges or between the judges and the protagonist, it was considered that the session could not confidently be considered to be resolved. To provide a credibility check for the ratings of in-session resolution, information relating to protagonists’ experiences of post-session change resulting from participation in the workshop was analysed. Elliott’s (2002) broad criteria for evaluating efficacy of an intervention, were applied; that is (i) evidence of a change
Chapter 7 66 in stable conditions shortly after the intervention was compared to (ii) evidence that there was no change or that the change was trivial and (iii) evidence of plausible links between session events and the reported change was considered against (iv) evidence for alternative explanations for the change.
Qualitative analysis of IPR Responses
Using qualitative analysis, IPR responses within each case were coded into domains or themes and then into core ideas within each domain. A cross-case analysis identified patterns in the data to produce descriptions of protagonists’ processes and a comparison of protagonists’ processes between resolved and not resolved cases. Steps in the within-case analysis and cross-case analysis are described here.
Within Case Analysis
Cleaning up the data. Director and protagonist responses were reviewed and responses that did not relate to the protagonist’s process during the drama were excluded from the analysis. Three types of response were excluded: 1. Director’s comments about her intervention, emphasising the director’s intentions or clinical assessment with no reference to the actual impact of the director’s intervention on the protagonist; 2. References to other group members with no reference to the impact on the protagonist; 3. The protagonist relating past experiences or general tendencies without reference to the actual impact of the event within the session. Establishing domains. Kellermann’s (1992) seven therapeutic aspects of psychodrama were selected as the initial domains for the qualitative analysis, because this is a well documented model developed from early research by Kellermann and the model was considered both general and comprehensive. The initial domains were: 1. Director’s skills 2. Enactment 3. Action insight. 4. Interpersonal 5. Emotional release or catharsis
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6. Surplus reality (as-if) 7. Non-specific factors. All IPR responses from the director and the protagonist were coded into these seven domains and the domains were reviewed to determine if additional domains were required to accommodate all responses or if any domains were redundant. Constructing core ideas. Each response within a domain was reviewed and the meaning of the response was written in a brief statement. Using these statements, similar responses were grouped together, and the core ideas that captured the groupings were determined. Core ideas across all domains were reviewed and accommodated into logical groupings. The domain headings were amended to reflect the ideas within them. Abstracts were written, describing each domain and its core ideas. Auditing. An auditor reviewed the domains and core ideas, to ensure that the raw material was allocated to the correct domain, that all important material within each domain had been abstracted, and that the wording of core ideas was clear and reflective of the data.
Cross case analysis
The extent to which domains and core ideas were represented in all three cases was considered, in line with criteria used by Hill, Thompson and Williams (1997). Hill et al. classify data to be either general (pertaining to all cases), typical (pertaining to more than half the cases) and variant (applying to only one or two cases, where they have studied seven or eight cases). These classifications were adapted here because only three cases were being studied and to distinguish between resolved and not resolved cases. Because the study was concerned with the question of in-session resolution, the general category was used to refer to results that applied to both cases of in-session resolution and results that applied to one resolved case and not the other were considered to be variant. Two additional categories were included: common referred to results that applied to all cases, both resolved and not- resolved and the not-resolved category applied only to the not-resolved case. The typical category used by Hill et al. was redundant in this study because of the small number of cases. In-summary, the representativeness of domains and core ideas across the three cases was categorised as being one of the following:
Common: applying to all cases, both resolved and not resolved;
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General: applying to both resolved cases; Variant: applying to one resolved case but not the other and Not-resolved: applying only to the not-resolved case.
Describing key protagonist processes
Key protagonist processes were described applying the conventions used by Timulak & Elliott (2003). Events were described within their context, drawing on the recall responses of the director and the protagonist and using different font formats in the presentation of the responses, to indicate whether the material was based on protagonist or director recall.
Results
The results are reported in two sections. Firstly, the determination of degree of in-session resolution for each case is given with a summary of protagonists’ experiences of post session change. Secondly, the results of the qualitative analysis of IPR responses are presented.
In-session resolution and protagonists’ experiences of post-session change In-session resolution of painful emotional experience was assessed from director and independent observer ratings using the DRS/PRP and protagonists’ reports of feeling resolved or not resolved. The DRS/PRP was treated as a dichotomous measure for the purpose of this research, where a rating between 1 and 4 was treated as not-resolved and a rating of 5 or 6 was treated as resolved. This allowed direct comparison between the director’s and independent observers’ DRS/PRP ratings and protagonists’ self-report of in-session resolution.
Interrater agreement on the DRS/PRP
The director and one independent rater agreed 100% of the time on DRS/PRP ratings, and these ratings agreed 100% with protagonists’ self report of resolution. The second independent observer rated all sessions as resolved and because her ratings were constant, no test of interrater reliability could be performed.
Credibility of the ratings of in-session resolution
Protagonists’ reports of their experiences of post-session change provide a credibility check for the ratings of in-session resolution and give a fuller picture of
Chapter 7 69 the meaning that resolution or non-resolution had for each protagonist after the intervention. In two cases, the protagonists (Karen and Erin) were judged to have reached in-session resolution and in one case the protagonist (Ella) was judged not to have reached in-session resolution. An analysis of protagonists’ responses to the post-workshop evaluation and client-change interviews supported the grading of Karen and Erin’s psychodramas as having in-session resolution and the grading of Ella’s psychodrama as not having in-session resolution. Each case is summarised below.
Case Study 1: Ella
Ella’s session was focussed on the impact on herself and her family of having a daughter with a long term potentially fatal illness. At the time that Ella registered for the workshop, doctors were positive about her daughter’s prognosis for the first time in ten years, and the sense of having finally come through the ordeal contributed to Ella’s decision to participate in the workshop. However, within the two weeks following the workshop, Ella’s daughter had relapsed and six months after the workshop her daughter died. Her daughter’s relapse clearly impacted on Ella’s ability to participate in the IPR interview. The IPR process was stopped by the investigator and a general interview was conducted in its place. The director and one independent observer rated Ella’s session as having reached Stage 4 (‘reaches the meaning bridge’), while the second independent observer rated the session as having reached Stage 6 (‘reaches resolution’). Ella identified having a clearer awareness of how difficult her situation was and greater insight into the impact of her behaviour on other family members, but reported continuing to feel ‘stuck’ during her psychodrama session. Ella’s report is more consistent with having achieved Stage 4 and her session was judged to be not resolved. Ella rated her psychodrama session as being somewhat helpful. Following the workshop, she reported a heightened awareness of her relationships with significant others, which she considered would have been unlikely to have happened without the workshop, but experienced no change in the nature or quality of the relationships. She felt emotionally exhausted after the workshop. Ella linked feeling exhausted with a pervasive sense of tiredness and hopelessness in her psychodrama. Shortly after the workshop, her daughter’s medical condition relapsed and another member of her extended family was diagnosed with a terminal illness. These events
Chapter 7 70 contributed to Ella’s emotional exhaustion and feeling of hopelessness. The lack of change in Ella’s experience was summarised in the following recall statement: ‘I feel so tired. There is no answer … I have a real sense I want people to leave me alone, the same people I should want to be close to.’ (Source: Client change Interview). Ella received ongoing counselling after the workshop, leading up to and following her daughter’s death.
Case Study 2: Karen
Karen’s session was focussed on her experience of childhood bullying. The director and independent observers rated Karen’s session as having reached Stage 6 (‘reaches resolution’) on the DRS/PRP. Karen reported experiencing resolution of her painful emotional experience during the psychodrama, but noted that while she felt that the old experience had been resolved, she remained unsure about how this would assist her in the way she managed an ongoing difficult situation. She rated her session as being extremely helpful. She noted a change in her own functioning and in her response to situations, at two week and three month follow-up, but this was tempered by ongoing concern about a current issue that generated some responses similar to those of the original painful emotional experience. She found that she was less engaged in analytically processing events, which had been a goal she had set for the workshop. She attributed this change to actively identifying how she used obsessive thinking as a strategy for avoiding feelings, during her session. She found that she was more relaxed in response to surprise encounters with a person she had a difficult relationship with and generally she was experiencing more humour in situations. These changes were unexpected and she attributed them to her psychodrama session, noting that a major learning from her session was to ‘trust more and have more fun’ (Source: Post-Workshop Evaluation).
Case Study 3: Erin
Erin’s session was focussed on the impact of her daughter’s eating disorder and a breakdown in her relationship with her daughter. The director and independent observers rated Erin’s session as having reached Stage 6 (‘reaches resolution’) on the DRS/PRP. Erin was emphatic in declaring that she felt her issue had been resolved, identifying a specific moment during her session which she experienced as an integration of change. Erin rated her session as extremely helpful. She reported a
Chapter 7 71 major shift in her relationship with her daughter at two week follow-up that was maintained at three months follow-up. She cited instances where major issues arose between them that would previously have been unmanageable but which Erin and her daughter had been able to resolve while continuing to relate well to each. Erin reported continuing to experience a sense of an internal shift that had first occurred during her psychodrama session. Other family members had commented on the change in Erin’s behaviour and noted that she was generally more relaxed around her daughter.
General Features of Protagonists’ Experiences of Change
Karen and Erin both identified specific events in their psychodramas that they associated with in-session resolution and/or post-session change. These events included receiving a previously unmet need in relationship to a significant person in their lives and allowing themselves to take in a new healing experience. These events did not occur in Ella’s session, suggesting that they may be important to the resolution process. They have been summarised in the qualitative analysis of IPR responses that follows, under the domain of ‘Social Atom Repair/Resolution’ (Refer to Table 7.2). There was evidence that factors other than the psychodrama intervention may have contributed to self-reported post-intervention changes. Both Karen and Erin reported that their participation in the workshop was part of an ongoing change process. Erin reported that the work of her psychodrama was ‘the culmination of about 10 months work’. Karen reported that deciding to participate in a psychodrama workshop was part of her commitment to address issues in a different way to what she had in the past, by allowing herself to participate in the process rather than intellectualising. Both reported other aspects of the workshop, apart from their specific psychodrama session, as having an impact on the resolution of their issue. However, they both identified specific moments within their own psychodramas as critical in the resolution of a previously unresolved painful emotional experience. On balance, it would seem that the psychodrama sessions contributed significantly to the post-session outcomes for these two protagonists, but that the impact of the sessions was influenced by other factors. For Ella, negative life events in the period immediately following the workshop, and at the time of the three month follow-up, were of a significant nature and could
Chapter 7 72 plausibly have overshadowed any impact from the workshop. However, the ‘unresolved’ nature of her issues at the end of her psychodrama session was apparent in her responses immediately following the workshop and in her IPR interview.
Qualitative Analysis of IPR Responses
The results of the qualitative analysis of IPR responses are reported as a summary of the domains and core ideas that describe protagonists’ processes in the three cases. Patterns that were apparent across these domains, which give more meaning to the therapeutic experience of protagonists, are then described.
Domains and Core Ideas
Six of the initial domains derived from Kellermann’s model accounted for all IPR responses. Those domains were: enactment, action insight, interpersonal, emotional release, surplus reality and non-specific aspects. Responses related to the director were more readily allocated to the interpersonal domain rather than to therapist skills, so that this latter domain became redundant. There was a gradual realignment of domains in order to make meaning of the core ideas within each domain. With the realignment of the domains, the non- specific factors domain became redundant. All responses within the surplus reality domain were considered to fit within the interpersonal and/or enactment domains, so surplus reality was placed as a core idea under these two themes. Responses referring to action insight related predominantly to the impact of enactment on cognitions and were therefore placed as a core idea under the enactment domain. A theme around social atom repair/ resolution was identified, pertaining to a sense of resolution of the problematic issue or the development of a new and satisfactory role relationship. Responses in this domain were also coded across other domains. In this instance, social atom repair/ resolution was included as a distinct domain, despite the element of repetition, because it captured information particularly pertinent to the focus of the research – the question of in-session resolution. The final domains emerging from the data were: 1. Enactment A. Producing the scene B. Surplus reality - Role reversal C. Action insight 2. Interpersonal
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A. Working alliance with group members B. Therapeutic alliance with the Director. C. Surplus Reality - Encounter 3. Emotional Release 4. Social Atom Repair/ Resolution
The themes and core ideas within each domain are listed in Table 7.2, and are described and illustrated with case examples.
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Table 7.2: Protagonist & Director Recall of Significant Events within Psychodrama: Four Domains and the Core Ideas within Domains.
1. Enactment
A. Producing the scene: Setting out or enacting the scene produces a deepening of the protagonist’s warm-up to the presenting problem. Com 1. When the director asks the protagonist to set out the scene, or asks specific questions about the scene, the protagonist becomes more aware of the problematic feelings associated with the scene, or has an increased experience of the emotional pain. Gen 2. When the group participates in the action, it reduces the sense of social isolation in the protagonist and assists the protagonist to develop a new response to the situation. Var 3. When the protagonist watches the auxiliaries enacting an aspect of the scene, (Karen) she feels more distressed about what is happening and becomes more aware of her own processes. B. Surplus Reality – Role Reversal Com 4. The protagonist makes a stronger interpersonal connection from the role of the other. Com 5. The protagonist is able to express something that has been previously unspoken in the relationship, from the role of the other person. Com 6. The protagonist produces a new response in role reversal Gen 7. The protagonist becomes more aware of the experience of the other person, from the other person’s role. Non 8. When a role reversal intervention from the director is ineffective, the protagonist repeats old behaviour. Non 9. Feelings of helplessness or being overwhelmed increase in role reversal C. Action Insight: Setting out or enacting an aspect of the protagonist’s system assists the protagonist to make more sense of her experience. Var 10. The protagonist makes a cognitive shift (accurately labelling or making new (Erin) meaning of the experience) in the role of the other. Var 11. The action of setting out the system assists the protagonist to make sense of (Karen) her internal functioning and reduces intellectualising.
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2. Interpersonal
A. Working alliance with group members Com 12. The group and the director are experienced as accepting and safe. Gen 13. In the process of selecting an auxiliary for a significant positive role, the protagonist builds interpersonal connection with the auxiliary. Gen 14. In the process of selecting an auxiliary for a challenging role, the protagonist becomes more conscious of an aspect of her own functioning in relation to others. Gen 15. Group participation in the action reduces the sense of social isolation in the protagonist and assists the protagonist to expand an emerging response to the situation. (Same as (2) above) Gen 16. Questions or comments that the protagonist experienced as affirming assisted the protagonist to connect with her experience in the moment. Gen 17. Questions or comments that the protagonist experienced as inaccurate, took the protagonist away from her own experience. B. Therapeutic alliance with the Director Com 18. The group and the director are experienced as accepting and safe. (12 above) Gen 19. The director’s comment about the protagonist’s process or the protagonist’s system is experienced by the protagonist as accurate and affirming, producing increased awareness and/or spontaneity in the protagonist. Var 20. The director’s comment about the protagonist’s process or the protagonist’s (Karen) system is experienced by the protagonist as inaccurate or incomplete but the protagonist can ‘let it go’ and go along with the process. Non 21. The protagonist experiences the director as pushing too much. C. Surplus Reality – Encounter Com 22. The auxiliaries taking up their roles in an emotionally painful scene initially produces a defensive response in the protagonist. Gen 23. The protagonist experiences receiving a previously unmet need from an auxiliary in the role of a significant other. Var 24. The protagonist becomes upset or distressed in response to the auxiliaries (Karen) taking up their roles in a scene.
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3. Emotional release
Gen 25. The protagonist experiences a deepening of affective experiencing and/or relief in response to hearing from an auxiliary in the role of a significant other. Var 26. The protagonist experiences emotional release in the role of the significant (Erin) other.
4. Social Atom Repair
Gen 27. The protagonist experiences receiving a previously unmet need. Gen 28. The protagonist takes in a new experience, without censoring. Gen 29. The protagonist experiences emotional release or a sense of relief. (See (25) or (26) above) Gen 30. The protagonist sets out a self-presentation that incorporates an expanded sense of self. Var 31. During the drama the protagonist experiences a sense of integration of new (Erin) learning. Non 32. The protagonist reaches a clearer awareness of her situation that emphasises the difficulty of the situation and feeling stuck.
Note: Com = Common: Applied to all three cases. Gen = General: Applied to both resolved cases, but not to the not-resolved case. Var = Variant: Applied to one of the two resolved cases. Non = Applied only to the non-resolved case.
The domains and core ideas that are outlined in Table 7.2 are discussed in relation to the three cases that were examined and illustrated with extracts from the IPR interviews. Themes are presented in four sections: (i) themes common to the three cases, (ii) general themes that applied to resolved cases, (iii) variant themes within resolved cases and (iv) themes applying only to the not-resolved case.
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Note: In the descriptions that follow, letters in brackets following a description correspond to the core ideas (numbered 1 to 32) in Table 7.2 above.
Themes common to the three cases
Specific characteristics of the group and aspects of the production of the enactment were identified as therapeutically helpful by all protagonists, irrespective of whether or not they reached in-session resolution. The group and the director were experienced as being accepting and safe and this contributed to protagonists being willing to present aspects of their experience around which they felt vulnerable (12, 18). The production of the enactment, in particular the experience of setting out a scene related to a painful experience and the impact of reversing roles with a significant other in that scene, increased protagonists’ affective experiencing and exploration of interpersonal dynamics. When protagonists began to physically set out a scene, they became more warmed-up to their affective response to the experience of that time. This produced an increased awareness of the impact of the painful emotional experience (1). Role reversals, where the protagonist moved into the role of a significant other, increased the spontaneity of protagonists, bringing out new material and new responses to the situation (6). Protagonists reported feeling less inhibited in the role of the other and were initially able to make stronger interpersonal connections (4) or to express taboo topics (5) from that role. For example, Erin recalled: “Being my daughter Peta, I was able to say terrible things about my other daughter. She can say it because she’s just the sister, whereas it’s a taboo for me, being a mum, to say something like that.” Early enactments of problematic events elicited defensive or problematic responses from all protagonists (21). These responses were experienced as accurate expressions of protagonists’ internal responses to the situation. The relationship between increased affective experiencing, heightened awareness of the problematic dynamic and the emergence of a problematic response, is illustrated below, with extracts from protagonists’ recall interviews. In the first extract, Karen was reviewing a scene where she was interacting with auxiliaries in her parents’ roles. The first part of the recall refers to Karen being in her parents’
Chapter 7 78 roles and expressing her experience of their hopes and concerns for her life. Karen has a tendency to intellectualise, but she begins to be aware of her feelings in this enactment, while also making sense of the dynamic operating between her parents and herself. The second part of the recall refers to Karen’s response to her ‘parents’, when she returns to her own role. Here she experiences her emerging anger and represses this feeling, reverting to an established passive response.
(Karen): “I felt sad – I’ve got to get it right to make up for everything mum and dad have gone through. Everything they’ve gone through is only worthwhile if I turn out better. I started to get angry at what they were doing, and then I became passive. When I got annoyed with them I felt bad because I’m not being caring enough, not appreciative enough of what they’ve gone through. It’s better to take it passively than to get angry with them because they don’t deserve that.”
The next extract is from Erin’s recall of a scene where she is engaging with ‘Peta’, her daughter. ‘Peta’ has been expressing hurt and anger in response to Erin, and has accused Erin of rejecting and abandoning her. Erin’s recall illustrates how she warmed up to the experience of her relationship with her daughter, and how her feelings of hopelessness and despair produced a defensive response.
(Erin): “When the auxiliary (as Peta) said ‘I’m just along for the ride. I come last with you,’ it might as well have been Peta speaking. She’s intimated that I had time for everybody else but not for her, but she’s never said it directly to me. I know from my perspective that that wasn’t the case! The reality is very different from her perception. So I was thinking ‘No! That’s not true!’ I felt despairing and hopeless. I wanted to say ‘but it’s not true!’ I felt so frustrated! ‘No! Can’t you stop and think, don’t you know that’s not the case. Stupid girl!”
A deeper warm-up to the painful emotional experience and the enactment of the protagonists’ problematic or defensive responses, were common to all cases. The movement to a different response to the situation differentiated resolved cases from the not-resolved case. Themes that applied to the resolved cases only, offer possible explanations for the difference in in-session outcomes and these general themes are presented next.
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General themes applying to both the resolved cases
General themes were those that applied only to Karen and Erin’s resolved cases. Resolution was linked to (i) a therapeutic alliance between the protagonists and the director, (ii) a working alliance between the protagonists and other group members and (iii) receiving a previously unmet need combined with deeper affective experiencing and a sense of relief. These themes are illustrated with extracts from Karen’s and Erin’s case summaries. Themes that were specific to Ella’s not-resolved case are also noted, where they illuminate a difference between the resolved and not- resolved cases. The therapeutic alliance between protagonists and the director. Karen and Erin both identified moments when they experienced the director being affirming of them or accurately reflecting something of their inner experience (12) and they experienced these responses as being helpful. They also reported taking a co- operative stance in relation to the director, where they were able to ‘trust’ the psychodramatic process and felt a freedom to go along with the director’s interventions (18, 19). Interestingly, the two protagonists experienced this freedom from two very different perspectives. Erin more often recalled the director as affirming and accurate and herself as being more spontaneous as a consequence. In her recall interview she stated: “The way the director affirmed me all the way through and picked out key things I said, I got a sense of being carried or of being directed. I didn’t have to get it right, that’s her job.” Karen, on the other hand, recalled points where she chose to engage with the director in a different way, rather than to revert to her more typical response of arguing the point or intellectualising. In her recall interview she noted: “I don’t know if I agreed with what the director said, but I didn’t say anything. It would have been a distraction and I didn’t feel a need to argue the point.” In contrast to the two resolved examples, Ella recalled that she experienced the director as pushing her too much during the session. A working alliance between the protagonist and other group members. A working alliance appeared to develop between protagonists and other group members when protagonists chose group members to be auxiliaries in their enactment (13, 14), and when group members participated fully in the enactment (2, 15).
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Erin and Karen reported a heightened awareness of their positive connection with a group member when selecting that person to play a significant role in their enactment, and this awareness increased their positive feeling at that time (13). Furthermore, when the group member was being chosen for a role that challenged the protagonist, the selection process increased protagonists’ awareness of their own functioning in that area (14). This is illustrated in the following extract from Karen’s recall. Reviewing her process as she looked around the group several times before choosing a group member, Susan, to be her imaginary trusted and trusting friend, Karen recalled: “I could have picked Susan on the first time around. She was always going to be the trustworthy friend and she knew it too. I needed someone who’s not going to run away when things get hard, and that’s her. Neither of us looked at each other the first time around. I know she’s thinking ‘Oh god, it’s me’, and I’m thinking, ‘Oh god, it’s her’.”
Ella did not recall experiencing a link with group members when she was selecting auxiliaries. On the other hand, she did recall being reluctant to ask anyone to take the role of her seriously ill child and feeling isolated as the mother of a sick child. The working alliance between protagonists and group members was also apparent in the resolved cases when the participation of group members reduced the protagonists’ experience of being isolated and subsequently contributed to building on new responses that protagonists were developing (15). An extract from Karen’s recall and the recall of the director, in response to a scene where Karen was being bullied by ‘other children’ when she was a child, illustrates this theme (see Figure 7.3).
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Karen: Participation of the Group Reduces Isolation and Increases Spontaneity.
Legend: Plain type = director’s recall. Italics = protagonist’s recall. (Brackets) = contextual information.
(Karen had been socially isolated as a child and felt separate from her peers based on cultural and individual differences. In this scene, Karen was a young child being verbally abused and pushed by other children.) The director noticed that Karen was angry with the children but was also scared of anger. Karen attempted to fight against the children and her first attempt worked to a point. She was able to spontaneously say “Go away” with some feeling. At first, Karen found being angry towards the children was too hard: “I didn’t want to have to be mean. I didn’t want to be angry and hurt people.” The director noticed that Karen was still very constrained, and thought that she needed role training to learn how to express anger. This thinking was confirmed when Karen said: “Do we have to do that again?” in a tone that suggested she wanted to have another go. (Group members were invited to join with Karen to stand up to the bullies. A number of people immediately responded to the invitation and joined Karen on the stage. Karen and the other group members then pushed the ‘bullies’ out of the action space). Karen recalled: “When we started pushing against the bullies as a group I wasn’t into it at first, but by the time we pushed them out of the space I was totally into it. It works when there are lots of people doing it together. It’s more than just my bit; you’re all in there together, so you’re no longer on your own.”
Figure 7.3. Extracts from the recall of Karen and her director: Group participation reduces isolation and builds spontaneity.
Receiving a previously unmet need, deeper affective experiencing and relief. Karen and Erin both reported events in which they experienced receiving a previously unmet interpersonal need from a ‘significant other’ in a surplus reality enactment (23). They recalled experiencing a deepening of affect (25) and a sense of relief (29) during these events. Extracts from both cases (see Figures 7.4 and 7.5 below) illustrate these common themes while also illustrating the differences in the experiences of the two protagonists. Differences will be considered more fully later in this section.
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Figure 7.4 incorporates an extract from Erin’s recall interview with an extract of her director’s recall. Erin was enacting a surplus reality encounter with ‘Peta’, her daughter, but whereas earlier in the drama Erin recalled feeling ‘despairing, hopeless and frustrated’ during her interaction with ‘Peta’, during this event she experienced having a longed-for encounter (23, 27). Erin experienced emotional release from her own role (25) and from Peta’s role (2).
Erin: A Surplus Reality encounter with ‘Peta’ fulfils an unmet need.
Legend: Plain type = director’s recall. Italics = protagonist’s recall. (Brackets) = contextual information.
(Erin separated from Peta’s father when Peta was 11 years old. A series of family difficulties following that time, had contributed to a breakdown in Erin and Peta’s relationship. Subsequently, Peta developed an eating disorder and Erin felt guilty and distressed that in the early days of her daughter’s disorder she did not trust her intuition that something was wrong and that she has not been able to assist her daughter with the problem. At the beginning of this event, Erin had reversed roles with ‘Peta’, so that she was being ‘Peta’ as a child, facing ‘Erin’ and crying.) The auxiliary being Erin was coached to take an active role as a mother. She moved towards ‘Peta’ and put her arms around her, and when she did this, Erin expressed the depth of her pain from her daughter’s role; she was in touch with her daughter’s loneliness. Erin recalled: ‘As Peta I was feeling lonely, scared, back to when I was 11. So when my ‘mother’ reached out to me as ‘Peta’ it was a huge relief that I wasn’t on my own and I didn’t have to struggle with this all by myself. I was being listened to. I remember what a release it was just to cry. That felt so good to do, it was really cathartic.’ (Erin then returned to her own role and held ‘Peta’.) Erin recalled: ‘I felt really sorry for Peta and I just wanted to put my arms around her and say I’m sorry. All these things that had been held down were finally getting a voice and it felt good. I guess that’s been part of the problem; Peta and I have never got to the space where we can talk about this. It’s such a relief to be able to have an honest talk and hear honestly from her about all those things.’
Figure 7.4. Extracts from the recall of Erin and her director: Receiving an unmet need, with emotional catharsis and relief.
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In Erin’s example, there was a clear emotional release, which was not present in Karen’s example. Nevertheless, Karen did recall deeper affective experiencing while receiving a previously unmet need. Her experience is described in Figure 7.5.
Karen: A Surplus Reality Encounter with a Father Figure.
Legend: Plain type = director’s recall. Italics = protagonist’s recall. (Brackets) = contextual information.
(After an earlier event, where Karen had stood up to childhood ‘bullies’ (see p. 72), the auxiliary who was being Karen’s ‘father’, began spontaneously to tell Karen that he was proud of her and encouraged her to stand up for herself.) When the ‘father’ began to present new possibilities to Karen, it touched her very deeply that her father could be proud of her and she had tears at that point. Karen recalled: “I felt sad because this is what I wanted to hear. I’d like to be told ‘You stand up for yourself and you don’t let people hurt you’. I know my parents wouldn’t want to see me get hurt but I don’t get that message from them.” (Karen then reversed roles with her ‘father’). Karen recalled: “It wasn’t easy for me to be my father because he avoids emotion. So I gave this meaning by thinking ‘This is a father figure but it’s not my father’, and then I could let myself be a father”. Karen was able to access the positive loving feeling more as the ‘father’. Then, when she was back in her own role, her face showed that she was taking in the loving feeling. Karen recalled: “I kept my eyes closed to hear what he was saying, because I wanted to have my own image of a father speaking to me this way. I felt peaceful. I thought, ‘Everything is at rest, everything’s OK and works out in the end’.”
Figure 7.5. Extracts from the recall of Karen and her director: Experiencing receiving an unmet need in a surplus reality encounter.
Variant themes within resolved cases
There were a number of differences between the two resolved cases. A major point of difference was that while the protagonists reported experiencing action insight and increased affect in response to a psychodramatic intervention, they differed as to the type of psychodramatic interventions that they experienced as helpful in producing these responses. In particular, Erin more often reported that her direct participation in interpersonal interactions within the enactment was helpful,
Chapter 7 84 while Karen more often reported interventions where she was actively setting out a scene or observing group members re-enacting a scene, as being helpful. Furthermore, there was a qualitative difference between the experience of the two protagonists that was reflected in differences in their ability to engage in the psychodramatic process and differences in their reports of in-session resolution. These variant themes (that is, those themes identified by one protagonist but not the other) are reported here. Action Insight. Erin and Karen both reported gaining new insight as a result of engaging in their psychodramatic enactments (10, 11). However, the types of interventions that produced insight varied. Karen recalled insight events arising from physically setting out a scene or concretising some aspect of her internal functioning (11), whereas Erin recalled action insight arising from role reversal, that is, from being in the role of a significant other, or from direct interaction with a ‘significant other’ (10). These variant themes are illustrated in examples from each case (see Figures 7.6 & 7.7).
Karen: Choosing an auxiliary to be her ‘friend’
Legend: Plain type = director’s recall. Italics = protagonist’s recall. (Brackets) = contextual information
(Karen was having trouble selecting a group member to take a role as her friend, and she was walking around the group, avoiding eye contact with group members and talking about whether it was possible to choose someone as a friend). Karen recalled: “When the director asked me if there was a friend, I felt teary because I realised nobody had stood up for me. It made me think, ‘Yeah right, if there had been, that might have helped’. Walking around and thinking about choosing a friend was not comfortable because it hooked into my feelings.”* The director considered that Karen was trying to avoid her feelings and was caught in an obsessive thinking pattern that stopped her from relating to members of the group in that moment. (The director asked Karen to concretise her thoughts and feelings by setting them out in some way in the enactment space. Karen gradually sets out a series of scarves, naming thoughts and feelings with each scarf. She places them in a circle.) Karen recalled: “I felt slightly silly doing this, to hold the scarves as these different concepts, but it did feel like the right thing to do to put them where I did. I wasn’t
Chapter 7 85 really clear what some of them were, but I knew I was putting them in the right spot. I started to make sense of what I was doing when I saw the cycle I had set out with the scarves. I realised I was caught in a cycle: worrying about people not liking me because I’m not perfect, and the reason I’m not perfect is that I’m worrying about people not liking me.” The director noted that Karen broke her obsessive loop at that point, had more humour in her response to herself and was then able to make an intuitive choice of a group member to take the role of her friend, rather than working it out in her head.
Figure 7.6. Extracts from the recall of Karen and her director: Action insight arising from concretising an obsessive thinking pattern. * Note: Karen’s discomfort with affective experience was evident in her recall responses as well as her enactment. Her language was cognitive rather than affective.
In contrast, Erin recalled having a deeper insight into the experience of a significant other as a result of embodying the role of that person (7). This was illustrated in her recall of her experience of the first time she reversed roles to be her daughter, Peta (Figure 7.7).
Erin: Being in the Role of her Daughter, Peta.
Legend: Plain type = director’s recall. Italics = protagonist’s recall. (Brackets) = contextual information.
(Erin had placed ‘Peta’ in the scene, sitting down under a ‘tree’. When Erin reversed roles to be ‘Peta’, she began speaking standing up and then moved to the sitting position that she had originally set out for ‘Peta’). Erin recalled: “When I first started to speak as Peta and to say what ‘I’ felt towards ‘mum’, I thought ‘Wow, this is how it is for Peta, this is her perception of what happened.’ Then, when I sat down as ‘Peta’ I really felt the whole emotion of how it must have been for her, having to face all that stuff and being so lonely.”
Figure 7.7. Extract from Erin’s recall: action insight in role reversal.
In both examples, there was a quality of felt knowing that was more than an intellectual understanding, reflected in the protagonists’ recall of their experiences. Deepening of affective experiencing while observing auxiliaries or when reversing roles with significant others. Watching the auxiliaries enact an aspect of
Chapter 7 86 the scene generated a feeling of distress in Karen and she became more aware of her own processes (3), for example: “It was when the (auxiliaries in the roles of) parents, said ‘just ignore them. Ignore them and they’ll go away’. Huh! I start to feel sad again. … What tapped into it was watching (the Auxiliaries playing) myself being overcome by these things.”
In contrast, Erin recalled a deepening of affect arising during interpersonal interactions, including the impact of experiencing and acting from the role of the other and affective responses that emerged in encounter with auxiliaries. Ability to engage in the psychodramatic process. Karen’s recall included many references to her difficulties in engaging with the process. This included feeling agitated when she moved into other roles and experiencing some of the director’s comments as inaccurate. She associated these difficulties with her perfectionist approach to life. Qualitative differences in reports of in-session resolution. While both protagonists reported experiences that indicated resolution of their painful emotional experience, there was a qualitative difference in their reports. In particular, both reported a sense of relief, but only Erin reported emotional release, or catharsis. In the following extract, Erin was reviewing a second cathartic experience, towards the end of her session, which she associated with resolving her long held sense of guilt in her relationship with her daughter. Erin recalled: “I thought I’d finished crying and I felt a sense of release and calm. The director asked what I wanted to do with my guilt and my fear was that I can’t let go of guilt just like that, not after 20 years. Then when I went to let go of it, all the emotion just got wound up. I didn’t know what was going on; there were no words for it. It was almost like the feeling was allowed to come up; there were no blocks, no censoring, just being really in the experiencing. When the director said ‘Let yourself feel the hurt, I thought ‘Yes, this is what it is’. I’ve cried the way I did there a few times over the years, but this time, when the director named the hurt, it just lifted from me.”
Immediately after the event described above, Erin recalled experiencing an integration of her new learning. In her words: “I was forgiving myself. Accepting myself; this was my purpose for the workshop.”
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Themes Relating to the Not-Resolved Case
Themes that were specific to the not-resolved case are of interest in that they shed a contrasting light on the resolved cases. Ella recalled feeling tired and hopeless during her session (32); and the director noted that role reversal, rather than increasing spontaneity as it had in resolved cases, at times increased Ella’s feelings of hopelessness or of being overwhelmed (9), or that role reversals would fail and lead Ella to reproduce old patterns of behaviour (8). Ella recalled that she experienced the director as pushing her too much during the session (21).
Discussion of the Findings of the Preliminary Study
In-session Resolution
The results from the three cases investigated in this study support the proposition that there can be in-session resolution of painful emotional experience during a psychodrama, although in-session resolution does not always occur. The consistency of DRS/PRP ratings by the director and one of the independent observers and the relationship between these ratings and the protagonists’ helpfulness ratings, suggest that the DRS/PRP is able to differentiate between resolved and not resolved cases. There are, however, a number of grounds for caution in concluding that the DRS/PRP is a measure of in-session resolution. The first issue is related to reliability of the measure. The second observer rated all sessions as resolved. In relation to Ella’s case, there was no other evidence to support a resolved rating. There are a number of possible explanations for this. Factors other than the degree of resolution may have influenced her decision: the deep emotional experiencing in Ella’s session may have been construed as resolution; or a desire to assist the researcher may have influenced the observer to be overly positive. More training in the use of the DRS/PRP may be required to reduce the possibility of producing false positives. An alternative explanation is that Ella did achieve in-session resolution, but as this is not supported by any other evidence, it is not considered likely. The combination of DRS/PRP ratings with protagonist recall of in-session experience and post-session change provides a better basis for arguing the plausibility of the resolution explanation, than does the DRS/PRP alone.
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The second issue is related to construct validity, that is, whether or not the DRS/PRP actually measures in-session resolution. Two other sources of information suggested that the DRS/PRP was a measure of in-session resolution. Ratings on the DRS/PRP were correlated with protagonists’ session helpfulness ratings. Session- helpfulness is not the same as in-session resolution, so the two scales, while consistent, may measure something other than in-session resolution. The assumption of this study was that, if a protagonist achieved in-session resolution, they would experience a sense of relief and renewal within the session and there would be some indication of improvement in their functioning immediately following the workshop. Mapping post-workshop information against ratings of resolution supports the proposition that, for these three psychodrama sessions, the DRS/PRP has measured in-session resolution. A high session-helpfulness rating appeared to reflect a sense of relief, positiveness or hopefulness that emerged from the session, and to the extent that this is the case, may be an indicator of ‘beginning to feel empowered to make the change’, which is a component of Stage 6: ‘reaching resolution’ on the DRS/PRP. There appears to be a qualitative difference between the in-session resolution of Karen and Erin that is also reflected in their reports of post-session change. This difference was identified by the director and the first observer, but not detected by the DRS/PRP. Erin reported a significant shift in her sense of self and an experience of integration during the drama, followed by major changes in a significant relationship immediately following the workshop. Karen reported resolving her presenting issue during the session, but being unsure how this would assist her to manage a current difficult situation. It was not anticipated that post-session change would be enduring, particularly in light of the single-session nature of the intervention. Nevertheless, Erin reported that important changes in her relationship were maintained at three-month follow-up and experienced the change she made during the workshop as an enduring one. The protagonists’ recall of their experiences during psychodrama suggested that the ability of protagonists to accept the experience of receiving a new positive response may be an important aspect of in-session resolution. Further exploration of the nature of resolution is called for.
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Unifying themes from Protagonist and Director Recall
Kellermann (1992) notes that one of the consequences of categorising therapeutic processes is that arbitrary distinctions can be made between different elements of the one process. This has the potential to limit our understanding of unifying processes that are therapeutically meaningful. Key unifying themes that were identified across different core ideas are presented next.
Relationship with the Director
Positive relationships between the protagonists and the director, and between the protagonists and other group members, were reported in all cases. This appears to have been an important contributing factor in creating a context that assisted protagonists to be able to present their issues in the group. The director’s interventions elicited different reactions from the three protagonists. Erin consistently recalled the director’s interventions being accurate and helpful, and experienced this as affirming. Both Karen and Ella reported experiencing the director as being inaccurate or too pushy at some moments in the session. However, Karen was aware of noticing the dissonance but choosing to stay with the process rather than be distracted; whereas Ella experienced the dissonance as problematic. In psychodramatic terms, Erin and Karen experienced the director’s interventions assisting or at least not inhibiting their warm-up, whereas Ella experienced the director cutting across or inhibiting her warm-up. Clayton (2006) talks about the readiness of a protagonist, in terms of their ability to maintain their warm-up with increasing flexibility in their response to what happens around them. The different responses of the three protagonists suggest that the readiness of the protagonist to engage with their own experience may have an impact on how they experience the director’s intervention. If this was the case, Ella’s less flexible response to the director may have been an early indicator that she was not ready to change. It also raises the possibility that it is not so much the accuracy of the director’s intervention that is significant to therapeutic outcomes, but the confidence or hopefulness of the protagonist that something positive will emerge from the session.
The Impact of Auxiliaries and Role Reversal
When core ideas from director and protagonist recall interviews were analysed, there was considerable overlay between themes referring to ‘role reversal’ and
Chapter 7 90 themes related to the ‘working alliance with group members’, and these two themes accounted for the majority of IPR responses for the two resolved psychodrama cases. The use of auxiliaries in the enactment of interpersonal dynamics is central to the psychodrama method and a major point of difference that distinguishes psychodramatic role reversal from gestalt therapy’s empty chair technique. Interaction with auxiliaries contributed to a reduction in social isolation and a deepening of experiencing and provided an interpersonal context in which the protagonists could experience new responses to problematic situations. Social isolation has been identified as a symptom of unresolved painful emotional experience (Bolger, 1999) and there were two areas where Erin and Karen reported that auxiliaries contributed to building interpersonal connections and reducing their sense of social isolation. Firstly, during the process of selecting group members to take on auxiliary roles in the early phase of their sessions, they had a heightened experience of their positive relationship with the group member, which increased their positive feeling at that time. Secondly, when the protagonists were making an early attempt to produce a new response to a situation that had been problematic, group participation in the action reduced their self-consciousness and social- isolation, and led to a stronger enactment of the new response. This suggests a link between social cohesion and warm-up, where group members acting on the warm-up to the new behaviour strengthened the protagonist’s warm-up at a point where she may otherwise have chosen to abandon the new action. When auxiliaries took on and expanded the roles they were given, the protagonists experienced being able to enter into the scene in a way that reflected their actual experience of the relationship, ‘as-if’ it were happening in the here and now. In the early phases of the sessions, this included having a deeper experience of problematic situations; while in the latter part of the sessions, it included being able to experience receiving a previously unmet need. The strength of the interpersonal response provided by the auxiliary, elicited feeling responses and new awareness of the situation.
Emotional Release
At the outset of the study it was anticipated that catharsis would be a significant therapeutic event in resolved cases. There is no consistent evidence for this. While both Erin and Karen experienced heightened feelings during their sessions and a
Chapter 7 91 sense of relief towards the end of their sessions, only Erin recalled experiencing emotional release. Karen’s emotional expression was more restrained than Erin’s. This difference may be an indicator of individual differences in expressiveness; alternatively, Erin’s experience of integration during the session may have been a product of experiencing emotional release.
Contextual Factors
Contextual factors may be important to the resolution process. There would seem to be a training effect for all group participants, leading to a greater ability to enact roles and engage in the process as the workshop progresses. If this is the case, it would be anticipated that later sessions were more likely to have a higher level of spontaneity in the group and consequently were more likely to have a creative outcome. Characteristics of protagonists may have affected both the readiness of the protagonist to engage in the process and the style with which the protagonist engaged.
Differences between the two resolved Cases
A major difference in the process of Erin compared to Karen, was that Erin’s heightened awareness of affect emerged in interaction with others and particularly in role reversal, whereas Karen’s arose more often from the observer position, as she watched and was affected by the enactment of the scene. There are a number of possible explanations that may account for these different processes, including: (i) the nature of their presenting problems; (ii) the protagonists’ established coping roles, (iii) the influence of the protagonists’ previous training and experience and (iv) differences in the protagonists’ developmental stages. It is beyond the scope of this investigation to determine which if any of these factors are relevant in these cases. However, from the perspective of Morenian theory it is interesting to consider whether the experiences of the protagonists reflect developmental differences. According to Moreno (1946/1980), the person operating at the developmental stage of the mirror is not yet sufficiently individuated to engage in an encounter and requires mirroring of their experience to be able to differentiate and make sense of what is happening. The person operating at the stage of role reversal, on the other hand, is able to role reverse with others and recognises what is their own experience and what is the experience of the other. In Moreno’s developmental model, Karen
Chapter 7 92 might be considered to be operating at the stage of the mirror and Erin at the stage of role reversal. Karen had some difficulty entering into the role of the others in her session. Interestingly, both experienced in-session resolution of their painful emotional experience. The question arises as to whether a protagonist needs to be at the stage of role reversal before they experience the catharsis and degree of integration that Erin reported.
Limitations of this Preliminary Study
The classical IPR method applied in this study enabled participants to reflect on a protagonist’s experience throughout the session, but was not intended to identify the most significant therapeutic events in the session. As Greenberg (1999) has noted, some session events are more therapeutically relevant than others. No conclusions can be drawn, then, regarding the key change events in the sessions. The open-ended nature of the recall sessions and the vast amount of material that was reviewed may have meant that recall participants did not always report on significant events. Responses of protagonists and the director could not always be compared, when they had not both selected a particular moment to reflect on. Ella did not complete her recall, because a worsening of her family situation after the workshop affected her ability to review and reflect on the video. A full recall from the not-resolved protagonist was therefore not available. However, the segment she did review, along with her post-workshop evaluation, was consistent with the recall of the director.
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Summary
This study established that there can be resolution of painful emotional experience during psychodrama. The DRS/PRP differentiated resolved and not- resolved psychodrama cases and mapping protagonists’ recall of in-session processes, with reports of in-session and post-session impact, provided corroborating evidence of resolution. Four psychodramatic constructs were associated with helpful events within the sessions: enactment, the protagonist’s working alliance with the director and with other group members, emotional release or relief and social atom repair. Based on the recall of the three protagonists in this study, the experience of resolution during psychodrama may include emotional release and a sense of relief, receiving a previously unmet need, accepting a positive response towards self and having an expanded sense of self during the session. There was no conclusive evidence that catharsis was necessary for resolution, with one resolved protagonist recalling her experience of catharsis as extremely helpful and the other resolved protagonist referring only to experiencing a sense of relief. An experience of integration within the session may indicate a higher level of resolution. As a preliminary study, the findings reported here are encouraging, but insufficient to draw general conclusions about protagonist’s processes that lead to in- session resolution of painful emotional experience.
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Chapter 8 An Investigation of Protagonist Processes Leading to In- session Resolution of Painful Emotional Experience during Psychodrama: Building the Model
This chapter introduces Study 2, the pivotal study of this thesis, which was a comprehensive analysis of change processes linked to in-session resolution of painful emotional experiences during psychodrama. The research plan for Study 2 is outlined in Figure 8.1.
WORKSHOP 2 (Cases 5, 6, 8 & 10) & WORKSHOP 3 (Cases 4, 7 & 9)
1. Identify Resolved & Resolved cases Not Resolved Cases 2. Identify significant change events
4. Develop Model ▪ Examining patterns in the data.
Not resolved cases 3. Detailed description ▪ Within Case Analysis ▪ Cross case analysis 5. Compare to detailed description Verify with further cases of not-resolved 6. Modify model in subsequent study. cases (see Chapter 11)
Figure 8.1. Study 2 Research Plan: Multiple Case Study Investigation of Significant Change Events Using Comprehensive Process Analysis.
Overview of Study 2
The overall aim of the four studies that make up this body of research was to build a model of protagonist processes leading to in-session resolution of painful emotional experience during psychodrama. Study 2 was designed to build such a model through the detailed analysis of twenty significant events across seven psychodrama cases. Comprehensive Process Analysis (CPA) was used to identify Chapter 8 95 and describe the therapeutic meaning of those events, by considering context, process and impact factors. Through the analysis of multiple cases, common themes were identified and a model of change was constructed. Not-resolved cases served as an internal control, so that the proposed model identified differences between the processes experienced by protagonists who achieved in-session resolution and protagonists who did not. Before introducing the study itself, the relationship of this investigation to the findings of the preliminary study (Chapter 7) is established. The main body of the chapter presents the research, detailing the rationale for using CPA and the steps in the procedure and analysis of the study. The findings are presented, with a summary of the seven cases and a description of protagonists processes, illustrated by case examples. Five meta-processes linked to in-session resolution are identified and a four-task model of in-session protagonist processes leading to in-session resolution of painful emotional experience is proposed.
Context for the Second Study The development of theory and models of practice in the psychodrama literature has relied heavily on published case reports that present psychodrama practitioners’ (directors’) observations of their own practice, at times accompanied by clients’ (protagonists’) reports of their experiences. There has been an absence of rigorous analysis of the processes that occur during a psychodrama session, apart from the work of Kellermann (1992), which relied on the reports of directors and protagonists some time after the intervention had taken place, and several small studies such as that of Brooks (2002), which was based on the recall of protagonists. Furthermore, these process studies have investigated psychodrama interventions generally and have not investigated targeted applications of the method. The preliminary study introduced a more rigorous approach to analysing directors’ and protagonists’ reflections on their experiences by applying a multiple case study design, using video-assisted interpersonal process recall (IPR: Kagan, 1980; Kagan & Kagan, 1991), focussing specifically on the resolution of painful emotional experience and analysing both resolved and not-resolved cases. In that study, protagonist and director recall of helpful and unhelpful events across three psychodrama sessions (2 resolved and 1 not-resolved) identified a number of experiences that were linked to in-session resolution of painful emotional experience. Chapter 8 96
Processes that were identified as being helpful included: (a) a reduction in the protagonists’ avoidant or defensive behaviour, when habitual defensive responses were concretised in action; (b) a deepening of experiencing and cognitive changes arising during the enactment; (c) decreased social isolation and increased spontaneity resulting from group members participating in the action; and (d) a deepening of affect and a sense of relief arising from the protagonist allowing herself to receive a needed, but previously unavailable response from a significant other, in a surplus reality enactment. An interesting finding of the preliminary study was that while both resolved protagonists identified similar change processes, in some instances they were achieved through the use of different technical interventions. This suggests that investigating protagonist change processes, rather than specific psychodramatic techniques, may be a fruitful area of enquiry. The earlier preliminary study had a number of limitations which this current study sets out to address. Firstly, it was based on a very small number of cases, and the analysis of additional cases is required before patterns can be identified with any degree of confidence. Secondly, the recall process scanned the whole session, rather than focussing on events that were identified as most therapeutically significant. It has been argued that not all processes within a session are equally important and that process research needs to focus on therapeutically significant events, that is events that are linked to therapeutic change, to ensure that the processes that are identified and described are therapeutically meaningful (Greenberg, 1986; Greenberg & Newman, 1996). Thirdly, the preliminary study relied on the subjective recall of the two central participants in the session, the protagonist and the director. While recall information makes a vital contribution to understanding therapeutic processes and in particular to uncovering the subjective experiences of the participants, an important motivation for this research was to address the lack of independent analysis and review in the psychodrama field. This requires a broader data base for analysis. This second study, which is reported here, was a discovery-oriented investigation that sought to describe in detail protagonists’ experiences of significant change events, using Comprehensive Process Analysis (CPA; Elliott, 1983; Elliott, Packer & Addison, 1989). It built on the findings of the preliminary study by drawing on a larger number of cases and targeting significant change events within sessions to enable an intensive analysis of these events. The therapeutic significance of in- session events was investigated by examining the in-session and post-session impacts Chapter 8 97 of these events. If the findings of the preliminary study can be substantiated with additional cases and the therapeutic significance of events established, a model of protagonists’ processes during psychodrama can be developed.
Research Questions In order to build a model of protagonist change processes, the following research questions were posed:
RQ 3: What protagonist processes are linked to in-session resolution of painful emotional experience during psychodrama?
RQ4 What is the post-session impact of protagonists’ in-session change processes?
Method
This section details the research method for this multiple case study. The research question is concerned with change processes and this requires establishing the links between processes and outcomes. In order to do this, the study was concerned with collecting and analysing data to (a) compare protagonists and other group members, to establish general effects of being a protagonist in a psychodrama; (b) investigate the efficacy of the psychodrama intervention, to establish links between the intervention and post-session changes; and (c) develop a detailed description of protagonist processes linked to in-session and post-session change.
Participants
Group members Expressions of interest were called for people to participate in a psychodrama workshop addressing painful emotional experience. People who expressed interest and met the suitability criteria for participation were allocated in order of their registration to one of two workshops. Suitability for participation was assessed in pre-workshop interviews, on the basis of participants being able to identify a painful emotional experience that continued to affect them in their lives and having adequate ego strength to participate in the workshop. Ego strength was assessed on clinical observations of the participant’s functioning, their ability to identify social supports outside of the Chapter 8 98 workshop setting; and having realistic strategies for managing the possible emotional distress that could arise through participating in the workshop. There were nine participants (six female and three male) in the first group (Cohort 2) and eight participants (six female and two male) in the second group (Cohort 3). The ratio of female to male participants is typical of other client groups run by the psychodrama directors in this study. The demographic characteristics of the participants are presented in Table 8.1. Participants ranged in age from 27 to 66 years, with a mean age of 46.9 years in cohort 2 and 41 years in cohort 3. They were mostly tertiary educated (15 of 17) and all but one, who was retired and working in a voluntary capacity, were in paid employment. There was a range of previous psychodrama experience, with about half of the participants having no previous experience of psychodrama. There was a range of exposure to other forms of counselling, although Cohort 2 had a higher percentage of participants with no previous counselling experience, than any other Cohort in the research.
Protagonists Seven participants volunteered to be protagonists (three females and one male in the first workshop and two females and one male in the second workshop) to address an identified unresolved painful emotional experience in a psychodrama session. The protagonists were aged from 35 to 60 years, and had no previous exposure to psychodrama with the exception of one protagonist who had participated in a one day introductory psychodrama program for health professionals. Chapter 8 99
Table 8.1. Demographic characteristics of the Study 2 cohorts, compared with characteristics of all participants across the four studies. Total 4 cohorts Cohort 2 Cohort 3 (N=32) (n=9) (n=8) Gender Female 24 (75%) 6 (66.6%) 6 (75%) Male 8 (25%) 3 (33.3%) 2 (25%) Age Range 27-66 yrs 29-66 28-59 yrs Mean 46 yrs 46.9 41 yrs Highest level Secondary 3 (9.4%) 2 (22.2%) 1 (12.5%) of education Tertiary 29 (90.6%) 7 (77.8%) 7 (87.5%) Prior Psychodrama experience None 16 (50%) 4 (44.4%) 5 (62.5%) One previous session 5 (15.6%) 1 (11.1%) 1 (12.5%) > one psychodrama group 4 (12.5%) 1 (11.1%) 1 (12.5%) Some psychodrama training. 7 (21.9%) 3 (33.4%) 1 (12.5%) Counselling history Currently receiving counselling 9 (28.1%) 1 (11.1%) 3 (37.5%) Counselling in past 12 months 6 (18.75%) 2 (22.2%) 1 (12.5%) Counselling in past 1-5 years 6 (18.75%) 1 (11.1%) 1 (12.5%) Counselling > 5 years ago or never 6 (18.75%) 2 (22.2%) 2 (25%) Never received counselling. 5 (15.6%) 3 (33.4%) 1 (12.5%) Type of painful emotional experience. 1. Emotional abuse * 7 2 (1P) 3 (2P) 2. Domestic violence 4 1 (1P) 2 (1P) 3. Physical &/or sexual abuse* 6 1 1 4. Death of parent* 2 1 (1P) 5. Death of family member 3 2(1P) 6. Separation from parents* 3 1 7. Partner with PTSD 1 1 8. Loss of health 1 1 9. Other 5
Notes: * Indicates childhood experience. (P) Indicates number of protagonists presenting with the nominated painful emotional experience. Chapter 8 100
Psychodrama directors Three certified psychodrama practitioners (directors), with extensive experience in the psychodrama method, participated in the study. The principal investigator directed two sessions in the first workshop. Another director participated in both workshops and directed three sessions in total (two in the first and one in the second workshop) and the third directed two sessions in the second workshop. The involvement of the principal investigator in the intervention phase was discussed in some detail in Chapter 6. This involvement offers a number of advantages for the collection and interpretation of data in discovery-oriented research. In proposing what he calls an ideal approach to psychotherapy research, Greenberg (1999) states: ‘I would insist on being one of the therapists participating in the study, as I believe that the researcher has to draw on his or her tacit understanding of change to help explicate change phenomena’ (p. 1468). Mahrer and Boulet (1999) likewise advocate that the researcher engage with the evolving process of discovery, by trying out emerging ideas to refine understanding of the phenomenon of therapeutic change. There are a number of potential limitations accompanying this approach, notably researcher bias in the intervention and analysis phases and the impact of the therapeutic relationship on participants’ responses to post-intervention questionnaires. These potential limitations were addressed both within the procedure and the analysis phases. Most sessions (five of a total of seven) were conducted by the other two psychodrama directors. Post-intervention interviews with protagonists who had been directed by the investigator were conducted by other members of the research team and the data analysis was carried out by a team using a consensus decision making approach and scrutinised by auditors. These steps are outlined later in this chapter.
Measures A battery of self-report questionnaires and semi-structured interview protocols were administered to all participants at pre-intervention, immediate post- intervention, two week and three month follow-up. Additional questionnaires and semi-structured interviews were administered to protagonists post-intervention and at two week follow-up. Details of the instruments used are outlined in Table 8.2.
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Table 8.2. Assessment Points for Outcome and Process Instruments Assessment Point* Instrument Pre Post Post 2 wk 3 mth 1 2 All Personal History Questionnaire X X X Participants Symptom Checklist X X X (SCL 90-R) Inventory of Interpersonal Problems (IIP- X X X 127) Post-workshop Evaluation X Participant Change Interview X Protagonists Session reaction scale X Helpful Aspects of Therapy (HAT) X Questionnaire Protagonist Recall Form X Director Director recall form X
Note: * Pre = pre-intervention, Post 1 = immediately after the psychodrama session, Post 2 = immediately after the completion of the workshop, 2 wk = 2 week follow-up, 3 mth = 3 month follow-up.
The Personal History Questionnaire (PHQ) and the Post-workshop Evaluation Form were developed for the preliminary study and a description of each can be found in Chapter 7. A description and discussion of the other instruments are provided here.
Outcome measures Symptom Checklist Revised (SCL90-R: Derogitas, 1983). The SCL90-R is a 90 item self-report symptom inventory designed to measure general psychological distress, that has been established as a reliable measure of clinical caseness and a useful measure of general therapy outcome (Derogatis,Fitzpatrick & Maruish, 2004). It has been extensively investigated for use as a clinical and research tool with a wide range of populations internationally (Derogitas et al., 2004; Olsen, Mortensen & Bech, 2004) and is commonly used in efficacy and change-process research (for example, see Elliott, 2002). In addition to an overall General Severity score (GSI), the inventory reports on nine sub-scales of psychological distress symptoms: somatisation (SOM), obsessive- Chapter 8 102 compulsive (OBS), interpersonal sensitivity (INT), depression (DEP), anxiety (ANX), hostility (HOS), phobic anxiety (PHO), paranoid ideation (PAR) and psychoticism (PSY). There is some debate over whether the SCL90-R is a multidimensional instrument or unidimensional instrument measuring general psychological distress. Clark and Watson (1991) propose that it has a tripartite structure of three factors: general distress, hyperarousal (specific anxiety) and anhedonia (specific depression); while others have concluded that the tripartite structure is not consistent across different populations and that different sub-scales combine to form different factors for different populations (Schwartzwald, Weisenberg and Solomon, 1991). Pedersen and Karterud (2004) suggest that the SCL90-R measures subjectively perceived symptom distress and that individual interpretations of the meaning of items are more likely to be identified and accounted for in clinical interviews making the instrument less reliable for differentiating specific disorders. The GSI was found to be an accurate predictor of clinical dysfunction in just over 90% of cases (Pedersen & Karterud, 2004). In summary, while the SCL90-R is a good measure of general psychological distress, clinical interpretations of the nine sub-scales need to be approached with caution. Inventory of Interpersonal Problems (IIP-127: Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988). The IIP-127 is a self report questionnaire that identifies general interpersonal distress and eight specific areas of interpersonal concern: dominance, vindictiveness, hostility, coldness, submissiveness, introversion, exploitability, excessive nurturance and intrusiveness. The inventory was constructed from interpersonal problems that people regularly present with for counselling and was designed to differentiate between interpersonal distress and distress due to non-interpersonal problems. Studies using the shorter form IIP-64 found that results correlate with self-reports of interpersonal performance, but not with peer reports of interpersonal functioning (Clifton, Turkheimer & Oltmanns, 2005; Leising, Rehbein & Sporberg, 2007). This supports the use of the inventory as a measure of interpersonal distress rather than of interpersonal functioning.
Process Measures The Degree of Resolution Scale: Unfolding Problematic Reaction Points. (DRS/PRP: Greenberg, Rice and Elliott, 1993). The DRS:PRP was used in the preliminary study to rate in-session resolution, and a description of the measure is Chapter 8 103 given in Chapter 7. Results of the preliminary study suggested that the DRS: PRP was a reliable measure of in-session resolution, when confirmed by protagonist reports of their experiences during the session and the impact of the session. In that study a rating of partial resolution (4 on the 6 point scale), was consistent with the protagonist reporting increased awareness of the impact of the painful emotional experience on their current functioning and interpersonal relationships; while ratings of in-session resolution (6 on the 6 point scale) were consistent with protagonists reporting experiencing some resolution in relation to an aspect of their functioning, and reporting improvements in their flexibility to respond to situations after the workshop. Revised Session Reaction Scale (RSRS: Elliott, 1993). The Revised Session Reaction Scale is a self-report measure of a client’s experienced effects of a single therapy session. The RSRS asks clients to rate the overall helpfulness of a just- completed therapy session on a 9 point adjective anchored scale, where 1 is ‘extremely hindering’ and 9 is ‘extremely helpful’; and to rate their experience on 24 items describing possible reactions to the session, on a 5 point scale (from 1 = not at all to 5 = very much). Factor analysis of the RSRS identified a substantial general factor of ‘helpful reactions’, that had a three sub-factor structure of ‘task helpfulness reactions’, ‘relationship helpfulness reactions’ and ‘hindering reactions’ (Reeker, Elliott & Ensing, 1996). RSRS helpful reactions were highly positively correlated with other measures of general session satisfaction and hindering reactions were negatively correlated with these measures; while there was no correlation between the RSRS and post-session outcome measures. Based on these findings, Reeker, et al. concluded that the RSRS is best considered a tool for investigating in-session process, rather than therapy outcome. The original Session Reaction Scale and the RSRS have been used extensively in experiential process research and the RSRS is one of a number of instruments routinely used in CPA. The RSRS was modified for this study to incorporate three items pertaining to possible reactions to group members; two relationship helpfulness reactions (supported by the group and understood by the group) and one hindering reaction (criticised by the group). Helpful Aspects of Therapy Questionnaire (HAT; Llewelyn, 1988). The HAT asks clients to identify the significant events in a session and to rate them on a 9- Chapter 8 104 point adjective-anchored scale, ranging from (1) extremely hindering to (9) extremely helpful. Client Change Interview (Elliott, 1999). The Client Change Interview is a semi- structured interview that asks clients to report on post-therapy changes and their attribution of cause for those changes, and to rate self-reported changes on three five- point scales: (i) importance of the change (1= not at all to 5= extremely), (ii) how much the change was expected (1= very much expected to 5= very surprised by the change) and (iii) how likely the participant thought it was that the change would have occurred without the intervention (1= very unlikely to 5= very likely). Protagonist and Director Recall Forms. The Brief Structured Recall (BSR) method is guided by two interview protocols: a Client Event Recall Form and a Therapist Event Recall Form (Elliott & Shapiro, 1988; Elliott, Packer & Addison, 1989). A combination of structured and open-ended enquiry is used to elicit protagonist and director recall of their in-session experience of the context, process and impact of significant therapy events. The protocols were designed for individual psychotherapy research and minor changes were made for use in this current project, referring to protagonist and director rather than client and therapist and including items asking about group interactions.
Procedure Seven psychodrama sessions were conducted over two separate workshops (four in the first workshop and three in the second workshop). Self-report questionnaires and semi-structured interviews were administered to participants prior to the workshop, and at several points during and after the workshops, and brief structured recall interviews were conducted with protagonists and directors at two week follow- up. The steps in the procedure are outlined in Figure 8.2 and then described.
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1. Base-Line Data
2. Intervention: video tape psychodrama enactments
3. Immediate Post-intervention follow-up
4. Two week follow-up
5. Three Month follow-up
6. Transcribe video-recordings
7. Brief Structured Recall (BSR)
8. Establish and train research team
Figure 8.2. Steps in the Procedure for Study 2
Baseline Data. All participants completed a battery of self-report questionnaires and inventories prior to the intervention (see Table 8.2).
Intervention Two psychodrama workshops were conducted, following a similar format to the workshop in Study 1 (Chapter 7) and psychodrama enactments were video-recorded. There were seven psychodrama enactments in total, four in one workshop and three in the other, each with a different protagonist.
Immediate Post-Intervention Follow-up Protagonists completed a Revised Session Reaction Scale, about one hour after their psychodrama session. At the completion of the workshop, all participants completed a Post-workshop Evaluation Form.
Two week and three month follow-up One week after the workshop, participants were given a copy of the Client Change Interview protocol and asked to reflect on the interview questions, in preparation for a follow-up interview. At a two week follow-up meeting, the SCL90- Chapter 8 106
R and IIP-127 were administered and change interviews were conducted. The SCL90R and IIP-127 were administered again at three-month follow-up and an abbreviated Participant Change Interview was conducted with protagonists.
Transcribing video recordings Video recordings of psychodrama sessions were transcribed by the investigator, identifying the speaker, the role the speaker was acting from and non-verbal behaviour. Video recordings and transcriptions were reviewed and the transcripts amended by members of the research team.
Brief Structured Recall Method (BSR; Elliot & Shapiro, 1988). At the two week follow-up interview, protagonists reviewed video-recordings of their sessions and completed a semi-structured recall interview for each significant event they had identified within their session, using the BSR method. To ameliorate the impact of the therapeutic relationship on the recall process, the investigator only conducted recall interviews with the four protagonists whose sessions she had not directed. An independent interviewer administered the recall interview for the two protagonists directed by the investigator. Selecting Significant Events. Significant events within enactments were selected by protagonists, after their psychodrama session. Prior to the BSR interviews, the investigator reviewed the recording of each enactment, located the events the protagonist had identified, and established markers for the beginning and end of the scene or sub-scene that contained each event. Although it is standard practice with BSR that clients determine the parameters of significant events, the investigator did so in this study because of the time required to identify a number of events within each session, and to ensure that contextual information that was theoretically relevant was included in the material to be reviewed. The marker for the start of each scene was selected on the basis of maintaining the integrity of the scene, so that the interviewee would be able to review events in their context. The end marker of each scene was selected as the point where there was a resolution of the particular event, or the physical scene in the psychodrama was changed. During the recall process, the protagonist was again able to identify event peaks or specific sub-events within each scene that they considered significant, ensuring that there was clear and specific information about the particular experience that was relevant to the protagonist. In Chapter 8 107 this way, the protagonist remained the authority on what was significant about the scene. Recall interviews. Each protagonist watched a recording of the first significant scene. Using the Protagonist Event Recall Form, the interviewer asked a series of qualitative and quantitative questions regarding the protagonist’s experience of the scene, peak events within the scene, and their impacts. This procedure was repeated for each subsequent significant scene. Directors reviewed recordings of the scenes that the protagonists had identified as significant, and completed the self- administered Director Event Recall Form.
Establishing the research team A four member research team was established, with the investigator and three other female psychologists. In selecting team members it was considered important that they had some experience of psychotherapy and that there was a mix of therapeutic perspectives, apart from psychodrama. All were registered practicing psychologists. Only the principal investigator was a certified psychodramatist; two team members had some psychodrama training, but their practice was based in other psychological approaches and the fourth had some awareness of psychodrama, but no formal training or experience in the method. The three members were invited to join the team because they expressed some interest in the research. They had experience in the field of counselling and psychotherapy and perceived that involvement on the team would offer a professional development benefit to them that was likely to keep them engaged in the project, and they were available to meet on a regular basis over a long period of time. At the commencement of the project, each team member wrote a written response to a set of questions about their personal expectations and biases in relation to the research topic. These statements are included in Appendix C. Team members were introduced to the rationale and procedures for Comprehensive Process Analysis. The consensus decision making philosophy was discussed and procedures for articulating and exploring differences were agreed. Decision making processes and norms within the team were reviewed at various times during the project. At each step of the analysis of single cases (refer to the Analysis section, below) the team reviewed the procedure before individual team members commenced their assessments. Chapter 8 108
Analysis The data analysis was carried out in four stages: (a) linear mixed models method with a repeated measures design was used to analyse pre and post intervention results for the 17 group participants; (b) hermeneutic single case efficacy design was applied to the seven protagonist cases; (c) cases were rated for degree of in-session resolution and (d) a Comprehensive Process Analysis (CPA) of significant therapeutic events was conducted. The purpose of each stage of the analysis is outlined in Figure 8.3, and the four types of analysis are then described in more detail.
ANALYSIS PURPOSE
Linear Mixed Models Method: Compare pre and post functioning on Repeated measures design standardized measures; compare protagonists and other group members.
Hermeneutic Single Case Efficacy Identify links between the psychodrama Design intervention & qualitative & quantitative indicators of post-session change.
Rate in-session resolution Classify cases for cross case analysis of CPA
Comprehensive Process Analysis Identify & describe Protagonist Change
(CPA) of Significant Change Events Processes.
Figure 8.3. Stages in the data analysis for Study 2
Linear Mixed Models Method
Linear mixed models method with a repeated measures design was used to analyse the within group and between group differences on the SCL90 -R GSI and the
IIP-127 at pre-intervention, two week and three month follow-up. Linear mixed models method provides greater statistical power when working with small sample sizes, by accounting for subject variance (Garson, 2008).
This analysis considered the following questions:
• Is there a difference overall between protagonists and non -protagonists?
• Is there a difference between participants’ scores at pre- intervention, 2-week
and three month follow-up?
• Is there a difference in the amount of change from pre-intervention to post-
intervention, between the two groups (protagonists and non-protagonists)?
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The analysis was exploratory rather than hypothesis based, with a number of factors which might potentially influence outcomes and variance within and between groups. Psychodrama principles of practice hold that all participants in a psychodrama enactment may benefit, regardless of whether they become protagonists. If this is the case, it could be anticipated that there would be no differences in outcomes between the two groups. However, findings from one study have suggested that being a protagonist in a psychodrama enactment can produce different in-session effects than for non-protagonists (Kim, 2003), and if this is a generalised effect, it might be expected that protagonists would report better outcomes than other group members. On the other hand, the research design assumed that some protagonists would reach resolution of their presenting concern, while others would not. There is some evidence that suggests that in-session resolution is predictive of post-session improvement (Watson & Greenberg, 1996), so that there may be variance in post-intervention change within the protagonist group. It was anticipated that there would be no significant differences between protagonists and other group members. Furthermore, this study did not target a clinical group and it was anticipated that this would reduce the likelihood of significant post-session changes.
Hermeneutic Single Case Efficacy Design (HSCED) Hermeneutic Single Case Efficacy Design (HSCED: Elliott, 2002) is concerned with understanding the impact of an intervention for an individual client. It aims to establish a plausible case for the efficacy or otherwise of the intervention, based on an analysis of a broad range of qualitative and quantitative data against pre- established efficacy criteria.
Rationale for using HSCED HSCED provides rich information about links between intervention and outcome, which can inform practitioners’ decision making (Elliott, 2002). This research was interested in the impact of the significant change events being analysed and short term and longer term therapeutic outcomes are one aspect of this impact. Identifying a link between in-session resolution of painful emotional experience and therapeutic outcomes is complex. The traditional approach of random clinical trials (RCTs) attempts to control for alternative explanations of change in the intervention design. There are limits to the value of this type of research when investigating systemic interventions such as Chapter 8 110 psychodrama. Firstly, group processes leading up to and following the protagonist’s session are intrinsic to the psychodramatic method and could not be excluded from the intervention design without affecting the integrity of the method. Secondly, possible research effects of allocating participants to psychodrama and non- psychodrama groups place additional constraints on clinical trials. So RCTs are not ideally suited to this context. But even if they were, they do not provide the richness of information about links between intervention and outcome that are possible through approaches such as HSCED. This approach allows the impact of the protagonist’s psychodrama session, as distinct from the general impact of the workshop and other possible mediating factors, to be considered. Furthermore, it was an assumption of this study that a lack of in-session resolution did not necessarily mean that a session was not therapeutically helpful; but that a comparison of the efficacy of resolved and not-resolved cases might provide a more detailed understanding of the post-session impact of in-session resolution.
Efficacy Criteria. Elliott, Packer & Addison (1989) proposed three general efficacy criteria (i) evidence of post-intervention change; (ii) evidence of a link between the intervention and the change and (iii) evidence of alternative explanations for the change. These criteria were applied to the seven cases, to assess the therapeutic significance (rather than in-session resolution) of the intervention. Qualitative and quantitative data from pre-workshop, within-workshop and post-workshop instruments, were analysed, adopting the detailed efficacy criteria recommended by Elliott (2002; refer to Table 8.3). Evidence of post session change. Post session change was measured with quantitative analysis of the results of the SCL90-R and the IIP-127 (see p. 9-10) and qualitative analysis of self-reports of pre-intervention functioning and post-session changes. The inclusion of qualitative measures of change provides a richer description of post-session changes and enables changes in functioning to be identified for people in the normal range of functioning, whose difficulties may not otherwise be identified with traditional outcome measures. Where evidence of positive change was identified, contradictory evidence of no-change or negative change was also considered. Chapter 8 111
Table 8.3. Data Sources matched to Elliott’s (2002) Efficacy Criteria A. Links between intervention & change B. No change or alternative explanation for change. Data Sources 1. Early change in stable problems 1. Non-improvement a. Qualitative evidence of stability of pre-intervention a. Changes described in highly qualified or ambivalent terms Personal History problematic functioning. b. Changes are rated as not important: (1 or 2) Questionnaire (PHQ) b. Participant rates self-reported changes as (4) c. Apparent changes are trivial Participant Change important or (5) very important 2. Statistical artefacts Interview. change c. Change in outcome measures between pre-testing a. Measurement error SCL90-R Evidence of and 2 week follow-up, meet criteria for clinically b. Outlier or regression to mean IIP-127 significant change (refer to Table 8.4). c. Experiment-wise error. 2. Retrospective Attribution 3. Relational artefacts: Report positive relationship with the RSRS a. The participant attributes a reported change to the director and there is an absence of critical or negative comment Post Workshop workshop or psychodrama session, without regarding director or process. Evaluation.
specifying the nature of the felt connection. 4. Participant Expectations or wishful thinking: Changes match Participant Change b. Changes are rated as (4) unlikely or (5) very participant’s pre-workshop expectations. Interview. unlikely to have occurred without the workshop or Changes rated as expected (1 or 2). Personal History psychodrama session. 5. Self-correction: Apparent changes reflect self-help & self- Questionnaire limiting easing of short-term or temporary problems. (workshop goals). 6. Impact of other workshop events: Protagonists report HAT workshop events (other than own session) that had an impact. BSR Protagonist Recall 7. Extra-therapy life events: Report relevant extra-therapy events between intervention & 2 week follow-up; Participant rates change as (1) very likely or (2) likely to have occurred without intervention. 8. Psychobiological factors: Changes in medication or herbal remedies; the impact of recovery from illness. 9. Reactive effect of research: Research conditions (e.g. presence References to impact of of AV equipment) consistent for resolved & not resolved cases. research were noted. 3. Process-outcome mapping Post Workshop Eval. Links between change and intervention. change between Links The participant’s self-reported changes at 2 week Participant Change follow-up correspond to specific events, aspects or Interview. processes within the workshop or psychodrama BSR responses. session. Chapter 8 112
Quantitative analysis used the clinical significance model developed by Jacobson and Truax (1991), designed to assess clinically significant change in single cases. Change is considered to be clinically significant when it meets two criteria: (i) a person improves from a pre-intervention score within the range of a clinically dysfunctional population, to a post-intervention score that lies within the range of the normal population and (ii) the degree of change is statistically reliable, that is, greater than would be expected by chance. Cut-off scores for clinical caseness and reliable change indices for the SCL90-R and the IIP have been developed in earlier studies (Ogles, Lambert and Sawyer, 1995; Barkham, Hardy & Startup, 1996) and these were adopted for this current study (see Table 8.4).
Table 8.4. Criteria for Clinical Dysfunction & Reliable Change Indices
Instrument Criteria for Min. value required for clinical case reliable change*
SCL-90-R (GSI)a ≥0.93 0.51
IIP-127b ≥1.5 0.79 (Total score) a Source: Ogles, Lambert & Sawyer (1995), in Elliott (2002) * p<.2 b Source: Barkham, Hardy & Startup (1996), in Elliott (2002).
Psychometric measures combined with clinical interviews provide indications of the direction and meaning of change in individuals. Qualitative measures of post- session change were used in this study to give a clearer picture of the direction and meaning of change on a case by case basis and to provide information about perceived change for participants who didn’t meet the criteria for clinical dysfunction at pre-intervention. The study did not target a clinical group and it was therefore anticipated that participants would be more likely to not meet the criteria for clinical dysfunction prior to the workshop. Protagonists’ reports of the impact of their unresolved painful emotional experience on the Personal History Questionnaire were used for qualitative base-line data. Elliott’s (1999) client change interview was used to identify post-intervention change because it has a very broad definition of the type of changes clients might identify and then asks them to rate the subjective Chapter 8 113 importance of the change, enabling the client to identify if changes have a therapeutic significance to them. Evidence of a link between post-session change and the intervention. Evidence of a link between the change and the intervention was identified by protagonist attribution of change at two week and three month follow-up and by evaluating logical links between reported change and significant in-session processes, termed by Elliott (2002) process-outcome mapping. Process-outcome mapping draws on the protagonist’s reports of the impact of significant therapy events elicited immediately after the intervention and during video-assisted recall interviews and the director’s report of anticipated impacts of significant events. Evidence for a link between the change and the psychodrama intervention was compared to evidence of alternative explanations for the change. Hopes and expectations of change have been linked to clients’ reports of change (Orlinsky, Grawe & Parks, 2004; Weinberger, 1995; Weinberger & Eig, 1999). Pre- intervention goals and expectations were identified in the Personal History Questionnaire and protagonists’ reports of being surprised by or expecting reported changes were recorded at two week follow-up. The possibility that the protagonist might have been influenced to report positively about the experience, by virtue of his or her relationship with the director, was considered by reviewing if the protagonist was able to critically evaluate their experience. The impact of life events independent of the intervention and changes in medication or medical conditions identified at two week and three month follow-up, were considered. For the purposes of this study the impact of other workshop events, such as the introductory workshop session, and the impact of participating in other people’s psychodramas, were important to identifying whether the change could be plausibly linked to the protagonist’s psychodrama intervention. Evidence of self-correcting behaviour by the protagonist, independent of the workshop experience, was also considered One of the possible alternative explanations for change that Elliott considers is the effects of the research conditions on participants. The presence of audio-visual equipment, attaching microphones to participants during sessions and the intrusion of questionnaires at various points during the workshops, made it obvious to participants that they were engaged in a research project. Enthusiasm to be part of the project may have inclined participants to interpret their experience in a positive light; while questionnaires on the first evening may have interrupted the typical flow Chapter 8 114 of the early stages of the workshops. Participants’ post-workshop evaluations did not refer to the impact of audio-visual equipment, but there were a number of comments about the discordant effect of having to complete questionnaires at the commencement of the workshops. Research conditions were not raised by protagonists when they were recalling their in-session process, irrespective of whether their sessions were resolved or not.
Rating In-Session Resolution The degree of in-session resolution of painful emotional experience was measured using the Degree of Resolution Scale and qualitative data from protagonists’ session reaction form, post-workshop evaluation and client change interview. Ratings were made by the director of the session and an independent observer. Each psychodrama session was rated for the degree of in-session resolution achieved by the protagonist, using the DRS/PRP. The director rated the session immediately afterwards and an independent observer rated the session from a videorecording after the workshop. The directors and observer agreed in all cases, so inter-rater reliability checks were not required. The preliminary study raised the possibility that the DRS/PRP could produce a false resolved rating and therefore corroborating evidence from protagonists’ self-reports of the impact of their sessions were also considered. The hindering reactions items on the Revised Session Reaction Scale (RSRS) have been linked to negative experiences of therapeutic sessions (Reeker, Elliott & Ensing, 1996) and these, along with low session helpfulness ratings were considered as possible indicators of lack of resolution. While the helpfulness scale nominates ratings of 5 or less on the 9-point scale as indicating that a session was not experienced as therapeutically helpful, it was considered that a rating of ‘6= Somewhat Helpful’ would also reflect an unhelpful session, in view of the assumption that there would be a skew towards positive responses from participants. On the other hand, session helpfulness ratings above 6 were not considered to be a definitive indication of resolution because it was assumed that progress could be achieved during a session whether or not an issue was resolved. Qualitative responses from the Session Reaction Questionnaire, Post- workshop Evaluation and Participant Change Interview, were checked against the resolution criteria of the DRS/PRP; which in broad terms were, for level (4) making Chapter 8 115 a link between the event and a problematic reaction; for level (5) relating the meaning of the link to his or her broader functioning; for level (6) feeling relieved, resolved or having a sense of completion and beginning to feel empowered to make a change. A session was judged to be ‘resolved’, when it rated as ‘6: reaches resolution’ by the director of the session and the independent observer, and protagonist self-reported session impact and session helpfulness responses supported the rating.
Comprehensive Process Analysis (CPA) of Significant Change Events The analysis of significant change events within resolved and not resolved cases followed the guidelines set out by Elliott, Packer & Addison (1989) and Hardy et al. (1998) for Comprehensive Process Analysis (CPA). CPA (Elliott, 1983, Elliott, Packer & Addison, 1989) is a hermeneutic research method designed to understand and describe in narrative form, the implicit meaning of significant therapy events. The method differentiates between meaningful and non-meaningful interactions during an event. Elliott designed CPA with the intention of bringing psychotherapy research more in line with clinical practice. The method assumes that therapeutic events can only be properly understood in the broader context in which they occur and are significant by virtue of their impact on the client. CPA gathers and analyses data relevant to context, process and impact of events. CPA has been used in studies that have investigated a range of therapeutic events in individual psychotherapy, including vague awareness events (Hardy et al., 1998), problem-clarification (Rees et al., 2001), weeping (Labbott, Elliott & Eason, 1992), and insight (Elliott et al., 1994).
Operational components of CPA. CPA has four core operational components: (1) sensitising factors provide a framework for data collection; (2) qualitative and quantitative data are gathered from a range of sources; (3) Brief Structured Recall (BSR; Elliott & Shapiro 1988) interviews access protagonists’ and directors’ experiences of significant events and (4) a team-based consensual decision making process is used to build an understanding of the implicit meaning of events. The role of each of these components is reviewed here. Forty sensitising factors that are broad non-specific possible descriptors of therapeutic events organise data into the three domains of context, process and Chapter 8 116 impact. Both qualitative and quantitative data are gathered at multiple points before, during and after the intervention. Furthermore, data are generated not only by the protagonist and the session director, but also by independent observers who then become part of the research team that makes sense of the range of information. BSR interviews that are conducted with protagonists and directors are an important part of information generation. BSR is a modification of Interpersonal Process Recall (IPR; Kagan, 1980) that was developed as a research tool for studying the experiences of clients and therapists in individual therapy. It differs from the traditional IPR method, in that the recall interview focuses on identified significant events within a session rather than the session as a whole and the interview takes a semi-structured format, asking qualitative and quantitative questions around the 40 sensitising factors of CPA. This study was concerned with investigating what happens in the natural context of a psychodrama session and developing the best fit description of the protagonist’s processes during the session. For this, a consensus decision making approach was selected on the grounds that having researchers independently review and then rigorously present and discuss their analyses of the data, would assist all researchers to develop a fuller understanding of the phenomena over time and a richer and more detailed description would result. As was discussed in Chapter 6, consensus decision making has made inroads into a range of qualitative methods that have traditionally relied on the work of a single investigator. Two methods, Comprehensive Process Analysis (CPA; Elliott, 1983; Elliott, Packer & Addison, 1988) and Consensual Qualitative Research (CQR; Hill, et al., 1997, 2005) have been developed specifically around the use of consensus-based research teams. The possibility that some team members would have undue influence over the decision making process, is reduced by having observers make independent observations before the consensus meetings are held and by the use of auditors to review the work of the team and recommend alternative explanations. (For a fuller discussion of the advantages and limitations of the consensus decision making approach, refer to Chapter 6: The Research Framework). The CPA involved within case analyses of significant change events to develop a rich description of protagonist processes and a cross case analysis to identify themes across resolved and not resolved cases. Results were then charted to identify Chapter 8 117 sequences of processes within significant events and across whole sessions. These steps are described in more detail below.
Data Analysis The analysis of significant events followed the CPA methodology outlined by Elliott, Packer & Addison (1989) and by Hardy et al. (1998). The steps in the analysis were: 1. Team members individually reviewed the video-recording and transcript of the complete session for one case, noting themes and sub-themes, markers of problematic issues and protagonist change points. The team met and discussed these observations. 2. Each event within the case was analysed for process, effects and context. In addition to the videorecording and transcript of the event, information was taken from the director and protagonist recall responses, Personal History Questionnaire, the Helpful Aspects of Therapy Questionnaire, Post-Workshop Evaluation and Participant Change Interview. This step constituted the core CPA analysis and was carried out in three parts: (i) Process. The implicit meanings of the protagonist’s Helpful Aspects of Therapy (HAT) statements were considered, in relation to the event as a whole and for the peak sub-events within it; and the process of the event was analysed in relation to action, content, style and quality. (ii) Effect. The impact of each sub-event was analysed in relation to effects immediately within the sub-event, within the session, immediately post-session and as reported at two week follow-up. (iii) Context. Factors that potentially influenced the event were analysed, including pre-workshop expectations and goals, relevant life events, preceding events within the workshop and within the session, experiences and events immediately preceding the sub-event and the therapeutic relationship. Within each of these three steps, team members first reviewed the information independently and presented their ideas to the principal investigator to collate. Ideas were collated under the headings of ‘agreed by all’ and ‘divergent’. The team then met and discussed the collated ideas until a consensus was reached about the best explanatory description of the event. Criteria for including ideas within the consensual description were those applied by Hardy et Chapter 8 118
al. in their study: (a) the evidence for the statement must be present and identifiable in the data, (b) it must contribute to explaining the event; and (c) it must not be contained in other ideas within this part of the description of the event. 3. Steps 1 and 2 were repeated for each resolved case. 4. When several events had been analysed they were reviewed by an auditor. The auditor checked the explanatory descriptions of events and made recommendations about possible alternative explanations or where it was considered that information had been overlooked. These recommendations were then considered by the research team. 5. A written summary of each event was composed applying the conventions used by Timulak & Elliott (2003). Events were described within their context, drawing on the recall responses of the director and the protagonist and using different font formats in the presentation of the responses to indicate whether the material was based on protagonist or director recall or observations from the research team. 6. Significant events within non-resolved cases were then analysed by the investigator and audited by the research team.
Cross Case Analysis Cross-case analysis was carried out by the author and audited by team members. Core ideas were identified from each event and events were categorised according to similar themes. The events within each category were reviewed and core ideas revised. Identifying types of events. Using the qualitative and quantitative impact of events data from BSR interviews, events were organised into similar themes. This formed the initial grouping of events. Constructing Core Ideas. The themes contained in the descriptions of each event within a group were written in a brief statement. Using these statements, similar responses were grouped together and core ideas that captured the groupings were derived. Core ideas across all events were reviewed to determine the best groupings. Abstracts were written, describing each event type and its core ideas. Chapter 8 119
Auditing. Auditors reviewed the events and core ideas to ensure that all important material had been abstracted and that the wording of core ideas was clear and reflective of the data. Representativeness of the data. The representativeness of the core ideas across cases was determined, applying Hill et al.’s (1997) categories. Core ideas were determined to be either (i) general, that is, applying to all resolved cases; (ii) typical, that is, applying to three of the four resolved cases or (iii) variant, that is, applying to only one or two of the resolved cases. Because some core ideas applied across both resolved and not resolved cases, a further category of ‘common’ was used to indicate this. Charting results. To identify themes across the progress of a session, the sequence of protagonist processes were charted. Sequential relationships were considered common if they occurred in all resolved and not-resolved cases, general if they occurred in all resolved cases, typical if they occurred in three of the four resolved cases and variant if they occurred in one or two cases.
The results of Study 2 are presented in two parts, in Chapters 9 and 10. Firstly, outcome and efficacy results are reported (Chapter 9). Then, the findings of the Comprehensive Process Analysis of significant events are described and a model of protagonists’ processes linked to in-session resolution of painful emotional experience, which was constructed from those findings, is presented (Chapter 10). Chapter 9 120
Chapter 9 Outcome and Efficacy Results (Study 2)
Outcome and efficacy results from Study 2 are reported in this chapter. Post- session outcomes in general symptom distress (measured by the SCL90-R) and interpersonal distress (measured by the IIP-127) are reported for all group participants and the findings of the efficacy analysis of the seven protagonist cases are summarised, identifying links between the psychodrama intervention and in- session and post-session changes.
Evidence of post-intervention change in general symptom distress and interpersonal distress Outcome results on the SCL90-R and the IIP-127 were considered across all participants using linear mixed model analysis and on an individual case basis using the clinically significant change method.
Homogeneity of Cohorts 2 and 3 An independent samples t-test was conducted to test the hypothesis that the two cohorts were comparable on SCL90-R scores and IIP-127 scores prior to the intervention. The t-test showed no significant difference in the means of the two cohorts on the SCL90-R(GSI) score (t(15) = .0105, p = .998; 95% confidence interval: -0.46114 to 0.45664 ) or on the IIP-127(Total) score (t(15) = 1.29; p = 0.215; 95% confidence interval: -0.15127 to 0.61800). Mean scores are shown in Table 9.1. Levene’s test for the equality of variances showed no significant difference between cohorts on either of the scales, supporting the assumption that there is equal variance.
Table 9.1. Comparison of mean pre-intervention SCL90-R(GSI) and IIP-127(Total) scores for cohorts 2 and 3.
Cohort N Measure Mean Std. Deviation Std. Error Mean 2 9 GSI 0.621 0.348 0.116 3 8 GSI 0.619 0.531 0.188 2 9 IIP-127 Total 0.898 0.359 0.12 3 8 IIP-127 Total 1.131 0.384 0.136
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Results of the linear mixed model analysis. Changes in general symptom distress as measured by the SCL90-R. Analysis of participants’ results on the General Severity Index (GSI) of the SCL90-R at pre- intervention, two weeks and three months follow up showed no significant difference between the pre and post scores, overall or between protagonists and non- protagonists (see Table 9.2). There was a borderline difference between protagonists and non-protagonists (p=0.057) that remained consistent over time.
Table 9.2. SCL90-R(GSI) scores for protagonists compared to non-protagonists
Type III Tests of fixed effectsª Numerator Denominator F p df df Individual differences 1 34.106 62.306 .000 Between groups 2 29.544 4.205 .057 Change over time 2 34.106 1.765 .189 Change between groups over time 4 29.544 .213 .929 Covariance parameters Parameter Estimate Standard Error Repeated measures Var: (Pre-intervention) .209292 .082091 Var: (2 week follow-up) .11.864 .043484 Var: (3 month follow-up) .090564 .035515
Note: ª Dependent variable: GSI score.
Paired t-test with outlier removed. A review of the distribution of participants’ GSI scores identified that there was one outlier who recorded clinically significant deterioration at two week follow-up. A paired t-test was conducted comparing GSI at pre-intervention and 2 week-follow-up with the outlier removed. The t-test showed a significant improvement from pre-intervention (M = 0.636; SD = 0.448) to two week follow-up (M = 0.385 SD = 0.262; t = 3.4265, p = .0045). The 95% confidence interval for the mean difference between the two scores was 0.09272 to 0.40914. Changes in interpersonal distress as measured by the IIP-127. (Refer to Table 9.3). Analysis of participants total scores on the IIP-127 showed a significant improvement in interpersonal distress over time (p = 0.009). There was a significant difference in the scores of protagonists and non-protagonists that was maintained Chapter 9 122 over time (p = 0.04), and there was a borderline difference in change over time between protagonists and non-protagonists (p = 0.052) suggesting that protagonists improved slightly more than non-protagonists.
Table 9.3. IIP-127 Total scores for protagonists compared to non-protagonists
Type III Tests of fixed effectsª Numerator Denominator F P Df df Individual differences 1 35.444 179.816 .000 Between groups 2 35.444 3.520 .040 Change over time 2 22.837 5.889 .009 Change between groups over time 4 22.837 2.773 .052 Covariance parameters Parameter Estimate Standard Error Repeated measures Var: (Pre-intervention) .075551 .029634 Var: (2 week follow-up) .095874. .037605 Var: (3 month follow-up) .157179 .061651
Note: ª Dependent variable: IIP-127 Total score.
Clinically Significant Change Clinically significant change was determined using Jacobson and Truax’s (1991) criteria of (i) improvement from clinical to non-clinical functioning and (ii) change that is statistically greater than what might be reliably expected by chance. As noted earlier, previously established reliable change indices (RCIs) have been adopted here. Only five of the 17 participants met the criteria for a clinical case prior to the intervention, four on the basis of their GSI scores and one on the basis of the IIP-127 (see Tables 9.4 & 9.5). The low percentage of clinical cases was anticipated at the outset of the study as participants were recruited on situational criteria (that is, identifying a problematic reaction) rather than clinical diagnosis. All five participants who met the criteria for a clinical case showed some improvement and were within the normal range of functioning at two-week follow- up. One participant met the criteria for reliable change at two weeks and at three- months there had been further improvement for all five, with four of the five recording improvements statistically greater than what might be reliably expected by Chapter 9 123 chance. Three of the participants with pre-intervention scores in the clinical range became protagonists and they had all achieved statistically reliable change by three months follow-up. However, being a protagonist was not a prerequisite for clinically significant change. Furthermore, one protagonist (Linda) showed a clinically significant elevation in general symptom distress at two week follow-up (Table 9.4). The GSI results for all participants are shown in Table 9.4, because clinical cases were equally represented among protagonists and non-protagonists. Only protagonists’ results for the IIP-127 are shown in Table 9.5, because no other participants met the clinical case criteria using this measure. Individual case results are considered further within the efficacy summaries, in the following section.
Table 9.4. Participants’ SCL90-R (GSI) at pre-intervention, 2 weeks & 3 months
Participant* Pre-intervention 2 Weeks 3 months (P) Geraldine ¹1.16 .966 º.477 (P) Julie ¹0.944 0.5 º 0.27 (P) Cheryl 0.74 0.34 º 0.14 (P) Ray 0.488 0.51 0.30 (P) Grant 0.677 0.422 0.355 (P) Jane 0.377 0.244 0.322
(P) Linda 0.86 ¹ ª 1.45 ¹1.26 (GM) #1 ¹1.63 º 0.588 º 0.433
(GM) #2 ¹1.2 0.755 0.722 (GM) #3 0.477 0.255 0.344 (GM) #4 0.355 0.355 0.255 (GM) #5 0.266 0.1 0.133 (GM) #6 0.233 0.177 0.222 (GM) #7 0.244 0.155 0.244 (GM) #8 0.111 0.022 0.1 (GM) #9 0.1 0.288 0.6
Notes: * (P) = protagonist, (GM) = non-protagonist group member. ¹ meets criteria for clinical case with GSI ≥0.93. ° statistically reliable improvement (i.e. change of magnitude of ≥ 0.51, p<.2). ª statistically reliable negative change. One participant did not complete follow-up and therefore results for 16 participants are reported. Chapter 9 124
Table 9.5. Protagonists’ IIP-127 (Total) at pre-intervention, 2 weeks & 3 months
Participant* Pre-intervention 2 Weeks 3 months
Geraldine 1.45 1.23 .796 Julie 1.35 1.1 0.25 Cheryl ¹ 1.85 1.09 °0.26 Ray 1.28 1.29 1.21 Grant 1.125 1.07 1.1 Jane .75 0.5 0.68 Linda 1.1 1.17 1.28
Notes: ¹ meets criteria for clinical case with Total ≥ 1.5. ° statistically reliable improvement (i.e. change of magnitude of ≥ 0.79, p< .2).
Efficacy of the Psychodrama Intervention The efficacy findings for the seven protagonist cases are summarised. This section is concerned with (a) if there was in-session resolution of the painful emotional experience; (ii) post-session change, as measured by statistically significant improvement on the SCL90-R and the IIP-127 or qualitative reports of change that were considered important by the protagonist; (iii) establishing if these changes were linked to the psychodrama intervention; and (iv) describing patterns in the nature of post-session change among resolved and not-resolved cases. These results contribute to an understanding of the impact of the psychodrama intervention.
In-session resolution Four cases were determined to be resolved (two in each workshop) and three cases to be not-resolved (two in the first workshop and one in the second). The resolution ratings and protagonist satisfaction ratings for each case are listed in Table 9.6. Interrater agreement. To evaluate interrater agreement of judgements of in- session resolution between protagonists, directors and an independent observer, the DRS/PRP was treated as a dichotomous scale, where a rating between 1 and 4 was treated as not-resolved and a rating of 5 or 6 was treated as resolved. This allowed direct comparison between DRS/PRP ratings and protagonists’ self-reports of in- Chapter 9 125 session resolution. The independent observer agreed with directors’ ratings in 100% of cases. Interrater agreement between directors and protagonists was evaluated using Cohen’s kappa. Using the crosstabs function of the SPSS, there was good interrater agreement (k = .75; Fleiss, 1981).
Table 9.6. Degree of Resolution Ratings & Protagonist Helpfulness Ratings.
Case Study # 1 Resolution Ratings Protagonist Helpfulness Rating /Protagonist Director* Observer* Protagonistª 4 Jane 6 6 Yes 9 (extremely) 5 Julie 6 6 Yes 9 (extremely) 6 Cheryl 6 6 Yes 9 (extremely) 7 Ray 6 6 Yes 9 (extremely) 8 Grant 4 4 No 6 (somewhat) 9 Geraldine 3 3 No 9 (extremely) 10 Linda 6 6 No 6 (somewhat)
Notes: * Director and observer ratings on DRS/PRP, where 6 = reaches resolution, 4 = reaches meaning bridge and 3 = explores stimulus situation. ª Protagonist reports of experiencing in-session resolution.
Resolved and not-resolved cases were evenly distributed among the three psychodrama directors (see Table 9.7).
Table 9.7. Number of resolved and not resolved cases per director
Director Resolved Cases Not-resolved Cases #1 1 1 #2 2 1 #3 1 1
1 Cases are numbered to include all cases across the four studies. Because there were three cases in the preliminary study, cases in Study 2 begin at #4. Chapter 9 126
Protagonists determined to have achieved in-session resolution were: Case Study 4 Cheryl Case Study 5 Julie Case Study 6 Jane Case Study 7 Ray
Protagonists determined not to have achieved in-session resolution were: Case Study 8 Grant Case Study 9 Geraldine Case Study 10 Linda
Summaries of the efficacy findings are presented for each case. The four resolved cases are described first, with an introduction to the protagonist, relevant background information and a summary of the efficacy results for that protagonist. The three not-resolved cases are then described following the same format.
Resolved Cases Four sessions (Cheryl, Julie, Jane and Ray) were judged to be resolved, based on DRS/PRP ratings of 6: reaches resolution, the protagonists’ Session Helpfulness Scale ratings of 9: extremely helpful (see Table 9.6) and protagonists’ subjective reports of feeling relief and resolution immediately after the session. The four protagonists reported post-session changes that they linked directly to their psychodrama sessions. In two cases pre-intervention scores were in the clinical range for either the General Severity Index (GSI) of the SCL90-R (Julie) or the Total Score of the IIP-127 (Cheryl). These scores had improved to fall within the normal range at two week follow-up and had improved further at three month follow-up, to meet the criteria for statistically reliable change (see Tables 9.4 and 9.5). These improvements were consistent with the protagonists’ subjective reports of post session changes. For Jane and Ray, whose pre-intervention scores did not fall in the clinical range, post-session change was identified from subjective reports of changes in interpersonal relationships and personal functioning. None of the protagonists undertook any other counselling or personal development programs that could account for the reported changes between the time of the psychodrama workshop and the three month intervention. A summary of relevant aspects of each resolved case is presented below. Chapter 9 127
Case Study 4: Cheryl Cheryl was a health care worker in her 50’s, who reported ongoing emotional abuse and neglect in her childhood, to which she attributed a pervasive feeling of worthlessness and fear of rejection that had resulted in her being over- accommodating and non-assertive. This picture was confirmed by Cheryl’s pre- intervention scores on the IIP-127 which met the criteria for a clinical case (see Table 9.5). Cheryl showed improvement on the SCL-90R GSI and the IIP-127 Total Score at two week follow up, at which time the IIP-127 Total score was within the normal range. The improvement on both measures at three month follow-up met the criteria for statistically reliable change (see Tables 9.4 & 9.5). Cheryl recalled the general impact of the session: This was my first psychodrama and I found it immensely powerful. I’m feeling so much better. The psychodrama worked through so many areas where I was blocked or stuck. It has struck me this past week that there isn’t anything I should be ashamed of from when I was young.
Cheryl identified changes in her behaviour and in her attitudes to herself and to significant others, most of which she rated as important or very important to her. Cheryl was very surprised by five of the six changes she reported. The changes were consistent with her pre-intervention goals, but while her goals had been stated in vague, general terms, she reported specific examples of shifts in her attitude and changes in her responses to significant people. Cheryl’s session was the third of three psychodrama sessions in the workshop. She rated other aspects of the workshop as helpful, but her own psychodrama session as the most helpful. The introductory session helped her to develop trust in the group and to focus on her issues. In the two subsequent sessions she realised that the group would accept strong feelings and that the leaders had the skills to manage what emerged in the psychodramas. In the session preceding her own psychodrama, Cheryl reported feeling unable to deal with her surfacing emotions and began feeling isolated and agitated. This response motivated her to put herself forward to do a psychodrama. There is support for the proposition that the workshop was therapeutically significant for Cheryl. She moved from clinical to non-clinical functioning on the Chapter 9 128
IIP-127, had statistically significant improvement on a number of sub-scales of the SCL-90R and reported changes in her functioning that she considered very important. On balance, it would seem that the overall workshop provided conditions that assisted Cheryl to volunteer to be a protagonist, while her psychodrama session provided events that she experienced as helpful to resolving her issue.
Case Study 5: Julie Julie was a human service professional in her 30’s. A close family member had died suddenly and she continued to be obsessed with memories of the person’s death, felt fragile in relation to other changes or disruptions to her routine and was avoiding interpersonal contact, particularly with family members. These responses were causing her significant distress and interpersonal difficulty, which were reflected in her pre-intervention scores on the SCL90-R (refer to Table 9.4). Julie’s pre-intervention score on the Global Severity Index (GSI, SCL90-R) was in the clinical range. At two week follow-up, this was within the normal range and improvement at 3 month follow-up met the criteria for statistically reliable change. Julie recalled the general impact of the session: I had support to revisit something that was pretty horrific. The most important loss for the family was not being able to have time with him when he died. This scene is what we needed and didn’t get. I confirmed that it would have been alright – I do know what makes a good farewell and I can be more deliberate about how I talk to younger family members about her. Following the workshop, Julia reported changes in her awareness, a move from being self-focused to being other-focused and oriented to the present and the future rather than the past. She rated all reported changes as extremely important. Her pre- intervention goals focused on symptom alleviation, in particular, reducing her obsessive thinking about the death. At her post-workshop interview she indicated that these had reduced. She was surprised by other changes, most notably being more accepting and understanding towards other members of her family and being clear about actions to take in relation to others. She was specific about the family relationships that these changes impacted upon and the actions she had begun to take in implementing the changes. Julie’s session was the fourth psychodrama session of the workshop. She rated earlier sessions as extremely helpful and noted that they had contributed to her Chapter 9 129 reassessing her relationships with family members and facing death. However, she identified specific events within her own psychodrama as producing (i) a full experience of her grief , (ii) acceptance of her family member’s death, (iii) resolution of some of her concerns about events following the death and (iv) specific intentions for post-workshop changes in her family relationships. Julie’s bereavement was recent and some improvement in her functioning would be expected as a natural function of the grief process. However, previous counselling following the death had not altered her obsessive thinking or her avoidance of family contact, whereas she experienced an immediate change after the psychodrama session.
Case Study 6: Jane Jane was a health care worker in her 50’s. When she was a child her mother was killed in an accident. Her father was emotionally and physically violent both before and after her mother’s death. Before the workshop, Jane described the defining and enduring impact of her mother’s death as: I feel deadness within myself; I’m always composed, keeping emotions under control. I burst into tears over minor sadness and have no feeling over major losses. She considered that this response had contributed to her not being able to establish intimate relationships. Jane had a major depressive episode eight months before the workshop and had been taking anti-depressant medication from that time to beyond the three month follow-up. She reported that she had recovered from the depression before the workshop but that her experience of being emotionally dead remained. All pre workshop measures indicated she was functioning in the normal range and did not indicate any depression. Jane recalled the impact of the session as A healing experience. … I experienced sadness and the dissociation ended, the split went. I felt more confident. I thought, ‘I’m here, I’ve arrived!’ Jane’s post-session results on the SCL90-R GSI and IIP-127 total score showed small but statistically insignificant improvements at two week follow-up (refer to Tables 9.4 & 9.5). Given that she had scored within the normal range before the workshop, these measures could not be expected to identify post-intervention improvements. Jane’s subjective report of post session change indicated that she had improved in areas of intra-personal and interpersonal functioning which she considered very important to her, unlikely to have occurred without the workshop Chapter 9 130 and, in some instances, surprising to her. She described feeling more confident and at ease, feeling free of a previously pervasive sense of helplessness and of being split and no longer being emotionally labile when watching television. She gave specific examples of being more flexible and emotionally responsive with others and having better boundaries at work. At three month follow-up, she reported having established an intimate relationship over the previous two months. Jane rated her session as extremely helpful and identified specific events within her session that contributed to her (i) recognising that she had unmet needs, (ii) allowing herself to experience grief over her mother’s death and (iii) experiencing herself as powerful. Her session was the third of four psychodrama sessions in the workshop. Other workshop events contributed to Jane’s readiness to approach her issue and her willingness to present herself to the group, but events within her own session were more specifically linked to the post-intervention changes that Jane reported. Previous counselling and life experience may have contributed to Jane’s awareness of the issues she wanted to deal with and her willingness to confront her experience.
Case Study 7: Ray Ray was a professional in his 40’s. He reported experiencing emotional abuse and neglect as a child. He felt emotionally cut off and fearful and had difficulty making decisions in his personal life, as a consequence of this formative experience. Ray’s pre-intervention scores on all measures were within the normal range (see Tables 9.4 & 9.5), and the assessment of his problematic condition was based on self-report. He experienced a pervasive sense of isolation and not deserving love from others, and had difficulty empathising with others, reinforced by an attitude that ‘I didn’t get (caring) so why should you.’ . Recalling the impact of the session, Ray said: I feel I had a significant release. It opened me up and brought up deep-seated pain, tears and anger, which I needed. There was increased intensity and crying when I was being hugged; I was feeling the love and warmth, getting what I missed out on. At two week follow-up Ray’s SCL90-R GSI score and IIP-127 Total score were effectively the same and while there was improvement in the GSI at three month follow-up, this was not at a statistically reliable level (see Tables 9.4 & 9.5). Chapter 9 131
Ray’s results on the psychometric tests suggest there was little or no improvement in his general functioning at two week or three month follow-up. Ray’s self reported changes following the workshop suggest that he continued to experience a grief reaction for a week afterwards and that he noticed a change in his ability to accept compassion from his partner immediately after the workshop. He reported experiencing a continuing physical releasing of energy for some days after the workshop, which he had anticipated. He considered this releasing would have eventually occurred without the workshop due to other processes he had engaged in previously, but that the reaction was expedited by the workshop. He allowed himself to be more vulnerable with his partner, crying in her presence and accepting physical comfort from her. He was surprised by this change and thought it was less likely to have happened without his psychodrama session, where he had been able to be vulnerable in a group setting and received hugs from others. He recalled being surprised by the depth of the pain he had experienced during his psychodrama and connected this with being able to feel compassion towards himself. Another unanticipated consequence was that he noticed he was more affectionate towards his son. At three month follow-up Ray reported a sense of a transition being completed. He was experiencing being more at ease in his relationship with his partner and with his son. He and his partner had made significant family decisions around issues that he had previously been avoiding. The process of allowing himself to continue to experience emotional release in the period after the workshop, may have been important in consolidating the learning from the session. Ray had been attending personal counselling before the workshop, but did not have any counselling between the time of the workshop and the three month follow-up. Based on Ray’s self-report, there is support for Ray having experienced a change in his ability to allow and express his feelings and to develop more intimate relationships within his family as a result of the work he did as a protagonist. These were experienced as important positive changes. At three month follow-up, he attributed his ability to make significant decisions in his relationship to changes in their interactions that were initiated after the workshop. Chapter 9 132
Summary of Efficacy Results for Protagonists who achieved In-session Resolution Two protagonists had pre-intervention test scores in the clinical range and for both these protagonists there was an improvement in their results at two week follow-up, taking them into the normal range of functioning on these measures, and a further improvement at 3 month follow-up that met the criteria for reliable change. All four protagonists reported improvement in significant interpersonal relationships. Jane, Julie and Cheryl also reported positive changes in their sense of self. Ray’s change in sense of self was focussed on continuing to allow himself to experience his feelings and he reported experiencing more grief and emotional pain in the period after the workshop. While some changes had been expected, all protagonists reported being surprised by the depth of the experience during the session and by some unexpected changes in their interpersonal relationships after the workshop. Changes that were reported by protagonists at two week follow-up were maintained and consolidated at three month follow-up. All resolved psychodrama sessions occurred in the second half of a workshop, in the third or later session. Events that occurred in previous sessions appear to have contributed to the protagonists’ readiness to approach their issues and to being adequately supported in the group to be able to present themselves. During their actual psychodrama session protagonists appear to have had an intense experience of their grief in the context of their specific painful emotional experience, developed a changed perspective in relation to themselves and significant others, and clear intensions about post-workshop changes in their relationships with others.
Not-Resolved Cases Three sessions (Grant, Geraldine and Linda) were determined to be not-resolved. In two of these cases this decision was based on DRS/PRP ratings (refer to Table 9.6). Grant’s session was rated as 4: Reaches the meaning bridge and he identified the impact of his session as increasing his awareness, but leaving him confused about where to go from there. Geraldine’s session was rated 3: Explores reaction to & construal of stimulus situation, and she reported having a greater awareness of the difficulty she experienced as a result of participating in the session. Geraldine rated her session as extremely helpful and identified the most important impacts of the session as defining problems for her to work on, feeling understood by the group and Chapter 9 133 feeling less alone because of her connection with the group. Linda’s session was determined to be not- resolved, even though the psychodramatist and independent observer both rated the session as 6: reaches resolution. Linda rated her session as somewhat helpful and reported feeling fragmented and somewhat distressed as a result of the session. While the psychodramatist rated the session as resolved, she also expressed vague dissatisfaction with the progress of the session. The efficacy findings for each of the not-resolved cases are summarised below.
Case Study 8: Grant Grant was a technician in his 30’s, who reported a history of childhood physical and emotional abuse. He experienced major difficulties making decisions and this was causing conflict in his current relationship and difficulty planning for the future. Grant described his upbringing as very critical and controlling, and that in response to this he had become compliant with other people’s plans for him. His pre- intervention score on the over-accommodating sub-scale of the IIP-127 was in the range of significant difficulty (defined by the authors of the scale as a T-score of 70 or more) and the non-assertive sub-scale approached the cut-off for significant difficulty. Grant described the impact of his session as: I became more aware of my mother’s role in what had happened. Experiencing the relationships I have with those around me and feeling the raw emotions, I felt a sense of self-worth and wanted to start setting goals and achieving things. I felt very stirred up afterwards and still feel a sense of confusion about what to do next. It feels unfinished. Two weeks after the workshop Grant reported changes in his focus, thinking about the future rather than the past and feeling internal pressure to make changes. He was having bad dreams and felt unsettled. Grant gained greater awareness of his family dynamic and made sense of how this contributed to him feeling stuck when he approached life decisions. He became more motivated to change, but was not able to form a plan for change or know how to implement change. There was no measurable improvement in his interpersonal relationships, particularly in the areas of assertiveness and over-accommodation which were of most concern to Grant. Chapter 9 134
Case Study 9: Geraldine Geraldine was a health care worker in her 40’s with a history of domestic abuse. Recalling the impact of the session, Geraldine identified achieving greater awareness but not being able to fully enter into the experience, as can be seen in the following excerpt from her recall: This session put somewhat into perspective why I couldn’t move forward or let go of my guilt, grief and anger. During the session I was curious and hopeful that I would find a key to changing, but I didn’t quite get there. I didn’t let go completely. I needed to go further into it to allow the feelings. Geraldine’s pre-intervention score on the SCL90-R placed her in the range for clinical dysfunction and on the IIP-127, just below the cut-off for clinical dysfunction (see Tables 9.4 & 9.5). She showed small non-significant improvement on both measures at two week follow-up and further improvement on both at three- month follow-up. The improvement on the SCL90-R between pre-intervention and three month follow-up was clinically significant, meeting the criteria for reliable change and taking her within the normal range of functioning. After the workshop, Geraldine reported changes in her response to others, but a continuing tendency to be highly self-critical, feel guilty and doubt herself. Shortly after the workshop she took positive steps to address a long term problem with other family members and she attributed this change to the impact of enacting an imaginary confrontation with her former partner during her psychodrama session. Given that Geraldine remained self-critical after the workshop, her continuing improvement on the SCL90-R and IIP-127 at three month follow-up is interesting, and may reflect the impact in her life circumstances that resulted from having addressed this long standing problem. In summary, Geraldine recorded clinically significant change between pre- intervention and three-month follow-up and there is strong support for the argument that Geraldine’s psychodrama session was a significant contributing factor in this change. New behaviour that Geraldine initiated after the workshop was maintained over time. At the same time, Geraldine identified that she continued to experience difficulties in relation to her sense of self, particularly feelings of guilt and self doubt. Chapter 9 135
Case Study 10: Linda Linda was a health professional in her 30’s, with a history of childhood abuse and later the combination of domestic abuse in her marriage while she was suffering from a potentially fatal illness. At the time of the workshop she was in the process of resolving outstanding issues from her marriage break-up. Linda described the multiple impacts of her session as: I realised I had to leave the relationship, there is no way to deal with my ex-husband. I felt the fear and anxiety of not knowing what’s going to happen next and for a few hours afterwards, I felt fragmented. I realized that my friends are here and they want to help. Linda’s elevated GSI (SCL90-R) at two week follow-up met the criteria for reliable change and took her into the range of clinical dysfunction. This suggests that the intervention had a negative impact. Linda reported feeling fragmented and somewhat distressed immediately after the workshop. She was extremely surprised by this and she attributed this change to specific events that occurred within her psychodrama session. She noticed that although she felt terrible, she did not become dissociated as she would have in the past. Linda also reported being more willing to ask friends for support and assistance after the workshop and she attributed this new behaviour to identifying and enacting positive friendship relationships during her psychodrama session. External factors most likely contributed to Linda’s reports of continuing difficulty at the three-month follow-up. A close family member became terminally ill and Linda became the primary carer, while also managing serious health problems of her own. Nevertheless, the elevation of symptoms immediately after the workshop is linked to the intervention. Linda sought follow-up counselling to continue to work through past and current experiences.
Summary of the Efficacy Results across the Seven Cases An analysis of protagonist responses to the post workshop evaluation and participant change interviews, supported the directors’ and observer’s ratings for all cases, with the exception of Linda’s, where there was evidence that the painful emotional experience had not been resolved. As in the preliminary study, there appeared to be different degrees of resolution within the level 6 category of the Degree of Resolution Scale/ Problematic Reaction Chapter 9 136
Points and the efficacy study suggests that these differences in resolution may be connected with qualitative differences in post-workshop outcomes. Three protagonists were in the clinical range on one or the other of two measures, prior to the intervention; Julie and Geraldine on the SCL90-R and Cheryl on the IIP- 127. All three were within the normal range on both measures at two week follow- up and had achieved reliable change on at least one measure at three month follow- up. This was irrespective of whether their session had been judged to be resolved or not. Linda’s SCL90-R score worsened, to fall in the clinical range after the intervention. Interestingly, the two male protagonists both reported a disturbance in their feelings after the workshop. Both reported positive aspects of this experience, but there were qualitative differences between the two which may have been linked to different degrees of in-session resolution. For Ray the disturbance in feelings was experienced as the positive and necessary allowing of emotional pain; whereas for Grant, it was associated with feeling frustrated that he didn’t know how to move forward. The efficacy findings of the seven cases summarised here, contributed to building an understanding of the impact of in-session events, which is a central element of Comprehensive Process Analysis. The results of the Comprehensive Process Analysis of significant events from these seven cases are reported in the following section. Chapter 10 137
Chapter 10 Results of the Comprehensive Process Analysis Of Significant Events (Study 2)
The findings from the Comprehensive Process Analysis (CPA) of 22 significant events within the seven cases of Study 2 are presented here. Firstly, a descriptive summary of protagonists’ in-session responses is given. This summary describes protagonists’ moment-by-moment experience within significant change events, but does not specify the therapeutic significance of these responses. Secondly, five meta-processes that were linked to in-session resolution of painful emotional experience are described. These meta-processes describe the contextual, process and impact patterns that make the therapeutic meaning of protagonists’ responses explicit.
Descriptive Summary of Protagonist Responses
Protagonists’ in-session responses included cognitive, affective and behavioural responses that were oriented towards self, interpersonal interactions or action. Within these three orientations, nine domains and 23 categories were identified. Table 10.1 lists these domains and defines the core ideas within each. The representativeness of core ideas across resolved cases is indicated, applying Hill et al.’s (1997) representativeness criteria, such that ‘general’ ideas were those found in all resolved cases and ‘typical’ were found in three of the four resolved cases. Variant ideas, those that were found in only one or two of the resolved cases, are not included in this table. A further classification of ‘common’ ideas indicates those that were found in resolved and not resolved cases. Chapter 10 138
Table 10.1. The representativeness of domains, categories and core ideas across the seven cases
Focus Domain Category Core ideas *Rep 1. Readiness to 1. Group cohesion The protagonist feels included in the group and experiences the group as warm and accepting. Common
engage in the The protagonist realises that other people have similar issues to him or her. Typical psychodrama General process. 2. Prior learning From experiencing psychodrama sessions earlier in the workshop, the protagonist realises that the group will accept the expression of strong feelings The protagonist has developed some understanding of how the psychodramatic process works General from watching other protagonists. In earlier sessions, issues that are relevant to the protagonist have been worked through and the General protagonist has already begun to experience some grief or reassess their beliefs or attitudes. 3. Compelling need Increased anxiety in relation to personal issue, increased awareness of internal conflict between General to address issue the desire to take action (act hunger) and fear of facing the issue (avoidance). Feeling that the issue can’t be avoided any longer. 2. Transitional 4. Markers of Indicator of underlying distress, that the protagonist is experiencing pain, anxiety or grief that is General problematic not being overtly expressed.
Self Markers Indication of a reaction The protagonist shows signs of experiencing or expressing internal conflict. problematic state or 5. Markers of The protagonist makes a significant shift which is in line with his or her purpose for the session. General change. resolution or After a period of distress or internal conflict, the protagonist experiences a resolution of the relief feeling and demonstrates clarity and ease in relation to self and/ or the situation. 3. Processing 6. Observing the When the painful scene is enacted by other group members, the protagonist watches and listens to General inwardly enactment, the the interaction intently and shows signs of distress or tears. Non-verbal protagonist is indicators of upset/distressed. deepening of 7. Taking in Observing the scene or listening to an auxiliary in the role of a significant other, where General affective positive or appreciative or affirming responses are being expressed, the protagonist’s stance is open and she experiencing in the affirming or he appears to be taking in, recognising as true, acknowledging or accepting the positive moment. messages messages.
*Note: Rep= Representativeness of the core idea across cases, where: Common = Applied to all resolved & not-resolved cases. General = Applied to all resolved cases. Typical = Occurring in three of the four resolved cases. Chapter 10 139
Domain Category Core ideas … cont *Rep 4. Emotional 8. Emotional release The protagonist cries continuously for an extended period of time. Crying can be loud sobbing or General Release quiet crying. The protagonist experiences crying as a release of feeling and the crying produces a feeling of relief. 9. Emotional release The protagonist cries for an extended period, while being held and comforted. Crying can be loud General while being held sobbing, or quiet crying, and is continuous. 5. Action Insight 10. Recognising and The protagonist becomes aware of his or her inner experience in the moment, recognises the General naming inner experience as a response to what is happening in the session & names the experience. Protagonist is affected experience The protagonist clearly states what his or her inner experience is in the moment. by the enactment and Inner experiences include problematic states (conflicted, confused, tension), distress or sadness, has new insight in the the positive or comforting impact of an event, feeling settled, at ease with self. moment. 11. Identifies problematic While interacting with an auxiliary who is being a ‘significant other’, or while observing General belief, interpersonal auxiliaries re-enacting a problematic scene, the protagonist realises something new about the difficulty, or needed problematic dynamic; either identifies a problematic belief that has maintained their behaviour, or Self cont. cont. Self change. recognises impact of other’s behaviour; or identifies the response they needed but didn’t get. 12. Recognising After emotional release or after a new, assertive response, the protagonist becomes aware of General resolution. having successfully resolved an intra-personal or interpersonal difficulty, and makes a statement indicating a new perspective towards self, others or the situation. This consistently incorporated an unequivocally positive, affirming attitude towards self. 6. Relationship 13. Conflicted The protagonist expresses confusion or conflict about his or her feelings or thoughts; or acts and Typical with speaks incongruently. auxiliaries & 14. Positive towards self Expressions of liking or affection; providing guidance or grounding; acknowledging distress or General or other unmet need, comforting; validating, affirming or genuinely apologising. group Includes ‘Positive to self’ when the protagonist is directly relating to an auxiliary who is in the members protagonist’s role. 15. Against self or other Expressing negative feelings and/or attitudes towards self or other, accusing or blaming the other Common (general) person, rejecting or dismissing the other person. Includes ‘against self’ where the protagonist is directly relating to an auxiliary who is in the protagonist’s role. 16. Self-disclosure Disclosing what has happened and the impact on the protagonist (or significant other, if Common (general) protagonist is in that role). Includes self disclosure about problematic behaviour of the other, interpersonal difficulties or distress, or internal conflict. Interpersonal 17. Self-disclosure – A specific category of self-disclosure, appearing across all cases. The protagonist identifies a Common unmet need significant unmet need, and the impact this has had on him or her.
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Domain Category Core ideas … cont *Rep 18. Assertively The protagonist speaks and/or acts with certainty, power and firmness towards self or other. Typical confronting The protagonist states what he or she wants or won’t accept, sets boundaries, firmly stating what he or she needed from the other person and did not receive, or otherwise confronting the other person about their behaviour and its impact. Speaking out begins tentatively and, over a number of talk turns, the protagonist becomes more firm and more assertive in stating his or her position. 19. Non-verbally going When an auxiliary, acting from the role of the protagonist or the role of a significant other, makes General along with what the a statement about the situation or about the experience of the protagonist, or about the relationship auxiliary is saying. between the protagonist & significant others; the protagonist responds in a minimal way that indicates he or she is agreeing with or positively considering what the auxiliary is saying.
Interpersonal Interpersonal 20. Organising The protagonist relates to group members in the context of setting out the scene or directing Common action. Includes selecting auxiliaries, showing group members where to place props, where to move in the scene, giving auxiliaries instructions in relation to the enactment of a role. 7. Relationship 21. Reflective response; After the director has made an observation (e.g. naming the protagonist’s experience, distress or General with the responding positively unmet need) the protagonist responds in a minimal way that indicates he or she experiences the director to director’s director’s response as accurate, or acknowledges the need or distress. suggestion The protagonist indicates agreement with or willingness to co-operate with the director’s suggestion for scene setting. This interaction continues for at least two talk turns each. 22. History, information The protagonist tells the director about people, self, or events; to describe or set out the scene & Common giving. people in it; to explain or clarify his or her view of the problematic relationship or unmet needs. Information may be given dispassionately or with apparent feeling. 23. Director’s skills From experience in earlier sessions of the workshop, the protagonist is confident that the directors Typical can manage strong feelings or reactions that may emerge in the group. 8. Interpersonal 24. Towards self or other The protagonist moves towards the other or self in a positive, caring manner. General Action Offers physical comfort to self, or responds to the offer of physical comfort from the other. 25. Against other The protagonist pushes against auxiliaries in the role of significant other(s). Typical The action is congruent with objecting to the response of the other. 9. Concretising 26. Organising The protagonist actively engages in setting out the scene, arranging props and positioning Common auxiliaries where he or she wants them on the stage. Action situational & self awareness There is a sense of purposefulness in the protagonist’s actions. Chapter 10 141
Oriented to Self
Self-oriented responses were those where the protagonists’ inner subjective experiences were dominant. A readiness to engage, or the group participant’s warm-up to the task of being a protagonist in a drama, was identified as one of the five meta-processes linked to in- session resolution, and is discussed in further detail later in this section. Transitional markers were observable, non-verbal shifts in protagonists’ functioning which indicated either (i) a problematic reaction or (ii) a sense of completion or resolution. These were used as markers of the start and end points of significant change events. Two self-oriented processes, processing inwardly and emotional release, occurred when there was little or no verbal involvement from protagonists (refer to Table 10.1). Protagonists were affected by the enactment of the psychodrama, either through observing auxiliaries re-enacting scenes or through directly experiencing the responses of auxiliaries in the roles of significant others. These were core components of a number of the meta-processes linked to in-session resolution, which are described later in this section. The final self-oriented process was action insight. This occurred as protagonists were observing or participating in the psychodramatic enactment, and was related to (i) awareness of self, (ii) awareness of self in relation to the difficulty or (iii) awareness of a new experience of self in relation to the situation. Often, new insight was articulated in the moment within the session, but at other times the action insight experience was an internal process which was articulated later, in post-session feedback or during recall interviews.
Oriented to interpersonal interactions
The interpersonal orientation included interactions with the director and interactions with other group members in auxiliary roles during the enactment. Interpersonal interactions with auxiliaries and other group members, included attitudinal responses, (i) being conflicted; (ii) moving towards, (iii) moving against and (iv) moving away from; which were common to all protagonists at some point in their enactments. Self-disclosure was also common to all protagonists. A process which has been termed non-verbally going along with what the auxiliary is saying, Chapter 10 142
describes moments when the protagonist’s behaviour indicates that the auxiliary is accurately representing some part of the protagonist’s experience. This process, occurring in all resolved cases but only some not-resolved cases, appeared to reflect a positive therapeutic alliance between protagonist and auxiliary. Similarly, a reflective response to the director, which was general to resolved cases but not present in all not-resolved cases, would seem to be one indicator of a therapeutic alliance between protagonist and director. Assertively confronting a significant other was typical of resolved cases but not typical of not-resolved cases.
Action-based responses Action-based responses included physical action in relation to others, in relation to self or in relation to the setting. Responses were allocated to this domain only if they were predominantly non-verbal and they were not readily accommodated in other domains. Most non-verbal responses were allocated to either the self-oriented or interpersonally-oriented domains.
The therapeutic meaning of protagonists’ processes
Broad inferences about protagonists’ processes leading to in-session resolution of painful emotional experiences can be drawn from the representativeness of the ideas described in Table 10.1. Processes which were general to resolved cases and occurred only in some not-resolved cases might be considered to be therapeutically meaningful. Such processes included core ideas related to a readiness to engage in the psychodrama process, emotional release, action insight, assertion, non-verbally going along with the auxiliary, reflective responses to the director and, not surprisingly, a marker of resolution or relief. However, the therapeutic meaning of these protagonist processes in relation to the experience of in-session resolution is not made apparent until the processes are described in terms of their context and impact. This is an underlying principal of the Comprehensive Process Analysis (CPA) method, which was applied in this study. The following section describes five meta-processes that were identified when protagonists’ responses were considered in relation to context, process and impact within significant change events. Chapter 10 143
Five Meta-processes Linked to In-session Resolution
The cross case analysis identified five meta-processes that were linked to in- session resolution of painful emotional experiences. These were, firstly, a precondition or ‘readiness to engage’ and then four in-session meta-events, namely (1) re-experiencing and insight, (2) activating resourcefulness, (3) social atom repair with emotional release and (4) integration (See Figure 10.1).
Pre-session Readiness
Re-experiencing Activating Social atom repair In-session: & insight personal with emotional Resolution resourcefulness release
In-session: Post -Resolution Integration
Figure 10.1. Five meta-processes linked to in-session resolution of painful emotional experiences during psychodrama.
Readiness to engage in the psychodramatic process
A characteristic common to all protagonists who achieved in-session resolution, was a readiness to engage in the psychodramatic process. This readiness involved three elements that a participant experienced before volunteering to be a protagonist: group cohesion, prior learning and recognising a compelling need to address an issue. Group cohesion related to a sense of warmth and trust in the group and a feeling that other group members were also committed to participating in the work. Most participants reported experiencing an increased sense of connection and trust in the group and this was most likely a core condition for a participant to be willing to volunteer to be a protagonist. Prior learning related to becoming familiar with the psychodramatic process through participation in other psychodrama sessions, developing confidence in how the directors responded to strong emotions and challenging situations and developing increased awareness or increased warm up to their own issues through experiencing other people’s psychodramas. The first psychodrama of each workshop both in this study and in Study 1 were not resolved Chapter 10 144
and this may in part be a result of a reduced or less focussed warm-up in the early stages of the workshop. The compelling need to address the issue was experienced as a sense that the issue could not be avoided and had to be addressed. It was associated with a heightened level of anxiety, but this was related to approaching the issue, rather than to performance anxiety. Protagonists whose sessions were not resolved, on the other hand, were more likely to report pushing themselves to volunteer to be a protagonist, being committed to participating, or getting on with it. These findings suggest that readiness to participate in the psychodramatic process was a pre-condition for protagonist to be able to fully engage during their psychodrama enactments.
Four in-session meta-events
Within the psychodrama enactment, four types of meta-events were identified, linked to in-session resolution of painful emotional experience. Sessions which achieved in-session resolution all contained three of these events, namely re- experiencing and insight, activating resourcefulness and social atom repair with emotional release. A fourth event, integration, occurred after in-session resolution and was identified in three of the four resolved cases. This event appears to consolidate the already achieved in-session resolution. There were examples of not-resolved cases sharing some or most of the characteristics of the re-experiencing and insight and activating resourcefulness events, but none met the conditions for social atom repair with emotional release or integration. The core ideas pertaining to each type of event are presented, illustrated by excerpts from protagonists’ recall and a comprehensive example of each event. Examples from not-resolved cases are given and core ideas that were more likely to occur in not-resolved rather than resolved cases are also described, to highlight similarities and differences between the two groups.
Event 1: Re-experiencing and insight
The re-experiencing and insight event is summarised in Table 10.2. Further descriptions of the core ideas general to all resolved cases for this event are then Chapter 10 145
given, with illustrative responses from protagonist recall interviews. One not- resolved case (Grant’s) also met the conditions for this event and extracts from his recall are included.
Table 10.2. Summary of Event 1: Re-experiencing and Insight
Summary of core ideas: Re-experiencing & Insight Context Occurs early in session Process Accurate re-experiencing of the original dynamic Initial Defensive Response Manage overwhelming feelings or avoidant response Positive response to self Distress Identify maladaptive dynamic Within Session impact New awareness Some acceptance of self Hopeful without identifying solution Crisis point Post-intervention Impact Increased awareness
Re-experiencing and insight was the first significant meta-event identified in each case. The core protagonist processes of this event were: 1. The protagonist accurately experienced herself or himself in the problematic situation. This produced a feeling of sadness or distress and then an expression of warmth or acceptance towards self, and led to the identification of the maladaptive belief or dynamic that had maintained the problematic response. This re-experiencing was typically not of the actual painful emotional experience (e.g. death, trauma or abuse) but was a re-experiencing of the dynamics of the family system that were the context for the painful emotional experience. 2. An iterative process occurred, through which the protagonist re-experienced the original event from a number of different perspectives. He or she gradually moved from identifying an undifferentiated or vague connection between his or her current problematic functioning and the past experience, through developing heightened awareness of the experience of the event, and then to making meaning Chapter 10 146
of the significance of the event and the cognitive meaning they gave to it at the time of the original experience. This iterative process entailed three general sub- events: (i) Experiencing the original scene ‘as-if’ it were happening in the here and now, produced the protagonist’s original avoidant response at the time of the event, accompanied by feeling overwhelmed, confused or distressed and numb. (ii) Further enactment by auxiliaries assisted the protagonist to have a heightened experience of responding to the painful situation and created a crisis point for the protagonist. The nature of the enactment differed between protagonists, and included: a. Auxiliaries maximising the physical enactment of people pushing the protagonist, produced a feeling of rage that produced a distressed objection from the protagonist; b. Experiencing the family interactions from the role of the significant other, the protagonist became confused and overwhelmed and experienced losing her sense of self; she was experiencing the feelings of the other person or trying to meet the needs of the other. (iii) Being taken out of the action space by the director and watching the enactment from the edge of the stage, assisted the protagonist to experience more clearly what was happening, without being overwhelmed. This process involved containment as well as observation. When the protagonist moved out of the action space he or she initially avoided looking at the scene, to avoid the overwhelming feelings that it generated. With doubling and coaching from the director or from an auxiliary, the protagonist was able to look at the scene. The doubling assisted the protagonist to contain his or her overwhelming feeling, by naming the experience and differentiating his or her own feelings from what was happening in the scene. The protagonist experienced a sense of support, of not being alone, in the presence of the double and was encouraged to look at the interaction. As the protagonist looked at the scene, he or she (a) experienced a positive connection (compassion, warmth or acceptance) with him or herself in the difficult situation; (b) felt sad or distressed and (c) recognised an important aspect of how the situation had impacted on him or her and the maladaptive belief that arose from the situation. The protagonist became more aware of what Chapter 10 147
he or she was trying to say or do in the scene and of what had interfered with being able to do that. 3. The most important impact of the event, as identified by the protagonist during the BSR, related to increased awareness, either (a) I realised something new about myself or saw why I did or felt something; or (b) I became more aware or clearer about my feelings or experience, I became more aware of experiences which I had been avoiding or what I was really feeling or trying to say became clearer. 4. The protagonist experienced a sense of hopefulness that a significant process had been identified and the session was heading in the right direction, even while in three of the four resolved cases the protagonist continued to experience the situation as difficult, with no sense of how it could be different. 5. This created a crisis point for the protagonist, who felt compelled to do something different. 6. This event was linked at two-week follow-up interviews, with increased awareness of the person’s behaviour.
The protagonists’ in-session experiences of this event are illustrated here with extracts from their recall interviews. Grant’s recall is included, as he met the criteria for re-experiencing and insight, even though he did not achieve resolution during his session. Ray: I thought ‘it’s a small event, pretending mum and dad are pushing me, so simple and almost meaningless’, but I realised it wasn’t meaningless. Being pushed and shouting ‘No’ louder and louder, I became overwhelmed. When I watched myself being pushed I thought ‘poor boy’. It was painful. I can’t believe how much pain it brought up. But when I was being the child and I received the message ‘poor boy’, I shut down, I just didn’t feel. I thought ‘I can’t have compassion, I don’t deserve it.’ Jane: This scene really connected me with my experience as a child. I felt distressed and realised with how difficult it was for me to stay with my needs as a child. I realized why I shut off and couldn’t feel myself. In the scene I was trying to listen to myself and support my mother, but it was impossible to do. I began to feel concerned for myself. Chapter 10 148
Julie: I’ve thought I’ve been overreacting to this death in my family. Part of my reaction has been ‘It’s bloody ridiculous to be this upset’. This scene reminded me how important he was to me and why his death is so upsetting. I got back in touch with what I value. Looking at the family scene I recognised the sadness and the loss; they’re all people. I hadn’t thought about how I was the youngest and hadn’t experienced a significant loss before. Cheryl: The scene brought the real life distress of my childhood and my family back. It felt as bad as it did then. I felt totally powerlessness and had to prove myself. I felt as though I didn’t exist. When the director took me out of the scene, I got back a bit of control; I could see what was happening without being swept up in it. I existed when I was out of the scene. Grant: I was really scared of the conflict and felt overwhelmed; especially when I was being mum, thinking about her feelings. I was worried I would hurt mum’s feelings. When some fear started coming up my barriers came down, then I let my guard down a bit and felt some of the sadness. I realised mum is warm but she uses guilt. I thought ‘I need to be more open with mum, but she needs to give something too, and I need to make myself happy’. This is hard to do, to get the balance. I was aware that I started to be more honest with myself, breaking away and taking control.
The following event summary (Figure 10.2) provides a more detailed description of Cheryl’s re-experiencing and insight event.
CHERYL: Re-experiencing and Insight Context: Cheryl’s psychodrama session was the third and last psychodrama in a two and a half day workshop. In previous sessions she reported that she felt supported by other group members, had observed that strong emotions were acceptable in this group, and had decided that the group leaders were able to manage strong emotions Chapter 10 149
when they emerged in the group. Earlier she had remarked that she usually only felt supported when she was at work. Cheryl had gone home the previous day feeling very agitated and annoyed that she had not put herself forward to be a protagonist. She was determined to be a protagonist the next day when she returned to the group. Cheryl had reported experiencing a lot of depression in her life and attributed this to her childhood experiences of being overly controlled and condemned. At the beginning of the session the director noticed that Cheryl was determined to do the work, and was clearer in her purpose for the session than the director had expected her to be. The director’s main intention going into this scene was to identify and intensify Cheryl’s experiencing and acceptance of her feelings. The director considered it was important to establish goals and help her to focus and clarify, particularly because she had noticed that Cheryl was at times slightly dissociated. Aware of Cheryl’s tendency to isolation, the director was keen to establish a feeling of support. Process: When the director asked Cheryl to set out the scene of her childhood home, Cheryl mentioned the kitchen. Based on her experience that protagonists often locate core family of origin scenes in the kitchen, the director anticipated that this would be an important scene. It became obvious that setting out the scene was having an impact on Cheryl. She was holding herself (arms holding her body); there was a blurring of roles between Cheryl and her mother. When the director was interviewing her for the role of mother, it was unclear whether Cheryl was answering as herself or as her mother. As the enactment of the roles deepened, Cheryl became more vulnerable, more fragile. When Cheryl was enacting the role of herself as a child, she became very agitated and was not able to put words to her experience. She remarked that she was better at playing her mother than herself, and this indicated some awareness of the enmeshment between herself and her mother that was being played out. The director sat beside Cheryl to be on the same level with her and, doubling Cheryl, put some words to what Cheryl was doing. When this happened, Cheryl was able to recognise that she was feeling anxious. Cheryl felt strongly supported by the director in that moment. Cheryl then began to speak about what was happening in the family at that time that created the tension, crying as she spoke. Chapter 10 150
The enactment of the scene brought the real life distress and feelings of childhood back. During the scene Cheryl had mental images of how it had been then – sitting at the table, being sent off to her room, having to return and apologise. It felt as bad as it did when she was a child. She re-experienced a total feeling of not being important, felt cold and distressed and she realized she had been totally powerless in the situation. In the role of her mother, Cheryl enacted a hostile response to the auxiliary being Cheryl as a child. Cheryl then became overwhelmed by feelings, crying and physically turning away from the scene. She was re-experiencing herself as not existing in the family. The director invited Cheryl to move out of the action space to observe auxiliaries enacting the scene. At first Cheryl found it difficult to watch the scene, was tearful and turned to the director for support. The director judged that Cheryl needed a support person to assist her to manage her own process. When an auxiliary came out and stood beside Cheryl to take up the role of a supportive sister, Cheryl felt the support and thought ‘I don’t have to be strong’. With coaching from the director, Cheryl was able to look at the scene. Up until then her tears had been quiet, but now she was able to let out her feelings and cry. This was a significant moment in the scene, when she realized that she existed when she was taken out of the scene. She recognised that she had got back a bit of control and could see what was happening when she wasn’t being overwhelmed by the experience. When she was setting out the scene of her childhood home, Cheryl was trying to describe the experience, put it into words so others could see it. She knew it was important to her, but she wanted the awfulness to be known by others (the group). At one point when Cheryl was observing the auxiliaries re-enact the scene, an auxiliary inaccurately portrayed Cheryl’s sister protesting to the mother. Cheryl realised that it wasn’t understood (by the group) how terrible the situation was and that the children were so scared that they wouldn’t have fought. She forcefully told the group “We wouldn’t be allowed to say that”, and as she said this she got clearer about what it had been like for her as a child in this family. She experienced the effect of her childhood situation more strongly and cried while naming the heart of her issue: “You have to apologise for existing. You’re humiliated in front of your family”. Chapter 10 151
Impact: During the scene Cheryl had a feeling of getting stronger, of being on the path to somewhere. She experienced herself advocating on her own behalf and was pleased to have done that. She became aware that she only felt as though she existed when she was away from her family.
Figure 10.2. Summary of Cheryl’s re-experiencing and insight event.
Variant themes in re-experiencing & insight events within not-resolved cases. Geraldine’s and Linda’s psychodramas met some, but not all the conditions of the re- experiencing and insight event. A comparison of their psychodramas with resolved cases highlights the therapeutic aspects of the re-experiencing and insight components of this event and, to this end, Geraldine’s case will be described in more detail. Geraldine identified a central concern but without a sense of re-experiencing the original situation. While she realised something new about herself and identified the maladaptive belief that she needed to present herself as strong and competent to protect herself, she did not report having an accurate experiencing of being in the moment; did not allow herself to experience a depth of sadness and distress in relation to her experience, was predominantly critical towards herself when she did begin to experience feelings and, although she reported having some hope that she was on the way to addressing her issue in the early phase of the event, did not experience a sense of hope by the end of the event. These processes are illustrated in the following extract from Geraldine’s case summary (Figure 10.3).
GERALDINE: Partial Re-experiencing & Insight Event Context: Geraldine’s session was the first psychodrama of the workshop and her first experience of psychodrama. In the introductory session she experienced the group as welcoming and non-threatening, but she felt inadequate when she couldn’t Chapter 10 152
identify what she was feeling or wanting to confront. After the first session she experienced some anxiety about her emotional state. The next morning, this anxiety combined with the positive atmosphere in the group led her to ‘want to participate and get on with it’. Process: Geraldine set out a chronology of events where she had experienced herself being isolated, leading up to and including her experience of an abusive marriage. The enactment largely involved setting out and talking about past events, rather than experiencing herself in the situations and the relationships. Geraldine found moving in and out of roles very difficult. The director avoided having Geraldine reverse roles on a number of occasions, because she was concerned that Geraldine would feel more hopeless if she engaged in unproductive dialogues. Consequently, the relationships between roles were not explored. However, on the few occasions when Geraldine did engage more with role reversals, greater depth of expression occurred in the moment. Geraldine experienced herself being highly critical, both of herself and of group members, during the enactment. At one point when she began to feel upset she thought to herself ‘You snivelling thing, get on with it.’ When auxiliaries got off track, she felt irritated, and thought: ‘You just don’t get it’, but she didn’t express these thoughts. Impact: Geraldine didn’t get to where she wanted to in this event; she thought that she needed to experience her feelings but mostly talked about what her experience had been. The most important impact of this event was realising that her rhetoric was a protective mechanism she used to project an image of being strong and competent; that she experienced herself and her needs as being invisible to others. Looking back at the events of her life she realised she needed to be clear and honest with herself and with others.
Figure 10.3. A partial re-experiencing and insight event from a not-resolved case.
Event 2: Activating Resourcefulness
The Re-experiencing and Insight event produced a crisis or impasse and, in resolved cases, led to the second meta-event, Activating Resourcefulness. In this Chapter 10 153
event, protagonists warmed-up to progressive roles and responded assertively to interpersonal difficulties that they had been avoiding. Resourcefulness involved setting a boundary in a relationship that had been problematic or initiating intimacy in a positive interpersonal relationship that the protagonist had been avoiding. This event occurred in all resolved cases and in the not-resolved cases of Geraldine and Linda. Activating resourcefulness is summarised in Table 10.3 and the processes are then illustrated with case examples.
Table 10.3. Summary of Event 2: Activating Resourcefulness.
Summary of core ideas: Activating resourcefulness Context Impasse between what the protagonist wants to happen and what he or she experiences happening. Process A. Boundary Setting Acknowledge anger Resistance from auxiliaries Positive response to self Tentative protest Protest supported by director or auxiliary Accept feelings as justified Assertiveness increased & maintained B. Intimacy Openly disclose importance of relationship Freely express difficult aspects of relationship Express positive feelings to self & other Openly explore in role reversal as significant ‘other’. Within Session impact Energised, active, hopeful Acknowledge own capabilities & limitations of other Imagine taking similar action in real life. Post-intervention Impact New behaviour with significant other.
In both types of resourcefulness event, the protagonist took action to address an interpersonal impasse and as a result of taking this action, felt energised, active and Chapter 10 154
hopeful. Processes for the two types of resourcefulness events, boundary setting and intimacy, are described below with case illustrations. Boundary setting (Resolved Cases: Jane, Ray, Cheryl; Not-resolved Case: Geraldine). Boundary setting involved assertively confronting a significant other in surplus reality and occurred in 3 of the 4 resolved cases. The core processes were: 1. The boundary setting event began with an experience of impasse where the protagonist initially felt caught in an old problematic response. Enacting a problematic situation, the protagonist had a powerful experience of not liking what was happening, of finding it unacceptable. Feelings of anger and frustration emerged, but were initially not expressed, as the protagonist felt unable to respond in the situation. 2. Interventions of auxiliaries within the enactment assisted the protagonist to identify that he or she was feeling angry. These interventions took the form either of physical resistance where auxiliaries physically blocked or pushed against the protagonist; or through modelling, where an auxiliary, acting as a double, voiced the protagonist’s unexpressed protest against the situation. 3. The protagonist became energised and this was reinforced when the protagonist experienced an affirming response to self. 4. The protagonist made an initial protest that was somewhat assertive but with high levels of emotionality. This response was either conflicted or expressed as a self- disclosure of distress. The protagonist moved away from this initial assertive attempt. 5. When the director acknowledged the protagonist’s response, he or she protested more assertively. The assertive response became stronger with repetition and was maintained over at least two interactions. 6. In most cases (3 of 4) the protagonist reassessed the original situation, acknowledged his or her own abilities and recognised the limitations of the other person. 7. At two-week follow-up, protagonists reported having clearer boundaries with others, expressed as either (i) decisive action to address specific issues with significant others, (ii) not responding to the demands of others as they previously would have or (iii) being less affected by others’ emotional states. Chapter 10 155
The protagonists’ in-session experiences of this event are illustrated here with extracts from their recall interviews: Jane (Recalling the scene where her father was verbally abusing her mother): When the auxiliary said (to ‘father’) ‘Stop that!’ it jerked me into being fully present and showed me that change is possible. I realised I could do what needs to be done. My father’s anger was horrible but manageable; I let go of the idea that mum could be a mother. Ray (recalling the scene where he confronts his parents): I started talking louder and realised that I should let the anger come up. This is the first time I’ve allowed myself to say ‘no’ to my parents, and get angry with it.
An extract from Ray’s case summary provides a more detailed description of a boundary setting event (see Figure 10.4).
RAY: Activating Resourcefulness (Boundary Setting) Context: Before the workshop, Ray reported feeling paralysed with fear whenever he considered making a major decision. He connected this experience in a general way with not having received warmth or encouragement in his family. He reported having difficulty identifying and expressing other feelings and had expressed some difficulty in identifying his affective responses during earlier sessions of the workshop. Ray’s activating resourcefulness event occurred in conjunction with re- experiencing and insight. His subjective experience of being pushed by his parents had been concretised by auxiliaries taking the roles of his parents and physically pushing him while telling him what to do with his life. The physical contact had a powerful impact on Ray, who experienced the scene ‘as-if’ his parents were pushing him in the moment. He felt powerless to change the situation and realised that his non-specific fear when faced with making decisions related to having no identity in the face of his parents’ persistent and controlling behaviour. In this event, he verbally objected to their demands, but in a pleading tone that suggested he had no choice but to comply, and continued to allow the auxiliaries to push him in the direction they chose. This reinforced his belief that saying ‘no’ had no impact on others. Chapter 10 156
Process: When Ray experienced the strength of the family dynamic, he began to feel agitated. He started saying ‘No’ repeatedly to his parents, with his voice becoming louder and louder. Originally, he was unaware that he was becoming louder, but when he did notice, he became aware of feeling angry and he decided that it was alright to be angry and that he should allow this feeling. Until this point, the auxiliaries had continued to push him and he had moved along with them. At this point, he stopped on the spot and yelled ‘No’ directly to them. The auxiliaries were stunned and stopped. The moment he had done this, Ray moved away from the auxiliaries and cried. This first assertive response arose from a release of frustration and Ray was initially overwhelmed by his feelings of powerlessness in the situation. The director acknowledged Ray’s new response and reframed his action as ‘protesting to his parents for the first time’. Ray immediately felt stronger in himself and recognised that he had successfully stood up to his parents. The event was re-enacted and Ray held his ground and loudly and firmly said ‘no’ to his parents. He maintained his stance when the auxiliaries attempted to push him and experienced himself as stronger than them. Impact: Ray experienced this as the first time he had allowed himself to feel angry while he was saying ‘no’ to his parents. His acknowledgment and acceptance of his feeling of anger in this event appeared to assist him to recognise other feelings and, shortly afterwards, he expressed empathy towards himself as a child. Immediately after this event, Ray was able to identify what he needed from the group for the first time.
Figure 10.4. Summary of Ray’s boundary setting event
Geraldine, whose session was not resolved, experienced a boundary setting event which met the criteria identified in the resolved cases and was linked to specific positive change at two week follow-up. However, she reported some restriction in her depth of experiencing and expression, which differed from the reports of resolved cases. The following extract from her case summary illustrates the themes that she shared with resolved cases and demonstrates the experience of restriction that she reported (see Figure 10.5).
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GERALDINE: Activating Resourcefulness (Boundary Setting) in a Not-Resolved Case Context: Geraldine’s activating resourcefulness event occurred at the end of her session. The session had been long and in this last scene Geraldine felt an urgency to get to what she wanted out of the situation. Geraldine had become more aware of her personal strength in previous scenes and this influenced her to enact a new response to the situation. Process: Geraldine confronted her ‘ex-husband’ about his behaviour and the impact it had on her, assertively stating her intentions for her ongoing relationships with their adult children. She maintained an assertive response in the face of the auxiliary who played her ex-husband and clearly articulated a different course of action for the future in response to him actively isolating her from their adult children. She recalled: ‘Enacting the scene was a good opening. I’ve never said these things directly with someone being my ex-husband.’ However, she also felt that she had not been fully tested in this enactment because the auxiliary playing her ex-husband was not able to portray the volatility and aggression that she anticipated. Geraldine also held back her own feelings. She experienced how much she hated her ex-husband; she wanted to push him to get through her anger, but didn’t want the group to see her out of control. Impact: After this event, Geraldine found that her thinking was stimulated, but she also felt detached from the group. She realised that what she had said during the enactment was what she wanted to do and this acted as a rehearsal for an assertive letter she wrote to her ex-husband after the workshop.
Figure 10.5. Boundary setting in a not-resolved case
Initiating Intimacy (Resolved Case: Julie; Not Resolved Case: Linda). The second form of Activating Resourcefulness, was initiating intimacy, which involved approaching a significant other with whom the protagonist had an established, positive relationship, but with whom they had been withdrawn or avoiding contact, as a response to the unresolved painful emotional experience. The core protagonist processes were: Chapter 10 158
1. The protagonist became aware of a difficulty or impasse inhibiting the expression of grief with the other person. 2. With coaching from the director, the protagonist spoke directly to the auxiliary being the ‘other’, freely expressing affection towards the other and expressing both positive and difficult aspects of the relationship.. 3. The protagonist experienced the auxiliary as accurately and sincerely taking the role of the other person and experienced the encounter ‘as-if’ speaking to the actual significant other. 4. The protagonist was able to move into the role of the other person, to freely express positive feelings to self from that role and openly explore the impact of significant events and/or the protagonist’s behaviour.
Julie’s was the only resolved case with an intimacy event, and her experience of this event is illustrated here with an extract from her case summary (see Figure 10.6).
JULIE: Activating Resourcefulness (Intimacy) Context: After a family member died suddenly, Julie felt isolated from other family members and was disturbed by how everyone had responded to the death. She felt particularly critical of her sister Michelle and avoided contact with her. In the earlier re-experiencing and insight event, Julie had begun to appreciate how the death had affected her and others in the family. With this new awareness, she decided she wanted to reconnect with Michelle. A scene was set for her to have an encounter with an auxiliary as Michelle. Process: Julie began to speak to ‘Michelle’ in a positive but matter of fact way and the director noticed that she was avoiding experiencing affect. When coached to take her time, Julie realised that she needed to feel and express her emotional pain and that although it would be difficult, she recognised that she was able to do this. She experienced allowing herself to cry Julie cried while she spoke to ‘Michelle’ openly and positively about what their relationship meant to her, saying: “I have always wanted to have a relationship with you and I love you the way you are”. She said what she wanted to say to Michelle and felt good to do this. She felt some relief from crying. Chapter 10 159
When she was in the role of her sister, she expressed affection towards her (Julie) and took some responsibility for the distance that had developed between them. Julie experienced the person who took on Michelle’s role as having a real sense of her, as being accurate and sincere. This made the encounter seem very realistic. Impact: The in-session impact of this event is clearly expressed in Julie’s own words: “When I was talking with ‘Michelle’, I recognised the sadness and the loss everyone was experiencing. I felt more accepting about what Michelle had said in the eulogy; her honesty was part of the healing experience of the funeral. I realised that there are shared values, love and support available to me within my family.” During the psychodramatic encounter Julie began to think of the future and realised she could do and say more, especially with Michelle, to let others know what was going on for her. After the workshop, Julie was surprised at the ease with which she re-established a positive relationship with Michelle.
Figure 10.6. Summary of Julie’s intimacy event
Linda experienced an intimacy event which met many of the conditions of Julie’s experience and which she linked to positive changes in her ability to seek support from friends immediately after the workshop. However, as with Geraldine’s example described earlier, Linda reported some restriction in depth of experiencing and expression. This is illustrated in the following extract from Linda’s case summary (Figure 10.7).
LINDA: Activating Resourcefulness (Intimacy) during a Not-Resolved Case Context: Linda’s activating resourcefulness event occurred in the second scene. Previously, she had set out a problematic scene and had felt immobilised. Linda had said that she had created a new life for herself since that time and the director thought that setting out her new life would assist her to experience the powerfulness of it and bring her up to date with herself, rather than living in the experience of the past. From the previous scene the director realised that Linda had done a lot of work on this past problematic relationship, that she was very self sufficient and isolated. Process: Linda set out a scene with friends and support people in her life now. “I was able to articulate my feelings and acknowledge how it was and share that with friends.” She experienced the auxiliaries as responding and acting just as her friends Chapter 10 160
would, being very supportive. She tried to soak up the experience which felt like a pause point among the stresses of her life. She was disappointed that she didn’t have enough time to get into the role of her most significant support person and didn’t really connect with what this person would have to say to her. Impact: During the event Linda felt supported and it reminded her that: “with the friendships I’ve got in my life now I’m on the right track again.” She wasn’t able to take the positive messages in, but got the idea that she should give herself more credit for what she has achieved. When, after the workshop, Linda felt fragmented and fragile (which she attributed to the impact of a later event within her session) she was able to contact friends and ask them for support. This was different to her usual response, which was to withdraw from others.
Figure 10.7. Intimacy in a not-resolved case
Event 3. Social Atom Repair with Emotional Release
As a result of activating resourcefulness in the previous event, protagonists felt energised and hopeful. However, this did not resolve the painful emotional experience. Social atom repair with emotional release was identified as the event most closely linked to resolution. In this event the protagonist experienced receiving a needed but previously unavailable response from a ‘significant other’, in the context of the unresolved painful emotional experience. The social atom repair with emotional release event is summarised in Table 10.4 and the protagonist processes are then described and illustrated with individual examples.
Table 10.4. Summary of Event 3: Social atom repair with emotional release
Summary of Core Ideas: Social atom repair with emotional release
Context Energised to face painful experience Chapter 10 161
Process Grief response Identifies & names unmet need or act hunger Positive to self and/or other Experiences enact the needed response from the role of significant other Emotional release while receiving needed response Experience both sadness and hopefulness/love. Within Session impact Sense of relief and resolution. Post-intervention Impact Change in sense of self and interpersonal relationships
All resolved cases included a social atom repair with emotional release event. The core ideas general to this event are listed here and illustrative responses from protagonist BSR interviews for each case are presented. The core ideas are:
1. The protagonist acknowledged a felt need or act hunger stemming from the time of their unresolved painful emotional experience. 2. The protagonist identified a belief that interfered with them satisfying their unmet need and 3. In surplus reality, the protagonist had a corrective emotional experience, receiving the interpersonal response they needed and didn’t get at the time of the painful emotional experience. The nature of this response varied between protagonists and included (i) containment and nurturing; (ii) guidance; (iii) protection and (iv) experiencing an adequate response to grief in the family system. 4. In the surplus reality scene, the protagonist took the role of the significant other and, as a competent adult, enacted the needed response. (This element occurred in all cases except Ray’s and this may be relevant when considering post-session impact of this event). 5. The protagonist experienced an emotional release of grief while being supported or while receiving the needed response. Emotional release was differentiated from other experiences of sadness or distress, in that it was experienced as free flowing feeling and culminated in a sense of relief or release. For most protagonists the crying was quiet and gentle. Often the protagonist didn’t speak while crying, but took in the experience of receiving the needed response. Chapter 10 162
6. The emotional release was immediately preceded by the protagonist experiencing a positive response to self. 7. Seeing and feeling the painful experience while being supported, led to an acceptance of the event. 8. The protagonist experienced feeling both sad and hopeful or loving. 9. At the end of the event, the protagonist experienced a sense of relief and an internal shift indicating that something had been resolved.
Protagonists’ experiences of this event are illustrated with extracts from Julie and Ray’s recall interviews. Julie: Setting up the (family member’s death) scene was confronting. When the director said ‘Can the children touch their father?’ this was what they needed to do and was missing. This was a true experience of what I like about my family. I felt miserable and proud. I felt grief that the kids won’t get what I got. I felt incredibly thankful for the people in my family and I realised there’s a fair amount of love and support available to me. Ray: The tears were delayed tears of pain of doing something when there was fear. I was opening myself up and bringing pain to the surface. The director asked people to come forward and I thought, ‘oh yeah, here we go, no-one will want to’. Then Sandra stepped forward. When I was being hugged it increased the intensity of crying and sobbing. When Geraldine hugged me, it felt maternal. I was feeling love and warmth – getting what I missed out on. I realized I was letting the compassion in.
A fuller illustration of a social atom repair with emotional release event is provided in the following extract from Jane’s recall accompanied by an excerpt from the transcript of her session (Figure 10.8).
JANE: Social atom repair with emotional release Setting the scene: Jane’s emotional release event occurs when she is watching the re-enactment of her mother dying in a hit and run accident. In this scene, Jane alternately takes the role of a supportive adult and of herself as a young child. Both are sitting on the floor out of the space of the re-enactment, with the supportive adult Chapter 10 163
holding the child. Jane has been in the role of the child and the director asks her to reverse roles with the adult. Jane’s recall of the event: Witnessing ‘mum’ being hit by the car, I felt it bodily and emotionally. It was validation that the accident did happen like that, that my mother didn’t abandon me. I realised that mum lived and now she’s dead. When the director said ‘It’s sad for a little girl’, I thought ‘No it’s not, I’m capable.’ Then, seeing the little girl being held and the auxiliary modelling crying, I thought ‘It’s OK to be held and cry. I can do it too. It really did happen; you’re allowed to feel this way’. I cried and the dissociation went, the split went. I noticed other people’s responses; they were acknowledging my mother’s death. I felt supported and cared for. An excerpt from the transcript: (Note: dialogue by the protagonist is in italics, dialogue by the auxiliary is in plain type. Core ideas are indicated in brackets beside the transcript). Jane (adult, looks at the scene, then at the child, she strokes the child’s head). I’m looking after you. I’m looking after you. (Positive to self- comforting) Auxiliary (child) Is her body all over the road?* Jane (adult) No her body’s not all over the road. (Positive to self – grounding) Auxiliary (child) There’s body parts everywhere?* Jane (adult): No, she just got knocked and fell to the side of the road. She didn’t even get run over. (Positive to self – grounding) Auxiliary (child) Is that my mummy? Jane (adult) (Sighs) Yeah. But it’s alright. It’s frightening, it’s a worry. But I’m going to look after you. (Positive to self- acknowledging, comforting) (Jane reverses roles to be the child; reaches up and puts her arms around the auxiliary in the role of supporting adult). Jane (child) It’s scary, and my little brother, he’s only a little baby. And I, I suppose I’m only little too. (Self-disclosure- distress) Auxiliary (adult) (Stroking her head) You’re only tiny. Jane (child) I’m only a little 6 year old. They’re just pretty little. They need somebody to look after them. (Self-disclosure- unmet need) Auxiliary (adult) (Holds the ‘child’ more closely) Chapter 10 164
Jane (child) (Cries. This continues for some time, while she is held and comforted by the auxiliary). (Emotional release while being held) (Jane reverses roles to be the adult and places her arm on the auxiliary who is now in the role of the child). Jane (Adult) (Sobs) It’s sad, and we can be sad together. (Positive to self- acknowledging, comforting) It’s sad because I didn’t get what I wanted from her and we’re not ever going to get it from her. (Positive to self – acknowledging; Action insight) Auxiliary (child) I need someone to protect me, and look after me. Jane (Adult) Yeah, I’m with you. I’m with you, I’ll nurture you. (Positive to self – nurturing).
Figure 10.8. Jane’s social atom repair with emotional release event Note: * The questions asked by the auxiliary as the ‘child’, arise from comments Jane had made earlier about images she had created of her mother’s death when she was a child.
Variant Themes in Not-Resolved Cases. The not-resolved cases did not have emotional release events. Linda had an event that had elements of social atom repair without emotional release and she described experiencing the intervention as a strategy rather than a process she was engaged with. Linda’s experience of this event is illustrated with an extract from her recall responses.
Linda: To begin with, I felt vulnerable and safe, but fearful that it would change if my parents came in. When the parents started coming in I tried to feel the support, but it felt like a strategy. I couldn’t see all the people who were supporting me and felt a deep grief of being alone.
Event 4: Integration
In-session integration was described in three of the four resolved psychodramas and occurred after protagonists had gained a sense of relief and resolution. The core ideas of in-session integration are summarised in Table 10.5.
Table 10.5. Summary of Event 4: Integration Chapter 10 165
Summary of Core Ideas: Integration
Context Feeling relieved or settled Process Encounter Express warmth or affection to self &/or other Oriented to future action Within Session impact Experience self as consolidated as an adult While enacting new role relationship, imagine taking new role into meeting with real life significant other. Post-intervention Impact Change in sense of self Change in interpersonal relationships
The core processes within integration events were: 1. Integration events occurred after the protagonist had gained a sense of relief and resolution in the session and was feeling settled. 2. The protagonist experienced a change in sense of self in the situation, a feeling of integration, that he or she is a competent adult whose functioning is congruent and who is able to deal with situations that arise. 3. The focus was on the present and the future rather than the past. He or she expressed clarity about how to move forward in life. In some cases, while experiencing the encounter with the other person, the protagonist developed an intention to have a similar interaction with a real life significant other in the near future. 4. The protagonist expressed warmth or affection towards self or a significant other. 5. After the workshop, the protagonist reported changes which were consistent with their experiences during this event. Those changes included maintaining the sense of self as an integrated adult in situations which were previously challenging and taking action consistent with their stated intent during this event.
An integration event is illustrated with an extract from Jane’s recall (Figure 10.9).
JANE: Integration In the final scene of her psychodrama, Jane had an imaginary encounter with her mother, adult to adult, with a focus on how she is in her life now. Jane recalled: Chapter 10 166
“I felt enormous relief after the previous scene, having cried and connected with my mum; but I still felt an internal struggle to be nice to her. In this scene now, being in the role of my mother and hugging the person being me warmed me up to having a loving relationship. The director saying ‘honesty is the best policy’, allowed me to pull back from hugging ‘mum’ straight away and to say what I needed to. I was able to voice my needs and how it really is. I’m not just a competent woman, I need love and support. I realised I now have more respect for my mother and feel her as real. I felt comfortable about letting mum go. I don’t feel as though she’s buried alive anymore; there’s a sense of peace in our relationship. I felt consolidated as an adult with needs and deserving of love.”
Figure 10.9. Extract of Jane’s recall of an integration event
General Patterns across the Four Meta-Events
Two additional themes were identified across the four meta-events: (i) a link between a positive attitude to self and the development of a new response and (ii) the development of insight over time, through multiple experiences around a central dynamic. These two themes are described and illustrated here.
The relationship between a positive attitude to self and the emergence of new responses
A relationship was identified between the protagonist’s attitude towards self and the emergence of new responses to problematic situations. The generation of a new response to a significant other or to a problematic dynamic, was immediately preceded by the protagonist accepting a positive response to self. The positive response was either generated by the protagonist, while relating to an auxiliary acting as the protagonist, or was generated by an auxiliary relating to the protagonist. In either instance, the protagonist experienced accepting the positive response to self in the moment. This pattern occurred within each type of meta-event. The relationship between the protagonist accepting a positive response to self in the moment and then generating a new response to the situation was evident at different stages within the enactment.
The dynamic development of insight over time Chapter 10 167
Protagonists’ abilities to make meaning of their experiences progressively expanded through multiple experiences of action insight over the course of psychodrama sessions. Action insight occurred when protagonists were engaged in experiential tasks and made a connection between felt experience and cognitive awareness. Three types of action insight were identified (see Table 10.1): 1. Immediate self-awareness, which centred on the protagonist’s inner subjective experience in the moment, without reference to the social system. 2. Identifying problematic dynamics or beliefs and recognising how these maintain a problematic response. This occurred when protagonists engaged in or observed the re-enactment of a problematic scene and was a central process in re- experiencing and insight events. The process of making meaning of problematic dynamics was typically expanded and deepened over the course of the session. 3. Making a new construction of the sense of self or a new construction of the situation. This type of action insight was oriented towards resolution, a new sense of self or a new solution in the situation and occurred either after the enactment of an assertive response, or towards the end of the session, after emotional release. It indicated that an experiential task had been successfully completed and that the protagonist had resolved an aspect of the problematic dynamic. Such insight consistently incorporated a positive attitude towards self.
These three types of action insight can be conceptualised as a hierarchy of complexity of insight, with a progressive expansion of awareness of self in relationship with the social system, over time. To demonstrate the dynamic unfolding of action insight over the course of a psychodrama session, the three types of insight are illustrated with extracts of transcripts from Jane’s psychodrama (see Figure 10.10). In Jane’s case the development of new insight focussed on her relationship with her mother and with her self, progressing from an undifferentiated experience of difficulty in relationship with her mother, through making meaning of her internal experience, making meaning of the problematic dynamic and, lastly, constructing a new meaning of her relationship with her mother and with herself.
The dynamic development of action insight, as Jane makes new meaning of her relationship with her mother and with herself Chapter 10 168
Jane’s mother died when Jane was a very young child, and she reported having an enduring sense of feeling abandoned and rejected and consequently of being unworthy of receiving love. At the outset of her session, Jane had said that she wanted to be able to speak with her ‘mother’ in surplus reality, adult to adult. However, when she sat facing an auxiliary acting as her mother, she was unable to speak.
1. Immediate self-awareness. Gradually, Jane realised that she was not able to maintain a sense of herself as an adult when she thought about her mother. In the early stage, however, she focussed on the task of speaking with her mother and felt frustrated with her inability to act. After making several false starts, Jane focussed on her felt experience in the moment, was able to name her experience and make tentative meaning of it. This first level of action insight, immediate self-awareness, centred on her own experience, without reference to the social system: Jane (addressing the director): This doesn’t feel real. But that’s OK because the only real connection I have (Jane points her finger to her head, indicating this is her internal construct) is being that little girl.
2. Identifying problematic dynamics and recognising how this maintains her problematic response. Jane progressively developed a deeper awareness of the dynamic operating between herself and her internalised experience of her mother. Firstly, she worked out a strategy that assisted her to be able to talk with her mother, calling her mother by her first name so that the mother-daughter relationship was temporarily avoided. As she did this, she recognised the unmet need that was interfering with her ability to relate: Jane (speaking to her ‘mother’): It’s a relief to call you Gwen. I was blocked with talking to you until I realised I didn’t have to call you mother. I can call you Gwen adult to adult. And umm, I feel, I feel sorry for you and that’s not what I want to feel. I want to feel valued by you instead of me having to look after you. Later in the same scene, after watching auxiliaries replay her childhood interaction with her mother, Jane expands on the problematic dynamic: Director: So, mum can’t listen to the little girl and you can’t listen to the little girl. Jane: No, I’ve got to listen to mum. I’ve got to look after her. I’ve got to look after my little brother too. I love him. Chapter 10 169
Towards the end of the session Jane sat down again to speak to her ‘mother’. Having had an experience of emotional release and social atom repair (refer to the earlier description of meta-events), Jane was now able to call her ‘mum’. She appeared to be more open to experiencing her mother and herself and this enabled a deeper encounter with her ‘mother’. There was an unfolding of new awareness as Jane made sense of how the relationship dynamic with her mother was maintained in the family system. New insight into her mother was expressed in role reversal as her mother and then, when she returned to her own role, Jane made new connections between her mother’s experience and her own experience. This is illustrated in the following transcript: Jane (as mum): I wanted to be a good mother and I wanted to love you more and appreciate you more. I think your energy was just one extra thing that I didn’t need. Jane (as self): Mmm. And I’m really sad about that because I’m realising as I listen to you now I probably laid myself down and (shakes her head) that’s what I always got criticised for by my father, you know, that I was always too quiet and not out there enough for him, and I was too out there for you. Goodness, I just realized now what a no-win situation I was in for myself. ... And I guess I have always had that expectation that I’m not going to be loved and I put the message out.
3. A new construction of the sense of self and of the social system. Jane began to develop a new construction of herself and the social system half way through her session, after she had made an assertive intervention, and this was further developed towards the end of her session, following emotional release. After confronting her parents about their violent behaviour and their neglect of her as a child, Jane speaks to her mother: Jane: This (Jane as a child) is a lovely little girl and she needs somebody else to look after her. (Pause) So I’ll find somebody else to look after her. (Pause) And I’m the best person to look after her! (Jane laughs). After the re-enactment of the scene where Jane’s ‘mother’ died, Jane was encouraged by the director to look at the group. She became aware of being witnessed and acknowledged by the group. She articulated the meaning of this experience shortly afterwards, when she recognised and acknowledge her mother’s positive feelings towards her. Chapter 10 170
Jane (as a child, noticing the group): (Smiling) I’m seeing being noticed with a lot of love. And I’m seeing that they know that my mother has gone. (…later…) Jane (as self, speaking to her mother): And it’s good to hear you loving me now. I’m taking that on board that I’m worth loving.
Figure 10.10. A case example of the dynamic development of action insight.
Summary of the findings of the Comprehensive Process Analysis of significant events
The findings of this study suggest protagonists complete four meta-events in the process of achieving in-session resolution of painful emotional experience: (i) re- experiencing and insight; (ii) activating resourcefulness; (iii) social atom repair with emotional release and (iv) integration. The social atom repair with emotional release event most clearly differentiated resolved and not resolved cases. Not-resolved cases met some but not all of the conditions of the first two events to varying degrees on a case-by-case basis; but did not meet the conditions for social atom repair with emotional release. Geraldine and Linda’s examples demonstrated that resourcefulness without resolution could produce positive changes in specific behaviour, but did not address feelings of guilt or anxiety that were associated with the original experience. The integration event, completed in three of the four resolved cases, appears to mark consolidation of the shift that occurs during social atom repair with emotional release. It would seem that a readiness to engage in the psychodramatic process, which combines a sense of connection with the group, trust in the director, basic understanding of the psychodramatic process and a personal drive to address the emerging issue, is a precondition to participating in the process to a depth that will enable in-session resolution of painful emotional experience. In psychodramatic terms this would be considered to be the level of warm-up that the person has to the group, to the form (psychodrama) and to their own experience. This does not necessarily equate to being comfortable in the group, as protagonists reported that a Chapter 10 171
feeling of anxiety or discomfort was part of the drive compelling them to work on their issue. The re-experiencing and insight event was the first significant event of the session. In this event, the re-experiencing was of the family dynamic that was the context for the painful emotional experience, rather than the painful emotional experience itself. Differences between the ‘resolved’ and ‘not resolved’ groups during this type of event, suggests two elements that may be important to the protagonist’s ability to reach resolution. Firstly, by the end of the event all four resolved protagonists experienced a sense of hope that they were moving in the right direction even though three of them continued to experience some difficulty without a solution at this point. Secondly, all protagonists in the resolved group reported experiencing the event as-if they were back at that time, with a full affective re- experiencing. In the unresolved group one protagonist reported affective re- experiencing, but continued to feel overwhelmed and hopeless in the face of these feelings, pushing himself to find a solution; and another reported feeling dissatisfied that she was not fully engaged with the scene. Affective re-experiencing of the core theme, along with some element of optimism, may be important at this stage. Given that three of the resolved cases appeared to be stuck in maladaptive responses at the conclusion of this event, it is interesting to consider where the optimism arose from in these three cases. One possibility is that acknowledging the difficulty along with the warmth they reported experiencing towards themselves in this first scene was beginning to make a difference to their experience of themselves in relation to the original painful emotional experience. The activating resourcefulness events occurred before the emotional release event. This is in contrast to Greenberg and Paivio’s (1998) proposition, discussed in Chapter 4, that empowerment is an outcome of allowing emotional pain. This finding suggests that experiencing themselves as competent may assist protagonists to be able to experience and resolve previously avoided grief. In three of the four resolved cases, the protagonist assertively set a boundary in a problematic relationship in this event. In the fourth case, the protagonist invited a stronger connection with a family member. For both types of resourcefulness, boundary setting and building intimacy, the protagonist took an active step to manage their emotional response and overcome their avoidance of a relationship difficulty. In the Chapter 10 172
example of building intimacy, the protagonist was addressing an issue of uncomplicated grief, but it is possible that for more complex grief involving abuse or trauma, a boundary setting response may be required before the protagonist can allow themselves to experience emotional pain in an emotional release event. The social atom repair with emotional release event appears to have a number of characteristics in common with Greenberg and Paivio’s description of ‘allowing and accepting painful emotional experience’ (see Chapter 4). Foerster and Greenberg (1995, in Greenberg, 1999) have established criteria for measuring components of the ‘allowing and accepting’ model, that could be applied to these events to determine whether they do in fact meet the same conditions. The first study (Chapter 7) raised the question as to whether or not catharsis was a necessary condition for resolution. In this study emotional release has been identified as an important condition and it is proposed that the combination of emotional release with the corrective emotional experience that is part of social atom repair is a cathartic experience, even though the expression of emotion was typically gentle and quiet. This question will be addressed further in the discussion (Chapter 13). Social atom repair occurred within a surplus reality scene in which the protagonist experienced an enactment of the wished-for response that had not been available at the time of the original painful emotional experience. Typically, the protagonist initiated the wished-for response in the role of a significant adult and then experienced receiving the response in their own role. Only one protagonist, Ray, experienced receiving the response without first initiating the intervention in the role of an adult and, interestingly, he was the only protagonist in the resolved group who did not go on to experience an integration event. The integration event fits with the psychodramatic principle of a ‘role test’, that is, the protagonist is confronted by a situation where she or he would previously have been unable to respond adequately and is now able to respond in a way that is appropriate to the situation. This suggests a level of resolution beyond the scope of the ‘Degree of Resolution Scale’ used in this study. An unexpected finding of the study was the immediacy of the link between the protagonist experiencing a positive relationship to self and the deepening of the protagonist’s warm-up. Positive responses to self immediately preceded major shifts in the protagonists’ responses during the session, such as the expression of Chapter 10 173
previously blocked distress, producing an assertive response and emotional release. This suggests that changes in the person’s relationship with self in the context of the situation, begins to be enacted and experienced at some level before a new response emerges, and before new meaning making is articulated. What has been described as allowing painful emotional experience (Greenberg & Paivio, 1998) may be a more complex experience of allowing a positive experience, such as being comforted, to co-exist with the recall of emotional pain. It is proposed that therapeutic change during psychodrama occurs partly as a function of training over time. The development of meaning making exemplifies this principle. As the protagonist is exposed to a number of different experiences related to the same theme over the course of a session, she or he appears to build on the meaning making that is made at each step. Similarly, assertive responses were developed through repetition. It may also be that emotional release, occurring as it does towards the end of a session, is the product of the development of the protagonist’s capacity for emotional expression during the session. While the DRS/PRP has been found to be a reliable measure of in-session resolution, some limitations have been encountered with its application in this study. Firstly, there would appear to be different degrees of in-session resolution captured within the highest level of the DRS/PRP, which can be linked to qualitative differences in reports of post session changes. This was consistent with the findings of the preliminary study reported in Chapter 7, which identified qualitative differences in in-session resolution between two resolved cases. The measurement of in-session resolution during psychodrama may need to go further than the DRS/PRP that has been used in the two studies so far, to include a level where the protagonist has integrated progressive functioning and has demonstrated a shift in orientation from focusing on the impact of the past to acting in the present and imagining and rehearsing for the future. A further limitation that was experienced with the DRS/PRP was the lack of fit between the terminology used in the scale and the conceptual frameworks of psychodrama practitioners and independent observers (who were not psychodramatists) in this study. Chapter 10 174
Implications for building a model of protagonists’ change processes
The four meta-events that were identified in this study might be considered to be tasks that protagonists complete in the process of resolving painful emotional experience. This proposition needs to be verified with the study of further cases. The apparent similarities between the social atom repair with emotional release event and Greenberg and Paivio’s (1998) allowing and accepting painful emotional experience model needs to be investigated as a possible alternative explanation for the process of resolution during psychodrama. These areas of investigation are taken up in the final two studies of this thesis, which are reported in Chapters 11 and 12. Chapter 11 175
Chapter 11 Verifying the Emerging Model of Protagonist Change Processes
The aim of the third study of this thesis was to verify the model of protagonists’ processes leading to in-session resolution of painful emotional experience, which was constructed in Study 2, by establishing if the criteria for the model could be applied to additional cases. The research plan is outlined in Figure 11.1.
Workshop 4: Cases 11, 12, 13, & 14
Chart Code Compare hypothesised Conduct protagonists’ actual & Modify protagonist psychodrama actual hypothesized the in-session intervention in-session process model process process
Figure 11.1. Research Plan for Study 3
Overview of Study 3 A model of protagonists’ processes leading to the in-session resolution of painful emotional experiences during psychodrama enactments, has been proposed (refer to Chapter 10). This model has five meta-processes, the first being a readiness on the part of the protagonist to engage in the psychodramatic process; and the other four being in-session events where protagonists (i) re-experience the interpersonal dynamic central to their painful emotional experience, and gain insight into how their maladaptive functioning is being maintained; (ii) activate themselves to move through an impasse in the interpersonal dynamic; (iii) experience social atom repair with emotional release and (iv) in some cases, experience in-session integration of new learning. The model was developed through the intensive analysis of a small number of cases, in line with the approach of Hill et al. (2005), who recommend that complex data sets are best managed by initially investigating a small number of cases and then checking the stability of emerging models through the investigation of additional cases. This current study compared protagonists’ observable in-session processes in Chapter 11 176 an additional four cases, with the descriptions of protagonists’ processes developed in the previous study.
Hypothesised Protagonist Processes Leading to In-session Resolution From the findings of Study 2, general patterns of protagonists’ processes leading to the in-session resolution of painful emotional experiences can be charted. The general patters for the four meta-events of the proposed model are described in diagrammatic form in Figures 11.2 through to 11.5. In the first meta-event, re-experiencing and insight (Figure 11.2), the protagonist re-experiences the original dynamic as if it was occurring in the here and now. Re- experiencing occurs as the protagonist enacts the original scene from different perspectives, that is, both from their own role and, in role reversal, from the perspective of at least one other person. The language used in the enactment indicates that the person is acting as-if the event was occurring in the here and now. The protagonist experiences feelings of distress or sadness. As the protagonist re- experiences the original dynamic, he or she may become overwhelmed by their affective response. A combination of re-experiencing, managing overwhelming affect and experiencing a positive response to self, leads to action insight, which has been defined elsewhere as ‘the integration of emotional, cognitive, imaginary, behavioural and interpersonal learning experiences ... achieved only in action’ (Kellermann, 1992, p. 86). During re-experiencing and insight events, insight included identifying the dynamic or belief that was operating in that original experience, recognising its maladaptive quality and recognising how the dynamic or belief maintained the protagonist’s current problematic response.
Re-experience Manage Positive Insight the problematic overwhelming response to self dynamic affect
Figure 11.2. Hypothesised protagonists’ processes for Re-experiencing & Insight event.
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The second event, Activating Resourcefulness, is a response to a problematic interpersonal dynamic and occurs in one of two forms, boundary setting (Figure 11.3) or intimacy (Figure 11.4). The boundary setting event has four components, (i) acknowledging the experience of anger or protest in response to the behaviour of a significant other; (ii) a tentative protest; (iii) the development of a sustained assertive response to the significant other and (iv) affirming self, expressed as a recognition of the protagonists’ strengths or abilities in relation to the significant other, and a recognition of the limitations of the other.
Acknowledge Tentative Sustained Affirm self anger or protest assertive protest response
Figure 11.3. Hypothesised protagonists’ processes for Boundary Setting Event.
The intimacy event occurred in only one resolved case, but is included in the proposed model because it appeared to have a similar function to the boundary setting event, as a self-affirming experience that preceded social atom repair with emotional release, and in which a different role relationship is established with a significant other. Furthermore, an intimacy event in a not-resolved case in Study 2 was linked to specific improvements in interpersonal behaviour at two-week follow- up, just as a boundary-setting event in a not-resolved case was linked to specific post-session changes. The intimacy event is a reciprocal encounter between the protagonist and a significant other, where there has been a disconnection in the relationship. Open self-disclosure with positive feeling towards the other is met with open self- disclosure with positive feeling from the significant other towards the protagonist.
Openly disclose & Acknowledge Openly Affirm self & affirm protagonist interpersonal disclose other while acting as impasse ‘other’.
Figure 11.4. Hypothesised protagonists’ process for Intimacy Event. Chapter 11 178
In social atom repair with emotional release events (Figure 11.5), protagonists identified a needed response or act hunger which was unavailable or inhibited at the time of the original painful emotional experience. Social atom repair involved experiencing a reparative role relationship where the previously unavailable or inhibited response was followed through. In most cases protagonists, acting as a significant other or as self, actively generated a reparative response and then, in role reversal, experienced receiving the reparative response. This produced an emotional release, expressed as quiet crying or sobbing, often without verbal expression. After this release the protagonist experienced a sense of relief and resolution.
Identify Actively Actively unmet generate receive Emotional Relief need or needed reparative release &/or act response response resolution hunger
Figure 11.5. Hypothesised protagonists’ process for Social Atom Repair with Emotional Release event.
A fourth event, integration, was identified in some resolved cases and occurred after social atom repair. In-session integration is conceptualised as integrating the experience of social atom repair, and was identified as an encounter with self and/or other, with four characteristics: (i) the protagonist experiences being consolidated as an adult; (ii)open self-disclosure is generated by the protagonist, (iii) there is a sustained positive attitude to self and/or the significant other, even though the encounter may involve confronting interpersonal difficulties, and (iv) there is an orientation to present or future healthy functioning. A hypothesised performance diagram has not been constructed for this event, because the event is defined by the qualities of the encounter between the actors, rather than by specific processes. Based on the findings of Study 2 it was anticipated that resolved cases would evidence a readiness to engage in the psychodrama process and meet the criteria of three meta-events of the proposed model, namely (i) re-experiencing and insight; (ii) activating resourcefulness and (iii) social atom repair with emotional release (refer to Figure 10.1 in Chapter 10). The integration event had been previously identified in some but not all resolved cases. The findings from Study 2 suggested that while Chapter 11 179 both resolved and not-resolved protagonists might experience re-experiencing and insight or activating resourcefulness, not-resolved protagonists would, at most, experience only one of these two types of events, while protagonists who went on to experience in-session resolution would experience both of these events, prior to the social atom repair event. It was further anticipated that only resolved cases would meet the criteria for social atom repair with emotional release or for integration.
Research Question This study investigated the following question: RQ5 Can the emerging model of protagonist change processes, identified in Study 2, be applied to additional cases in which protagonists address painful emotional experience?
Method
This study compared protagonists’ observable processes during four psychodrama enactments, with the hypothesised processes derived from Study 2. In this current study, the core ideas described in Study 2 are treated as the criteria for coding protagonists’ processes. Four psychodrama enactments (two resolved and two not resolved) were coded against these criteria and results for resolved and not- resolved cases were compared.
Group Participants Expressions of interest were called for people to participate in a psychodrama workshop addressing painful emotional experience. Eight people expressed interest and met the suitability criteria for participation. One person withdrew due to illness, leaving seven participants, six females and one male. As with the previous studies, suitability for participation was assessed in pre-workshop interviews on the basis of participants being able to identify a painful emotional experience that continued to affect them in their lives and having adequate ego strength to participate in the workshop. Ego strength was assessed on clinical observations of the participant’s functioning, their ability to identify social supports outside of the workshop setting and having realistic strategies for managing the possible emotional distress that could arise through participating in the workshop. Chapter 11 180
Participants ranged in age from 28 to 60 years, were tertiary educated and were either currently working or retired from work. There was a range of previous psychodrama experience in the group, with a higher representation of people with some psychodrama training, compared to participants in the earlier studies of this research. Just over half of the participants in this study indicated that they were receiving counselling at the time of registering for the workshop, compared to 28% of participants across all the studies. (No participants in the current study attended counselling between the workshop and the two-week follow-up interview). Demographic characteristics of the participants in this study (Cohort 4) compared with characteristics of all participants, are shown in Table 11.1.
Protagonists In line with conventional psychodrama practice, five participants volunteered to be protagonists during the workshop. Of these five, four nominated an identified unresolved painful emotional experience that they wanted to address. The fifth protagonist participated in a brief, focussed intervention which did not identify or address a specific painful emotional experience. Analysis of her in-session and post- session outcomes is included, but this case was excluded from the process analysis because of a lack of specificity of the issue being addressed. The protagonists were all female and were aged from 28 to 60 years. All protagonists had some training in counselling or behavioural science. Two of the protagonists (one resolved, one not-resolved) had extensive prior experience with psychodrama, one protagonist (resolved) had attended two psychodrama workshops several years earlier and the other two (one not resolved, and one, mentioned above, which was excluded from the process analysis) had no previous exposure to psychodrama.
Psychodrama Directors
The three certified psychodrama practitioners (directors) who participated in Study 2 directed the psychodrama enactments in the current study. The investigator conducted three psychodrama sessions (one resolved, one not-resolved and one excluded from the process analysis) and the other directors conducted one psychodrama session each (one resolved and one not-resolved).
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Table 11.1. Demographic characteristics of Cohort 4 compared to characteristics for all research participants. Total ª Cohorts 2/3º Cohort 4 (N = 32) (n = 17) (n = 7) Gender Female 24 (75%) 12 (71%) 6 (86%) Male 8 (25%) 5 (29%) 1 (14%) Age Range (in years) 27-66 28-6 27-57 Mean 46 44.1 48 Highest level Secondary 3 (9.4%) 3 (17.6%) 0 of education Tertiary 29 (90.6%) 14 (82.4%) 7 (100%) Prior Psychodrama experience None 16 (50%) 9 (52.9%) 3 (42.9%) One previous session 5 (15.6%) 2 (11.8%) - > one psychodrama group 4 (12.5%) 2 (11.8%) 1 (14.2%) Some psychodrama training. 7 (12.9%) 4 (23.5%) 3 (42.9%) Counselling history Currently receiving counselling 9 (28.1%) 4 (23.5%) 4 (47.4%) Counselling in past 12 months 6 (18.75%) 3 (17.6%) 1 (14.2%) Counselling in past 1-5 years 6 (18.75%) 2 (11.8%) 1 (14.2%) Counselling > 5 years ago. 6 (18.75%) 4 (23.5%) 1 (14.2%) Never received counselling. 5 (15.6%) 4 (23.5%) - Nature of painful emotional experience. 1. Separation from parents 3 1 1* (P) 2. Emotional abuse (including 7* 5* 1* bullying)* 3. Physical &/or sexual abuse* 6* 2* 2 (1P)* 4. Death of parent* 2* 1* 1 (P)* 5. Death of family member/ partner. 3 2 1 (P) 6. War related trauma* 1* - 1 (P)* 7. Other 10 6 -
Note: (P) = Protagonist. ª Total = summary for all participants from the 4 Cohorts. º Cohorts 2/3 = Study 2 participants. * Indicates the event occurred in childhood. Chapter 11 182
Measures
Outcome and session impact measures. Self-report questionnaires and semi-structured interview protocols were administered to participants prior to the intervention, immediately post-intervention and at two week follow-up. Table 11.2 lists the measures and outlines when and to whom they were administered. All measures have been described in Study 2 (see Chapter 8).
Table 11.2. Assessment Points for Outcome and Process Instruments
Instrument Assessment points* Pre Post 1 Post 2 2 wk Personal History Questionnaire X X Symptom Checklist (SCL 90-R) X X Inventory of Interpersonal Problems (IIP-127) X X Session Reaction Scale X Post-workshop Evaluation X Participant Change Interview X Helpful Aspects of Therapy (HAT) X
Note: * Pre = pre-intervention, Post 1 = immediately after the psychodrama session, Post 2 = immediately after the completion of the workshop, 2 wk = 2 week follow-up,
Process measure The Degree of Resolution Scale: Unfolding Problematic Reaction Points (DRS/PRP: Greenberg, Rice & Elliott, 1993) was used as a measure of in-session resolution. This scale is described in Chapters 7 and 8. Chapter 11 183
Procedure The procedure for Study 3 is outlined in Figure 11.6 and described below.
1. Pre-intervention measures
2. Psychodrama Intervention 5. Transcribe sessions
3. Immediate post- intervention reaction 6. Rate resolution measures
7. Identify significant events 4. Two-week follow-up Measures 8. Code key change events against core ideas from study 2.
9. Modify model
Figure 11.6. Steps in the Procedure for Study 3
Pre-intervention measures Immediately before the workshop participants completed a Personal History Questionnaire, the SCL90-R and the IIP-127. These measures provided baseline data for comparison at two week follow-up. The data were also used to compare this group of participants to the participants from Study 2.
Psychodrama intervention A psychodrama workshop of seven sessions was conducted over two and a half consecutive days. The first session was general group work focused on inclusion and goal setting; sessions 2, 3, 4, 5 and 6 were psychodrama sessions; and the final session was general group work focussed on group closure. The five psychodrama sessions each included the classical psychodrama phases of warm-up, enactment and sharing.
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Immediate post-intervention reaction measures After each psychodrama session, the protagonist completed a Revised Session Reaction Form. All participants completed a Post Workshop Evaluation Questionnaire immediately after the workshop.
Two week follow-up All participants completed self-report questionnaires at two week follow-up, and participant change interviews were conducted.
Transcribe sessions Psychodrama enactments were audio taped and recordings were transcribed, identifying the speaker, the position the speaker was acting from, and vocal qualities. Significant non-verbal action was noted on the transcript and these notes were checked for accuracy, by a workshop leader. Audio-recordings were used in this study because of the significantly lower cost and technical support requirements compared to video-recordings. Recordings were used to prepare transcripts for coding, but not for recall interviews as they had been in the earlier studies, and audio-tapes were considered sufficient for this purpose.
Rate resolution After the session, the director rated the degree of in-session resolution using the DRS/PRP. An independent observer reviewed the audiotape and transcripts of sessions, and rated each session using the DRS/PRP.
Analysis
The analysis of data was carried out in four parts (results are reported later in this chapter): (a) Base-line SCL90-R(GSI) and IIP-127 scores for participants in this study (Cohort 4) were compared with those for participants in Study 2 (Cohorts 2 & 3); (b) Pre-post intervention changes were examined using a paired t-test and the clinically significant change method; (c) Sessions were rated for in-session resolution and (d) Significant events were coded against criteria for the hypothesised model of protagonists’ in-session processes. Chapter 11 185
Pre-post intervention change on the SCL90-R and the IIP-127 Paired t-test. Paired t-test analyses were conducted to evaluate if there was a statistically significant change in general symptom distress, as measured by the SCL90-R and interpersonal distress, as measured by the IIP-127. Clinically significant change. The clinically significant change method (Jacobson and Truax, 1991) was used to evaluate if there was evidence of statistically significant and clinically meaningful change on an individual case basis. This method is described in Chapter 8.
Judging In-session Resolution As in Studies 1 and 2, the degree of in-session resolution of painful emotional experience was measured using the Degree of Resolution Scale: Unfolding Problematic Reaction Points (DRS/PRP) and protagonists’ self-report of reaching resolution. (See Chapter 7 for a description of the DRS/PRP and Chapter 9 for inter- rater agreement results from Study 2). The DRS/PRP was treated as a dichotomous measure, where ratings of 1-4 were treated as ‘not-resolved’ and ratings of 5 or 6 were treated as ‘resolved’. DRS/PRP ratings were made by the director of the session and an independent observer. The rating of in-session resolution was central to the comparison of cases and therefore, as with the earlier studies in this thesis, cases were only accepted as resolved if the director and the protagonist agreed that resolution had been reached.
Coding significant events against criteria for the hypothesised model. In order to evaluate if resolved and not-resolved cases met the conditions for the hypothesised model of protagonists’ processes, criteria for components of the model were established, significant in-session events within each case were identified, individual cases were coded and actual processes compared to hypothesised processes. The steps in the analysis of significant events are outlined in Figure 11.7 and then described. Chapter 11 186
Establish coding criteria.
Judging in-session resolution
Select transcript segments for coding
Code transcripts
Compare actual process to hypothesised model process
Figure 11.7 Steps in the analysis of significant events
Establishing Coding Criteria. Coding criteria were constructed from the detailed descriptions of each meta-process in Study 2 (see Chapter 10). These criteria are outlined in Table 11.3. The proposed model was built on an analysis of subjective recall of protagonists’ experiences as well as observations of protagonists’ in-session processes. This current study, however, relied primarily on an analysis of session recordings and transcripts. It was assumed that not all protagonists’ processes would be readily identified from these sources, but that the defining components of each event would be observable. These defining components are indicated in bold italic type in Table 11.3, and are treated as the essential criteria for meeting the conditions of each meta- event. Other components that are included in Table 11.3 represent significant processes which were either found in most but not all resolved cases in Study 2, and therefore could not be considered general criteria of the meta-event, or which were considered to be less likely to be reliably observable from the analysis of session recordings and transcripts. Criteria for a readiness on the part of the protagonist to engage in the psychodramatic process, which related to events leading up to the protagonist’s psychodrama enactment, were established, drawing on information available from protagonists’ Personal History Questionnaires and post-workshop evaluations. Selecting Events for Coding. Transcripts of psychodrama sessions were reviewed to identify (i) discrete scenes and (ii) potential markers of each of the hypothesised meta-events (refer to Table 11.3). Chapter 11 187
A scene involved explicit enactment of an event or interpersonal relationships and/or a specific location in time and space. Each scene was reviewed for markers of meta-events, keeping in mind that any one scene may contain more than one meta- event. Potential re-experiencing and insight events or activating resourcefulness events were marked by the verbal expression of or enactment of avoidance of a situation. Potential social atom repair with emotional release events were marked by sustained crying. The marker for a potential integration event was the expression of relief or release at the conclusion of a social atom repair event. When one or more markers were identified within a scene, the transcript of the complete scene was selected for coding, so that contextual information from the transcript could inform the coding procedure. Coding Transcripts. Using an Observer’s Coding Form based on the checklist of significant processes (Table 11.3), the investigator and an independent coder individually coded session transcripts. The independent coder was blind to the research question and hypothesised processes, and to whether sessions had been rated as resolved or not resolved. Verbal and non-verbal responses were coded. Processes were deemed to be represented in a transcript when both coders agreed that they were present. Comparing actual process to hypothesised process. Summary statements were written for each case and resolved and not resolved cases were compared. Chapter 11 188
Table 11.3. Checklist of Significant Protagonist Processes
META-EVENT COMPONENT CORE IDEA Pre-condition: Group cohesion ° In earlier workshop sessions, the protagonist experienced other group members as warm, Readiness to accepting, having some similar issues or concerns, or being willing to self-disclose. engageº Prior learning ° The protagonist has developed some understanding of how the psychodrama method works and what is expected of group participants. Participating in earlier workshop sessions (i.e. before the participant became a protagonist), produced a deepening of the warm-up to personal issues. In earlier sessions, the protagonist realised directors were able to manage strong feelings and/or difficult situations & group members were accepting of people expressing strong emotions. Compelling need to Before volunteering to be a protagonist, the group member experienced a sense of urgency or a address issue° compelling desire to address a personal issue. Chapter 11 189
Table 11.3. Checklist of Significant Protagonist Processes
META-EVENT COMPONENT CORE IDEA
Event 1: Re-experiencing* The protagonist re-experiences the original dynamic ‘as-if’ in the here and now and
Re- • Enacts the original situation from the role of self & the role of at least one significant other. experiencing & • Expresses feelings, beliefs, attitudes or actions of different roles, directly and using the Insight present tense, as if he or she is that person at that time. *
• Responds to the situation in the original dysfunctional way, which might be to feel overwhelmed and/or confused, to agree with a negative evaluation of self, to withdraw from the situation, to comply with the unreasonable expectations of others.
• Expresses sadness or distress (verbally or non-verbally).
Experience positive In the role of ‘other’ within the enactment, or from the position of observer watching the response to self enactment, the protagonist expresses a positive response to an auxiliary who is being the
‘protagonist’ in the original scene. This might be an expression of approval, acceptance, compassion, or understanding.
An auxiliary responds to the protagonist with approval, acceptance, compassion or understanding; and the protagonist’s verbal or non-verbal behaviour indicates that he or she is experiencing and accepting the positive message. Chapter 11 190
Table 11.3. Checklist of Significant Protagonist Processes
META-EVENT COMPONENT CORE IDEA
Insight* The protagonist names a maladaptive dynamic or belief arising from the re-experienced event,
The protagonist makes a statement or a series of statements that indicate that he or she has
• Identified a maladaptive dynamic or belief operating in the original situation;
• Identified how the dynamic or belief has impacted on behaviour and/or relationships.
• The protagonist recognises that the decision he or she made arising from the maladaptive
dynamic is now dysfunctional.
Event 2: Interpersonal impasse Indicator of impasse in interpersonal relationship: a statement of desire, wish or need or of distress, combined with inability or difficulty, conflicted or inhibited action. Activating Resourcefulness Boundary setting* The protagonist
• Makes an initial verbal statement of protest or displeasure (using words such as ‘I don’t want’, ‘I don’t like’; ‘don’t do that!’ (The initial statement may be tentative; action, tone and words may be conflicted or congruent).
• Makes a more assertive statement going against the action of significant other. The verbal statement is supported by congruent actions. Chapter 11 191
Table 11.3. Checklist of Significant Protagonist Processes
META-EVENT COMPONENT CORE IDEA
• Maintains a congruent assertive position for at least two talk turns.
Intimacy* The protagonist openly communicates:
• Discloses to significant other, his or her intention or invitation to a reciprocal relationship; makes a statement about the value of the relationship or about what would make the relationship valuable.
• Freely expresses difficult aspects of the relationship in an open manner.
• Expresses positive feelings towards self and towards other.
• In role reversal, as the significant other, the protagonist openly discloses to an auxiliary who is being the ‘protagonist’.
Acknowledge own The protagonist makes a statement acknowledging own abilities or firmly agrees with capabilities &/or significant other making a positive statement about protagonist’s abilities. limitations of other.
Event 3: Grief Cries for at least two talk turns.
Identifies and names The protagonist names a wish or need relating to the painful emotional experience, (using Chapter 11 192
Table 11.3. Checklist of Significant Protagonist Processes
META-EVENT COMPONENT CORE IDEA unmet need or act words such as wish, need, want) and Social atom hunger. repair with Recognises that this wish or need has not been satisfied, either because a significant other was Emotional unavailable or unwilling to provide, or because the protagonist’s actions had been inhibited at Release. the time.
Either through overt expression or implied with crying or tone of voice, the protagonist
expresses distress or sadness associated with the need not being satisfied.
Positive to self &/or The protagonist freely expresses, from an ‘adult self’ role or the role of a significant other, an other attitude of compassion, acceptance, liking and /or love towards self.
The protagonist freely expresses an attitude of compassion, acceptance, liking and/or love
towards a significant other.
Generates the needed In the role of a significant other or in an ‘adult self’ role, the protagonist freely offers affection, (reparative) response. comfort, affirmation, encouragement, witnessing and acknowledging, defending or protection.
Reparative role The protagonist receives the affection, comfort, affirmation, encouragement, witnessing and relationship.* acknowledging, defending or protection. The protagonist is able to complete the previously interrupted action. Chapter 11 193
Table 11.3. Checklist of Significant Protagonist Processes
META-EVENT COMPONENT CORE IDEA
Event 3: Emotional release* While experiencing the needed response, the protagonist experiences an emotional release, crying continually for more than two talk turns (may include an extended period when the Social atom protagonists cries but does not speak). repair with Emotional Sense of relief or At the end of the emotional release, the protagonist indicates that he or she feels resolved, at Release. Cont. resolution peace, satisfied with the outcome. Vocal tone is calm.
Event 4: Marker of beginning of The expression of relief or release following social atom repair marks the point after which event integration might occur. Integration Congruent adult The protagonist acts from an ‘adult self’ role. Self disclosure is made directly to a significant functioning.* other and is confident, is not conflicted and is emotionally calm.
Orientation to future & The protagonist makes a clear, confident statement of intent regarding future action. active intention *
Positive to self & other Self-disclosure is positive to self and (sometimes) positive towards other.
Sense of peace, at ease, The protagonist indicates in words that he or she feels resolved, at peace, satisfied with the resolution. outcome. Vocal tone is calm. Notes: * Components in bold italics indicate essential criteria. Components in plain type are significant but not essential, or are subjective experiences which are less likely to be reliably observed from session transcripts or recordings. º Source: Post Workshop Evaluation & Personal History Questionnaire. Chapter 11 194
Results
This current study seeks to build on the work of Study 2 and thus baseline data for the participants in the two studies are compared to examine if the studies were based on homogenous groups. The results of this study are then reported in four parts. 1. Post-intervention change is reported, with findings from the paired t-tests and the analysis of clinically significant change. 2. In-session resolution judgements are reported, with inter-rater agreement. 3. Overall findings of the occurrence of meta-processes across resolved and not-resolved cases are reported. 4. The four cases are presented in more detail, presenting evidence of links between the psychodrama intervention and post-session change and illustrating the occurrence of meta-processes with extracts from session transcripts.
Limits to Homogeneity Between Study 2 and Study 3 Cohorts Demographic data and measures of general symptom distress (SCL90-R) and interpersonal distress (IIP-127) were analysed to establish whether the participants in this current study (Cohort 4) were similar to the participants in Study 2 (Cohorts 2 & 3) prior to the intervention. Demographic information, reported as percentages (see Table 11.1) shows that age and educational background of participants was similar, but that there were differences in recent counselling experience and psychodrama experience between the participants of the two studies. A higher percentage of Cohort 4 (57%) reported that they were receiving counselling at the time of the workshop, compared to Cohorts 2 and 3 (23.5%) and Cohort 4 had a higher percentage of participants with some psychodrama training (42.9%) compared to the earlier study (23.5%). Pre-intervention measures of general symptom distress (General Severity Index of the SCL90-R) were significantly higher for Cohort 4 (M = 1.181, SD = 0.506) than for Cohorts 2 and 3 combined (M = 0.616, SD = 0.443), t(23) = 2.6995, p = .0134.). The 95% confidence interval for the mean difference between the two scores was 0.12976 to 1.00035. The mean pre-intervention GSI score for Cohort 4 (M = 1.181) was above the cut-off score for the clinical range and this cohort had a slightly higher representation of participants in
Chapter 11 195 the clinical range prior to the intervention (3 out of 7 participants = 43%), than did cohorts 2 and 3 (4 out of 17 participants = 23.5%). There was no significant difference in interpersonal distress, as measured by the IIP-127 Total scores for participants in the 2 Studies (t(23) = 0.5500, p = 0.588).
Evidence of Protagonist Change at Two-week Follow-up.
Results of the paired t-test Two-week follow-up scores were only available for six of the seven participants. The results of a paired t test indicated that there was significant improvement in SCL90-R(GSI) scores at two week follow-up (M = 0.758, SD = 0.528) compared to pre-intervention (M = 1.181, SD = 0.506), t(5) = 3.742, p = .009). The 95% confidence interval for the mean difference between the two scores was 0.11717 to 0.62340. However, there was no significant change from pre-intervention to two week follow-up on the IIP-127 (t(5) = 0.790, p = 0.465).
Clinically Significant Change As in Study 2, clinically significant change was determined using Jacobson and Truax’s (1991) criteria: (i) improvement from clinical to non-clinical functioning and (ii) change that is statistically greater than what might be reliably expected by chance. Elliott’s (2002) criteria for clinical caseness and reliable change were adopted. (Refer to Tables 11.4 & 11.5 for the specific criteria). Pre and post intervention GSI scores are shown in Table 11.4. Two protagonists (Isabel and Margaret) and one other participant were in the clinical range at pre- intervention. One protagonist, Angela, and one other participant were just below the clinical range (GSI = .91) at pre-intervention. All participants showed some improvement at two week follow-up, three showed statistically reliable change and Margaret met the two criteria for clinically significant change (that is, change is statistically reliable and the person’s score is no longer in the clinical range).
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Table 11.4. Participants (protagonists & other group members) SCL90-R Global Severity Indices (GSI) at pre-intervention and 2 week follow-up.
SCL90-R GSI Scores Pre-intervention 2 Weeks Sue 0.70 0.422 Angela 0.91 °0.33 Patricia 0.83 0.50 Isabel *1.9 *1.68 Margaret *1.12 °0.266 Participant A *1.9 *°1.2 Participant B 0.91 No data
Note: * indicates meets criteria for clinical case with GSI ≥0.93. ° indicates statistically reliable improvement (i.e. magnitude of change ≥ 0.51, p<.2).
Pre and post intervention IIP-127 Total scores are shown in Table 11.5. One participant who was in the clinical range at pre-intervention showed a slight, but not significant improvement at two weeks and one protagonist (Margaret) showed reliable improvement at two week follow-up.
Table 11.5. Participants (protagonists & other group members) IIP-127 (Total) scores at pre-intervention and 2 week follow-up.
IIP-127 Total Scores Pre-intervention 2 Weeks Sue 0.52 0.89 Angela 0.308 0.282 Patricia 0.72 0.58 Isabel 1.17 1.12 Margaret 1.42 °0.61 Participant A *1.75 *1.57 Participant B 1.16 No data
Note: * indicates meets the criteria for clinical case with Total ≥ 1.5. ° indicates statistically reliable improvement (i.e. change of magnitude of ≥ 0.79, p< .2).
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In-session Resolution Two cases were judged to be resolved (Sue and Angela) and two cases to be not- resolved (Patricia and Isabel). The resolution ratings and protagonist satisfaction ratings for each case are listed in Table 11.6. Interestingly, there is no clear link between protagonists’ reports of in-session resolution and session helpfulness ratings. All protagonists who achieved in-session resolution predictably rated their sessions as extremely helpful. Surprisingly, the ‘not-resolved’ protagonists also rated their sessions as either extremely or greatly helpful. Possible explanations for these ratings are considered in the relevant case summaries.
Table 11.6. In-session Resolution & Session Helpfulness Ratings. Case # Protagonist Degree of Protagonist’s Protagonist’s Resolution Ratings self-report of Session (DRS/PRP) resolution. Helpfulness Director Observer (Yes / no) Rating 11 Sue 6 6 Yes 9 (extremely) 12 Angela 6 6 Yes 9 (extremely) (*) Margaret 6 6 Yes 9 (extremely) 13 Patricia 5 6 No 9 (extremely) 14 Isabel 3 3 No 8 (greatly)
Note: *As discussed earlier, Margaret was not a case study subject, because her enactment did not focus on an identified painful emotional experience.
Inter-rater agreement between directors and protagonists Directors and protagonists agreed on their judgements of in-session resolution in four of the five cases (80%). Cohen’s kappa (k = .55) found fair inter-rater agreement (Fleiss, 1981). The small number of cases (5) contributed to the lower k compared to that in the second study, where there was good inter-rater agreement. When inter-rater agreement between director’s and protagonists ratings was evaluated for all fifteen cases in the research, agreement was good (k = .70).
Occurrence of Meta-processes in Resolved and Not-Resolved Cases. The proposed model is constructed of five meta-processes leading to in-session resolution of painful emotional experience: a readiness to engage in the
Chapter 11 198 psychodramatic process before the psychodrama session, followed by four in-session meta-events. The representation of central components of the five meta-processes within resolved and not-resolved cases, is shown in Table 11.7.
Table 11.7. Representativeness of meta-processes in resolved & not-resolved cases.
Meta-process Component Protagonists* Representativeness R NR Readiness to Group cohesion All protagonists 2 2 engage in the Prior learning R: Sue, Angela. 2 1 psychodrama NR: Patricia process Compelling need R: Sue, Angela. 2 0 to address issue Re-experiencing Re-experiencing R: Sue, Angela. 2 & insight NR: Patricia. 1 In-sight R: Sue, Angela. 2 NR: Patricia. 1 Activating Boundary setting R: Sue, Angela. 2 0 resourcefulness Intimacy 0 0 Social atom Social atom R: Sue, Angela. 2 1 repair with repair N: Patricia. emotional release Emotional R: Sue. 1 0 release1 Integration 0 0
Notes: * R = protagonists who reached in-session resolution, NR = protagonists who did not reach in-session resolution. 1 Emotional release as defined at the beginning of this study. It was concluded from an analysis of Angela’s session, that she experienced emotional release defined more broadly.
All components of readiness to engage in the psychodramatic process were reported in the resolved cases, but a compelling need to address the issue was not reported in either of the not-resolved cases. All protagonists reported some qualities of group cohesion, but these were more specific in resolved than in not-resolved cases.
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Re-experiencing and insight was evident in both resolved cases (Sue and Angela) and in one of the two not-resolved cases (Patricia), while activating resourcefulness occurred in the two resolved cases but was absent in the not-resolved cases. A social atom repair with emotional release event was identified in only one resolved case (Sue) and, as predicted, was not evident in not-resolved cases. An unexpected finding was that in two cases, one resolved (Angela) and one not resolved (Patricia), there was evidence of social atom repair, but without emotional release as defined by the criteria established for this study. The absence of emotional release in this event was the only central component of the model which was not observed in Angela’s enactment. The detailed analysis of their transcripts, suggests that Angela experienced emotional release but as an expression of previously inhibited joy, rather than grief, whereas there was no indication that Patricia experienced emotional release. Neither of the resolved cases had an integration event, with a focus on future action, as defined by the proposed model. These processes are further described and illustrated in the case descriptions that follow.
The Four Cases: Context, Process and Impact Patterns. Descriptions of the four cases are presented next, with contextual information, impact data (degree of in-session resolution and post-session change) and a description of process patterns, illustrated by protagonists’ process diagrams and session transcripts. The two resolved cases of Sue and Angela are presented first. Patricia’s case is then considered in terms of the conditions that differentiated her session from those that were resolved. Patricia’s case is interesting in that it had the appearance of in-session resolution, as indicated by the agreement in the DRS/PRP ratings of the director and the independent observer, without the experience of resolution, as reported by the protagonist. An analysis of the differences between her case and the two resolved cases may further delineate the experience of in-session resolution. Isabel did not meet the criteria for any of the four meta-events, and a summary only is given of her case.
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Format of Transcript Extracts
Extracts from session transcripts have been provided to illustrate protagonists’ processes. The following format guidelines will assist the reader to understand the extracts. 1. When recordings are transcribed, all dialogue and relevant action is documented. For example, a simple interaction between a protagonist, Joanne, and an auxiliary being her mother, might look like this: Joanne: But I really want to go to the party tonight! Director: Reverse roles. Auxiliary as ‘Joanne’: It’s really important to me that I go to the party. Joanne as ‘Mum’ Well, I’ve already said you can’t do that.
When extracts of transcripts are included in the text, most of the input from auxiliaries and the director is omitted. The extract of the transcript above would look like this:
Joanne: But I really want to go to the party tonight!
‘Mum’ Well, I’ve already said you can’t do that.
This adds to the ease of reading the transcript, because repetition of dialogue in role reversal is omitted. Where the response of the auxiliary or director is qualitatively different to what the protagonist has said, or will assist the reader to make sense of protagonists’ responses, this will be included in the extract. 2. As illustrated in the above examples, protagonist dialogue is in blue type regardless of the role the protagonist is in. Dialogue of auxiliaries or the director is in black type. 3. A name in quotation marks indicates that the protagonist or auxiliary is acting as that person. In the examples above ‘Mum’ in blue type refers to the protagonist acting as mum, and ‘Joanne’ in black type refers to an auxiliary acting as Joanne.
Case Study 11. Sue (Resolved)
Background Sue is a mental health worker in her 40’s. Her partner, Mary, died after a long battle with a terminal illness. Mary had denied that she was going to die almost until the time of her death and this had been a source of conflict between Sue and Mary.
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They have two young children, Peter and Lauren, and Mary had refused to talk to the children about the possibility that she would die. Despite receiving counselling in the past 12 months, Sue has remained preoccupied with thoughts about Mary’s death. Sue’s session was the fourth and final psychodrama of the workshop. The enactment was focussed on interactions between Sue, Mary and their children around the time of Mary’s death.
In-Session Resolution Sue’s session was judged to be resolved. The director and independent observer both rated the session as 6: reaches resolution on the DRS/PRP and Sue reported feeling relieved immediately after the session. In her post-workshop evaluation she stated: “I feel like I have worked through a great burden. I feel released and relieved and very positive”.
Post Session Change Sue’s pre-workshop functioning, as measured by the SCL90-R(GSI) and the IIP- 127, was in the normal range. At two week follow up Sue had a slight but not statistically significant improvement in general symptom distress (see Table 11.4), and a slight but not significant elevation in interpersonal distress (see Table 11.5). Sue reported being more accepting of her own feelings and more confident about the decisions she was making for herself and her children, after the workshop. She experienced anger towards Mary, which she now accepted as a normal and appropriate response. She noted that she was less tolerant of other people’s intrusive behaviour and more assertive in response to others.
In-session Process. There was evidence of a readiness to engage in the psychodrama process and the session met the criteria for three of the four meta-events of the model of protagonists’ processes, re-experiencing and insight, activating resourcefulness and social atom repair with emotional release. The core ideas of each of these processes as they occurred in Sue’s psychodrama are described below. Extracts form the transcript of her session are provided, indicating the occurrence of each core idea. Readiness to engage in the psychodrama process. Evidence of Sue’s readiness to engage was extracted from her Personal History Questionnaire and Post-workshop Evaluation. Prior to her session, she reported experiencing other group members as
Chapter 11 202 very positive and ready to work (group cohesion). Sue had participated in two psychodrama workshops, prior to this current one. She reported that in earlier sessions of this current workshop, she recognised the skill of the directors and felt that she could trust them. During one session she experienced ‘extreme anger’ and recognised that she was hiding very strong emotions behind her appearance of passive acceptance (prior learning). Sue reported being more anxious at the prospect of being a protagonist at the beginning of this workshop than she had been in previous groups and being surprised by the extent of her angry reaction in response to events in someone else’s psychodrama. She realised that this was something she had to work on (compelling need to address issue).
Event 1: Re-experiencing and Insight. (Figure 11.8). The re-experiencing and insight event occurs during a scene where Sue’s partner Mary is in bed ill, with Sue and their children around her. Mary is adamant that she will not die and will not discuss the possibility of dying, up until the evening before her death. Sue experiences the scene from the roles of all family members and, as she does so, re- experiences feeling tired and stuck and withdrawing from the situation (2, 9, 12). She identifies the problematic role dynamic (6) and the maladaptive belief that if she talks about Mary dying, Mary’s death will then be her fault (9). She identifies the impact of this dynamic on herself and the children (19, Figure 11.9). Sue’s affective response is subdued, until she recalls a compassionate response from her mother-in- law, and she is then able to cry and acknowledge her own struggle (13).
# Speaker Transcript 1 ‘Mary’ The most important thing is I’m not going to die. I’m not going to talk about dying Sue. 2 Sue (Dull, defeated tone) I know. I know you’re not. 3 Director What do you want to say to Mary? 4 Sue (laughs) I love you so much, but you deserve a really good smack. (To the director) She’s just so determined. It drives me mad. I hate the way we can’t talk about this. (To Mary) You’ve got it in your head that if we talk about this it will happen. 5 ‘Mary’ I don’t want to talk about this.
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6 Sue I know you don’t. But it’s happening love, it’s actually happening. 7 (To the director) I’m scared that if I talk about it and she does die it will be my fault. A part of me wants to believe that she’s not dying. A part of me actually does believe it. But the rational part of me can see what is happening to her. 8 ‘Mary’ Are you going to leave me? 9 Sue No. I’m just tired, and it’s getting really hard for me to cope. And I think I need some help. 10 ‘Mary’ So you are leaving me! 11 Sue No. No. I’m not, I’m just tired and I need some help. (To the Director) and it just goes on and on like this.
12 Sue She just goes on and on and on until I just can’t stand it any longer, and so I leave the house, and she rings her mother and tells her I’m 13 going to leave. So, I ring Mary’s mother and tell her I’m not leaving, and I cry. Mary’s mother is really caring towards me. 14 ‘Mother- I know you’re not going to leave and I know this is really hard for in-law’ you. I wish I could help you more. 15 Sue (Cries) This is so hard.
Figure 11.8. Extract from Sue’s transcript: Re-experiencing & Insight. Note: Dialogue or action of the protagonist, either as self or other, is in blue type. Dialogue of the director or an auxiliary is in black type.
Event 2: Activating Resourcefulness. There were two events within Sue’s psychodrama enactment which might be considered activating resourcefulness events. The first was an enactment of the everyday relationships between Mary, Sue and their children. This was a practical display of daily life and did not meet the conditions of the particular description of intimacy developed in Study 2. Nevertheless, it may well be an example of intimacy being enacted rather than overtly expressed. The second example met the conditions of a boundary setting event and is illustrated in Figure 11.9. In the previous event, Sue recognised that she was angry with Mary, but in an early attempt to address the issue she was conflicted in her response and expressed her anger to the director rather than to ‘Mary’ (6, 9). In this activating resourcefulness event, Sue begins to address the issue directly with Mary
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(15), then backs away from a confrontation (17, 19). When the director offers an alternative solution (20), Sue identifies what she wants, expresses herself forcefully to Mary and affirms that she, Sue, is not responsible for what is happening (21).
# Speaker Transcript 14 Director Go ahead now and say the things that you weren’t able to say then. 15 Sue (To Mary) I think you need to talk to the children about dying
16 Director Reverse roles 17 Sue (To Director) There’s no point (in reversing roles) ‘I’m not dying’ that’s what Mary says all the time. 18 Director So what do you actually do? Do you talk to the children? 19 Sue Well, I do, but it’s a sideways thing. I don’t talk to them about mummy dying. The first time they heard that Mary could die was the night I put them to bed and she died at two in the morning. 20 Director I think we need to redo history. I want you to have that talk with the children before she dies. 21 Sue I want Mary to do it! (To ‘Mary’) You cow! You bloody do it yourself. It’s like I’m the baddy. ‘Mary’ Look what you’ve done Sue, you’re upsetting the children. Sue It’s not me that’s upset them, it’s bloody life!
Figure 11.9. Extract from Sue’s transcript: Activating Resourcefulness.
Event 3: Social Atom repair with emotional release (Figure 11.10). The social atom repair with emotional release event occurred in a scene with Sue and the ‘children’ gathered with ‘Mary’ just before she died. In the previous event, Sue expressed her need to have Mary speak to their children about dying. In this event the protagonist as ‘Mary’ experiences telling the children that she is dying and expresses her love to the children (22, 25). Then, back in her own role, Sue watches an auxiliary being ‘Mary’ speak to the children about dying (27-30). This is the wished-for experience and, as she watches, Sue experiences an emotional release. She cries for an extended period (27-34). Sue expresses both her sadness about how the situation has been and her appreciation of Mary (32-38). Sue experiences a sense of satisfaction with the re-enactment (38) and in her post-session evaluation reported feeling a sense of release following the session.
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Speaker Transcript
22 ‘Mary’ (To the children) Well, sometimes when people are sick they
actually die. It means that, it means that they’re not in their bodies any more. It means that their spirit or the essence of who they are leaves their body. So they can’t talk and they can’t hug and they can’t have fun anymore because their body stops working. I think that’s going to happen to me soon. I just needed to let you know how much I love you both. 23 ‘Lauren’ I love you too mum. 24 ‘Peter’ I don’t want you to die mummy. 25 ‘Mary’ I don’t want to die either sweetheart. I’d much rather stay here with you. I’m going to try to not die. I’ve been trying for a long time because I love you so much and I want to be here for you. 26 ‘Peter’ I will be sad. I will be terribly sad. I don’t want you to go mummy.
After further interaction between Mary and the children, with the protagonist in Mary’s role, the director asks the protagonist to return to her own role. Sue watches the interaction being replayed.
27 Sue (Cries as auxiliaries enact interaction between Mary and the children) 28 Director (to P) Let it go 29 Sue (sobs for another 30 secs, as continues to watch interaction between Mary and the children) 30 Sue I wish that had happened. (cries) 31 Director Are there words you want to say? 32 Sue I just wish you would have been honest. (sobs more) 33 Director Let her know now how hard it has been for you. 34 Sue (Cries) 35 Director Right. What does it do to you when you can’t talk about it? 36 Sue It just, I don’t know. I shut down I think, and I just had to try and prepare the children without looking like I was. I had to
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Speaker Transcript be sneaky. I hated that we couldn’t do it together. We used to be able to do the important things together. Fear got in the road. Fear got in the road. 37 Director So this redoing, it’s very satisfying to see the kids involved. 38 Sue Yeah, it’s very sad as well. Actually it feels good to see this happen. (To Mary) I think that if you had known you were going to die, you would have spoken to the children, because you’re very loving. (cries) (Hugs Mary and sighs) Life is a funny thing. I’d live it again.
Figure 11.10. Extract from Sue’s transcript: Social Atom Repair with Emotional Release.
In other cases, the emotional release associated with social atom repair occurred in the context of the protagonist accepting a positive response to self, in the form of nurturing, acceptance or encouragement. Sue’s social atom repair event varied from other cases in that the emotional release occurred as Sue experienced ‘Mary’ responding with love to their children.
Summary
Sue’s enactment met all the central components of the model of protagonists’ processes, with the exception of the integration event. The final interaction between Sue and her partner was a mature and open encounter; however, a core characteristic of in-session integration as it was defined at the beginning of this study, is that the encounter is oriented to the present or the future. This encounter was focussed on unfinished business from the past.
Case Study 12. Angela (Resolved)
Background. As a young child Angela’s homeland had been invaded in wartime and the men in her family had been killed or had disappeared. In recent times Angela had experienced debilitating anxiety in relation to the well-being of her husband and her grandson, when they were away from her.
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Angela’s session was the third of four psychodramas during the workshop. The session was focussed on her experience as a young child, of being overprotected and confined by her extended family, which consisted solely of women.
In-Session Resolution Angela’s session was judged to be resolved, based on the director’s and independent observer’s DRS/PRP ratings of 6: reaches resolution and Angela’s report of feeling resolved immediately after the session. In her post-workshop evaluation she reported: “I realised my mother’s worries and madness did not belong to me. I am a strong, resourceful person and I stand on my own two feet”.
Post Session Change Angela showed statistically reliable improvement in general symptom distress at two-week follow-up (see Table 11.4) and a slight but not significant improvement in interpersonal distress (see Table 11.5). Her score on the SCL90-R anxiety sub-scale, was in the clinical range at pre-intervention (T-score = 70) and had improved by more than three standard deviations at two week follow-up (T-score = < 40). This improvement was confirmed by Angela’s reports of post-session changes. She described a number of situations that had occurred immediately after the workshop, which previously would have generated intense anxiety and obsessive thinking about potential disasters. The day after the workshop, Angela’s grandson suddenly became ill and was taken to hospital. Under these circumstances Angela would usually have been extremely anxious, but this time she reported that she was able to assist other family members and slept easily. Associated problems with her grandson’s health arose over the following days and Angela took appropriate action, remained calm and continued to feel that everything would be okay. She reported having a new awareness that the anxiety she had experienced belonged to her mother and that her mother had good reason to be anxious; that her mother was a little mad from her wartime experiences and that she, Angela, was not mad. She attributed these changes to events in her psychodrama enactment.
In-session Process There was evidence of a readiness to engage in the psychodrama process and the session met the criteria for two of the four meta-events of the model of protagonists’ processes, re-experiencing and insight and activating resourcefulness.
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Angela’s session met the criteria for social atom repair, but not for emotional release, which had been defined as a release of grief or pain, evidenced by crying. Angela did, however, exhibit release of previously suppressed joy in the context of receiving a needed but previously unavailable response. It is suggested that this is consistent with the model, while expanded the understanding of emotional release in the context of social atom repair of painful emotional experience. The core ideas of each of these processes as they occurred in Angela’s psychodrama are described below and illustrated with extracts from Angela’s enactment. Readiness to engage in the psychodrama process. Angela had some training in psychodrama and was familiar with the method, but had not been in a psychodrama workshop for about 10 years. She experienced the directors as insightful, kind and supportive and reported making a decision to participate fully in the group in the introductory session. In the psychodrama session that immediately preceded Angela’s, there had been a scene where a ‘baby’ was being held and nurtured. During that enactment, Angela became agitated and was aware that she did not want to participate in the scene because she had been held too much as a child. She experienced a strong need to claim some space for herself and volunteered to be a protagonist. Event 1: Re-experiencing and Insight (see Figure 11.11). Angela’s re- experiencing and insight event occurs in a scene where she sets out and enacts the family system as she experienced it in her childhood. In the segment immediately preceding the transcript that is provided here, Angela acts from the roles of each of the adult female relatives in her family system, expressing their fears and concerns and enacting the various ways in which they control Angela’s behaviour. Participating in the enactment as her 6-year old self, Angela experiences distress and expresses her need for autonomy (3, 7, 11). She enacts the problematic dynamic between herself as a 6 year old and her mother. Observing the enactment, Angela becomes aware of blocking her expression of emotion and giving in (24) and as ‘6- year old Angela’ she experiences being confused (26). As she experiences her mother manipulating Angela through crying (20, 22) she realises that this has influenced her to shut down her own emotional response (24). Angela experiences a positive connection with self, expressed as compassion and comforting (28), and
Chapter 11 209 identifies the maladaptive belief that reinforces this behaviour, arises from her concern as a child that her mother was going to die (32).
Speaker Transcript 1 Angela (Angela sets a scene with ‘6 yr old self’ being surrounded by adult women – mother, older sister, aunt, nanny and others - who are putting their arms around her protectively). 2 (Auxiliaries take up roles, surrounding and holding the ‘child’ and giving the messages Angela has articulated previously). (Mum) No, no. no, you better stay inside. It’s too wet out there and it’s too dangerous. And there are snakes out in the garden (Nanny) I love you very, very much. You’re so skinny, you have to eat more. Come on, eat. (Aunt) I want to protect you. I don’t want you to feel pain or to get into danger. Do as you’re told, listen to your mother. 3 Child A God. I can’t stand being in here. (As auxiliaries continue surrounding her & repeating their messages) No, no, no! (Louder each time). Look I’m going, I want to play. 4 ‘Mum’ (Cries) Oh no, don’t go, what will happen to you? What will happen to you? What will happen? You’ll get hurt; I have these dreams where you get hurt. 5 Child A Ohhh. Ohhh. (Moves to ‘mum’ to comfort her. ‘Mum’ puts her arms around the ‘child’). 6 Director (Instructing auxiliaries) As soon as Angela gets there with her mum, everyone else come in. 7 Child A (Cries, as auxiliaries take up their roles, surrounding her) 8 ‘Nanny’ I need to get more food inside you. You’re so skinny. 9 ‘Aunt’ Do as you’re told, we want to keep you safe. 10 ‘Nanny’ We’ll look after you. We’ll look after you. 11 Child A (continuing to cry) I don’t want to be like this. I want to go, I want to be free but you won’t let me. 12 ‘Mum’ We want to look after you and keep you with us. You’re the only one I have left. I need you. I have to have you here.
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Speaker Transcript 13 Child A But mum I want my own room like other girls have. I have to sleep with you and I don’t like sleeping with you. 14 ‘Mum’ Well I’d be all alone then 15 Child A I don’t care 16 ‘Mum’ (Cries loudly) Oh, that is so cruel 17 Child A Shhh shh sshhh shhh (puts arms around ‘mum’ and comforts her) 18 Director I want you to step out of the scene and watch the auxiliaries re-enact what has happened. 19 (Auxiliaries re-enact the scene between ‘child’, ‘mum’ and other women) 20 Angela Yeah, mum’s good at doing this. (Pause) She’s awful. (Pause) She wants me to look after her. 21 Director (Auxiliary as ‘Angela’ goes to comfort ‘mum’) Do you see what happens? 22 Angela Yeah, because I can’t stand mum crying. 24 Angela No, and I never cry now. (Quietly crying as she continues to watch the auxiliary being the ‘child’ comforting ‘mum’). She’s giving in. 26 Child A You know, I’m really confused 28 Angela I feel really sorry for you. (takes ‘child’ by the shoulders) Don’t worry about mum, she doesn’t know any better. 29 ‘Mum’ (Cries loudly) 30 Angela She will get over the crying, she’s a really strong woman 31 ‘Mum’ (Cries loudly) 32 Angela I don’t know which way to go. I’m pulled. (To Director) I have to step out of the scene and tell you why I’m pulled. My mother was old when she had me. She was an old woman and I thought she was going to die.
Figure 11.11. Extract from Angela’s Transcript: Re-experiencing & Insight. Notes: * Child A indicates Angela as a child.
Event 2: Activating Resourcefulness. At the end of the re-experiencing event described above, Angela identified the conflicted response she had to her mother. In the following extract (Figure 11.12), acting as an adult she confronts her mother and maintains an assertive response to her. Angela has a powerful experience of the
Chapter 11 211 problematic dynamic between herself and her mother and protests (34). She is no longer conflicted, but maintains a strong assertive response, as her ‘mother’ attempts to draw her into the old dynamic (36-46).
Speaker Transcript 33 (Angela is watching auxiliaries re-enact a scene from her childhood, with ‘Mum’ holding the ‘child’.) 34 Angela (To ‘mum’) I love you, I really love you but, (voice becomes stronger) This really makes me sick; I can’t stand having this cobweb around me. 35 ‘Mum’ (Cries) 36 Angela Don’t come with that. You know you’re just horrid when you do this, when you cry. 37 ‘Mum’ I need her, she’s holding me up. 38 Angela She’s not holding you up mum, you’re bloody well holding on to her 39 ‘Mum’ I’m holding on to her, but she’s got to hold me up as well. 40 Angela No she’s not; you’re standing as straight as a die. And she’s leaning into you because you want her to. 41 ‘Mum’ Yes I do, because it feels so good. 42 Angela (Quiet voice). It’s time you let go mum, time you let go. 43 ‘Mum’ I’ll fall over. 44 Angela You can stand there, you’re strong 45 ‘Mum’ Look, a push like that and I’ll fall right over 46 Angela (laughs) You’re a bloody good actress you know, mum.
Figure 11.12. Extract from Angela’s Transcript: Activating Resourcefulness event.
Event 3: Social atom repair with emotional release. Angela’s enactment met the conditions for social atom repair, but not the conditions for emotional release as it was defined from the findings of Study 2. However, she did experience emotional release of joy, as is illustrated in an extract of the transcript of her enactment (Figure 11.13). In the social atom repair event the Angela, as the ‘child’, identifies her need for autonomy (48, 50). As an adult in role reversal, she affirms and clarifies the child’s
Chapter 11 212 experience (49, 51). She stands up to her mother (53) and coaches the ‘child’ to move away from her mother (53, 55). As the ‘child’, she becomes playful and explores the action space, clearly enjoying herself (56, 58). When a ‘snake’ is found among the props, Angela uses this to confront her mother’s fears in a confident and playful manner (58). She experiences relief and a release from the pressures of her family (66), affirms herself (70) and acknowledges the limitations of her mother (71).
Speaker Transcript
47 ‘Mum’ (cries loudly) 48 Child A I don’t want to go near her. I don’t want to go near her because you know she’ll only want me to do what she wants me to do. I’m only 6 yrs old and I don’t want to go there. 49 Angela Yes. Angela, don’t let her do this to you, because it will really ruin your life when you get older. You’ll always be scared when you get older. So don’t let her do this. (pause) I don’t know. It’s like treacle; it’s like being in treacle. 50 Child A I do need her, because she’s my mother, but I don’t want the way she’s doing it 51 Angela Yeah, well the way she’s doing it is wrong. Come (to ‘child’) we’re going for a walk in the garden. 52 ‘Mum’ No, no, there are snakes out there! 53 Angela Oh, shut up! (To ‘child’) don’t look back at her. 54 ‘Mum’ (cries) 55 Angela Look at the flowers, aren’t they good. 56 Child A (Playfully) Let’s run. (As the ‘child’ Angela skips around the stage, laughing. The playfulness continues for some time, with the auxiliary as ‘adult Angela’ joining in). 57 ‘Angela’ Look at the garden. (The auxiliary finds a snake among the props) Oh look, it’s a snake! 58 Child A (Laughs). Let’s go and show it to mum and show her it isn’t
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Speaker Transcript going to hurt her. (Skips over to ‘mum’). (Playful voice) Looook what weeee found! 59 ‘Mum’ (Screams). 60 Child A (laughs) well, if you don’t stop it’s going to bite you. 61 Angela That was lovely in the garden wasn’t it. It was a cute snake 62 ‘Child A’ There are some poisonous snakes out there 63 Angela This one was only a python, it’s just a little python. And you know it did stop mum. 64 ‘Child A’ It was fun 65 Angela It was fun, yes. 66 ‘Child A’ I think I’ll put the snake back. It’s done its job and got rid of mum. That feels better. No mum crying, no nanny trying to feed me, no aunt trying to take care of me. It feels so good. And look at the beautiful trees and the flowers, 67 Director Do you want to go further out? 68 ‘Child A’ Well, we might not go too far out, because this is the garden and it has a fence and it’s safe. 69 Director And you can actually judge for yourself? 70 ‘Child A’ Mmmm. Yeah, I know what’s good for me. (To adult self) You’re very good. You know you got me out of there and you were my friend. You didn’t tell me ‘oh no, don’t do that’ 71 Angela Yeah, and that’s what I want from my mum but I don’t think she’ll ever give it to me.
Figure 11.13. Extract from Angela’s Transcript: Social atom repair with emotional release event.
This event differed from other ‘social atom repair with emotional release’ events in that emotional release was not expressed through crying. As such, it did not meet the criteria for emotional release that were established at the outset of the study. Nevertheless, Angela experienced an emotional release of joy while enacting previously inhibited playfulness. The social atom repair occurred through the
Chapter 11 214 development of a new role relationship, an adult encouraging and supporting Angela to explore the world outside and to develop her autonomy through playfulness and trusting her own judgement.
Summary Angela’s case demonstrates a re-experiencing and insight event, a boundary- setting resourcefulness event and a social atom repair event. Angela did not experience grief during the social atom repair event, but she did experience and express a joyfulness that was not previously present in the session. It is proposed that this experiencing of joy was itself an emotional release, in that her free expression of joy had been inhibited in her family situation. A possible explanation for the lack of an emotional release around grief is that Angela’s session was dealing with the consequences of a painful emotional experience (a restrictive family system) rather than the painful emotional experience itself (the death of her father and the disappearance of other family men, during the war).
Case Study 14: Patricia (Not-resolved)
Background Patricia is a mental health worker in her 50’s. She reported experiencing deep feelings of loneliness throughout her life, having difficulty developing and maintaining intimate relationships and having a strong feeling of abandonment when she encounters problems in relationships and friendships. She had been sent away from her family at a young age while her mother resettled the family after being evacuated from a war zone. Patricia’s stated goal for the session was to ‘Make some peace with my mother and see some caring for myself and some acknowledgment of how hard it was for me.’ Patricia’s session was the first of four psychodramas conducted during the workshop.
In-Session Resolution Patricia’s session was judged to be not-resolved. Although the director and independent observer both rated the session as 6: reaches resolution on the DRS/PRP, Patricia reported feeling some peace in relation to her mother after her session, but not experiencing the sense of resolution that she had expected. She reported the impact of her session as gaining new insight into her area of difficulty
Chapter 11 215 and what she needed to address and producing some changes in her perception of others, but not a sense of completion or relief. This is illustrated in the following extract from her post workshop evaluation: “I acknowledged further my fear of being ‘needy’ and became aware of my powerful feelings of antipathy towards myself as a child’. Patricia noted that she was surprised she didn’t feel warmer about the work she had done in her session. Patricia rated her session as extremely helpful and this rating appeared to be linked to the new insight she reported during her session, which she considered was a catalyst for further insights during later sessions of the workshop.
Post Session Change At two-week follow-up, Patricia reported feeling less isolated, feeling much less needy in relation to close friends and being more assertive at work. She associated these changes somewhat with her psychodrama session, but she considered that a major impact of her psychodrama was to realise the extent of the antipathy she felt towards herself when she was needy. She attributed group interactions later in the workshop with assisting her to accept that as a young child she had genuine needs that had not been met. Patricia showed slight, but not statistically significant improvement in general symptom distress and interpersonal distress at two-week follow-up (see Tables 11.4 & 11.5).
In-session Process There was limited evidence of a readiness to engage in the psychodrama process, based on Patricia’s post-workshop evaluation. The session met the criteria for re-experiencing and insight and some of the criteria for social atom repair, but not for emotional release. Readiness to engage in the psychodrama process. Patricia’s responses to the Post-workshop Evaluation did not identify specific criteria of readiness to engage. Patricia reported a general, but not specific, positive attitude to the group from the introductory session which preceded her psychodrama: having a sense of herself in the group, making contact with others and getting to know group members. She did not report any experiences that might reflect a compelling need to address her issue. Although Patricia’s session was the first psychodrama of the workshop, she had
Chapter 11 216 extensive prior experience in psychodrama and was therefore familiar with the psychodrama method. Event 1: Re-experiencing and Insight (see Figure 11.14). Patricia’s Re- experiencing and Insight event occurs in a re-enactment of the family scene when she is sent away from home as an infant. Patricia enacts the scene from her own role as a child and from the roles of various family members, and expresses beliefs, attitudes and affect directly from those roles. When she experiences the family dynamic as her child self, she experiences emotionally shutting down (9, 12). When an auxiliary acting as her double (see Glossary of Psychodrama Terms) expresses distress (11, 13), Patricia becomes distressed and experiences her loneliness as a young child (14, 16). She becomes aware of having a positive connection with her sister Melanie (17) and experiences the distress of separation from her sister (23-27). In role reversal as her sister, Patricia experiences Melanie’s distress, helplessness and wishes for her own life (28, 30). This experience leads to insight about the problematic dynamic operating between Patricia and Melanie and the impact that dynamic is having in Patricia’s life now (33). In contrast to the experience of protagonists who achieved in-session resolution, Patricia continued to feel negative towards herself at the end of this event (34).
Speaker Transcript 1 ‘Mum’ This is awful, this is really awful. I have no country, I have no family here. I am absolutely bereft. I have no husband with me, I have four children, and I have no-one. I’m absolutely alone. 2 ‘Baby P’ (Cries out loudly, & continues to do this throughout next part of action) 3 ‘Mum’ She’s just hungry, she wants a feed. But I can’t feed her yet. It’s not been 4 hours. (‘Baby’ cries loudly) Oh, just shush. I can’t listen to this; we’ll have to go to the end of the house. (Moves to other area of stage) I can’t feed her. (‘Baby’ cries loudly). Stop! 5 ‘Mum’ I think I might be going a bit mad actually. A mother’s not supposed to be like this with her daughter. And we don’t do things like this in my country. If they want to feed we feed them. But here it’s different and I have to be British. If I want to be accepted I have to be British. 9 Baby P I think I’ve stopped crying
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Speaker Transcript 11 Double* I’m shutting down. I’m shutting down, I’m not feeling anything. 12 Baby P Mmm. I’m shutting down. 13 Double (Distressed) She’s not coming, she’s not coming 14 Baby P (Begins crying, as double keeps saying ‘she’s not coming’) (Loudly) Noooooo! Noooo! (sobs) 15 Double (Continual) Why isn’t anyone coming) 16 Baby P (Cries loudly for little longer) I feel so lonely 17 Patricia (Sobs . Looks up at the scene with ‘baby’ crying and being held by
‘Melanie’ and cries quietly). I think Melanie mothered her actually. (To Melanie) I think you did alright. You did, you loved me. (sighs) 18 ‘Melanie’ I have to be in charge I think. 19 Baby P You’re really my mummy 20 ‘Melanie’ Yeah (Pause, surprised) But I went away to school. 21 Director How do you tell Patricia? 22 ‘Melanie’ Look, I’m going away Patty and you’re going to be looked after, by the Smiths. They’re really nice. They’ll look after you while mummy goes out and finds somewhere for us to live properly. You’ll be fine. 23 Baby P Don’t leave me. Don’t go. 24 ‘Melanie’ But I’m not really leaving you, I’ll come back. 25 Baby P But then I’ll be left with her and the two boys, and neither of them like me very much. 26 ‘Melanie’ No, no, you’re going to be with Nanny and she’ll love you very much. 27 Baby P Don’t leave me Melanie. Don’t go. 28 ‘Melanie’ (Upset) But I’m only a child. I don’t know how to do it properly. 29 ‘Baby P’ (Crying) But I’ll be left with them and none of them like me. I want you to stay. 30 ‘Melanie’ (Crying) I can’t. I’m only 9. I want to go away. I don’t want to leave
you, though. I can’t be an adult anymore, it’s too hard. I want to play. 31 ‘Baby P’ Ooohh. It’s very scary 32 ‘Melanie’ I know. I’m sorry.
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Speaker Transcript 33 Patricia I’m realizing something about my relationship with my sister. I get hurt very easily if she doesn’t want to give me what I feel I need and then I feel abandoned by her. So it’s like I replaced something with her, she was my mum. I’d never thought of that. And she can’t bear it if I’m unhappy. 34 Patricia (Watching ‘baby P’) I know it’s really weird, but I don’t feel a lot of tenderness towards her.
Figure 11.14. Extract from Patricia’s transcript: Re-experiencing & insight event. * Note: A double is an auxiliary in a ‘specialised role of playing the part of the inner self” to assist the client to be aware of and put words to their inner experience (Blatner, 1988, p.28).
Event 3: Social atom repair with emotional release Patricia’s social atom repair event was a surplus reality scene which she set out with her ‘parents’ in an idealistic setting, without the environmental stresses of war and separation that had been the context of their actual lives. From these roles, she expressed positive connections towards each other and love and acceptance of ‘baby Patricia’. As ‘baby Patricia’, she enjoyed the experience of hearing her ‘parents’ express their affection towards her. Patricia did not experience emotional release in this scene. From Patricia’s post-session reports, it would seem that the immediate impact of this event was to achieve some resolution in her cognitive map of her relationship with her mother, but increased experience of herself as needy. It should be noted that in the social atom repair scene, the auxiliary acting as ‘baby Patricia’ was placid and receptive, rather than the crying and needy ‘baby’ in the earlier scene. Later, in role reversal, Patricia was also calm as ‘baby Patricia’. It may be that this event was not fully experienced as social atom repair, because there was not an enactment of a reparative response to the needy infant and Patricia did not experience as a ‘needy infant’, being responded to in an adequate way. However, it was beyond the scope of this study to investigate this possibility.
Summary Patricia’s re-experiencing and insight event included the central components of re-experiencing the original problematic relationship as-if it were happening in the here and now, gaining insight into the maladaptive dynamic and the impact of that
Chapter 11 219 dynamic on her current functioning. She experienced a positive response from her sister towards herself in this event, but remained critical of her own behaviour. The social atom repair event included the enactment of a positive relationship between her parents and Patricia as a baby, but without emotional release. There is an open question about whether or not the social atom repair event actually addressed Patricia’s unmet need.
Case Study 15: Isabel (Not-resolved)
Background Isabel is a professional woman in her early 30’s who has difficulty maintaining intimate relationships. Her mother died when Isabel was a young child and she was isolated from her siblings and her father when he remarried. Isabel’s session was the second of five psychodrama sessions conducted during the workshop and was focussed on the scene at her mother’s hospital bed shortly before she died, with Isabel and her siblings around the bed.
In-Session Resolution. Isabel’s session was judged to be not-resolved. The director and independent observer both rated the session as 3: “recalls salient aspects of the stimulus situation; explores both own internal affective reaction to situation and own subjective construal of potential impact of the stimulus situation” on the DRS/PRP. In her post-workshop evaluation, Isabel stated: “Being in a scene with both parents and happy siblings, I realised we were once a family. But I felt quite blocked and stagnant at times (during the psychodrama). I found it difficult to connect with my mother and that made me feel guilty, angry and ashamed”. In light of these comments, it is surprising that Isabel rated her session as greatly helpful. One possible explanation for this is that she was influenced by loyalty to the group, to report positively on her experience. However, an alternative and equally compelling explanation is that experiencing her family of origin as an intact unit, combined with the effect of having the attention of the group during the enactment, was a positive experience for Isabel, irrespective of the difficulties she experienced during the session.
Post Session Change There was slight but statistically insignificant improvement in Isabel’s general symptom distress and interpersonal distress at two-week follow-up (see Tables 11.4
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& 11.5). Isabel was in the clinically dysfunctional range on the SCL90-R at pre- intervention and again at two week follow-up. Although there was a slight improvement at two weeks, this did not meet the criteria for reliable change. Her subjective reports of post-session changes were inconclusive. After the workshop, Isabel attended a major family function and reported mixed reactions to contact with family members. She was less reactive in interactions, but over time felt guilty and ashamed that she was not able to relate better to her family.
In-session Process. Isabel did not meet the criteria for any of the meta-events of the proposed model. She reported some experience of group cohesion before her session and partially completed a re-experiencing and insight event. These processes are summarised below. Readiness to engage in the psychodrama process. Isabel’s post-workshop evaluation indicated a limited readiness to engage in the psychodrama process. She reported that during the introductory session she enjoyed getting to know others and was able, through the group activities, to communicate through action, because she didn’t have words to express herself. She felt resistant but decided to participate fully. Isabel had no prior experience of psychodrama and there was minimal indication of prior learning from the workshop sessions that preceded hers. Her session was the second psychodrama of the workshop and she reported that, during the previous psychodrama enactment (Patricia’s), she became aware of her own experience of being dislocated from her family. The four meta-events. Isabel did not complete any of the meta-events as described in the model in Study 2. She met some of the criteria for the ‘Re- experiencing’ but not for ‘insight’ into the maladaptive belief or problematic role relationship that was interfering with her functioning. In other words, she re- experienced without, it would seem, making meaning of her experience in relation to her functioning. The re-experiencing itself was not complete. Isabel set out the family scene, but did not reverse roles with family members apart from her mother. This role reversal was itself incomplete, in that Isabel had difficulty speaking from the role as-if she were in the here and now. Isabel’s post-workshop evaluation responses suggest that she re-experienced being overwhelmed during the re- enactment. She reported feeling numb when she tried to take her mother’s role. She
Chapter 11 221 described standing back from the action and watching auxiliaries enact the scene as ‘interesting’, but felt somewhat distanced from the experience.
Summary of the Results of Study 3 The two resolved cases met the conditions for three of the meta-processes proposed in Study 2: (i) readiness to engage in the psychodrama process, (ii) re- experiencing and insight and (iii) activating resourcefulness. Both met the criteria for social atom repair, but only one case had emotional release expressed as grief or crying. Angela expressed grief in the earlier re-experiencing event, but in the social atom repair scene her emotional release was of the previously inhibited expression of joy. An integration event was not identified in either of the resolved cases. The not-resolved cases differed significantly from each other. Isabel did not have a full re-experiencing and insight event or meet the conditions for activating resourcefulness or social atom repair with emotional release; whereas Patricia completed a re-experiencing and insight event and met the conditions for social atom repair, but not for emotional release. The resolved sessions occurred later in the workshop, supporting the proposition that warm-up increases with the progress of the group and that this assists in-session resolution. For both resolved cases, protagonists reported feeling very much relieved immediately following the session and reported post-workshop changes in their interpersonal relationships and in their sense of self that they attributed to events in their psychodramas. The not-resolved protagonists reported experiencing some group cohesion, but did not refer to other components of readiness to engage in the psychodrama process. All components of the re-experiencing and insight event were identified in the two resolved cases and in Patricia’s partially resolved session, and an activating resourcefulness event was identified in the two resolved cases. Different experiences in the Social atom repair with emotional release event provide support for this event being central to resolution, but also suggest that emotional release needs to be defined more broadly. Whereas in other resolved cases emotional release has been associated with expressions of grief, Angela’s emotional release was associated with the expression of previously inhibited joy. This is consistent with Kellermann’s (1984) definition of catharsis as “release of
Chapter 11 222 stored up content through affective expression … the particular experience of release that occurs when a longstanding state of inner mobilization (warming-up) finds its outlet in action” (p.3). The absence of emotional release in Patricia’s social atom repair event seems to be linked with a lack of resolution in her relationship with herself during this event. These cases lend support to Clayton’s proposition that during catharsis there is “an expansion of the psyche … The freeing up of different abilities so that those different abilities become much more available” (Clayton & Carter, 2004, p.239). Patricia’s session was particularly instructive because her partial resolution was linked with some changes in her construction of her relationship with her mother that produced some peace, but was also linked with increased agitation immediately after her session. That the director and the observer both rated Patricia’s session as resolved strengthens the argument that a protagonist may appear to have resolved an issue when they enact a new response, but without an internal shift in the relationship to self, the experience of resolution is not complete. Such internal shifts may at times be expressed verbally in the session, but are more reliably identified by protagonists’ reports. Patricia reported changes in her interpersonal relationships and her sense of self after the workshop, but noted that workshop events subsequent to her psychodrama session had enabled her to resolve outstanding aspects of her issue. Isabel reported that she was not at all relieved after her session and did not report any significant post-session changes. This study did not produce any cases where an integration event was clearly evident, so the nature of this event and its relationship to in-session resolution cannot be examined further at this stage. There is general support for the model that was described in Study 2, if emotional release associated with social atom repair is defined more broadly as the release of previously inhibited emotion and not necessarily expressed as crying.
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Chapter 12 Verifying the Application of Greenberg’s ‘Allowing and Accepting Painful Emotional Experience’ Model to the Psychodrama Method
The preceding three studies have described cases where emotional release was therapeutically helpful in healing painful emotional experiences, when it occurred in the context of social atom repair. Other psychotherapy change process research has also identified therapeutic weeping as a central process in healing painful emotional experience (Greenberg, 1996, 1999; Greenberg & Paivio, 1998; Greeenberg & Saffran, 1989). In the empirically-based model of allowing and accepting painful emotional experience therapeutic weeping is considered to be an indicator that the person is allowing an inner experience of emotional pain (Greenberg, 1999; Greenberg & Paivio, 1998). Greenberg (1999, 2008) proposes that allowing emotional pain is a transforming experience and that the client’s central task in all therapies is to move towards, rather than avoid, this experience. This fourth and final study investigates the proposition that protagonists’ experiences of healing during psychodrama can be explained, at least in part, by the allowing and accepting painful emotional experience model.
Greenberg’s Allowing and Accepting Painful Emotional Experience Model
Greenberg and his colleagues argue that allowing and accepting emotional pain is central to therapeutic change (Greenberg, 1996, 1999, 2008; Greenberg & Bolger, 2001; Greenberg & Paivio, 1998). Therapeutic weeping, defined as ‘an intense form of the expression of distress/sadness (that) involves surrender to the experience and its expression’ (Greenberg, 1999, p. 1471), is considered to be a primary marker that the client is allowing the experience of emotional pain. Beginning from a hypothesis that therapeutic weeping marks an adaptive, reparative response to loss, Greenberg and his colleagues investigated weeping events in emotion-focussed therapy (formally known as process-experiential therapy), to identify client change processes that differentiated between therapeutically helpful and unhelpful weeping events (Greenberg, 1999; Greenberg
Chapter 12 224 and Paivio, 1998; Greenberg & Saffran, 1989). They concluded that allowing affective experiencing of emotional pain was the central process that produced resolution of painful emotional experience. The process of allowing is considered to involve an internal shift in the client’s relationship to themselves and to the experience of emotional pain, such that they consciously experience their affective response and accept the response as part of them. The internal process of allowing and accepting emotional pain is marked by therapeutic weeping, which is ‘a differentiated expression of primary distress’ (Greenberg, 1999, p. 1475). When there is no resolution of the painful emotional experience, weeping is more likely to be accompanied by protesting against the emotion, complaining or externalising the experience. The initial shift from avoiding to approaching the emotional pain was found, in many cases, to be associated with the expression of secondary maladaptive emotions, such as guilt, shame and hopelessness. This has led Greenberg (2002) to argue that secondary maladaptive feelings need to be expressed in order to access the primary adaptive emotions that they are masking. Allowing emotional pain is considered to bring about shifts in cognitive processing. The client identifies the maladaptive beliefs that had interfered with affective processing (typically self-rejecting or being rejected by others) and recognises previously unmet emotional needs at a visceral level. Clients appear to shift out of the distressed state when unmet needs are accessed and acknowledged and when maladaptive beliefs are challenged. The immediate impact of the allowing and accepting emotional pain is considered to be a change in relationship to self, experienced as a sense of relief and affirmation of self. Greenberg (1999) concluded that therapeutic weeping is a transformative process that alters the person’s internal pain-inducing structure, producing affective and motivational change, a change in beliefs, including a change in perception of self and others, and rejuvenation, experienced as relief and self-affirmation. The process of allowing and accepting painful emotional experience is illustrated in Figure 12.1, which has been reproduced from an article by Greenberg and Paivio (1998).
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Change in Internal Relations Awareness of Re-owning Interruption belief
Approach Allow Accept Agency Relief & Self- Vs Avoid affirmation
Mobilising unmet need
Figure 12.1. The Process of Allowing and Accepting Painful Emotional Experience. (Source: Greenberg & Paivio, 1998, p.55).
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The findings of the earlier studies of this research, suggest that the fit between Greenberg’s model and protagonists’ experiences of change, warrants further investigation. The social atom repair with emotional release event, which was identified and described in Chapter 10, appears to share some of the characteristics of the allowing and accepting model, specifically (i) emotional release of grief, (ii) articulating unmet needs, (iii) new meaning making and (iv) a sense of resolution or relief. Similarities and differences between Greenberg’s emotion-focused model and Moreno’s spontaneity theory will now be considered.
Emotion or Spontaneity as the Catalyst for Change
The allowing and accepting painful emotional experience model defines specific differences between therapeutic and non-therapeutic weeping which may cast light on the debate over the therapeutic utility of catharsis during psychodrama. Therapeutic weeping is seen to produce cognitive change, which has parallels with Hollander’s Psychodrama Curve (1969, 2002; see Chapter 2, figure 2.1), where catharsis of abreaction is considered to precede the peak of creativity in a psychodrama session. Both models emphasise the therapeutic utility of emotional release leading to cognitive change. The Hollander Psychodrama Curve is a general model that describes the progression of a psychodrama session across the three phases of warm-up, spontaneity and integration, irrespective of the central issue being addressed. Greenberg and Paivio, on the other hand, offer a detailed description of the process that a client engages in to resolve painful emotional experience. Their model could offer a more specific explanation of protagonists’ processes where the resolution of painful emotional experience is involved, which could complement Hollander’s model. However, a significant area of difference between Greenberg’s model and psychodrama theory is the emphasis on emotion (Greenberg) compared to spontaneity (Moreno), as the therapeutic agent. Greenberg and Paivio (1998) define the goal of therapy as being to allow the previously avoided painful emotional experience, so that new meaning is created in the allowing process. The therapeutic goal of psychodrama, on the other hand, is to complete unfinished warm-up processes, so that spontaneity is increased and new responses are developed and integrated.
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The differences between these two approaches may be semantic, but it is also possible that the differences between the emotional construct and the spontaneity construct identify a core conceptual difference. This difference is encapsulated in the element of readiness used to describe both constructs. Emotion has been defined as a motivating agent for action and accessing primary emotion is considered to promote readiness to respond in a particular way, consistent with the structure of that particular emotion. Spontaneity, on the other hand, is seen as a readiness to respond in the moment, as required by the situation; and would include a flexibility to change that response as the context changed. Moreno (1987) was emphatic that spontaneity was neither an emotion nor a component of emotion. He saw the production of feeling as assisting the development of spontaneity and, in cases where spontaneity was inhibited, considered catharsis as a necessary step for producing a new response to a situation.
Rationale for Study 4
Investigating the fit between protagonists’ change processes during psychodrama and the allowing and accepting painful emotional experience model will build on the work of Greenberg and his colleagues and contribute to understanding the function of therapeutic weeping in the healing process. The allowing and accepting painful emotional experience model was constructed from the analysis of significant therapeutic events in emotion-focused therapy, but Greenberg and Paivio (1998) claim that the model is based on a general principle of therapeutic change which applies across therapeutic modalities. Quantitative measures have been established for components of the model (Foerster and Greenberg, 1995, in Greenberg, 1999), thus enabling this claim to be tested in different therapeutic settings, but to date this challenge has not been taken up.
Verifying the Model within the Task-analytic Research Approach
The allowing and accepting painful emotional experience model has been developed and progressively modified through the task-analytic research approach (Greenberg, 1999). Task analysis (Greenberg, 1986, 1994; Greenberg & Foerster, 1996) investigates in-session client processes linked to the resolution of specific therapeutic tasks, through a combination of rational and empirical analysis. It
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incorporates the three phases of change-process research that are identified by Greenberg and Newman (1996): (i) the intense observation and detailed description of a small number of cases, (ii) the development of an explanatory model through systematic measurement and contextual analysis and (iii) verification of the explanatory model. Rational analysis begins with the construction of hypothesised models of client change processes, based on clinical experience and theoretical understanding. Empirical analysis of successful examples of the task being investigated is then carried out and diagrams of actual client performances are constructed and compared to the hypothesised models. A model is developed that accounts for the change process in the successful cases under investigation and a description of each component of the model is made, specifying the unique features of that component in observable and quantifiable terms. In the verification phase of task-analysis, client performances of successful and not-successful cases are compared against these criteria. Measuring ‘allowing and accepting painful emotional experience’. To verify the allowing and accepting painful emotional experience model, Foerster and Greenberg (1995, in Greenberg, 1999) studied resolved and not resolved cases, restricting their investigations to clients’ observable performances and identifying measures for performances linked to in-session resolution. Using a set of process measures to describe relational characteristics and the quality and intensity of clients’ experiences, they developed multi-dimensional descriptions of client performances linked to resolution. They concluded that four components of client performance distinguished between resolved and not resolved cases: acknowledging secondary bad feelings, allowing emotional pain, articulating a maladaptive belief and accessing a previously unmet need. Figure 12.2 shows these components and their multi-dimensional descriptors. These descriptors become criteria for testing the model in any therapeutic context. To support the contention that this is a general model of client change, wider verification is called for. One possible limitation in testing the model within the framework set by Foerster and Greenberg is that their choice of measures is based on assumptions about the nature of the client’s in-session relationship with the therapeutic process itself. Their measures emphasise verbal content during a session and this may have limited
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application when measuring processes in psychodrama. Study 2 (see Chapter 11) identified non-verbal experiencing by the protagonists as therapeutically significant and specifically linked to emotional release. Opportunities for protagonists to express themselves in non-verbal forms and for protagonists’ inner experiences to be enacted or articulated by other group members in auxiliary roles, mean that measures that rely on the protagonists’ overt in-session verbal accounts may miss vital aspects of in-session processing. It is important to test whether research is investigating the application of the model or the efficacy of the actual measures. Greenberg (1999) acknowledges that their proposed measures are preliminary. The question remains as to whether Greenberg and Foerster’s measures are the most appropriate way to test the model, or if they test the model as it unfolds within a particular therapeutic approach and not in others. The use of video-assisted recall to uncover clients’ subjective experiences is founded on the assumption that significant experiences are not always explicitly expressed. This issue is not confined to the psychodrama context, but the psychodrama method intentionally incorporates experiences where protagonists are actively engaged in the therapeutic process with little or no verbalisation, so it could be anticipated that measures of verbal performance would not account for all significant protagonist processes. This study is primarily concerned with verifying the model under the conditions established by Foerster and Greenberg, so that the results can be compared to their study within the task-analytic framework. Keeping in mind that a failure to locate the components of the model using their measurement criteria would not conclusively refute their conceptual model, additional steps have been taken to consider protagonists non-verbal experiences. These steps are described in the analysis section.
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1. 2. 3. 4.
Acknowledge Secondary Allow emotional pain Articulate maladaptive Access Need Bad Feeling. belief.
Negative or coercive to Helpless, disappointed, Crying > 2 talk turns self (ES) Overtly expressed wish anxious or ashamed. Openly disclose (SASB) (EXP) 3 or above. (CCRT) (CCRT) Spontaneous self, self- & Either Language = need, want, Vocal quality= focused nourish, self-accept or Self monitor, self-indict, goal, desire, wish. or emotional (CVQ) self-protect (SASB) self-reject or self-neglect Self-assert & openly (EXP) 3 or above. Immediate inner (SASB) disclose (SASB) awareness. (ES) Or (EXP) 4 or above Response of other is to control, reject, oppose or call bad /not trustworthy (CCRT).
Figure 12.2. Criteria for the four components of the allowing and accepting painful emotional experience model, based on the work of Foerster & Greenberg (1995, in Greenberg, 1999).
Note: Scales used to measure criteria are indicated in brackets after the description. CCRT= Core Conflictual Relationship Theme Measure; SASB = Structural Analysis of Social Behaviour; EXP = Experiencing Scale; ES = Expressive Stance Measure. CVQ = Client Vocal Quality Scale. (Refer to the descriptions of these measures in the Method section of this chapter).
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Hypotheses
If the allowing and accepting painful emotional experience model is a general model of client change processes, it would apply to the resolution of painful emotional experience during psychodrama. It was hypothesized that the components of ‘acknowledging secondary bad feeling’, ‘therapeutic weeping’, ‘articulating a core maladaptive belief’ and ‘accessing need’, would occur in resolved cases and that these components were more likely to occur within what have previously been described as social atom repair events. Furthermore, it was hypothesized that ‘therapeutic weeping’, ‘accessing need’ and ‘affirming self’, were more likely to occur in resolved than in not resolved cases, while ‘acknowledging secondary bad feeling’ and ‘articulating a core maladaptive belief’ were less likely to differentiate between resolved and not- resolved cases.
Research Questions
To test this claim, the following research questions were posed:
RQ6 Do psychodrama enactments where there is in-session resolution of painful emotional experience meet Foerster and Greenberg’s criteria for allowing and accepting emotional pain?
RQ7 Do Foerster and Greenberg’s criteria for allowing and accepting emotional pain differentiate between those psychodrama enactments where there is in- session resolution of painful emotional experience and those enactments where there is not in-session resolution?
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Method
Greenberg and Foerster’s criteria for allowing and accepting emotional pain were applied to nine psychodrama cases, to establish whether these criteria could be linked to in-session resolution of painful emotional experience during psychodrama. The research plan is outlined in Figure 12.3. The transcripts from nine psychodrama sessions which had previously been rated for degree of in-session resolution of painful emotional experience were analysed using process measures identified by Foerster and Greenberg. Each protagonist’s performance on these measures was compared to Foerster and Greenberg’s hypothesised performance criteria and the results for resolved and not resolved cases were compared.
Compare Identify Chart actual Compare resolved and protagonists’ performance resolved to not-resolved performance. to not- psychodrama hypothesised resolved cases performance. cases.
Figure 12.3. Study 4 Research Plan
Protagonists
Transcripts of the psychodrama sessions of nine of the ten protagonists from Studies 1 and 2 were used in this fourth study. There were two male (one resolved case and one not resolved case) and seven female (five resolved cases and two not resolved cases) protagonists, ranging in age from 35 to 60 years. Details of the protagonists and their presenting concerns are provided in Chapters 7 and 8.
Process Measures
A number of measures were used to code protagonists’ in-session processes. Firstly, the Degree of Resolution Scale: Unfolding Problematic Reaction Points (DRS/PRP: Greenberg, Rice and Elliott, 1993) was used to rate in-session resolution.
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These ratings were carried out in earlier studies of the thesis (see Chapters 7 & 8) and the DRS/PRP and its use in this research is discussed there. Foerster and Greenberg (1995, in Greenberg, 1999) used seven process measures to describe components of their model, five of which have been used here. The Core Conflictual Relationship Theme Measure (3rd Edition) and the Structured Analysis of Social Behaviour (SASB) measure intrapersonal and interpersonal relationship dynamics. The other three instruments, the Experiencing Scale (EXP), the Client Vocal Quality Scale (CVQ) and the Expressive Stance Scale (Ex), measure the quality and intensity of the person’s experience and expressiveness. Foerster and Greenberg used an unpublished Needs Scale to identify relationship motivators and in this study the ‘Wishes’ component of the CCRT was used in its place. An Emotional Arousal Scale cited by Greenberg (1999), was also unavailable for this study. The process measures that were applied in this study are described below.
Interactional measures
The Core Conflictual Relationship Theme Measure (3rd Edition) (CCRT; Luborsky, 1998; Luborsky & Crits-Christoph, 1990; Luborsky, Crits-Cristoph & Cooper, 2006). The CCRT analyses interpersonal and intra-personal relationship episodes in terms of three components: wishes or needs, response of the self and response from the other. The scale was first derived from an analysis of the most common themes in clients’ narratives in therapy, across 16 cases. An expanded second edition, incorporated category sets from other theorists, to include 96 standard categories: 35 wishes, 31 responses of self and 30 responses from other. The third edition, which is used here, derived eight clusters for each of the three components of the measure. The ‘response of self’ and ‘response from other’ components identify themes in interpersonal interactions. ‘Response of self’ clusters are: (i) helpful, (ii) unreceptive, (iii) respected and accepted, (iv) oppose and hurt others, (v) self-controlled and self-confident, (vi) helpless, (vii) disappointed and depressed and (viii) anxious and ashamed. ‘Response from other’ clusters are: (i) strong, (ii) controlling, (iii) upset, (iv) bad, (v) rejecting and opposing, (vi) helpful, (vii) likes me and (viii) understanding. The third component, ‘wishes’, identifies relationship motivators, that is wishes, needs and desires, clustered as (i) to assert self and be independent, (ii) to oppose, hurt and control, (iii) to be controlled, hurt and not responsible, (iv) to be distant and avoid conflicts, (v) to be close and
©C.McVea 31.12.08 Chapter 12 234 accepting, (vi) to be loved and understood, (vii) to feel good and comfortable and (viii) to achieve and help others. The eight clusters of the wishes component were used in place of the unpublished Needs Scale described by Greenberg (1999). The CCRT is typically used to describe a client’s general style of relating, or core themes, by identifying recurring themes over a number of relationship episodes on different occasions In this current study, the CCRT is used to identify relationship themes in the moment to moment process of the protagonist and to identify changes in relationship themes over the course of the session. Structural Analysis of Social Behaviour (SASB; Benjamin, 2004; Benjamin & Cushing, 2000). The SASB is a circumplex measure of intra-personal and interpersonal interactions. Responses are classified as being either focussed on self, focussed on other or having an introjected focus, and are further classified into eight clusters along two axes: hostility Vs affiliation and autonomy Vs dominance. The focus on self and focus on other are concerned with interpersonal relationship themes, while the introjected focus is concerned with intra-personal themes or relationship to self. The SASB can be used in two ways; either as a self-report inventory of interpersonal and intra-personal attitudes and behaviour, or as a tool for judges to analyse the process and content of interactions. In this instance, the SASB was used by judges to code transcripts of significant events.
Measures of Quality and Intensity of Experience and/ or Expression
The Experiencing Scale (EXP: Klein, Mathieu, Gendlin & Kiesler, 1969, 1969a). The EXP was developed to measure degree of experiencing overtly expressed by the client in therapy. Experiencing is defined as ‘the quality of an individual’s personal, subjective awareness … a process of looking inward to find a felt sense of significance which provides the content for self expression.’ (Klein et al., 1969, p. 50). The EXP describes seven stages of experiencing, ranging from Stage 1 which is characterised by impersonal expression to Stage 7 which is characterised by expression that ‘reveals the speaker’s expanding awareness of his (sic) immediately present feelings and internal processes’ (p. 62). The scale is designed to be used with transcripts or recordings of therapy sessions, to assess the depth of experiencing. It is designed for use with verbal therapies and assumes that verbal expression reflects the inner experience, or at least the willingness of the client to share inner experience. Depth of experiencing is considered a core curative factor in experiential
©C.McVea 31.12.08 Chapter 12 235 psychotherapy (see Watson, Greenberg & Lietaer, 1998) and the EXP has been used extensively in experiential psychotherapy process research. Client Vocal Quality Scale (CVQ; Rice, Koke, Greenberg & Wagstaff, 1979, in Watson & Greenberg, 1996). The CVQ was designed to assist therapists and researchers to identify possible inherent meanings in clients’ speech as a way of understanding the client’s level of experiencing in the moment. Rice et al. identified four categories of vocal quality: (i) focussed, suggesting that the client is focussed on inner experience and trying to put that experience into words; (ii) emotional, where verbal expression is interrupted by non-verbal emotional indicators such as crying, suggesting that the client is experiencing the feeling in the moment; (iii) externalizing, where the client appears to be distanced from the experience and the speech has a practiced quality and (iv) limited, where the client is distanced from the experience and appears fragile (in Greenberg, Watson & Lietaer, 1998). Expressive Stance Measure (ES; Rice, Watson & Greenberg, 1993, in Watson & Greenberg, 1996). The ES measures the verbal expressions of the attitude that clients’ take towards their own experience. Client dialogue is rated on eight mutually exclusive categories: (i) focussing inwardly and actively re-experiencing emotion or feeling; (ii) observing own reactions and feelings in general; (iii) focussed inwardly and trying to understand own reactions; (iv) describing a situation or person with immediacy; (v) asserting self; (vi) negatively evaluating self or making coercive statements about self; (vii) reflexively enquiring and examining themselves and their experience and (viii) describing or observing generally own experience. This measure was designed for use in process change research.
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Procedure The steps in the procedure are outlined in Figure 12.4 and then described below.
Identify resolved and not resolved cases.
Select transcript segments for coding
Train judges in process measures
Code transcripts
Construct detailed individual protagonist performance diagrams
Compare actual performance to hypothesised model performance
Compare resolved and not-resolved cases
Figure 12.4: Steps in Procedure for Study 4
Selecting Resolved and Not-Resolved Cases
Ten cases from Studies 1 and 2 had been rated for degree of in-session resolution on the six point Degree of Resolution Scale: Problematic Reaction Points (DRS/PRP; Greenberg, Rice and Elliott, 1993). To ensure that the between group comparison of results examined the difference between resolved and not-resolved cases, only sessions where there was agreement between the director, the independent rater and the protagonist, that there was resolution or not-resolution, were included. One of the ten cases was omitted from this study, because the ‘resolved’ rating given by the director and the independent rater, was not verified by the protagonist’s report of the impact of the session (refer to Study 2). In another case, there was agreement between the director, the protagonist and one independent rater, but not a second independent rater, that the case was not resolved. In this instance, the two raters and the investigator (who had not been one of the raters) discussed their interpretations of the resolution scale and arrived at a consensus that the case was not resolved. Consequently, six resolved and three not resolved cases were used in this study.
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Sessions were considered to be either resolved (ratings of 5 or 6 on the DRS/PRP and the protagonists’ reports in-session resolution) or not resolved (ratings of 4 or less on the DRS/PRP and protagonists reports of non-resolution). As was reported in Chapter 9, interrater agreement between the directors’ and observers’ DRS/PRP ratings was extremely high (94.4%) and agreement between director’s ratings and protagonists reports of resolution was good (k = .70).
Identifying Events to be Analysed
The task-analytic strategy for analysing transcripts is to identify markers of the specific component under investigation and to begin with passages of text that are judged most likely to contain that component. Further passages are then analysed until all the criteria have been identified, or until all the text has been analysed. In accordance with the hypothesis that social atom repair events would meet the Foerster and Greenberg’s criteria for allowing and accepting emotional pain, these events were analysed first. ‘Therapeutic weeping’ has been proposed as a marker of allowing emotional pain (Greenberg, 1999) and therapy events that contained weeping were targeted in Foerster and Greenberg’s study. Study 2 of this thesis identified two events that were likely to contain a weeping episode: the re- experiencing and insight event and the social atom repair event (refer to Chapter 11). It was considered that the second of these events was more likely to contain the elements of Greenberg et al.’s model, therefore social atom repair events were coded first. These events had already been located for cases in Study 2, but not in Study 1. Transcripts and protagonists recall responses from Study 1 cases were reviewed by the investigator to identify events that met three core conditions of social atom repair: (i) weeping, (ii) protagonists reported experiencing a previously unmet need during the event and (iii) protagonists reported feeling relief or resolution as a result of the event. If all the criteria were met within the social atom repair event, no further analysis was required for that case. If there was not an identified social atom repair event (as in not-resolved cases), or if the criteria for all components of the model had not been met, other events that contained weeping were analysed next, followed by events that contained a statement indicating a felt need (‘I want’, ‘I need’, etc.), until all components had been identified, or until all significant events had been analysed.
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Selection and Training of Judges
Coding was administered by the investigator and two independent judges. To establish the trustworthiness of the coding, two independent judges coded 20% of the transcripts. These judges were experienced psychologists who were blind to the research questions, to the findings of the previous studies and to whether the events they were coding were from resolved or not resolved cases. In accordance with the training manuals for each scale, judges were introduced to the theory behind the scales and trialled sample transcripts before coding the research transcripts.
Coding Transcripts
Coding was carried out from the session transcripts. Luborsky (1998) suggests that while recordings provide fuller information about voice quality and behavioural context, transcripts are an adequate and more accessible source of information for extracting CCRT. The SASB and EXP are designed to be used with transcripts. The coding was carried out in two stages; the transcript was prepared for coding by the investigator and then coded by the investigator and two other judges. Inter- rater reliability was assessed by comparing the ratings of the investigator against those of the two independent judges for a sample of 20% of the transcripts. Preparing the transcript. Preparation of the transcript involved identifying segments to be coded for each measure, to ensure that all judges were rating the same data sets. The procedure for preparing the transcripts followed the guidelines set out in the respective manuals for both the CCRT and the SASB. The CCRT divides transcripts into relationship episodes, whereas the SASB begins with conversation sequences. Selecting relationship episodes. Using the procedure described by Luborsky (1998), transcripts were divided into discrete relationship episodes comprising explicit narration or enactment of a relationship with another person or with the self. In selecting relationship episodes, the following four criteria were applied: (1) The episode involved the protagonist and one other main person. The ‘other’ could be a group, where the group had a single identity within the episode, or could refer to the protagonist, where the episode involved his or her relationship with self. (2) Discrete episodes were identified where either the main other person was different, or the nature of the event was different. Where interpersonal interactions
©C.McVea 31.12.08 Chapter 12 239 or narratives were sub-episodes of larger interactions or narratives, they were considered as the one episode. (3) Relationship episodes were rated for completeness of narrative on a scale of 1-5, where a rating of ≥3 is considered complete enough for CCRT components to be accurately rated. Only relationship episodes with a rating of 3 or more were selected for coding. (4) Relationship episodes were identified on the transcript with a coloured strip along the length of the episode. Each episode was numbered. Sub-episodes from different scenes within a psychodrama but relating to the same episode were given the same number. Relationship episodes were classified according to whom the episode related to and whether it was primarily narrated or enacted. Identifying CCRT components within relationship episodes. The second step in preparing transcripts for CCRT coding involved determining whether components of relationship episodes were classified as a wish or need (W), a response of self (RS) or a response of other (RO). Components were indicated on the transcript beside each piece of dialogue, or conversation sequence. Where a complete response was made in a number of consecutive conversation sequences (i.e. when a protagonist’s speech was interspersed by the speech of others), the consecutive items were grouped together. Items that did not contain enough information to be rated, such as minimal responses and responses that related to the setting out of the session (e.g. director’s instructions to the protagonist or other group members) rather than to the relationship, were omitted. Identifying SASB elements and foci. The SASB is concerned with both content and process aspects of interpersonal dialogue and codes elements of dialogue in relation to three foci: self, other and introject. For each conversation sequence in the transcript, elements representing complete thoughts were marked, such that some conversation sequences contained a number of different elements. The focus was indicated beside each element. Where content differed from process, this was marked on the transcript, indicating that the element was to be coded for both. Coding protagonists’ responses. Protagonists’ responses included any dialogue spoken by the protagonist in whatever role he or she was speaking from. By coding only protagonists’ responses, the results reflected relationship themes that were expressed by the protagonist and did not include content initiated by the director or other group members, unless and until that content was verbalised by the protagonist.
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The transcript was first marked for general indicators of the four components of Greenberg and Foerster’s model; that is, (i) crying, (ii) words indicating a statement of need, such as ‘I wish’, ‘I want’ or ‘I need’, and (iii) a statement of a dysfunctional belief. Protagonists’ responses were then coded on the two interactional measures (the CCRT and the SASB) and, if these responses matched any of Foerster and Greenberg’s criteria, the three measures of quality and intensity (the EXP, ES and CVQ scales) were then applied. The specific procedure for coding each measure is described here. CCRT: Responses were rated using the standard categories developed in the second edition of the CCRT and translating these to the clusters developed in the third edition. The cluster scores were used for the analysis and to measure inter-rater reliability. Judges rated each response within a relationship episode, choosing the best fitting and, where they considered it appropriate, the second best-fitting standard categories. Wishes were scored at 2 levels of inference (a) explicit expression of wishes, typically using words such as ‘I wish’, ‘I want’, ‘I need’, and (b) those that were not explicit but were moderately inferable. Only explicit expression of wishes was considered to meet Foerster and Greenberg’s criteria for ‘accessing need’. SASB: Responses had been pre-classified (see above) as being focussed on self, other or introject. Judges rated each response for affiliation and dominance, to indicate which one of eight clusters within the self, other or introject focus, the response best fitted. EXP; CVQ and Ex: Where excerpts of transcripts met established criteria on the interactional measures described above, those excerpts were then coded on relevant quality and intensity measures. A general EXP rating was given for each relationship sub-episode. Coding for individual cases was assessed against Foerster and Greenberg’s criteria. Protagonists’ performances within resolved and not-resolved groups were charted and the results for the two groups were compared.
Constructing Protagonists’ Performance Diagrams
Performance diagrams were constructed using Greenberg and Foerster’s (1996) conventions. Protagonists’ responses were indicated with a circle where they were responding as themselves, or with a square where they were responding as a significant other. A multi-dimensional description was written next to each response,
©C.McVea 31.12.08 Chapter 12 241 defining the interactional and expressive qualities of that response. Where auxiliary responses had also been coded, these were included in the diagram and indicated with dashed borders, such that a dashed-circle indicated an auxiliary responding as the protagonist and a dashed-square indicated an auxiliary responding as a significant other. Conversational sequences were numbered in chronological order and further arranged with the time continuum moving from left to right and from top to bottom of the diagram. Sequences organised from top to bottom indicated substantially similar descriptors. These performance diagrams are provided in the results section.
Comparing actual performance to hypothesised model performance
There were two areas of interest in comparing hypothesised and actual performances for each case: (i) whether the social atom repair event matched all the components of Foerster and Greenberg’s performance model, and (ii) whether the session taken as a whole matched the hypothesised performance model. Each component was considered to be present in a segment of transcript, only when all criteria for that component were met.
Comparing resolved and not-resolved cases
The representativeness of each component within the resolved and not resolved groups was described using Hill et al.’s (2005) categories of general (applying to all or all but one case in the group), typical (applying to more than half the cases in the group) or variant (applying to half the cases in the group or less). Because there were only three cases in the not-resolved group, components were considered general to not-resolved cases only when they occurred in all three cases. Fisher’s exact test was applied to determine which components significantly differed between resolved and not-resolved cases (see Table 12.3). Fisher’s exact test calculates the statistical significance of the association between two variables on a 2 by 2 contingency table, where sample sizes are small (Agresti, 1992).
Results
Inter-rater Reliability for Process Measures
Interrater reliability for process measures used to code transcripts was assessed by comparing the judgements of an independent rater against those of the
©C.McVea 31.12.08 Chapter 12 242 investigator, for a sample of 20% of the transcript. Inter-rater reliability for the EXP was assessed using Pearson’s product moment correlation. For the SASB and CCRT Cohen’s kappa was used. Inter-rater reliability coefficients are shown in Table 12.1.
Table 12.1. Interrater reliability coefficients for process measures
N Pearson’s r EXP 14 0.91
Cohen’s weighted kappa SASB 123 0.81 CCRT 148 0.79 Cohen’s kappa CVQ 30 0.78 ES 33 0.81
Note: EXP = Experiencing Scale; SASB = Structured Analysis of Social Behaviour;
CCRT = Core Conflictual Relationship Theme; CVQ = Client Vocal Quality;
ES = Expressive Stance Measure.
Occurrence of Components of the Allowing and Accepting Model in Resolved and Not-resolved Cases
The cases that met Foerster and Greenberg’s criteria for each component of the allowing and accepting painful emotional experience model are shown in Table 12.2. Acknowledging secondary bad feeling and articulating core maladaptive beliefs were common to resolved and not-resolved cases and accessing needs was common to all but one not-resolved case. Allowing emotional pain was general to resolved cases, but was absent in all not-resolved cases.
Table 12.2. Occurrence of Criteria of the ‘Allowing & Accepting’ Model across resolved and not-resolved cases.
Criteria Groupª Present Absent Rep* Acknowledging R Erin, Karen, Jane, Julie General secondary bad Cheryl, Ray.
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feeling N Ella, Grant, General Geraldine Allowing R Erin, Jane, Julie, Karen, General emotional pain Cheryl, Ray. N Ella, Grant, None Geraldine Articulating R Erin, Cheryl, Jane, Julie. General maladaptive Karen, Ray, belief N Ella, Grant, General Geraldine Accessing need R Erin, Jane, Julie, Karen General Cheryl, Ray N Geraldine, Grant. Ella Typical
Note: ª R = resolved; N = Not resolved. *Rep = representativeness of the component within the group; Hill et al.’s (2005) categories, described in Chapter 9, are used. General = applies to all or one less than all cases in the group (NB Must apply to all not resolved cases, because there are only 3 cases in the group); typical = applies to more than half of the cases in the group.
The results of Fisher’s exact test, which examined the statistical significance of differences between the resolved and not-resolved groups, are shown in Table 12.3. The only component that discriminated between resolved and not resolved cases, was allowing emotional pain.
Table 12.3. Occurrence of Criteria of the Allowing & Accepting Model in Resolved and Not-resolved Cases. (Fisher’s exact test)
Criteria Resolved Not-resolved P
Acknowledge Present 5 3 secondary bad Absent 1 0 p=.66 feeling. Allow emotional Present 5 0 pain. Absent 1 3 p=.047
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Articulate core Present 5 3 maladaptive belief. Absent 1 0 p=.66
Access need. Present 5 2 Absent 1 1 p=.583
Contrary to one of the expectations of this study, Foerster and Greenberg’s criteria were not always met within a ‘social atom repair with emotional release’ event (see Table 12.4). Consequently, while five of a possible six cases met these criteria at some point during the session, during the social atom repair event only three met the criteria for ‘acknowledging secondary bad feeling’ or ‘allowing emotional pain’ within the social atom repair event, two met the criteria for ‘articulating maladaptive belief’ and four met the criteria for ‘accessing needs’ during this event.
Table 12.4. Occurrence of criteria of the ‘Allowing & Accepting’ model in ‘social atom repair’ events
Component Present in Social Absent in Social *Representativeness Atom Repair Atom Repair of the component Event Event across cases. Acknowledging Erin, Cheryl, Julie, Ray, Variant secondary bad feeling. Karen. Jane.
Allowing emotional Erin, Jane, Karen, Ray, Variant pain. Cheryl. Julie.
Articulating core Erin, Cheryl Karen, Ray, Variant maladaptive belief. Julie, Jane.
Accessing need. Erin, Jane, Karen, Julie. Typical Cheryl, Ray
Notes: * Hill et al.’s (2005) categories for representativeness of the data are used here. Typical = applies to more than half of the cases. Variant = applies to less than half the cases.
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As Hill et al. (2005) have noted, results from very small samples are unstable, so that caution should be used in interpreting these findings, particularly in light of the very small not-resolved sub-group.
Performance Patterns within Resolved Cases
A detailed description of when and how the criteria of the allowing and accepting model were met in resolved cases is presented next. Significant in-session events which met some or all of Foerster and Greenberg’s detailed criteria are described for each resolved case. These are illustrated with protagonists’ performance diagrams which show the sequence of protagonists’ processes in relation to Foerster and Greenberg’s criteria and are accompanied by relevant extracts from session transcripts (see Figures 12.5 through to 12.10). The performance diagrams for the six protagonists who reached in-session resolution are presented next. Descriptive information about each case is provided in Chapters 7 and 9.
Protagonists’ performance diagrams are formatted using conventions adapted from Greenberg and Foerster (1996): i Only the protagonist’s processes are included in the performance diagram. Where the responses of auxiliaries or the directors give clarity to a protagonist’s processes, these responses are included in the transcript. ii The protagonist speaking as self is indicated by a circle and the protagonist speaking as the other, is indicated by a square. iii Non-verbal processes are typically not included in the extracts, except where the protagonist is crying. iv Chronological sequence is indicated by the numbers within the circles and squares. These numbers correspond to the numbers in the accompanying transcripts. v Processes linked to specific components of Foerster and Greenberg’s model, are organised vertically in the diagrams. vi The descriptors of each process are indicated. Only those descriptors which form part of the criteria for Foerster and Greenberg’s model are indicated, to illustrate how judgements were made about the fit between protagonists’ in- session performances and the hypothesised performance.
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Figure 12.5. Format of protagonists’ performance diagrams.
Erin. (See Case Study 1, Chapter 7) Erin’s painful emotional experience was the breakdown in her relationship with her daughter Peta and her distress in response to Peta’s eating disorder. Contextual family issues included Erin’s divorce from Peta’s father and subsequent remarriage and the needs of a seriously ill second child, Dianne. There were two social atom repair events in Erin’s psychodrama, one in which she experienced emotional release from Peta’s role and one in which she experienced emotional release from her own role. In the latter event, most of the interpersonal and intra-personal experiencing was non-verbal, so the language-based measures adopted by Foerster and Greenberg were not sufficient to describe the protagonist’s in-session performance. The diagram in Figure 12.6 is of the first social atom repair event, experienced mostly with Erin in the role of her daughter. In this event, Erin met all the conditions of Foerster and Greenberg’s model. As can be seen in Figure 12.6, this event began with Erin articulating a core maladaptive belief that she had failed as a mother (1). In the beginning of the enactment, Erin displays the approach-avoidance dynamic in her relationship with her daughter. When she begins to identify her distress and her need to be close to her daughter (2), she quickly returns to self-indictment, which has overtones of feeling helpless and ashamed (3). When she begins to respond with positive caring and understanding towards her daughter (4), she reverts to blaming her daughter (5). In the subsequent enactment, Erin expressed the need for closeness (6), the indictment of herself as a mother (7, 8) and the secondary bad feeling of helplessness (8, 9) from her daughter’s role. At this stage, the protagonist’s crying is associated with protesting rather than release. The full expression of these maladaptive processes appears to free the protagonist to express more of her internal experience. She begins to ‘self’-disclose more directly as Peta and then discloses the emotionally painful feeling of loneliness (9). The crying becomes therapeutic, associated with expression of inner experiencing. There is a non-verbal expression of nurturing when the auxiliary moves towards the protagonist and the protagonist leans against the auxiliary and weeps (11). The protagonist then acknowledges her need for
©C.McVea 31.12.08 Chapter 12 247 closeness and nurturing, from a position of self-acceptance and acceptance of other (12).
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Maladaptive Accessing need Secondary Transcript Belief bad feeling 1. Erin: Some part of me believes I should have guided Peta and assisted her
1. 2. 3. through life, but I made a pig’s ear of it. Helpless, Self-indicting. Openly disclose 2. … Someone I love and care about should have had a good life and it didn’t Negative/ Articulate need ashamed Coercive to self. Openly disclose turn out the way I wanted it to. I just want to get close to her again. Emotional 3. … (To Peta): I was really hurt when I found out you were vomiting your food
4. 5. and really shocked that I didn’t know. And when I did know I didn’t know
what to do and I should have done. Affirm self Blaming Articulate need 4. … I just wanted to (deep breath) make it better for you. I know you didn’t like it when I remarried and it’s been really tough for you living with Dianne 6. (cries).
Articulate need 5. … Even though you thought you came last, you were always offered time. 7. Crying But you didn’t want to listen. You shut me out and put your hands over your Negative to self Treated as bad. ears. Emotional 6. Peta: When I was growing up I wanted your time. 7. … (Crying) You should have had time, you were my mother. I wish I lived 8. Openly disclose in a normal family. It’s not fair. You said you’d never get married again. Negative to self You promised it would be just you and me and Dianne. I don’t want anyone Treated as bad. Emotional else. I just want it back the way it was. (Sobs) You’re my mum; you’re supposed to have all the answers. I want my life back. You ruined it. 8. … You ruined my life and I could never tell you that. Because I was left with you and I was afraid that if I said anything there’d be nobody.
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Accessing need Allow emotional Transcript pain
9. Peta: I just don’t like myself. I’ve worked so hard to be popular and 9. Crying to look good, and I thought that would make me feel better, but it Negative to self Treated as bad. didn’t. (Crying) I feel so lonely inside and nobody knows about it and Emotional I can’t tell anyone. 10. 10. … (Leans into auxiliary being ‘Erin’ and cries deeply for 90 seconds). Crying 11. … (Lifts her head). I’ve wanted to do that for a long time, but I didn’t know how. This is really nice. It reminds me of how we can be 11. Articulate need sometimes. Accept self
Figure 12.6. Performance diagram of Erin’s first social atom repair event, with extract from her transcript.
Notes: Numbers in boxes indicate sequence of processes & correspond with transcript numbers.
Indicates a link to another element of the same component of the model. 249
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Secondary Maladaptive Allow Transcript bad feeling belief emotional pain (Auxiliaries being Karen’s ‘feelings’ are moving around the stage). 1. Karen: The feelings are messing up the perfect (tearful, she bends 1. Anxious down & straightens the cloth that she has set there to be ‘perfect’). (Director: Reverse roles with one of your feelings). 2. Karen: I don’t want to be any of them, they mess up the perfect. 2. Self-monitor & restrain, emotional (Crying) I just have to let the feelings go for a bit and then I can fix them up. I can’t mess it up, I can’t get into that. 3. Self-monitor & 3. … I still get the shakes; when I get scared I can’t control them. restrain Immediacy, (To auxiliaries being ‘feelings’) How can I control you? I can’t focussed control you, but I want to. I’ve tried breathing and writing things down and that kind of works, but I can’t control the shakes. 4. 4. … It’s OK to be sad. People let me be sad because it’s Self-monitor & restrain understandable. But I can’t have fear because people will use that to make me scared and I can’t be angry because that might get me 5. into trouble. Cries (Auxiliary as ‘Dad’: Thank god we had a perfect daughter.) 6. Self- monitor 5. Karen: (Cries) Emotional 6. Karen: (Crying) Yeah, I’ve got to meet these expectations. I’ve got to take it for them, because they can’t.
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Allow emotional pain (Auxiliary as ‘Dad’: I’m proud of you.) 7. Karen: Are you really? … Yeah, I know you are (cries). 7. Cries (Auxiliary as ‘Dad’: I did all those things when I was younger. I stood up for myself. But I’m old, that’s why you don’t see me doing those things now. You can do this too; I’ve seen you do it. I 8. Cries always approve of you, you’re my daughter. I love you and I’m proud of you. [‘Dad’ hugs Karen]). 8. Karen: (Hugs ‘dad’ and cries). 9. Cries 9. … (Crying softly) I love you. I don’t want you to go, and I don’t Loving Emotional want you to die.
Figure 12.7. Karen’s performance diagram with extracts from her transcript.
Notes: Numbers in boxes indicate sequence of processes & correspond with transcript numbers.
Indicates a link to another element of the same component of the model. 251
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Karen (Case Study 2, see Chapter 7).
Karen’s painful emotional experience was being bullied as a child. There were two episodes in Karen’s psychodrama that contained gentle, quiet crying, but she was the only protagonist in the resolved group who did not meet the criteria for ‘allowing emotional pain’. Figure 12.7 has a performance diagram of these two episodes. The first episode centres on the exploration of Karen’s maladaptive belief and attempts to contain her feelings through worrying. Leading up to this episode, Karen identifies her felt need to have a friend or support for herself. The first weeping episode begins when Karen uses props to set out ‘perfect’, how she was supposed to be as a child and in her life now, and selected auxiliaries to be vaguely experienced feelings. These auxiliaries move about and disturb the ‘perfect’ and Karen becomes agitated (1). She experiences not wanting to have anything to do with feelings, becomes more agitated and aware of worrying (2). Karen articulates her maladaptive belief more strongly, is aware of being out of control and becomes concerned about how she can control her feelings (3). Agitated, she identifies some dysfunctional beliefs that are guiding her (4). An auxiliary who is being her ‘father’, intervenes with a message that reinforces the family’s expectation that Karen is ‘perfect’ (5) and Karen is immediately affected. She begins to cry and identifies the core maladaptive belief (6). Crying in this episode is accompanied by self-monitoring that Foerster and Greenberg linked to maladaptive beliefs, rather than the positive introjects associated with allowing emotional pain. In the social atom repair event there is a second weeping episode which more closely fits Foerster and Greenberg’s criteria for allowing emotional pain, although the protagonist’s immediate inner experience is not verbalised. The episode begins with the auxiliary as Karen’s ‘father’, being nurturing towards Karen (7). Karen’s first response is to push this message away (8), but she appears to shift internally and accept the intervention (9). When she does this, she cries. This internal shift suggests that Karen is self-nourishing in that moment, but this is not overtly expressed. From her father’s role, Karen is able to reinforce and expand on the positive message (10). As herself, Karen receives a hug from her ‘father’, cries quietly and then acknowledges her positive relationship with her father (11).
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Jane (Case Study 4, see Chapter 9). Jane’s painful emotional experience was the death of her mother when Jane was a young child. The session met the criteria for the four components of Foerster and Greenberg’s model ‘Therapeutic weeping’ and ‘accessing needs’ occurred in the social atom repair event, while the other three components appeared in the re- experiencing and insight event. A performance diagram of segments of these two events is set out in Figure 12.8. Jane identifies the conflict between her dysfunctional belief that she must look after her mother and her need as a child to be loved and supported (1, 2, 4 & 5). As her 6-year old self, Jane openly discloses her need for nurturing; her vocal quality is emotional (3). She continues to self-disclose as an adult, but becomes immediately aware of her response to her mother (4, 5). Her vocal quality moves is emotional when she begins to focus on her own experience (e.g. 3) and externalised when she talks about needing to care for her mother (e.g. 5). Jane has not had a full expression of the secondary bad feeling during this event, but identified her sense of helplessness in the face of her mother’s situation (1, 5). She is not able to attend to her own experience for long and at the end of this event she is stuck in the core maladaptive belief (6, 7). Jane’s therapeutic weeping occurred in the social atom repair event, which was a re- enactment of her mother’s death. At this time, her vocal quality was emotional and she maintained a focus on her own experience. Jane identified an inner experience of sadness (8) and responded to the auxiliary who was being ‘Jane as a child’ with nurturing and acceptance (9-11). The auxiliary verbalised one of the traumatic images of her mother’s death which Jane had created as a child, and Jane was now able to ground the ‘child’ with a realistic image of what had occurred (10). In role reversal as the child, Jane recognises that she has the same needs as her young brother and cries freely (12). She expresses her grief for her mother (13, 14). In role reversal Jane continues to cry while she comforts the child and makes sense of her sadness (14).
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Accessing Secondary Articulating Extract of Transcript from Re-experiencing and Insight Event Need bad feeling maladaptive 1. Jane: (Speaking to her ‘mother’) I feel sorry for you and that’s not belief what I want to feel. I want to feel valued by you instead of having to look after you. 1. Articulate need 2. …. What I’m distressed about as an adult, what I feel confused about is Assert self & openly disclose Helpless, disappointed; immediacy … I keep wanting to be supportive of her but I want support for me. 3. Child J*: (Speaking to ‘Jane’): What about support for me? What 2. Articulate need about support for me? I’m a little girl and I need someone to love me. Confused, helpless; immediacy 4. Jane: (Speaking to ‘mother’). I was a little girl who came into your
3. life and I needed your love and your energy and your engagement. Articulate need Emotional 5. … And now I’m thinking of you again, that you were so sad and your life was so awful. 4. 5. 6. Articulate need 6. Child J: I have to look after her, she’s so pathetic. Assert self Helpless Coercive to self 7. … I can’t listen to me; I’ve got to listen to her.
7. Extract of Transcript from Social Atom Repair Event Self-neglect Allowing 8. Jane: I’m feeling a bit like crying. I feel sad. emotional pain 9. … (Looks at the scene where ‘mother’ has died, looks down at ‘Child 8. J’ & strokes the ‘child’s’ head) But I’m with you; I’ll take care of you. Immediate inner awareness (Auxiliary as ‘Child’: Are her body parts all over the road?ª)
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Accessing Allowing Extract of Transcript from Social Atom Repair Event, cont. Need emotional pain 10. Jane: No, her body’s not all over the road. She just got knocked and fell to the side of the road. She didn’t even get run over. 9, 10 & 11 (Auxiliary as ‘Child’: What am I going to do without my mummy?) Self-nourish 11. Jane: Yeah it’s really frightening. But I’m going to look after you. 12. 12. Child J: It’s scary and my little brother, he’s only a baby. And I Openly disclose Articulate need suppose I’m only little too. I’m only a little 6 year old. They’re just pretty little. They need somebody to look after them. 13 13. … (Cries, while being comforted by auxiliary being ‘Jane’) Cries 14. … (Sobs) Mum always tried to dress me pretty. … I want my mum.
14 … I don’t have anybody to protect me from my father now. Not that Cries Openly she protected me much, but he’d yell at her instead of at me. discloses 15. Jane: (Sobs, arms around ‘Child’): It is sad. We can be sad together.
15 It’s sad because we’re never going to get what we wanted from her. … Self- accept I’ll listen to you, I’m with you and I’ll nurture you. Self nourish
Figure 12.8. Jane’s performance diagram with extracts from her transcript. Notes: Numbers in boxes indicate sequence of processes & correspond with transcript numbers. Indicates a link to another element of the same component of the model. * Child J = Jane as a child ª At the beginning of the session, Jane spoke of what she had imagined as a child her mother’s death had been like and reported that these 255 255 images continued to haunt her. In this scene, the auxiliary introduced these images in her dialogue as the child.
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Accessing Allowing Transcript Need emotional pain Extract from Resourcefulness event. 1. Julie: (Speaking to ‘Michelle’) I don’t want you to feel like you’re second best, that the only way you got to be important is now that 1. Articulate need Bill is dead. The kids and I have always wanted to have a Self assert & relationship with you and we love you as you are. openly disclose 2. Michelle: I think some of that’s the choices I make in my life. I miss Bill too. And it’s shown me that we need to see more of each 2. Self assert & 3. other, it’s good for our kids. Crying openly disclose 3. Julie: (Crying) I like you as you are. There is a heap I can learn Articulate need Spontaneous (as ‘other’) self from you and I enjoy every day I spend with you. Extract from Re-experiencing and Insight event. 4. 4. Julie: (Cries, watching auxiliaries set out the change in the family Crying structure, after Bill’s death) 5. … (Crying) It’s incredibly sad and it’s difficult. In some ways it’s
5. harder to relate to people now because everyone’s dealing with it Crying Openly disclose differently.
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Accessing Allowing Extract from Social Atom Repair event. Need emotional pain 6. Julie: (Speaking to ‘children’ who are sitting around ‘Bill’ who has just died). We can’t wake him up. He’s peaceful now, he didn’t have to suffer. ªHe’s at home with all of us. It’s OK to
6. 7. touch him; he’s not cold or anything. Responding to need* Crying 7. … (Leans against ‘Bill’s wife’ and cries) (Auxiliary as ‘Bill’s daughter’: My daddy! My daddy!) 8. Julie: (Cries). 8. Cries
Figure 12.9. Julie’s performance diagram with extracts from her transcript.
Notes: Numbers in boxes indicate sequence of processes & correspond with transcript numbers. Indicates a link to another element of the same component of the model. * At the beginning of the session, Julie had said that there had been no opportunity for the family to be with Bill and touch him, after he died.
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Julie (Case Study 5, see Chapter 9). Julie’s painful emotional experience was the death of her brother. There were three relationship episodes in her session where weeping was maintained for more than 2 conversation sequences. The first was an encounter with her ‘sister’ Michelle, which met the criteria for allowing emotional pain and accessing needs; the second was a scene in which Julie observed a concretisation of the new family structure, without her brother Bill; and the third was the social atom repair event, with a re- enactment of the time immediately following her brother’s death. This last episode also met the criteria for allowing emotional pain and accessing needs. In each of these events, Julie appeared to access her primary feelings without accessing maladaptive beliefs or secondary bad feelings. A performance diagram of segments of these events is set out in Figure 12.9. Julie freely expresses her love for her sister and her need for a closer relationship between them, and begins to explore the impact of Bill’s death, with free flowing weeping (1, 3). She experiences that this feeling is reciprocated from the role of her sister (2). When Julie watches the auxiliaries setting out the new family structure after her brother has died, she cries freely (4) and expresses the sadness in her family (5). In the social atom repair event, Julie cries freely (9, 11) in response to the auxiliaries acting as family members, but she does not verbalise the introjected focus that Foerster and Greenberg associate with therapeutic weeping. Julie’s responses are focussed on nurturing and accepting other family members (6, 7). Julie was the only protagonist in the resolved group who did not articulate a maladaptive belief or clearly acknowledge secondary bad feelings during her session. As discussed in Chapter 9, during her post-intervention interview she recalled re- evaluating her beliefs during the session, noting: ‘Part of my reaction has been that it’s bloody ridiculous to be this upset about Bill’s death; but this showed me why it is so upsetting.’ Thus, while she did not meet Foerster and Greenberg’s criteria for these components, her subjective recall suggests they may have occurred during the session.
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Cheryl (Case Study 6, see Chapter 9) Cheryl’s painful emotional experience was emotional abuse and neglect in childhood. There were three weeping episodes in Cheryl’s session, two in an early ‘re-experiencing and insight’ event and one in the social atom repair event. Cheryl’s social atom repair event met all Foerster and Greenberg’s criteria. A performance diagram of this event is set out in Figure 12.10. An excerpt from the earlier ‘re- experiencing event’, is also included, because Cheryl clearly articulates her maladaptive belief in that event. Cheryl experiences a sense of hopelessness (secondary bad feeling) and identifies a maladaptive belief centred on her right to exist within her family (1). Crying at this point approaches the criteria for allowing emotional pain, but Cheryl is speaking as an observer, not with immediate inner awareness. Cheryl identified a need for autonomy (2) but continued to feel stuck at the conclusion of this event (see Chapter 9). In the social atom repair event, Cheryl openly expresses her anxiety (secondary bad feeling), her attempts to self-monitor and control (maladaptive belief) and her need for sense of self (3). Speaking as a child in the situation, the quality of immediate inner awareness is more apparent. Responding as an adult, she begins to be self-nurturing (4) and this appears to enable her to articulate that she needs self- acceptance to gain a sense of self (5). When Cheryl responds to herself as a child, she weeps freely (6). She experiences herself as self-nurturing and self-accepting (7 & 8).
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Articulating Accessing Secondary Transcript: Re-experiencing and Insight Event maladaptive need bad feeling (Cheryl is watching the re-enactment of a childhood scene. Auxiliaries, belief acting as ‘Cheryl’ and her ‘siblings’ begin to challenge their ‘mother’) 1. Cheryl: There’s no way you would be answering mum back. You’d 1. 2. Response of Crying be just doing as you’re told. You can’t do anything. You’re stuck other: control & Articulate need call bad. there and when you get to the point of not being able to do anything, Crying you go to your bedroom and lie on your bed and cry. (Cries) And then you’re brought out and you have to apologise to people for not 3. behaving right, for existing. You’re humiliated. Anxious, ashamed Articulate need. 2. … (Cries) I need to stick up for myself. Self-assert & openly disclose Transcript: Social Atom Repair Event. Allow emotional pain 3. Child C*: I don’t know who I am. I feel like I’m always trying to be somebody who’s acceptable, to mum in particular. So I just try to play 4. along and do the right thing. Every now and then I mess it up and she Self-nourish gets upset, so she cries or hits me. I just feel tense and the tension means I don’t know who I am. It would be nice to know who I am. 5. 4. Cheryl: (to ‘Child’). What can I do to make you feel better? Articulate need 5. Child C: Accept me as I am.
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6. Cheryl: I do accept you. You’re a lovely girl. You have so much 6. Crying, Self- going for you. Your mum’s depressed. She doesn’t love herself so she nourish, self- accept can’t love you. You’re cute. (Smiles at ‘child’ and cries) You’ve got a Openly disclose gorgeous smile, lovely big blue eyes. Your sister’s got brown eyes and you used to think you were adopted because you have blue eyes, but I 7. can assure you that you belong in this family whether you like it or not. Crying, Self-accept 7. Child C: Thankyou. They are nice things to be said, they are things I
value about myself. Thankyou (reaches out and hugs ‘Cheryl’ and cries). 8. Crying, 8. Cheryl: (Cries and hugs ‘child’). That’s good, that’s really good. Self-accept
Figure: 12.10. Cheryl’s performance diagram with extracts from her transcript.
Notes: Numbers in boxes indicate sequence of processes & correspond with transcript numbers. Indicates a link to another element of the same component of the model. * Child C = Cheryl as a child.
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Ray (Case Study 7, see Chapter 9). Ray’s painful emotional experience was centred on his experience of emotional neglect and over-bearing control from his parents as a child. There were two weeping events in Ray’s session. The first occurred in Scene 1. This event met the criteria of Foerster and Greenberg’s model, but did not produce an experience of resolution or relief for Ray. In the second event, Ray had an extended period of weeping associated with non-verbally acknowledging and receiving a previously unmet need (see Chapter 11). This later event produced an experience of relief. Because the second scene was largely experienced through non-verbal processes, it did not meet the language-based criteria for Foerster and Greenberg’s model. The performance diagram (Figure 12.11) is taken from the first event. Ray clearly identifies a goal to be autonomous (1) and then experiences the secondary bad feelings connected with his inability to achieve his goal, including a sense of helplessness and anxiety (2). From his parents’ roles, he forcefully expresses the controlling influence they exert on him (3, 4). In his own role as a child, he protests against this control (5). Then, when he takes up his own role as an adult and observes the dynamic between his parents and himself as a child, he has a compassionate response to himself, where he weeps freely and expresses the pain and loneliness that he has felt (6, 7). However, when he returns to his role as a child, he experiences an inability to accept compassion, and identifies a core maladaptive belief that he doesn’t deserve compassion and has to work harder to earn it. (8).
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Accessing Articulating Secondary Transcript: Re-experiencing and Insight Event need maladaptive bad feeling 1. Ray: I want to go somewhere. I want to succeed, I want to get more belief out of my life; so all this has just got to stop. 2. … I can’t, I can’t. It’s an old childhood feeling, a feeling of my 1. 2. Articulate Response of other: controlling parents pushing me somewhere and I don’t want to go there; it’s a sort need Helpless, anxious of paralysing fear. The feeling of lack of choice, basically. Vocal quality is focused 3. ‘Father’: (Pushing ‘Ray’) OK son, this is where you’re going and this
3 & 4. Allow is what you’re going to be doing. Controlling. emotional 4. ‘Mother’: Listen to your father. This is what’s best for you. Vocal quality pain is focused 5. Child R*: I don’t want to go there. Don’t say that. I don’t want to. 5. 6. 6. Ray: (to ‘Child’) You poor boy (cries, with his head in his hands). Articulate Crying need Self-accept 7. … (approaches ‘child’ and sighs) You poor boy, it’s not fair. It’s Vocal quality is emotional been lonely and it’s been scary; (cries) really scary. 7. 8. Child R: Yeah, but I can’t accept that, I can’t accept the compassion. Crying Openly disclose I can’t, I can’t. I hear the words but I just (bends over) phew, the pain. Self-accept 8. It’s almost like I don’t deserve it. I’ve got to earn the compassion. Coercive to self Self-indict . Figure 12.11. Ray’s performance diagram with extracts from his transcript.
Notes: Numbers in boxes indicate sequence of processes & correspond with transcript numbers. * Child R = Ray as a child. 263 Indicates a link to another element of the same component of the model.
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Performance Patterns within Not- Resolved Cases
Three not-resolved cases were analysed, those of Ella (See Chapter 7), Geraldine and Grant (see Chapter 9). None of the three ‘not-resolved’ protagonists met Foerster and Greenberg’s criteria for ‘allowing emotional pain’. Ella and Grant both had weeping episodes, but without the introjected relationship qualities of self acceptance, self-nourishment or self-protection. Foerster and Greenberg suggest that this indicates there is no acceptance of the emotional pain. Ella had a prolonged weeping episode that was accompanied by feelings of helplessness, hopelessness and self-blame; Grant’s weeping episode was accompanied by protesting and feeling helpless; while Geraldine did not have a weeping episode in her event. All three protagonists identified secondary bad feelings and maladaptive beliefs which were typically associated with weeping, as noted above.
Summary of the Findings of Study 4
This study set out to investigate the fit between protagonist processes during psychodrama and the allowing and accepting painful emotional experience model, as operationalised by Foerster and Greenberg (1995, in Greenberg, 1999). The findings of the study suggest that Foerster and Greenberg’s model can be applied to the psychodrama context. All components applied generally to resolved cases and the ‘allowing emotional pain’ component differentiated between resolved and not resolved cases at a statistically significant level (p=.047). This lends support to Greenberg and Paivio’s (1998) claim that their model applies to the process of resolving painful emotional experiences beyond the setting of process-experiential therapy where the model was developed. At the outset of this study, the question was raised of whether or not Foerster and Greenberg’s measures, which relied on verbal expression, would identify key protagonist processes in psychodrama where there may be high levels of participation and experiencing without verbal content. It would seem that the verbal measures used by Foerster and Greenberg are sufficient, in most instances. The resolved cases met Foerster and Greenberg’s criteria for the four components of the allowing and accepting model, with two exceptions. Julie was the only ‘resolved’ protagonist who did not articulate a maladaptive belief or acknowledge a secondary bad feeling during her session, although her subjective recall suggests that these
Chapter 12 265 processes may have occurred but not been articulated. Karen was the only ‘resolved’ protagonist who did not meet all the criteria for ‘allowing emotional pain’. Interestingly, non-verbal characteristics of one of her weeping episodes suggest that Karen may have been ‘allowing emotional pain’, but there was no overt expression to support this proposition. Aspects of the findings raise three areas of interest to understanding protagonists’ experiences of the resolution of painful emotional experience during psychodrama. Firstly, the sequence of protagonists’ processes differed from the hypothesised performance model proposed by Foerster and Greenberg, suggesting that the interaction between the components of the model may differ in the psychodrama context. Secondly, the lack of general occurrence of most components within the social atom repair event appears to indicate a difference between the experience of emotional release that has previously been identified with this event (see Chapter 11) and the process of allowing emotional pain. Thirdly, two components of the model, acknowledging secondary bad feelings and articulating the maladaptive belief occurred generally in both resolved and not resolved cases, raising the question of what is the intervening dynamic that means that some protagonists go on to allow emotional pain and experience resolution and others do not. These three issues will be considered briefly here and re-examined in the discussion of the thesis in Chapter 14.
Sequence of protagonists’ processes
Although the components of Foerster and Greenberg’s model were apparent in the resolved cases, the actual sequence of protagonists’ processes suggests that the resolution during psychodrama is different to the hypothesised performance illustrated in Figure 12.2. The hypothesised performance diagram based on Foerster and Greenberg’s model, proposes that emotional processes precede cognitive processes: (1) acknowledging secondary bad feelings leads to (2) ‘allowing’ the primary painful emotion, enabling the person to (3) articulate the maladaptive belief that maintained their original avoidance response, and (4) access previously unmet needs. While Greenberg (1999) observed that clients varied in the order they experienced these processes, the model represents the typical sequence identified in their research. In contrast, the cases investigated in this study consistently revealed a pattern that linked articulating maladaptive beliefs with acknowledging secondary
Chapter 12 266 bad feelings on the one hand, and therapeutic weeping with accessing needs on the other. Previously unmet needs were often identified at both these points, although in qualitatively different ways, as described later in this section. The actual performance pattern across resolved cases is illustrated in Figure 12.12.
Acknowledge Allow secondary emotion bad feeling al pain
Articulate maladaptive Access belief Need
Figure 12.12. General performance pattern in resolved cases.
Protagonists acknowledged secondary bad feelings and articulated maladaptive beliefs in the re-experiencing and insight event. These components were typical in resolved cases, but also occurred in all three not-resolved cases. This awareness of the cognitive and emotional processes that maintained the protagonist’s avoidant behaviour was often accompanied by recognition of the personal or interpersonal need that was not being met at that time. There was a deepening of affective experience, which in most cases (resolved and not-resolved) was expressed by protagonists crying. This crying did not meet the criteria for ‘allowing emotional pain’. In resolved cases, allowing emotional pain occurred later: in some cases during the same event, but in most cases in a subsequent event after a lapse of some time. Therapeutic weeping was linked to articulating the associated unmet need. It should be noted that unmet needs were typically identified earlier, but the expression of need with therapeutic weeping rated more highly on the Experiencing Scale (EXP), indicating a more expansive and personal expression of the experience of felt need.
Differentiating ‘Emotional Release’ during Social Atom Repair and ‘Allowing Emotional Pain’
An unexpected finding of the study was that allowing emotional pain, as measured by Foerster and Greenberg, did not typically occur during social atom repair with emotional release events. Two possible explanations are offered for this.
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Firstly, the verbally-based measures used by Foerster and Greenberg may have failed to identify the protagonist’s subjective experience of emotional pain, as it occurs in social atom repair events. All social atom repair events contained episodes of weeping that might be considered therapeutic, but in some cases weeping was accompanied by little or no verbal interaction from the protagonist. In these cases, protagonists may have been fully engaged in experiencing the enactment and not felt compelled to communicate verbally. An alternative explanation is that the general characteristics of social atom repair events are describing something different to allowing emotional pain, so that while protagonists may experience emotional pain during these events, this is not essential to the event. The social atom repair event is primarily an interpersonal experience and the emotional release within this event has been previously linked with a corrective emotional experience (see Chapter 11). The findings of this current study support the proposition that the emotional release that occurs with social atom repair is primarily linked with the experience of receiving a previously unavailable but needed response to a painful emotional experience, rather than being primarily an indication of experiencing emotional pain. If so, this may be more important to the experience of resolution than allowing emotional pain alone.
The transition from ‘awareness’ to ‘allowing emotional pain’
Given that two components of the model, acknowledging secondary bad feelings and articulating the maladaptive belief occurred generally in both resolved and not resolved cases; then these two processes are not sufficient to account for why some protagonists go on to allow emotional pain, while others do not. These findings suggest that there may be an intervening dynamic that facilitates the transition from the protagonists’ experiences of acknowledging secondary bad feelings and articulating the maladaptive belief on the one hand, and allowing emotional pain and accessing needs, on the other. The findings of the previous studies in this thesis, suggest two possible intervening dynamics, (i) readiness to engage in the process, which is influenced by group cohesion, the prior experience and experiencing a compelling need to change, and (ii) the activation of the protagonists’ own abilities to intervene in maladaptive dynamics. The following chapter discusses the findings from the four studies of the thesis, and in doing so, considers the relationship between Greenberg’s allowing and accepting painful emotional experience model and the emerging model of
Chapter 12 268 protagonist processes leading to the resolution of painful emotional experience during psychodrama.
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Chapter 13 Discussion
The findings of this research and the application of the findings to theory and practice are discussed in relation to the aims of this thesis and the specific research questions that were addressed. The strengths and limitations of the thesis are then considered and areas for further research are recommended.
A Review of the Aims and Research Questions The primary aim of this thesis was to construct an explanatory model of protagonists’ processes that are linked to in-session resolution of painful emotional experiences during psychodrama, which could inform psychodrama theory and practice. The research was structured around the two phases of change process research, a discovery-oriented phase and a verification phase, that are reflected in the research questions that the four studies investigated. The first two studies were discovery- oriented and addressed the following research questions:
RQ 1: What is the protagonist’s experience of change during a psychodrama enactment? RQ 2: Can there be in-session resolution of painful emotional experience during psychodrama? RQ 3: What protagonist processes are linked to in-session resolution of painful emotional experience during psychodrama? RQ 4: What is the post-session impact of protagonists’ in-session change processes?
The final two studies were concerned with examining two possible explanations of change emerging from the preceding studies; the model of protagonist processes derived from Study 2 and Greenberg’s (1999) empirically supported allowing and accepting painful emotional experience model. The research questions for the second phase of the thesis were:
RQ 5: Can the emerging model of protagonist change processes, identified in Study 2, be applied to additional cases in which protagonists address painful emotional experience? Chapter 13 270
RQ6 Do psychodrama enactments where there is in-session resolution of painful emotional experience meet Foerster and Greenberg’s criteria for allowing and accepting emotional pain?
RQ7 Do Foerster and Greenberg’s criteria for allowing and accepting emotional pain differentiate between those psychodrama enactments where there is in- session resolution of painful emotional experience and those enactments where there is not in-session resolution?
In-session Resolution The thesis was initiated on the premise that there can be in-session resolution of painful emotional experience during a single-session psychodrama intervention and an early aim of the research was to establish if this premise is true.
Confirming that there can be resolution of painful emotional experience during psychodrama The premise that there can be in-session resolution of painful emotional experiences during psychodrama was derived from clinical experience and from case reports describing such processes occurring. Nevertheless, it was an assumption of the investigator that published case reports reflected best-case scenarios and were not necessarily indicative of typical outcomes achieved during psychodrama enactments. It was anticipated, therefore, that while some cases would achieve in-session resolution, the majority would not. The preliminary study (Chapter 7) specifically addressed the question of in- session resolution. Two of the three psychodrama sessions in this study were judged to have reached resolution, a higher percentage than expected, but clearly based on a very small number of cases. Subsequent studies also had slightly higher numbers of resolved cases than was anticipated. Across the 15 cases that were examined in this thesis, nine were judged to have achieved in-session resolution and six were judged to have reached partial or no in-session resolution. This confirms that there can be in-session resolution of painful emotional experience during psychodrama, as it was defined in this thesis. Furthermore, the experience of in-session resolution was not exceptional, with resolution being reached in at least half of the cases in each of the four workshops, and with all directors who participated in the research directing at least one session where there was in-session resolution. Chapter 13 271
Measuring in-session resolution For the purposes of this thesis, in-session resolution was defined by the Degree of Resolution Scale: Unfolding Problematic Reaction Points (DRS/PRP) as having occurred when the protagonist “gets a whole new view of important aspects of (his or her) own mode of functioning and what self-changes he/she wants to make … (and begins) to feel empowered to make the change” (Greenberg, Rice & Elliott, 1993, p. 148). This is the first time that the DRS/PRP has been used to measure change- process in a psychodrama enactment and therefore the use of the scale was exploratory. The DRS/PRP was found to be a reliable measure, with good inter-rater reliability across 151 psychodrama sessions (Cohen’s Kappa; k = .70). The credibility of the measure was examined by comparing directors’ DRS/PRP ratings with protagonists’ self-reports of resolution and protagonists’ qualitative reports of the in-session impact of the psychodrama enactment (See Table 13.1). There was an 86.7% agreement between directors’ DRS/PRP ratings and protagonists’ self-report of resolution (13 matches of a possible 15). Where directors and protagonists agreed that there was in-session resolution (9 cases), protagonists also reported feeling relieved, having worked through a significant impediment and being generally more positive to themselves and others. The two cases that were rated as ‘4: reaches the meaning bridge’, were matched with protagonists reports of insight into the impact of the original experience on current problematic responses, and the two cases that were rated as ‘3: recalls salient aspects of the stimulus situation’, were matched with protagonists’ reports of not being emotionally engaged and not being able to role reverse fully with others during the enactment. There were two cases where the director rated the session as resolved but the protagonist reported incomplete or no resolution. In these cases, protagonists’ recalled experiencing either distress or a negative response to self immediately after the session, supporting the conclusion that they had not reached resolution.
1 Although 15 psychodrama enactments were rated for in-session resolution across the four studies, only 14 were included in the change-process analysis. In Chapter 11 the rationale for excluding one enactment from further analysis is explained. Chapter 13 272
Table 13.1. Resolution ratings mapped to protagonists’ session impact reports.
No.¹ Res* of D P Examples of protagonists’ session impact reports Cases 9 6 R ‘I’m feeling so much better. (I) worked through so many areas where I was blocked or stuck.’ ‘It was a healing experience. … I experienced sadness and the dissociation ended, the split went.’ ‘I have worked through a great burden. I feel released and relieved and very positive’. 2 6 N ‘I felt the fear and anxiety of not knowing what’s going to happen next and, for a few hours afterwards, I felt fragmented. I also realized that my friends are there and they want to help.’ ‘I acknowledged my fear of being needy and became aware of my powerful antipathy towards myself as a child’.
2 4 N ‘I felt a sense of self-worth and wanted to start setting goals and achieving things. I felt stirred up afterwards and still feel a sense of confusion about what to do next. It feels unfinished.’
2 3 N ‘I was curious and hopeful that I would find a key to changing, but I didn’t quite get there. I didn’t let go completely. I needed to go further into it to allow the feelings.’ ‘I felt quite blocked and stagnant at times. I found it difficult to connect with my mother and that made me feel guilty, angry and ashamed.’
Note: ¹ Includes resolution rating for 15 psychodramas, although process analysis was carried out on only 14 cases (See Chapter 11 for explanation). * Res = resolution ratings; D = Director’s DRS/PRP Rating, where 6 = ‘reaches resolution’, 4 = reaches meaning bridge & 3 = recalls salient aspects of the stimulus situation; P = Protagonist’s report of resolution, where R = Resolved & N = Not-resolved. Bold type indicates cases where directors and protagonists agreed.
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Interestingly, the directors of these two sessions reported some uneasiness about the session or rated their own skilfulness as less than that in other sessions they had conducted, despite rating the protagonist as having ‘reached resolution’. These two cases appear to indicate a difficulty in objectively identifying in-session resolution in some cases, where the protagonist’s outward behaviour masks his or her subjective experience. There were no instances where protagonists reported experiencing in- session resolution and the director or independent observer rated the session as not- resolved. In other words, while there would appear to be examples of rating false positives or false resolution, there were no examples of false negatives. These findings suggest that while the DRS/PRP does, in most cases, distinguish between resolved and not resolved cases, protagonists’ reports of resolution are a more accurate indicator. Although the DRS/PRP was an adequate measure of in-session resolution for the purposes of the research, the scale would need to be applied across a larger number of cases to determine what categories best describe the different degrees of in-session resolution that are possible during a psychodrama enactment. There was also some suggestion that a higher degree of resolution than that described by ‘6’ on the DRS/PRP might be reached by protagonists who experience in-session integration of new functioning.
Evidence for the Efficacy of the Classical Psychodrama Intervention Although in-session change (that is, protagonists’ in-session resolution of painful emotional experience) was the specific focus of this research, post-session change was also assessed for all participants. Group participants showed overall improvements in symptom distress at two-week and three month follow-up and there were encouraging indicators of post-session improvements in interpersonal distress. These findings and evidence linking post-session changes to in-session processes are considered next.
Evidence of post-session improvement Post-session changes in participants’ functioning were measured using the semi- structured client change interview and, in Studies 2 and 3, with standardised measures of general symptom distress (the SCL90-R) and interpersonal distress (the IIP-127). Participants’ subjective reports of change are considered later in this Chapter 13 274 section, in support of a link between in-session processes and post-session changes. Evidence of statistically significant change, available for the 24 participants in studies 2 and 3, is considered here. There was evidence of improvement in general symptom distress in both studies. Although an initial analysis of the SCL90-R(GSI) scores from Study 2 (n = 17) found no significant difference between pre-intervention, two-week and three-month follow-up, a further analysis with one outlier removed, did find a significant improvement at two-weeks. This improvement was repeated with the participants in Study 3 (n = 7). There was a statistically significant improvement in interpersonal distress for participants in Study 2, but an apparent improvement for participants in Study 3 was not statistically significant. Evidence of clinically significant change was encouraging. Most participants were not in the clinical range of functioning on either the SCL90-R or the IIP-127, prior to the psychodrama intervention and therefore there was limited scope for achieving clinical improvement. Nevertheless, among those participants who did meet the clinical criteria, there were strong indicators of post-session improvement. Eight participants had pre-intervention scores in the clinical range, seven on the SCL90-R and two on the IIP-127 (with one participant meeting the clinical criteria for both measures). At two week follow-up, two of these eight met the criteria for clinically significant change, two recorded statistically reliable improvement but remained in the clinical range and another three had improved to fall within the normal range. Changes were maintained or increased at three months, at which time a further three participants recorded clinically significant improvement. One participant (4% of the 24 participants who completed the SCL90-R) recorded clinically significant deterioration at two week follow-up. This is well within the 7% deterioration rate considered to be a good achievement in psychotherapy research (Worthen & Lambert, 2007). At the commencement of this research, it was anticipated that statistically significant post-intervention changes might not be identified. This expectation was based on (i) the format of the psychodrama intervention and (ii) the non-clinical focus of the therapeutic concern. The intervention design used a single-session format. Most psychotherapy research investigates client change over a series of therapy sessions, where even with brief interventions clients often participate in up to 10 sessions. It was anticipated that in this current research, positive in-session Chapter 13 275 experiences might accelerate the therapeutic process, but that these in-session experiences would require further processing or integrating before significant measurable impacts would be identified. Contrary to this expectation, the psychodrama intervention appears, for some participants at least, to produce immediate and sustained improvements. Secondly, the research targeted experiential events (unresolved painful emotional experiences) rather than a clinical group and, as has already been noted, only one third of participants who were tested recorded pre-intervention scores in the clinical range of functioning. Statistically significant results are less likely when baseline scores are low. Given these expectations, the results are encouraging.
No statistical evidence for a differential effect from being a protagonist As a group method, psychodrama is seen to have a therapeutic effect for group participants who are engaged as auxiliaries or audience members, as well as for protagonists. Kim (2003) concluded from a study of 12 psychodrama sessions, that there was a higher in-session therapeutic effect for protagonists than non- protagonists, but that this difference between the two groups was reduced over time. The small numbers of protagonists and non-protagonists in this current research limited the statistical comparisons that could be made between these two sub-groups. In Study 2 protagonists showed a greater improvement in interpersonal distress than non-protagonists (p = .05), but no significant difference in the degree of change in general symptom distress was identified. One outlier was identified in this study, but a comparison of protagonists and non-protagonists without the outlier, was not statistically viable because of the small participant numbers. In Study 3 there were not sufficient numbers of non-protagonists (n = 2) to compare to protagonists (n = 5). Findings from the clinically significant change analysis suggested that meaningful improvement is equally likely for protagonists and non-protagonists, with most participants who recorded clinical levels of functioning, recording clinically significant change by three month follow-up, whether or not they were a protagonist. The small number of participants who were in the clinical range at pre- intervention (8 of a possible 24), the impact of an outlier in the protagonist sub-group in Study 2 and the lack of a substantial non-protagonist comparison group (n = 2) in the third study, may have obscured any differences in the impact for protagonists and Chapter 13 276 non-protagonists. Alternatively, a lack of difference between protagonists and non- protagonists is consistent with Moreno’s proposition that all participants benefit from engaging in a psychodrama enactment. One way of understanding the lack of difference between these two sub-groups, is that change may be a product of the quality of each participant’s in-session experience, regardless of whether they were a protagonist or not. Some non-protagonists may have reached a form of resolution through their participation in the enactment of another person’s drama, and it might be of interest to compare all participants who experienced in-session resolution with those who did not.
Evidence that post-session change was linked to the psychodrama intervention For those participants who recorded statistically reliable improvement in either interpersonal distress or general symptom distress, these results were supported by subjective reports of specific improvements in either interpersonal or intra-personal functioning, or both. They consistently judged at least some of these changes as being highly important to them and unlikely to have occurred without the psychodrama intervention. Likewise, a number of participants who did not record statistically meaningful change nevertheless reported important post-intervention improvements in their functioning, which they attributed to the psychodrama intervention. There was compelling evidence that these post session improvements could be attributed, at least in part, to the psychodrama intervention. Participants consistently attributed post-session changes to their experiences within the workshop. When they described specific changes in their relationships with significant others, or in their affective experiencing or their attitudes to self, these changes could be mapped to specific in-session processes. There were a number of reports of increased difficulty following the psychodrama intervention. In these cases specific post-session changes could also be linked to in-session processes; although in the two most notable cases, a protagonist from Study 1 (see Chapter 7) and a protagonist from Study 2 (see Chapter 9), post-session difficulties were exacerbated by crises that occurred following but independent of the workshop. The nature of reported post-session changes was generally consistent with the nature of the protagonist’s in-session experience. Differences in reports of post-session change were particularly apparent between protagonists who reached in-session resolution and those who did not. These differences are considered briefly here and Chapter 13 277 are then discussed later in this chapter, when a model of protagonists’ change processes is proposed.
Links between in-session resolution and post-session changes A premise of this thesis was that in-session resolution is therapeutically meaningful and is therefore worthy of further investigation. To establish the merit of this claim, links between in-session resolution and post-session improvements in interpersonal and intra-personal functioning were examined. The clinically significant change results, discussed earlier, suggested that while a psychodrama intervention can be effective in reducing a protagonist’s general symptom distress; this effect is not dependent on the protagonist achieving in-session resolution. However, subjective reports of change did suggest a link between in-session resolution and post-session improvement in interpersonal and intra-personal functioning. Protagonists’ reports of their subjective experiences of post-intervention change, suggested a qualitative difference between the experience of protagonists who reached in-session resolution and those who did not. Protagonists who reached resolution consistently reported improvements in sense of self as well as specific changes in their responses to significant others. They attributed these changes to events within their own psychodrama enactments and the specific changes could be mapped to specific in-session processes. Protagonists who did not reach in-session resolution were more likely to report feeling more agitated about their presenting problem, which was linked to achieving insight without developing a new response and produced greater dissatisfaction with their current functioning. Interestingly, this increased agitation was typically not reflected in an increase in symptom distress. Some protagonists who did not experience resolution, reported post-session improvements in their responses to specific interpersonal situations, which could be linked to in-session processes, but did not report general improvements in sense of self. It would seem that there was a therapeutically meaningful qualitative difference in the impact of the intervention for those who reached resolution compared to those who experienced partial or no resolution. These differences are articulated further in the following discussion of a proposed model of protagonist change processes that emerged from this research. Chapter 13 278
A Proposed Model of Protagonist Processes Leading to In-session Resolution of Painful Emotional Experience during Psychodrama Significant therapeutic events were identified and described for 14 psychodrama cases; eight where there was in-session resolution of a painful emotional experience and six were there was incomplete or no resolution. Five meta-processes were identified and described through the comprehensive process analysis (CPA) of twenty scenes within seven cases in Study 2, and these meta-processes were substantially verified, with minor modifications, when four additional cases were examined in Study 3. A model of protagonist change processes leading to in-session resolution of painful emotional experiences has been constructed around these meta- events, which are: (i) readiness to engage in the psychodrama process; (ii) re- experiencing and insight, (iii) activating resourcefulness; (iv) social atom repair with emotional release and (v) integration (see Figure 13.1). The first meta-process, readiness to engage, occurred prior to the psychodrama enactment. The other four meta-processes occurred within the enactment and can be conceptualised as meta- events that protagonists engaged in as they moved towards previously avoided experience and created a new response to that experience. In the proposed model each meta-event is oriented towards specific therapeutic goals, has identifiable action, insight and emotional components and is linked to specific qualities of self- reported changes to sense of self and/or interpersonal functioning. The model is outlined in Figure 13.1 on the following page and each meta- process is then discussed. A more complete description of each event within the model is found in Chapter 10 and modifications arising from the study of further cases are described in Chapter 11.
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Readiness to engage in the psychodrama process
1. 2. 3. 4. Impasse Re-experiencing & Activating Energised Social Atom Repair with Settled Integration Insight Resourcefulness Emotional Release
Action Exploration of the Boundary setting Initiating & receiving Application of new orientation system or Intimacy reparative relationship learning to the present and future
Action Awareness of Awareness of personal Awareness of new experience Awareness of new Insight problematic dynamic & resourcefulness of self in situation possibilities impact of the dynamic
Emotional Acknowledge strong Free-flowing release of Settled, calm component Stuck & hopeful emotional response previously restricted emotion
Post session Awareness of problematic New response to a Improved interpersonal Consolidation of change Impact dynamic & its impact specific situation relationships & sense of self
2
Figure 13.1. A Model of Protagonist Processes Leading to In-session Resolution of Painful Emotional Experience during Psychodrama. 79 Note: This model is based on the descriptions of each meta-process provided in Chapter 10 and the minor modifications described in Chapter 11. Chapter 13 280
Readiness to engage in the psychodrama process Protagonists who reached resolution identified a readiness to engage in the psychodrama process which influenced the decision to volunteer to be a protagonist. The description of this readiness has some resonance with Carter’s (1992) definition of spontaneity as a ‘readiness for a free and vital response to the emerging moment’ (p. 41) and appears to reflect the protagonists’ warm-up to their own inner experience and their relationship with the group. When group members experience some urgency to confront issues and they perceive the group and the group leaders to be willing and competent to respond adequately to them, they may be more likely to engage fully with the experience. Protagonists who did not reach in-session resolution were more likely to report acting from a desire to be active participants and described pushing themselves to address an issue. There is a difference between the flowing process of a person who is ready to address an issue and the coercive relationship to self of the person who wants to be ready, but perhaps isn’t ready. This supports Lambert and Barley’s (2001) suggestion that client characteristics have a significant impact on outcome and that effective therapies facilitate clients’ natural healing processes. In this instance, the capacity of the group and the group leaders to engage with the potential protagonist may be important facilitative factors. Resolution did not occur in the first psychodrama enactment of any workshop. In later sessions, potential protagonists had more opportunities to be affected by the work of the protagonists who preceded them, were more likely to have participated in earlier sessions in auxiliary roles and thus experienced how the method worked and had more opportunity to experience how the directors and group members responded to the self presentation of other participants, and therefore to volunteer to be a protagonist from a more informed position. Life experience may influence a person’s readiness to engage in the therapeutic process. Only two protagonists across the four studies were under the age of 30 and neither of these protagonists reached resolution. Previous experience in psychodrama, on the other hand, did not appear to influence whether a protagonist reached in-session resolution or not, with equal numbers of experienced and inexperienced participants reaching resolution. Chapter 13 281
Re-experiencing and insight Re-experiencing and insight events were oriented towards deepening the protagonist’s experience of aspects of their intra-personal and interpersonal system (social atom) that have specific relevance to the painful emotional experience. Protagonists re-experienced a significant interpersonal dynamic that was central to the emotionally painful event, but this did not always involve re-experiencing the emotionally painful event itself, at this point in the enactment. Experiencing the dynamic as though it were happening in the here and now generated in the protagonist the original problematic response. When the protagonist experienced a supportive connection with the director or with an auxiliary within the enactment, previously overwhelming emotions were contained and the protagonist gained new insight into the problematic dynamic and realised how current problematic behaviour was being maintained. From case examples where protagonists completed the re- experiencing and insight event, but did not go on to reach resolution, this event appears to be linked to increased awareness but not to changes in behaviour or to the sense of self. Understanding the problematic dynamic and the impact of that dynamic on the protagonist’s general well-being was not sufficient to produce a change in the dynamic. The lack of post-intervention change in the sense of self in not-resolved cases where there was a re-experiencing and insight event is of interest in considering on- going therapeutic interventions. Action insight during this event was preceded by a shift in internal relations, where the protagonist experienced a more positive relationship with the self. However, this in-session shift in internal relations was only maintained post-intervention if other in-session changes in the problematic dynamic occurred later in the session.
Activating resourcefulness In activating resourcefulness events, protagonists generated progressive adult functioning to respond assertively to a problematic interpersonal dynamic. Key characteristics of this event were that the protagonist experienced a crisis point where he or she was aware, on the one hand, of experiencing a strong emotional response to the situation, and on the other hand, of being caught in a habitual avoidant response. The transition from being stuck to taking action appeared to be facilitated by the protagonist accepting the strong emotional response and experiencing a positive Chapter 13 282 response to self. With coaching from the director or from an auxiliary acting as a double, the protagonist was able to build and maintain the assertive response. This generally produced a re-configuration of the original dynamic, with the protagonist acknowledging his or her own abilities and recognising the limitations of the other person. For most protagonists in this study, resourcefulness was expressed as assertive boundary setting in response to an enmeshed family dynamic. However, in one resolved case activating resourcefulness was expressed as intimacy. The intimacy event was considered to be a variant example of the principle process of activating resourcefulness, because it emerged as a new response to an impasse in the protagonist’s relationship with a significant other, involved competent adult functioning, resulted in the protagonist experiencing herself and the other in a more constructive way and occurred prior to the resolution event. Greenberg and Paivio (1998) describe a process of self-affirmation which they propose occurs as a result of allowing and accepting emotional pain. In contrast, activating resourcefulness events incorporated an experience of self-affirmation that occurred before protagonists experienced a substantial emotional release and before they experienced resolution of their emotional pain. Activating resourcefulness events occurred in a number of not-resolved cases. When there was an activating resourcefulness event, but not in-session resolution of the emotional pain, protagonists reported post-intervention changes in the specific interpersonal behaviour that had been addressed in the enactment. This suggests that activating resourcefulness can be an effective rehearsal for future action.
Social atom repair with emotional release Social atom repair with emotional release occurred only in resolved cases and was most clearly linked with protagonists’ reports of experiencing relief and feeling resolved. This event was essentially a reconfiguration of the original experience, in which the protagonist experienced the completion of an act hunger in relation to significant others in the original scene. This entailed the enactment of previously inhibited responses and deeply experiencing a reparative response from an auxiliary acting as a significant other, as-if it were happening in the moment when the response had previously been missing. This was a corrective emotional experience Chapter 13 283 for the protagonist, who experienced receiving comfort, support or affirmation within the context of the previously painful emotional experience. In most but not all cases, the social atom repair event was generated by the protagonist acting from a progressive adult role. That is, the protagonist initiated a comforting, supportive or affirming response towards an auxiliary who was being the ‘protagonist’ and then, in role reversal, experienced receiving that response. The impact of the social atom repair event was more enduring when protagonists experienced themselves from both perspectives of the corrective emotional experience: (i) as the person who experiences receiving an adequate response to their own emotional pain and (ii) as the person who is able to maintain their adult functioning as they respond to an expression of emotional pain. While experiencing social atom repair, the protagonist experienced a free flowing release of previously restricted emotion. In most cases, emotional release was expressed as crying, but in one case it was expressed in the release of previously restricted joy. The release of emotion during this event appeared to be associated with the protagonist experiencing a new role relationship. This dynamic is considered later in this chapter, when the place of catharsis in psychodrama is discussed.
Integration In-session integration events were identified only in resolved cases and occurred after the social atom repair event, when the protagonist had already experienced relief and resolution of the painful emotional experience and was feeling settled. The integration process entailed the protagonist functioning in a progressive adult role in an interpersonal encounter with a significant other, communicating warmth and being clear about how he or she wants to move forward in life. There is a shift in the protagonist’s orientation, from a focus on the emotionally painful experience of the past, to a focus on establishing healthy relationships in the present and the future. In-session integration events were identified in three of the four resolved cases in Study 2, but not in either of the resolved cases in Study 3. One factor which may influence whether integration occurs during the session is the degree of initiative the protagonist brings to the earlier social atom repair event. Protagonists who experienced receiving a reparative response from an auxiliary during the social atom Chapter 13 284 repair event, but who were not able to initiate that reparative response from the adult role, did not go on to experience in-session integration.
Pre-conditions for social atom repair of the painful emotional experience While the protagonist’s experience of resolution was located in the social atom repair with emotional release event, the model of protagonists’ processes that has been constructed here, proposes that both re-experiencing and insight and activating resourcefulness are necessary pre-conditions for resolution. Interestingly, most not- resolved cases contained either a re-experiencing and insight event or an activating resourcefulness event, but not both of these; whereas resolved cases exhibited both, before the experience of social atom repair. This suggests that it is the combination of these two processes that prepare the person to re-experience the original painful emotional experience in a new way and to generate and take in the corrective emotional experience. The processes that facilitate the transition from awareness of a problematic response to the experience of social atom repair are examined further in the following sections, which discuss the implications of this model for understanding Moreno’s spontaneity theory and the psychodramatic construct of social atom repair.
Implications of the Model of Protagonist Change Processes for Moreno’s Theory of Spontaneity. Moreno proposed that spontaneity is both a therapeutic aim and a core curative factor of psychodrama. As was indicated in Chapter 2, Moreno (1946) defined spontaneity as an internal dynamic, a readiness to act; but spontaneity is more easily identified by its product, the spontaneous response, which has the qualities of flexibility, novelty and adequacy, is directional and purposeful. The resolved cases in this research showed evidence of an incremental development of spontaneity over the course of a psychodrama session, with a gradual development in the protagonist’s flexibility of response (see Figure 13.2). The increased level of spontaneity with each successive event, suggests that there is a spontaneity training effect over time. Spontaneous responses within the re-experiencing and insight event had three core qualities: (i) a positive response to self, (ii) acceptance of the inherent difficulty of the old situation and (iii) hope. However, it would seem that there was only a Chapter 13 285 partial development of spontaneity at this time and that protagonists continued to experience unresolved act hunger at the conclusion of this event. This is underscored by protagonists’ reports of feeling both hopeful and stuck during re-experiencing events. Spontaneity was not produced to a level where the protagonist was able to freely act in the situation and the spontaneity that was developed in the re- experiencing event was not always sustained. In the second event, activating resourcefulness, protagonists progressed from this feeling of being stuck, to generating a new response to a problematic situation. Once again, the spontaneous response incorporated a positive response to self, but now when the protagonist becomes aware of having a strong emotional response in the moment, he or she consciously accepts the emotion and chooses to act. The protagonist’s response is tentative but, with coaching and doubling from the director or from auxiliaries, the new response is strengthened and maintained. The intervention of the director or auxiliaries at this time assisted the protagonist to recognise and build confidence in the emerging response. In the social atom repair with emotional release event there is a high level of spontaneity, reflected in protagonists’ responses being freer flowing and less intervention being offered by the director. The protagonist and auxiliaries are engaged in an encounter, where the protagonist is able to receive a positive response with a free flowing expression of emotion and, in most instances, also initiate a new response to the painful emotional experience. For many resolved protagonists, the social atom repair event was the peak manifestation of spontaneity during the session. However, in cases that had an integration event, protagonists demonstrated an ability to maintain a high level of spontaneity or ‘readiness for a free and vital response in the emerging moment’ (Carter, 1994, p. 41), as they engaged in surplus reality encounters in new situations. The integration encounter involves new responses not previously rehearsed in the session, suggesting that the protagonist has learned how to maintain spontaneity, rather than how to respond in a particular situation. Immediately preceding the emergence of a new response, protagonists experienced a shift in their internal relations, with a more positive orientation to self. This suggests that an increased acceptance of self in the moment increases the person’s capacity to generate a new response. Chapter 13 286
Hollander (1969, 2002) placed the protagonist’s process during the warm-up and enactment stages of a psychodrama on an emotional continuum, with emotional experiencing gradually building towards a peak where the protagonist has a catharsis of abreaction and where, presumably, spontaneity is at its highest and a creative response is produced (see Chapter 2, Figure 2.1). As was suggested in Chapter 2, Hollander’s construction of the psychodrama session may have contributed to the view that psychodrama is a primarily cathartic method, centred on the production of emotion. A modification of Hollander’s Psychodrama Curve is proposed here, based on the findings of this research and describing the development of spontaneity and meaning making during a psychodrama session where there is in-session resolution of painful emotional experience (see Figure 13.2). This modified curve places the progress of the psychodrama enactment on a spontaneity continuum rather than an emotional continuum. Hollander’s original emotional continuum is overlayed on Figure 13.2, as a point of comparison. It is suggested that the increased emotion as Hollander conceived it, could more accurately be seen to be a freeing up of the protagonist’s capacity to express emotion, along with the freeing up of other aspects of his or her functioning that occurs with increased spontaneity. After the emotional release that comes with social atom repair, there may be a further expression of spontaneity (spontaneity continuum) even though the expression of emotion is settled (emotion continuum). This modified psychodrama curve is consistent with the ideas proposed by McVea & Reekie (2007) when they described protagonists’ processes during the application of a psychodrama role training intervention. Chapter 13 287
High Awareness of Awareness of problematic dynamic resourcefulness CA Positive to self Positive to self Hopeful & stuck Identify & accept CI Heightened awareness strong emotion of inability to act Tentative response strengthened by coaching & doubling
CI/A Awareness of new Awareness of self experience of self as integrated adult Free flowing emotion Free flowing Free flowing response encounter in the in the moment emerging moment
Re-experiencing Activating Social atom repair Integration & Insight resourcefulness with emotional release Low Temporal Continuum (Enactment phase only)
Figure 13.2 The development of spontaneity when there is in-session resolution of painful emotional experience, compared to Hollander’s (1969) emotion continuum. 28 7 Notes: Proposed ‘spontaneity continuum’, on which CI = Catharsis of Integration. Hollander’s ‘emotional continuum’, on which CA = Catharsis of Abreaction; CI/A = Catharsis of Interaction (refer to Figure 2.1, Chapter 2). Chapter 13 288
Further Explication of the Psychodrama Construct of Social Atom Repair The constructs of spontaneity and social atom repair are intrinsically linked in psychodrama theory. New roles are seen to emerge from spontaneity and social atom repair is defined as the development of new roles and role relationships. However, social atom repair has a therapeutic orientation, referring specifically to the development of new roles and role relationships where the existing social atom has produced coping and fragmenting rather than progressive roles. While the previous discussion of the development of spontaneity is directly relevant to social atom repair, in this section the emphasis will be on evidence for the development of progressive functioning linked to Clayton’s (1993; Clayton & Carter, 2004) core principles of social atom repair: the development of a larger perspective of the social system and greater flexibility of response. Specifically, he considered that social atom repair included the development of a new warm-up as a result of allowing into consciousness ‘other elements outside of oneself’ (Clayton & Carter, 2004, p. 337), a corrective emotional experience and the strengthening of progressive roles. All of these elements were evident in the social atom repair with emotional release event described in this research. The corrective emotional experience occurred in surplus reality, when the protagonist experienced receiving the needed and previously unavailable response from a significant other in the context of the painful emotional experience. Furthermore, there was evidence to suggest that the impact of the corrective emotional experience was enhanced when the protagonists’ progressive functioning was developed enough to create the needed response. In other words, the strengthening of progressive functioning in part preceded the corrective emotional experience. While this event was the cornerstone of social atom repair, there was a gradual development of the conditions required for this to occur as well as incremental repair episodes earlier in the session. An important aspect of the re-experiencing and insight event was to assist the protagonist to become more open to their system. A comparison of the experiences of protagonists who achieved the core conditions of a positive response to self, acceptance of the inherent difficulty of the old situation and hope and those who did not, suggest two processes that assisted protagonists to develop a new warm-up to the old situation. The first was experiencing the situation
Chapter 13 289 from other roles. In most cases there was minimal or no actual encounter at this stage, but role reversal appears to have been important for the protagonist to progress in this task. In cases where the re-experiencing and insight task was not completed protagonists identified either an inability or a lack of opportunity to reverse roles with significant others in their system. The second process that assisted the development of a new warm up was the ability to observe the situation without becoming overwhelmed. Directors’ interventions that assisted the protagonist to be able to do this were identified by protagonists as some of the most helpful peak events in their sessions. The two interventions that were typically used were either doubling from an auxiliary or coaching from the director. The protagonist who was rated as having achieved the lowest level of resolution did not develop a capacity to observe the scene without becoming overwhelmed within her session. This has implications for the application of Hudgins prescribed functions for working with traumatic material and will be revisited later in relation to her model. An unexpected finding of the study was the immediacy of the link between the protagonist experiencing a positive relationship to self and the deepening of the protagonist’s warm-up. Positive responses to self immediately preceded major shifts in the protagonist’s responses during the session, such as the expression of previously blocked distress, producing an assertive response and emotional release. This suggests that changes in the person’s relationship with self in the context of the situation begins to be enacted and experienced at some level before a new response emerges and before new meaning making is articulated.
Implications of the Findings for other Therapeutic Models of Psychodrama
Kellermann’s Therapeutic Aspects of Psychodrama Kellermann (1992) described six broad factors which he considered were central to the therapeutic efficacy of the psychodrama method: (i) therapist skills, (ii) catharsis, (iii) action-insight, (iv) learning through interpersonal relationships, (v) behavioural learning through enactment; and (vi) imaginary simulation through the ‘as-if’ enactment of surplus reality. In this research, aspects of each of these factors were linked to the resolution of painful emotional experience.
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Therapist skills. This thesis focussed on protagonists’ processes and an in-depth analysis of the contribution of directors’ therapeutic skills was beyond the scope of the research. Nevertheless, trust in the ability of the director to manage emotional pain and to work with the group dynamic was identified as a precondition for group participants volunteering to be protagonists and was identified as important by group participants more generally. The dynamics of catharsis. Protagonists found catharsis to be therapeutically helpful and reported experiencing relief after releasing previously restricted emotion. Protagonists who reached in-session resolution experienced emotional release, sometimes during the re-experiencing and insight event and in all cases during the social atom repair with emotional release event. It was the latter catharsis, which had the qualities of a catharsis of integration rather than a catharsis of abreaction, which was most clearly associated with in-session resolution of painful emotional experience. In the social atom repair with emotional release event, there was evidence to support the concept of catharsis occurring as the protagonist incorporates a new experience of self, as proposed by Clayton (Clayton and Carter, 2004). The structure of the social atom repair event and its place in the sequence of events, suggest that this emotional release occurs at the point where the protagonist has already begun to have a new experience of self and is beginning to accommodate the experience into his or her construct of the world. The nature of the catharsis depended on the nature of the previously restricted expression of feeling. For all but one protagonist, the emotional release involved free flowing weeping which appeared to be both an expression of a deeper experiencing of grief and a deeper experiencing of appreciation of the new role relationships that were being enacted. One protagonist had an emotional release of joy and this was associated with freeing up of both feeling and action that had been previously restricted. In the cases investigated here, catharsis was found to be necessary for in-session resolution. This conclusion is supported by the lack of emotional release in cases where protagonists did not achieve resolution and particularly from the case of one protagonist who experienced a surplus reality scene which met most of the criteria of social atom repair but without emotional release (see Chapter 11). In this case the protagonist reported experiencing some healing of a fractured relationship after
Chapter 13 291 enacting a reparative relationship with a significant other, but also reported being agitated and having a lack of warmth towards her. It is proposed that, while the enactment of the new role relationship may have assisted the protagonist to have a different perspective of the relationship, the absence of emotional release was symptomatic of a lack of engagement with the enactment and that consequently there was not an expansion of the sense of self during the event. The intensity of outward expression of the emotional release differed markedly between protagonists. Three protagonists experienced deep and prolonged sobbing consistent with the stereotypical notion of a cathartic experience, but the majority of protagonists experienced a gentler, quiet process of emotional release. In the first study there was a marked difference in emotional expressiveness between the two protagonists who achieved in-session resolution, giving rise to the question of whether catharsis was necessary to in-session resolution or if personality or expressive style could account for the perceived difference. The findings of subsequent studies supported the proposition that emotional release, even when expressed gently and quietly, was associated with feelings of relief and resolution. Nor was the more expressive release a predictor of greater therapeutic gains. The capacity to engage with all elements of the social atom repair scene seemed to be more relevant to the degree of resolution than did the apparent intensity of catharsis. Action insight and meaning making. As Kellermann suggests, action insight was identified as occurring when the protagonist was engaged in an experiential task and made a connection between felt experience and cognitive awareness. Three categories of action insight were identified: (i) immediate self awareness, (ii) awareness of the problematic dynamic and its impact on the protagonist’s response and (iii) awareness of a new sense of self combined with a new construction of the situation. As protagonists engaged in a number of different experiences related to the same theme over the course of a session, they experienced different action insight events that built on the meaning making that had gone before. This incremental process of meaning making supports the proposition that therapeutic change during psychodrama occurs partly as a function of training over time. A case example of this process was provided in Chapter 10 (see Figure 10.10). The nature of the experiential tasks that produced action insight differed within a session and between protagonists and the differences between protagonists were particularly noticed during: re-experiencing and insight event. An awareness of
Chapter 13 292 others was consistently produced in role reversal, but awareness of the dynamic working in the system and the impact of the dynamic on the protagonist were achieved for some through encounter and for others through observation. Some protagonists benefited from a full engagement in the encounter with a significant other and, as the enactment developed, would have moments of insight that were incorporated into the enactment. For most protagonists, awareness of the problematic dynamic was facilitated by mirroring, when the protagonist stood apart from the action and was assisted, through doubling or coaching, to observe a re- enactment of the scene. This difference may have resulted from intervention choices of directors rather than differences within protagonists, but for at least some of these protagonists there was evidence that being in the enactment reduced their capacity to differentiate their own experience from that of others. Moreno (1952) proposed that the psychodramatic techniques of doubling, mirroring and role reversal replicated stages of infant development. Role reversal is the most advanced of these three stages and the ability to role reverse is considered to indicate the development of a sense of self separate from others. Protagonists may have been functioning at different stages of development during their psychodramas and this is a possible explanation for the process differences that were identified. Learning through enactment. The psychodrama intervention could be construed totally as learning through enactment. One specific aspect of learning directly attributable to enactment was the impact of rehearsal and practice. Within boundary setting tasks, assertive responses were developed through repetition. Protagonists reported directly translating these in-session enactments into new interpersonal behaviour following the workshop. Learning through interpersonal relationships. Protagonists learnt through interacting with other group members and through observing and being affected by interpersonal events throughout the workshop. Protagonists reported experiencing a reduced sense of isolation through group interaction. One interesting aspect of the therapeutic process that emerged from the analysis was the construction of a therapeutic relationship between the protagonist and group members in auxiliary roles. An auxiliary in the role of a significant other was experienced by the protagonist in the dual position of the role that had been assigned to them and as a group member with whom the protagonist experienced a connection
Chapter 13 293 in the here and now. Contemporary psychodrama theory holds that tele relationships, the underlying sociometric relationships between group members, influence the protagonist’s choice of auxiliaries (Blatner, 1994; McVea, in press). In the first study, protagonists reported being aware of their connections with others in the process of selecting auxiliaries and of strengthening interpersonal bonds in the process of selecting key auxiliaries. The therapeutic relationship between protagonist and auxiliaries became more apparent with the analysis of significant events in the second study, where it was found that protagonists were influenced during the enactment by auxiliaries with whom they had a strongly positive alliance and that the protagonist appeared to develop a working alliance with the auxiliary as much as with the director. Zerka Moreno (2006) proposed that when an auxiliary takes up a role within an enactment the auxiliary accesses experiential information about the role. Introducing that information into the enactment can assist the protagonist. The findings of this research support this proposal. Spontaneous production by auxiliaries assisted protagonists to deepen their experiencing in the moment and the impact of auxiliaries as doubles and models for the protagonist was apparent. Furthermore, protagonists observed or quietly took in what was being said to them by auxiliaries to a surprising extent. Perhaps the psychodrama process gives protagonists an opportunity to absorb what is happening without experiencing a pressure to produce a response. Surplus reality. Surplus reality scenes, in particular those scenes where protagonists enacted a wished for interaction, were identified by protagonists and directors as being extremely helpful in the resolution process. Some surplus reality events were considered helpful in non-resolved cases as well as resolved cases, and in these instances they were typically linked to reports of post-intervention improvements in specific situations. Zerka Moreno (2006) defined surplus reality as an aspect of the inner reality of the protagonist. and protagonists’ recall of significant events suggested that the surplus reality quality was therapeutically significant. For example, one protagonist recalled: ‘I know that’s what she would have said; this is the conversation we couldn’t have.’ The events were therapeutically helpful when the protagonist experienced the event as being true or real, or when the protagonist was simultaneously imagining having the interaction with a significant other in the future.
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The event was experienced as less helpful or even unhelpful, if the protagonist felt disconnected from the experience and could not imagine it actually happening.
Hudgin’s prescribed functions of restoration, containment and observation Hudgins (2000, 2002) considers that the three functions of restoration, containment and observation need to be present in a protagonist’s system to enable conscious re-experiencing of traumatic material without re-traumatising the protagonist. While it was beyond the scope of this thesis to directly investigate her proposition, there was evidence that the combination of observation and containment assisted protagonists to be able to acknowledge and make meaning of problematic experiences. The role of a double assisted the protagonist to be affected by the enactment while containing overwhelming feelings, when he or she was standing outside of the action, so that the protagonist could then attend to what was happening in the enactment (refer to the discussion of social atom repair, p. 283). This observation process then produced new awareness of the system (refer to the discussion of action insight and meaning making, p. 292).
The Fit Between Greenberg’s ‘Allowing and Accepting Painful Emotional Experience’ Model and Protagonists’ Experiences of Resolution In Chapter 3 two alternative explanations for the core curative factor in the resolution of painful emotional experience were proposed: the activation of spontaneity as proposed by Moreno and the activation of emotion as proposed by Greenberg and his colleagues. In the preceding discussion, protagonist change processes have been described in relation to the activation of spontaneity, and emotional release, or catharsis, has been described as a function of the integration of new roles and role relationships. However, at the beginning of this research it was proposed that the empirically supported allowing and accepting painful emotional experience model (Greenberg, 1999; Greenberg & Paivio, 1998) would fit protagonists’ experience of resolution during psychodrama. In summary, the allowing and accepting model proposes that, (i) allowing emotional pain, expressed through therapeutic weeping, is a transformative process whereby clients experience a shift in internal relations that enables them to experience previously avoided emotional pain and accept the
Chapter 13 295 emotional pain as part of themselves; (ii) the transition from avoiding to approaching the painful emotional experience is facilitated by accessing secondary bad feelings that mask the primary adaptive emotional pain; (iii) once the emotional pain is accessed, previously unmet needs can be mobilised and the maladaptive belief that had maintained the secondary emotion becomes more apparent to the client and can be challenged. Greenberg and Paivio (1998) had argued that this was a general model of change which could be applied to all therapeutic modalities. A preliminary examination of the descriptions of protagonist change processes, particularly within social atom repair events, suggested that this was true for the cases in this research. This claim was tested by applying Foerster and Greenberg’s (1995, in Greenberg, 1999) empirically established criteria for measurable components of the model, to six resolved and three not resolved cases (see Chapter 12). Resolved cases met all the criteria established by Foerster and Greenberg and, consistent with their model, only resolved cases met the criteria for therapeutic weeping that has been described by Greenberg and his colleagues as an indicator that the client is allowing emotional pain. Of the four components of the model: (i) articulating a maladaptive belief, (ii) acknowledging secondary bad feelings, (iii) accessing needs and (iv) allowing emotional pain, only the latter differentiated between resolved and not resolved cases. However, the sequence in which these four criteria occurred during resolved cases suggests that the process of resolution of painful emotional experience during psychodrama differs from the process proposed by Greenberg and Foerster. A reconfiguration of Greenberg’s criteria for allowing emotional pain is proposed (see Figures 13.3 & 13.4). The transition from avoiding to approaching emotional pain, is shown to be facilitated by a combination of acknowledging the secondary bad feeling and experiencing the problematic dynamic that has produced the maladaptive belief system. Secondary bad feelings such as hopelessness, helplessness, weariness, guilt, despair or resignation were experienced within the context of the original emotionally painful situation and the protagonist then recognised these responses as being part of the problematic dynamic occurring at that time. Both these processes occurred before there was therapeutic weeping. It appears that when protagonists recognised a problematic dynamic in close proximity to experiencing secondary bad feelings, they were then able to recognise the relationship between the feeling and
Chapter 13 296 the belief. This assisted them to challenge the belief and to affirm themselves. This shift in internal relations appeared to make the experience of emotional pain tolerable. While protagonists identified maladaptive beliefs during their sessions, the in- session experience of identifying maladaptive beliefs was sometimes reported during recall interviews, rather than articulated during the session. What was consistently articulated during the session was identification of the problematic dynamic or role relationship; such that the protagonist’s previous response was experienced in the context of other people’s behaviour or other events at that time. The emphasis was on enactment of the system rather than articulating what was happening in the moment. This seemed to produce a sense of accepting the earlier response in that context, and was probably a factor in developing a more positive response to self. This research raises the question of whether the resolution of emotional pain rests on the protagonist allowing and accepting emotional pain, or being able to receive an unmet need associated with the pain. Some protagonists met the criteria for allowing emotional pain before they experienced social atom repair with emotional release, and in these cases, while the first event was recalled as being therapeutically helpful, it was the latter event which was specifically associated with producing resolution and relief. Greenberg (1999) stated that ‘therapeutic’ weeping possibly involved ‘receptivity to contact/ comfort and social support’ (p.1471). This research would go further to suggest that therapeutic weeping can be as much an indicator of the protagonist allowing compassion for self as it is an indicator of the protagonist allowing the experience of emotional pain. This may be pertinent to healing the fracturing of the sense of self that has been identified as a core experience of emotional pain (Bolger, 1999). While acknowledging and accepting the painful emotional experience was an aspect of protagonists’ experiences, it would seem that the emotional release could equally be described as an experience of allowing comforting, or allowing compassion. The healing experience occurs when the individual allows the possibility of a new reality.
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Allow emotional pain Acknowledge Challenge secondary bad Access need feeling Articulate belief
maladaptive Affirm self belief
Figure 13.3. Allowing emotional pain (Source: Greenberg, 1999)
Acknowledge secondary Allow bad feeling Articulate need emotional pain Challenge belief Relief Affirm self Affirm self Articulate maladaptive Access belief Need
29 7 Figure 13.4. Modification of Greenberg’s (1999) Allowing emotional pain model, to fit Psychodrama (McVea, 2009).
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Applications of the Research
Application for the development of psychodrama theory The thesis has presented an explanatory model of protagonists’ processes leading to in-session resolution of painful emotional experiences. This model contributes to the advancement of spontaneity theory in three areas: (i) articulating the importance of the protagonist’s warm-up to the enactment, or readiness to engage, in influencing the outcome of the psychodrama intervention; (ii) clearly differentiating between the activation of emotion and the activation of spontaneity over the course of a psychodrama session and (iii) identifying a link between experiencing a positive response to self and the activation of spontaneity. The model also contributes to understanding the psychodrama constructs of social atom repair, catharsis and action insight. A specific form of social atom repair has been described. This social atom repair has been shown to be a necessary process for protagonists to experience in-session resolution of painful emotional experiences and has been further linked to the healing of the damage to sense of self and disconnection from others that result from unresolved painful emotional experience. The importance of catharsis of integration within this healing process has been articulated. The development of action insight over time, linked to the development of greater levels of spontaneity, has also been described, and the relationship between mirroring and doubling, in the development of insight, has been clarified. These areas have been discussed in some detail in the previous pages.
Applications for the practice of psychodrama Efficacy of the psychodrama method. This research provides empirical validation for practitioners’ claims that painful emotional experiences can be resolved during psychodrama. Furthermore, there is evidence that a single intensive psychodrama intervention can reduce general symptom distress and produce specific improvements in interpersonal functioning. This supports the case that psychodrama can be a suitable therapeutic intervention for resolving problematic reactions arising from unresolved painful emotional experiences. A model to guide practitioners’ clinical decisions. The model of protagonists’ processes leading to in-session resolution of painful emotional experience that is proposed in this thesis provides a general map that can guide practitioners’ clinical
Chapter 13 299 decision making. In particular, the model describes the types of processes a protagonist can be expected to engage in when moving from experiencing a problematic response associated with an unresolved painful emotional experience, to developing new responses to self and others in the context of that earlier experience and then orienting towards progressive functioning in the present and the future. The model describes the post-session impacts of psychodrama enactments where there is partial or no resolution and gives practitioners some indication of the areas in which the client may benefit from further therapeutic focus. This is of particular relevance in therapeutic settings where the intensive psychodrama intervention is a component of a broader therapeutic plan. Greenberg (1999) refers to models of psychotherapy as mini-theories that contribute to understanding the complex non-linear processes of psychotherapy. The variations between cases in this research suggest that the model cannot be used to prescribe events that a protagonist must be led through in a psychodrama session, but rather describes protagonists’ processes as they unfold. The meta-events operated differently for each protagonist. The model describes general and typical themes that were present in resolved cases and the variable themes that were important to a small number of cases are not always included in the case reports that are provided. Identifying the impact on the protagonist of the psychodrama intervention. Practitioners can be encouraged by the correlation that was found between directors’ judgements of in-session resolution and protagonists’ reports of experiencing resolution. However, the two cases where directors rated sessions as resolved, but protagonists disagreed, highlight the possibility that a protagonist’s outward behaviour might mask a significant difficulty that he or she has experienced during the session. The need to discuss the impact of the session with the protagonist is identified.
Contribution of the thesis to understanding common factors of therapeutic change Meta-analytic studies of psychotherapy outcome research have concluded that the common factors operating across modalities explain most client change (Ahn & Wampold, 2001; Wampold et al., 1997). Key common factors that underlie effective psychotherapies have been identified as (i) client characteristics, (ii) the therapeutic relationship, (iii) having a coherent explanation for the problems that are being experienced, (iv) exposure to the problem, either through imagination or in situ and
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(v) a corrective emotional experience (Lambert, 1994; Orlinsky, Grawe & Parks, 1994; Rosenzweig, 1936; Stricker & Gold, 2008). This thesis has contributed to understanding the operation of each of these factors within the psychodrama context. The impact of the client’s readiness for the therapeutic intervention. Client characteristics and qualities of the therapeutic relationship were found to influence participants’ decisions to volunteer to be a protagonist and were linked with in- session resolution. The client’s readiness to engage in the therapeutic process would seem to be a good predictor of the outcome of the session. This readiness was influenced by client qualities (notably, the client’s depth of warm-up and a compelling drive to address the issue), the client’s perception of qualities of the therapist (the ability to manage the emotional material of the client and the group) and the client’s understanding of how to engage in the particular therapeutic process. Exposure to the problematic dynamic produces cognitive change and new behaviour. It was noted in the introduction (Chapter 1) that there is a growing consensus across therapeutic modalities that exposure to problematic experience produces positive therapeutic outcomes when the exposure activates emotions and is associated with a change in cognitions and/or behaviour (e.g. Foa and Kozac, 1986; van der Kolk et.al., 1996). Psychodramatic exposure is through the re-enactment of the original situation as-if it were happening in the here and now. In this thesis, the re-enactment was associated with a change in cognitions when the emotion of the original experience was activated within the enactment, and when the protagonist was able to regulate their emotional response, either while engaged within the enactment or, more typically, when they stepped out of the action space and watched the re-enactment by auxiliaries. In the early stage of resolved sessions, protagonists’ insights focussed on new understanding of how the original problematic response had developed and were associated with the protagonist being more accepting of how they had responded. This could be seen as the development of a coherent explanation for the problems being experienced, which has been identified as a common factor in therapeutic change (Rosenzweig, 1936; Stricker & Gold, 2008). Interestingly, although this was experienced as therapeutically helpful, insight alone was not sufficient to produce changes in behaviour. Exposure was associated with new behaviour when the protagonist accepted a positive response to self, either from a ‘significant other’ or as an inner response to self, and when the new behaviour was affirmed.
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Social atom repair as a specific form of corrective emotional experience. The social atom repair with emotional release event that has been identified in this research constitutes a specific form of corrective emotional experience, which combines emotional, cognitive and interpersonal action components. The therapeutic significance of the protagonist being able to initiate as well as accept the reparative response is described. Furthermore, two processes, depth of experiencing and resourcefulness, have been identified as necessary preconditions for the corrective emotional experience to occur. Verifying Greenberg’s ‘allowing and accepting painful emotional experience model. A major contribution of this thesis to understanding common factors of therapeutic change has been the testing of the allowing and accepting painful emotional experience model, within the psychodrama context. The findings lend qualified support to Greenberg and Paivio’s (1998) claim that theirs is a general model of change. A modification to the allowing and accepting model is proposed, arising from the sequence of protagonists’ processes leading to resolution. Furthermore, it is suggested that therapeutic weeping arises as much from allowing the experience of receiving compassion as it does from allowing emotional pain, so that the person’s capacity to accept a new reality for themselves is central to the healing process.
Contribution of the thesis to designing future psychodrama research One of the interests of this research was to investigate the application of current psychotherapy research methods to the particular context of the psychodrama group intervention. This is the first time that research methods designed to investigate questions of efficacy and the process of change in individual psychotherapy, have been applied to psychodrama group therapy. It was proposed in Chapter 3 that linking post-session change to psychodrama interventions poses a significant challenge for researchers, because of the difficulties inherent in isolating the impact of the psychodrama intervention from the impact of other factors, including general group factors. Study 2 demonstrated that Hermeneutic Single Case Efficacy design (HSCED; Elliott, 2002) can establish links between the psychodrama intervention and post-session changes, while maintaining the integrity of the psychodrama intervention.
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Similarly, Comprehensive Process Analysis (CPA; Elliott, Packer & Addison, 1989) was applied to complex psychodrama group processes, to identify and describe change processes, making the links between protagonists’ processes and in-session and post-session impacts explicit. This opens the way for more focussed research in the areas of efficacy and change-processes in psychodrama. The demands of time and personnel required for Comprehensive Process Analysis restricted the number of cases that could be realistically examined using this method. However, since this research was conducted Elliott and Zucconi (2006) have published a modified form of CPA, which they consider achieves a good balance between rigour and practicality.
Strengths of the Research
Direct relevance to practitioners A major strength of this thesis is that it is practice based and therefore can be expected to have direct relevance to practitioners. Significantly, rigorous research methods were applied while maintaining the integrity of the psychodrama method. Potentially confounding factors, such as participants’ expectations, general group processes and the influence of other life events, were treated as part of the phenomenon under investigation. Consequently, the findings are likely to reflect the actual experiences of psychotherapy clients. Psychodrama directors were encouraged to make therapeutic decisions as they would in their clinical practice. Four directors were involved in conducting the psychodrama sessions and therefore the results are founded on protagonists’ experiences within a variety of different therapeutic styles. While all four directors were female, worked as psychotherapy practitioners and were possibly influenced in their professional orientations by interactions with one another, they had been exposed to different psychodrama traditions in their training and practice. The issues that were presented by group participants are common concerns of psychotherapy clients and the case studies will resonate with practitioners.
The research methods This research applied more rigorous methods to the collection and analysis of data than have been used in psychodrama process research before. A total of fourteen cases were examined, enabling patterns to emerge across different
Chapter 13 303 protagonists and different psychodrama directors. Qualitative and quantitative data were collected from a range of sources, including standardised questionnaires, semi- structured interviews, video recordings and session transcripts, and director and protagonist recall interviews. Multiple analysts contributed to the discovery and verification phases of the research and auditors reviewed the findings at various points.
Examining resolved and not-resolved cases The examination of both resolved and not-resolved cases created an internal control group, against which the link between protagonists’ processes and in-session resolution could be tested.
Building on established research By investigating the application of an established model of client change processes, the allowing and accepting painful emotional experience model, this thesis has built on the work that has been done by Greenberg and his colleagues. This supports the movement towards psychotherapy integration and encourages dialogue between psychotherapists and researchers based in the psychodrama method and those operating from other modalities.
Limitations of the Research
Limits to the generalisability of the findings The 14 protagonists included in the development of the model were predominantly female (12), tertiary educated (12), currently working (13) and working in or had worked in health or welfare related professions (11). Most protagonists (11) had minimal or no prior exposure to psychodrama. Although a high proportion of participants had little experience of psychodrama, it is reasonable to assume that the people who volunteered to participate were predisposed to psychodrama, or were at least curious about the method.
Gender bias among directors, researcher team and observers All psychodrama directors, independent observers and research team members were female. This may have influenced the style of interventions that were made and biased the observations of the team members.
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Limited specificity of the target problem Participants were recruited on the basis of being able to identify an unresolved painful emotional experience that they considered was impacting on their current circumstances, not on the basis of identified clinical diagnoses. The fourteen cases that were investigated covered a range of different types of painful emotional experience, including the death of a parent when the protagonist was a child; emotional abuse; domestic violence; the recent death of a close family member and the serious illness of a child. The model that has been developed appears to be fairly robust to be able to account for themes that are common to this range of experiences, but may lack sensitivity to key processes in the resolution of emotional pain associated with different categories of painful emotional experience. The analysis of further cases in each category may give a more complete picture of the processes for resolving particular types of painful emotional experience.
Small number of cases in the verification phase of the investigation. The principle of saturation in multiple case-studies research asserts that more cases should be added until the addition of further cases no longer contributes significant understanding to the phenomenon being investigated (Hill et al., 1997). Study 3 (see Chapter 4), which was designed to verify the emerging model of protagonists’ processes, introduced new ideas about the process of catharsis, which warrant further investigated. However, Study 3 did substantially support the earlier findings, and it is argued here that further investigations would more profitably be targeted to specific categories of painful emotional experience. Similarly, the very small number of not resolved cases (3) in the study that tested Greenberg’s allowing and accepting painful emotional experience model, mean that the results of this study need to be interpreted with caution (see Study 4, Chapter 12). Greenberg and his colleagues built this model from the study of weeping events in resolved and not resolved cases, and only two of the three not-resolved cases in Study 4 included weeping events.
Small number of cases in the not-resolved comparison group Limited conclusions can be drawn about the impact of partial completion of the model. The not resolved cases suggest that, for example, completion of the re- experiencing and naming core issue event alone, leads to increased awareness and
Chapter 13 305 increased disturbance. Although this conclusion fits the logic of the model, it is based on only one case.
Limitations of the outcome analyses This thesis was primarily concerned with the dynamics of in-session change rather than post-session outcomes. While the outcome results are encouraging, they need to be interpreted with caution.
Areas for Further Research As the first detailed investigation of client change processes linked to in-session and post-session change in psychodrama, this research raised a number of questions that merit further investigation. 1. The differences within cases were as interesting as the common themes that were shared across cases, indicating that further research could focus on specific presenting problems or process issues. Investigating the resolution of specific types of painful emotional experience, for example early childhood loss of significant attachment relationships, childhood abuse, adult trauma and adult loss, would contribute further to the understanding of the therapeutic process within psychodrama. The conditions in which boundary setting rather than building intimacy are conducive to promoting the healing of painful emotional experience, is a process theme that might be explored further. 2. Age and other developmental factors may have an impact on participants’ readiness to engage in the psychodramatic process. 3. Further investigation of Moreno’s theory of infant development and the relationship between these stages and the psychodramatic techniques of doubling, mirroring and role reversal, might inform practitioners’ in-session decision making. 4. Although this research was not oriented to investigating outcomes and did not target a clinical population, the post-session change results are encouraging. Further investigation of the efficacy of a single session psychodrama intervention targeting clinical groups, is recommended.
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A Framework for Building Psychodrama Practice-based Research One of the interests of this research was to consider the application of current psychotherapy research methods to the particular context of the psychodrama group environment and to find out what forms of research showed promise for the development of psychodrama theory. The adoption of multiple case study design and change-process research methods that have traditionally been applied to the investigation of individual psychotherapies, offers a way forward for future psychodrama research. Hermeneutic Single Case Efficacy Design shows promise for researching the impact of the psychodrama intervention within its context, so that the integrity of the method is maintained. The use of video recordings to access protagonist and director in-session experiencing and to give researchers more direct access to information about in-session processes is recommended. Non-verbal experiencing was identified by protagonists as an important therapeutic aspect of the psychodrama intervention and therefore verbal measures of therapeutic process may not be sufficient to measure protagonists’ in-session processes. This highlights the importance of recall methods that access subjective experience.
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Chapter 14 Conclusion
This thesis presents four studies that build a detailed picture of the processes that lead to in-session resolution of painful emotional experiences during psychodrama. In doing so it provides empirical validation for the claims of the professional literature that painful emotional experiences can be resolved during psychodrama. Furthermore, there is evidence that a single intensive psychodrama intervention can reduce general symptom distress and produce specific improvements in interpersonal functioning. The findings contribute to the development of psychodrama theory and practice, with the construction of a model of change and extending the understanding of the psychodramatic constructs of spontaneity, social atom repair, catharsis and action insight; and contribute to the development of general models of therapeutic change, most specifically by testing Greenberg’s (1996, 1999) allowing and accepting painful emotional experience model in the psychodrama context. The primary aim of this thesis was to build an explanatory model of protagonist processes linked to the in-session resolution of painful emotional experiences during psychodrama, which could inform psychodrama theory and practice. A model has been constructed that conceptualises therapeutic change as the incremental development of progressive functioning, in which protagonists (1) re-experience the original problematic dynamic and make new meaning of the impact of that experience on their current functioning, (2) activate internal resourcefulness to address an interpersonal impasse, (3) experience social atom repair with emotional release, and (4) integrate progressive functioning by orienting to current and future possibilities. Experiencing a readiness to engage in the psychodramatic process was a necessary precondition for protagonists to reach resolution. The nature of psychological healing during psychodrama has been further defined, through the explication of the social atom repair event. Depth of experiencing and resourcefulness, were identified as necessary preconditions for social atom repair with emotional release. There was evidence that the corrective emotional experience that occurred during this event produced healing of both the sense of personal shattering and the interpersonal disconnection that Bolger (1999) identified as primary effects of unresolved painful emotional experience.
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Strengthening of progressive functioning preceded the corrective emotional experience and the impact of the experience was enhanced when the protagonist was able to initiate a reparative response to self. When the protagonist initiated a reparative response to self from a progressive adult role, the experience of social atom repair was integrated and the protagonist’s sense of self as a competent adult was consolidated. In-session resolution was linked to protagonists’ reports of post-session resolution, supporting findings elsewhere that in-session changes are a predictor of post-session change. However, measures of general symptom distress and interpersonal distress found no differential effect from being a protagonist. Spontaneity is considered to be a core curative factor in psychodrama (Moreno, 1946/1980). Two contributions to spontaneity theory are proposed from this thesis, one regarding the construct of spontaneity itself and the other regarding the practical application of spontaneity theory during a psychodrama session. Firstly, protagonists experienced a positive relationship to self, immediately preceding the emergence of a new response. This suggests that an increased acceptance of self in the moment increases the person’s capacity to generate a new response, consistent with Carter’s (1994) definition of spontaneity as ‘a readiness for a free and vital response to the emerging moment’ (p. 41). Secondly, protagonists’ experiences of resolution suggested an incremental development of spontaneity over the course of a psychodrama session, with a gradual development in the protagonists’ flexibility of response. A modification to Hollander’s (1969; 1981/2006) original Psychodrama Curve has been constructed, that more clearly differentiates between heightened emotion and heightened spontaneity (see Figure 13.2, Chapter 13). This modified Psychodrama Curve is consistent with the ideas proposed by McVea & Reekie (2007) and suggests that there is a spontaneity training effect over time. This thesis builds on Kellermann’s (1992) therapeutic aspects of psychodrama, by linking these aspects to specific in-session and post-session changes. Most notably, the therapeutic utility of three core psychodrama constructs, catharsis, surplus reality and action insight are clarified. The primary experience of catharsis was of a release of previously inhibited emotion, expressed as gentle weeping or deep sobbing or, on one occasion, as joyfulness. Emotional release was linked to social atom repair events. Abreaction without social atom repair was not experienced as therapeutically helpful and
Chapter 14 309 enacting a wished-for event without experiencing emotional release was experienced as less helpful than the two combined. Emotional release occurred as the person allowed a new experience of self in relation to self and/or others. This challenges the historical description of psychodrama as a primarily cathartic therapy, by locating the therapeutic experience of emotional release within the development of new role relationships. This is consistent with Clayton’s definition of catharsis of integration as ‘an expansion of the psyche … The freeing up of different abilities so that those different abilities become much more available’ (Clayton & Carter, 2004, p. 239). Social atom repair occurred in surplus reality, in the enactment of a wished-for, but previously unavailable experience. The event was experienced as surplus reality when the enactment was consistent with the protagonist’s internal reality, that is, when the interaction was experienced as being somehow true, either as an expression of unexpressed intent or as a possibility for future action. This consistency was necessary for the enactment to be experienced as therapeutically helpful. Insight was developed over time, suggesting that there is a training effect when a protagonist engages in a number of different experiential events related to the same central concern. Multiple action insight events produced a gradual deepening and extending of the meaning protagonist’s made of their experience. Three categories of action insight were identified: (i) immediate self awareness, (ii) awareness of the problematic dynamic and its impact on the protagonist’s response and (iii) awareness of a new sense of self combined with a new construction of the situation. All three categories of action insight were experienced by protagonists who reached in-session resolution, but there were notable differences in the types of psychodramatic interventions which promoted these events. Some protagonists achieved insight primarily through role reversal, while the majority of protagonists in this research achieved insight from a position of mirroring, that is, while observing and being affected by auxiliaries re-enacting a significant moment. These differences may be indicative of different developmental requirements of the individual and further investigation of action insight events may be fruitful. The therapeutic utility of psychodramatic doubling for containing overwhelming affect and the importance of mirroring in making meaning of experience has been identified in this research. Furthermore, the cases presented here identify a link between these two functions, illustrating how the regulation of overwhelming affect
Chapter 14 310 through doubling assisted protagonists to observe and be affected by the re- enactment of core events and subsequently make new meaning of their experience. In addition to its direct application to psychodrama theory, this thesis contributes to the literature on general models of therapeutic change. This is the first study that has tested Greenberg’s (1996/1999) allowing and accepting painful emotional experience model, outside of the emotion-focussed therapy modality in which it was developed. The process of allowing pain did distinguish resolved from not resolved cases, strengthening Greenberg and Paivio’s (1998) claim that this is a general model for the resolution of painful emotional experience that can be applied across therapeutic modalities. However, the sequence of protagonists’ processes differed from that identified by Greenberg (1999). Specifically, affirming self and challenging the maladaptive belief system produced an acknowledgement of the unmet need associated with the painful emotional experience, and these processes preceded, rather than followed from, the experience of emotional release. This shift in internal relations appears to make the acknowledgment of the unmet need and the subsequent experience of emotional pain, tolerable. A reconfiguration of the process of allowing emotional pain is proposed (see Figure 13.4, Chapter 13). The reconfiguration of Greenberg’s model highlights a difference in the underlying assumption of what the experience of emotional release means for the client. While Greenberg and his colleagues emphasise allowing emotional pain, these findings suggest that it is the experience of a new reality, of being able to receive a previously unmet need associated with the emotional pain, that is central to the healing process. This research was carried out in a practice setting, enabling the dynamics of psychodramatic processes to be examined in the context that practitioners typically operate in. Consequently, the findings have direct relevance to practitioners. This is the first time that change-process research has been adopted to investigate the links between specific psychodramatic events and within session and post-session changes. In contrast to simple process research, this approach applies more rigorous criteria for ascertaining and describing the therapeutic significance of events. Links between psychodramatic interventions and in-session and post-session impact have been demonstrated. A significant contribution of this analysis has been to compare resolved and not resolved cases, so that a picture emerges of the therapeutic impact when key change processes are not completed.
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There was a difference in the qualitative reports of change between protagonists who achieved in-session resolution and those who did not. An unexpected finding was that where there was in-session resolution, post-session changes were maintained or increased at 3 month follow-up. Post-session changes in the SCL90-R and IIP-127 for participants with pre-intervention scores in the clinical range were encouraging, for protagonists and non-protagonists. However, clinical cases were represented by only a small number of participants, and further investigation with more clinical cases would be required to be able to draw conclusions with any confidence. The model of protagonists’ change processes that has been constructed from this research does not prescribe how to conduct a psychodrama session to reach resolution. Instead, it provides some principles for understanding the change processes of protagonists, which can assist practitioners to make sense of events as they are occurring and guide their choice of interventions at particular points. From the comparison of resolved and not resolved cases, this research contributes to a broader understanding of the experience of protagonists where there is not in-session resolution. Worthen and Lambert (2007) found that providing therapists with information about lack of client change during therapy can improve eventual outcomes for these clients. In this research, the absence of in-session resolution did not necessarily equate to an absence of post-session change, but it was generally linked to a continued dissatisfaction in sense of self and to less change at 3 month follow-up. The model provides a construct for identifying degrees of in-session resolution that are linked to specific post-session changes and proposes areas for focus in future therapy for the individual client. The model raised possibilities of the types of tasks a client might address through participating in a psychodrama session, as well as the type of follow-up that might be necessary afterwards. This information could assist communication between practitioners, where a psychodrama intervention is used for a specific therapeutic purpose within a comprehensive program of therapy. A major challenge confronting psychodrama research is how to maintain the integrity of this complex therapeutic method while meeting the demands of rigorous research. This study has shown that established one-to-one psychotherapy research tools can, with only minor adaptation, be applied to psychodrama group interventions.
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In summary, this thesis contributes to the field of psychotherapy through the development of psychodrama theory and the development of general principles of change that promote the integration of therapeutic modalities; and offers a practical model of protagonists’ change processes that can inform practitioners’ in-session decision making.
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Appendix A A1
Personal History Questionnaire
Age …………………….. Sex (circle one): male / female Occupation: ………………………………..
Highest level of education completed (please tick): Primary school Tertiary Secondary school Post graduate tertiary If you are currently enrolled in study, what level of study are you undertaking? ...……………………. ...……………………. ...……………………. Health: Please tick all of the following that currently apply to you: I have a physical illness which affects my daily living. Details ……………..…………………………………………………………
I have a disability which affects my daily living.
Details …...…………………………………………………………………...
I have been diagnosed with a psychiatric illness. Details .…..…………………………………………………………………...
I am currently under the treatment of a psychiatrist, or have been under the treatment of a psychiatrist in the past 12 months. I am currently on the following medication (including herbal remedies) Medication For what Dose/ How long? Last Name symptoms? frequency Adjustment?
Have you previously sought counselling for psychological/emotional issues? (Tick the response that best applies to you): I have never received counselling/therapy. I am currently receiving counselling/therapy. I have sought counselling/therapy within the past 12 months, but am no longer receiving any. I sought counselling/therapy 1-5 years ago, but am no longer receiving any. I sought counselling/therapy more than 5 years ago, but am no longer receiving any. Appendix A A2
Group Work Experience: (Please tick as many boxes as apply to you.) I have participated in other therapeutic or personal growth groups I have participated in other psychodrama personal growth groups. I have had training in psychodrama. Approximate hours of training ……… I have had training in other approaches to group work. Approximate hours of training ……………..
Workshop Goals
The focus of this workshop is ‘Resolving painful emotional experiences’. Consider your personal goals for attending this workshop, and what outcomes you would like for yourself, from your participation. d. What painful emotional experience do you want to resolve? (Describe) ……………………………………………………………………………………
………….………………………………………………………………………… e. How does this experience impact on your life now?
• Identify the impact this painful emotional experience has on your life now under each of the headings that are relevant to you (a. to d. on the following pages). • Rate how important or significant to you personally you consider each impact to be, on the following scale: 1 = not at all important 4 = very important 2 = slightly important, 5 = extremely important. 3 = moderately important, a. Personal well-being (e.g. how does it affect your general sense of well-being, beliefs or attitudes you have about yourself, your emotional responses to other situations ….). Impact on my life now Importance 1...2...3...4...5 1...2...3...4...5 1...2...3...4...5 b. Interpersonal well-being (e.g. how does it affect how you relate to your family or close friends). Impact on my life now Importance 1...2...3...4...5 1...2...3...4...5 1...2...3...4...5
Appendix A A3 c. Social well-being (e.g. how does it affect how you are at work, the activities you are involved with, or your general friendships). Impact on my life now Importance 1...2...3...4...5 1...2...3...4...5 1...2...3...4...5 d. Spiritual well-being (e.g. how does it affect your sense of meaning or purpose in life). Impact on my life now Importance 1...2...3...4...5 1...2...3...4...5 1...2...3...4...5
e. What changes do you hope to achieve as a result of participating in this workshop?
……………………………………………………………………………………
Appendix B A4
Post-Workshop Evaluation Form 1. Please rate how helpful or hindering this workshop was to you overall.
1 2 3 4 5 6 7 8 9 Neither Extremely Greatly Moderately Slightly Helpful Slightly Moderately Greatly Extremely Hindering Hindering Hindering Hindering Nor Helpful helpful Helpful Helpful Hindering
Comments. ………………………………………………………………………….... ……………………………………………………………………………………....
2. What, if any of your issues were made worse by your experience in the workshop? ………….………………………………………………………………………….... ………………….…………………………………………………………………....
3. What, if any, changes do you anticipate making, as a result of participating in this workshop? ………….………………………………………………………………………….... ………………….…………………………………………………………………....
FOR EACH SESSION WITHIN THE WORKSHOP ANSWER THE FOLLOWING QUESTIONS
SESSION #: (Complete questions a to d for each session of the workshop)
a. Please rate how helpful or hindering this session was overall.
1 2 3 4 5 6 7 8 9 Neither Extremely Greatly Moderately Slightly Helpful Slightly Moderately Greatly Extremely Hindering Hindering Hindering Hindering Nor Helpful helpful Helpful Helpful Hindering
b. Please comment on what, if anything, you learnt, became aware of or decided to do, as a result of participating in this session. …………………………………………………………………………………. ………………………………………………………………………………….
c. What aspects of this session were helpful to you? …………………………………………………………………………………. ………………………………………………………………………………….
d. What aspects of this session were unhelpful to you? …………………………………………………………………………………. ………………………………………………………………………………….
Appendix B A5
Overall Workshop Reaction (Revised Session Reaction Scale, Elliott, 1993. Modified, with permission from R. Elliott, to refer to psychodrama participants & group context). Take a minute to think back over the workshop and rate the extent to which you have experienced each of the following reactions. Some of the items include a number of related but somewhat different descriptions. Where some of the items in an item fit your experience but others do not, rate on the basis of the descriptions which fit best and ignore the others. Circle the appropriate number for each item.
Not at all Slightly Somewhat Pretty Much Very Much 1 2 3 4 5
1 2 3 4 5 1. SEEING THINGS FROM ANOTHER PERSON’S PERSPECTIVE. As a result of the workshop, I have begun to see things (about myself or others) from another person’s point of view, including that of the director.
1 2 3 4 5 2. PRESSURED OR CONTROLLED. As a result of the workshop, I feel too much pressure is being out on me to confront something or to change, or I feel manipulated by the director or pushed to do something I don’t want to do.
1 2 3 4 5 3. DEFINITION OF PROBLEMS FOR ME TO WORK ON. As a result of the workshop, I have realised or become clearer about what I need to work on or what my problems or goals are, for personal development or in general.
1 2 3 4 5 4. DEPRIVED OR UNCARED FOR. As a result of the workshop, I now feel let down, abandoned or left on my own by the director; I feel deprived of guidance or support; I feel my needs have been ignored or not properly attended to by the director; or I experience the director as cold, bored, insensitive or uncaring.
1 2 3 4 5 5. INSIGHT INTO SELF: MADE NEW CONNECTIONS ABOUT MYSELF. As a result of the workshop, I have come to understand myself or my feelings or actions better, through seeing reasons or causes involving what I think, feel or do; I have learned why I do something.
1 2 3 4 5 6. MORE DISTANCED. As a result of the workshop, I am less able to feel certain feelings; or I am now pushing away or stopping myself from experiencing particular thoughts, feelings or memories.
1 2 3 4 5 7. SUPPORTED. As a result of the workshop, I now feel supported, reassured or protected by the director, either as a
Appendix B A6
person or in specific ways; or I now feel the director is ‘on my side’.
1 2 3 4 5 8. INSIGHT INTO OTHERS: MADE NEW CONNECTIONS ABOUT OTHER PEOPLE. As a result of the workshop, I have come to understand someone else better, though seeing reasons or causes for what they have done or said; or I have come to see why they are the way they are.
1 2 3 4 5 9. RELIEVED. As a result of the workshop, I now feel generally less negative, depressed, guilty, anxious or hurt; I feel more positive, relieved, unburdened, safe, relaxed, generally confident or encouraged. (Refers to positive change in emotional state, not your view of yourself).
1 2 3 4 5 10. STUCK/LACK OF PROGRESS. As a result of the workshop, I now feel stuck, blocked, floundering, or unable to progress with my issue; or I feel impatient, frustrated, angry, bored disillusioned or critical of the psychodrama process or the director.
1 2 3 4 5 11. CLOSE TO DIRECTOR. As a result of the workshop, I feel close to the director, I trust the director; I am impressed by the director, including her caring or competence; I have come to experience the director as a person or fellow human being, or I feel less alone because of my connection with the director.
1 2 3 4 5 12. CLOSE TO GROUP MEMBERS. As a result of the workshop, I feel closer to group members, I trust group members more than I did; I have come to experience other group members more as fellow human beings, or I feel less alone because of my connection with the group.
1 2 3 4 5 13. UNDERSTOOD BY DIRECTOR. As a result of the workshop, I now feel understood by the director, either generally as a person or in specific ways; or I am impressed by how accurately the director understood what I was thinking, feeling or trying to say.
1 2 3 4 5 14. UNDERSTOOD BY GROUP MEMBERS. As a result of the workshop, I now feel understood by group members, either generally as a person or in specific ways; or I am impressed by how accurately group members understood what I was thinking, feeling or trying to say.
1 2 3 4 5 15. CRITICISED BY DIRECTOR. As a result of the workshop, I now feel attacked, put down, rejected or judged by the director, or I feel the director has been critical or judgemental of me.
Appendix B A7
1 2 3 4 5 16. CRITICISED BY THE GROUP. As a result of the workshop, I now feel attacked, put down, rejected or judged by the group, or I feel the group has been critical or judgemental of me.
1 2 3 4 5 17. MORE AWARE OR CLEARER ABOUT OTHER PEOPLE. As a result of the workshop, I have become more aware of things about other people (not counting the director) or my situation; I am facing the reality of an other or outside situation; or I have become more aware of another person’s responsibility for things that have happened.
1 2 3 4 5 18. DISTRESSED. As a result of the workshop, I now feel upset or uncomfortable (for example, scared, overwhelmed, depressed, sad, embarrassed or in physical pain); I feel worse than when I started the group today; or I am more bothered by unpleasant thoughts, feelings or memories.
1 2 3 4 5 19. MORE AWARE OR CLEARER ABOUT SELF. As a result of the workshop, I am now more in touch with my feelings, thoughts or memories; I have realised something about myself or who I am; I have become clearer about things in myself that I have been avoiding or having trouble putting in words; or I am able to ‘own’ particular experiences of mine or aspects of myself.
1 2 3 4 5 20. POSITIVE BELIEFS ABOUT OTHERS. As a result of the workshop, I have begun to feel more positively or less negatively about another person or people (not counting the director), or I feel hopeful about someone else.
1 2 3 4 5 21. POSITIVE BELIEFS ABOUT SELF. As a result of the workshop, I have come to see myself or specific things about me more positively or less negatively; I have come to feel stronger, more powerful or entitled, or more complete or whole; I have a sense of having begun to make progress; or I have gained hope about the possibility of my changing in the future.
1 2 3 4 5 22. DISTRACTED OR CONFUSED. As a result of the workshop, I now feel more confused about my problems or issues; I feel interrupted, or sidetracked by the director, or I feel I have been allowed to stray or become distracted from what is important to me to work on. 1 2 3 4 5 23. PROGRESS TOWARDS KNOWING WHAT TO DO ABOUT PROBLEMS. As a result of the workshop, I have figured out how to go about resolving a specific problem or how to achieve a specific goal; or I have decided what to do about my problems or situation
Appendix C A8
Client Change Interview Protocol (Modified with permission from R. Elliott)
You will soon be contacted and asked to complete a semi-structured phone interview, about the impact of the psychodrama workshop you participated in. The major topics of this interview are any changes you have noticed since the workshop, what you believe may have brought about these changes, and helpful and unhelpful aspects of the workshop. The main purpose of this interview is to allow you to tell us about the workshop and the research in your own words. This information will help us understand better how psychodrama works; it will also help us to improve the workshops. Please provide as much detail as possible during the interview (you don’t have to make a written response to the questions).
1. General Questions.
a. What medication are you currently on? (ie any changes from pre- workshop information you gave?) b. What was the workshop like for you? How did it feel to be in the workshop? c. How are you doing now in general?
2. Changes
a. What changes, if any, have you noticed since the workshop? (For example, are you doing, feeling or thinking differently from the way you did before? What specific ideas, if any, have you got from the workshop, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) b. Has anything changed for the worse for you since the workshop? c. Is there anything that you wanted to change that hasn’t changed since the workshop?
3. Change Ratings:
Go through each change and rate it on the following three scales:
a. For each change please rate how much you expected it, Vs were you surprised by it (Use this rating scale :)
1. Very much expected it 2. Somewhat expected it 3. Neither expected nor surprised by the change 4. Somewhat surprised by it 5. Very surprised by it.
b. For each change please rate how likely you think it would have been if you hadn’t participated in the workshop.
Appendix C A9
1. Very unlikely without the workshop. (Clearly would not have happened). 2. Somewhat unlikely without the workshop. (Probably would not have happened). 3. Neither likely nor unlikely (no way of telling). 4. Somewhat likely without the workshop. (Probably would have happened). 5. Very likely without the workshop. (Clearly would have happened).
c. How important or significant to you personally do you consider this change to be? (Use this rating scale)
1. Not at all important 2. Slightly important 3. Moderately important 4. Very important 5. Extremely important.
5. Attributions: In general, what do you think has caused these various changes? In other words, what do you think might have brought them about? (Include things both outside of the workshop and to do with the workshop).
6. Helpful aspects: Can you sum up what has been helpful about the workshop? Please give examples. (For example, general aspects, specific events …).
7. Problematic Aspects:
a. What kinds of things about the workshop have been hindering, unhelpful, negative or disappointing for you? (For example, general aspects ,specific events …).
b. Were there things in the workshop which were difficult or painful but still OK or perhaps helpful? What were they?
c. Has there been anything missing – what would have made the workshop more effective or helpful?
8. Suggestions: Do you have any suggestions for us, regarding the research or the workshop? Do you have anything else that you want to tell me?
Appendix D A10
Statements of Expectations and Biases of Research Team Members
Research team member 1
Gender: Female. Age: 40-45 years.
Professional background
Qualifications: B.A. (Hons). Registered psychologist.
Psychodrama experience: Participated in psychodrama personal development groups. One year of psychodrama training (approx. 180 hours).
Describe the approach you typically take in your counselling/ psychotherapy practice. Include reference to any theoretical or philosophical approaches you are guided by. Engage client in process of consciousness-raising, including cognitive, emotional, spiritual and physical awareness. Use action, meditation, visualisation, art etc, as processes to link person with intuition/ personal knowing. Influenced by Moreno, Rogers, Ellis, Beck, Perls. Existentialist/ humanistic approach.
Expectations about client processes for resolving painful emotional experience.
What processes do you expect clients to go through, in resolving painful emotional experiences, regardless of the therapeutic approach they are engaged in?
• Clarity about breadth and depth of issue.
• Having a sense of the point of origin and how that impacts on the now.
• Developing an understanding of choice points and the impact of choices.
• Awareness of ambit of control, that is, boundaries.
• Changed consciousness of self and capacity for change
• Resolve to create difference
• To feel fully their experience in a safe environment.
In a psychodrama session, what processes would you expect a protagonist to go through, in resolving a painful emotional experience?
• Establishment of a safe space
• Warm-up to self and the drama
Appendix D A11
• Unfolding of key components in each unit of the drama
• Experiencing the role more fully through role reversal, doubling, mirroring.
• Actively choosing to be part of reconfiguring their experience and healing
• The protagonist needs to physically, emotionally and spiritually engage in the process.
• Catharsis of emotions
• Explore space with increased role repertoire.
• Share and review experiences.
Personal biases
What biases or personal experiences are you aware of that may interfere with you objectively analysing videos of people addressing painful emotional experiences? I identify strongly with feelings and am less attuned to cognitive functioning or finer processes. I often expect significant change events to be overtly ‘dramatic’. I’m aware of internal process, but look towards external markers for reality of change. I have high expectations of what people are capable of and therefore may miss significance of smaller shifts in looking for resolution.
Research Team Member 2
Gender: Female. Age: 30 – 35 years
Professional Background Qualifications: B.A. Dip.Psych. Registered psychologist. Psychodrama experience: Participated in two workshops (approx 35 hours) Describe the approach you typically take in your counselling/ psychotherapy practice. Include reference to any theoretical or philosophical approaches you are guided by. .I use an eclectic, client centred approach, with an emphasis on action methods.
Expectations about client processes for resolving painful emotional experience.
What processes do you expect clients to go through, in resolving painful emotional experiences, regardless of the therapeutic approach they are engaged in?
Appendix D A12
• Recognition at some level that they are experiencing discomfort.
• Willingness on the client’s behalf to sit with that discomfort.
• A gradually increasing (although sometimes rapid) awareness of their issue
• Resolution of their issue, either through strategies to manage the issue, or re- experiencing.
In a psychodrama session, what processes would you expect a protagonist to go through, in resolving a painful emotional experience?
• Identification, either consciously or unconsciously, of an issue
• Experiencing that issue through dramatic re-enactment and role reversal.
What biases or personal experiences are you aware of that may interfere with you objectively analysing videos of people addressing painful emotional experiences?
• I want to understand what is going on for the client and tend to label their experience internally
• A drive to find the answers and resolve the conflict or issue for the client.
• Reading meaning into a drama that isn’t there.
Research team member 3
Gender: Female. Age: 25-30 years.
Professional background
Qualifications: B.BSc. Dip.Psych. M.Psych. Registered psychologist.
Psychodrama experience: 2 years of psychodrama training (approx. 260 hours).
Describe the approach you typically take in your counselling/ psychotherapy practice. Include reference to any theoretical or philosophical approaches you are guided by. Process-oriented, client-centred therapy. Influenced by psychodrama, Rogers, gestalt therapy, cognitive-behavioural therapy, reality therapy and solution-focussed approaches.
Expectations about client processes for resolving painful emotional experience.
What processes do you expect clients to go through, in resolving painful emotional experiences, regardless of the therapeutic approach they are engaged in?
Appendix D A13
• Awareness that some aspect of functioning is impaired.
• As the client moves closer to the issue, barriers of avoidance, withdrawal or dissociation arise.
• The client is able to see these barriers and overcome some of them, at which point the underlying emotions are experienced, some form of unmet need or issue is expressed or realised.
• The client is then able to form a new understanding or meaning of the experience.
In a psychodrama session, what processes would you expect a protagonist to go through, in resolving a painful emotional experience? I would expect similar processes as stated above, but I would expect the protagonist to move through the process more quickly than if using other methods. There may be a greater expression of emotion. The integration phase, where the protagonist finds new meaning of the experience, may occur at the end of the drama or after the drama.
Personal biases
What biases or personal experiences are you aware of that may interfere with you objectively analysing videos of people addressing painful emotional experiences?
My experience as a protagonist and auxiliary in psychodrama groups has led me to expect people to express deep emotion before working through an issue or coming to resolution. This may potentially mean I take more notice of larger expressions of emotion as transition points in someone’s drama, and may overlook less overt shifts. It is important to remind myself that people’s individual personalities and learning styles differ and will affect how significant transition points are demonstrated.