Healthcare Training Institute - Quality Education since 1979
CE for Psychologist, Social Worker, Counselor, & MFT!!
Psychodramatic groups and couples who enter treatment come with different expectations. Although group members expect to work actively and on their own problems, the couple arrives with the expectation that the therapist will help them solve their problems by talking while they assume a more passive stance. Using psychodramatic techniques with a couple represents a break in an expected pattern. J. L. Moreno illustrated his work with a couple in a psychodrama group in one of his earliest articles (Fox, 1987). On the West Coast, active techniques were tried early on. Fritz Perls (Perls, Hefferline, & Goodman, 1973) introduced the notion of having couples address each other directly, rather than speaking to the therapist about their problems. Virginia Satir (1972) also discovered that family members were more effective when communicating directly. Thus, the first request to a couple to play a role may have been, "Play yourself," because speaking directly to a partner in a social situation in which one expects to address the therapist is a shift away from ordinary conversation. Satir developed a technique called family sculpture (Jefferson, 1978), which she incorporated into her work with couples and families. Since then, there has been a widely accepted blend of family and couples therapy and experiential work (Fisher, 2002; Gladding, 1985; Guerin, 1976; Jefferson, 1978; Kipper, 1986; Papp, 1976).
Psychodramatists also began to work with families and couples. Zerka Moreno, for example, describes her psychodramatic work with families in a chapter that illustrates the adaptibility of role play to the family therapy setting (Holmes & Karp, 1991).
Couples usually enter therapy with each person blaming the other. Taking no responsibility for what has gone wrong, each partner expects the therapist to join in blaming the other person. Without active intervention from the therapist, blame can easily dominate the therapy sessions, and verbal intervention alone is often insufficient.
Couples work is difficult, partly because of its inherent systemic problems (Chasin, Grunebaum, & Herzig, 1990; Fisher, 2002; Papp, 1976; Wile, 1981). As the outsider in a trio in which two members communicate in negative but, at the same time, well-rehearsed, intimate, and protective communication, the therapist may experience frustration, anger, and helplessness, rather like the child of quarreling parents. Through objective identification, a process by which an individual teaches another how to behave in a pattern established earlier (Fisher), the therapist is often induced to join the harmful process. So much recrimination fills the air that the increasingly discouraged therapist begins to want to blame the couple for blaming.
Moreno called sponteneity the ability to respond authentically and appropriately to a new situation and viewed it as the basic building block of mental health (Fox, 1987). When recrimination provides the main content, the therapy has entered what family therapists often refer to as the blame frame, a state in which both clients and therapist have lost their spontaneity. Often at the beginning of couples work, psychodramatic techniques can make the difference. The therapist’s interrupting a couple’s demonstration of woe by doubling or requesting to make a sculpture of their relationship can shift a pathological routine to sponteneous interaction.
The following case vignettes are drawn from my own clinical experiences and those of therapists I have trained. Names and identifying information have been changed to preserve privacy, and the dialogue has been edited to make it more readable.
One of the obstacles, brought up again and again by therapists and students, to the use of active techniques in individual and couples therapy is the difficulty of getting up out of the therapist’s chair. Even therapists trained in psychodrama seem to have difficulty initiating action once they have taken on a talk therapist’s role. The expectation of being an expert is enough to glue them in one place, talking endlessly. Again and again, participants tell me that, once having got up, the process becomes easy and fun.
Doubling is a technique with great range. The therapist’s self-knowledge, confidence, and sensitivity to the couple’s responses are what determines this therapist’s timing and particular choices of action techniques. Another therapist or the same therapist with another couple may not have chosen to risk being perceived as intrusive or presumptive (Leveton, 2000) and would have introduced such work by asking permission in a more formal way (Fisher, 2002).
Without straying far from the role of therapist and by using perceptions of the client to time comments and participation, a therapist can use doubling as a way to access action techniques. As the client experiences the double in a supportive—if at times challenging—role, it is not unusual for the therapist to change back and forth between double and therapist roles. When the therapist takes on the role of someone not in the room, distance from the accustomed role creates a greater risk.
The therapist’s role flexibility (Leveton, 2000) can vary for the same therapist and among therapists as a group. Not all therapists feel comfortable with role shifts, nor do all clients. Individuals vary in the amount of structure, direction, and support they need to role play. Although many are able to be flexible, others need to play one role in a setting in which the therapist’s role never varies. The therapist must assess each couple’s ability to shift as the therapist tries different action techniques. A look of confusion, a question about the process, or an inappropriate response is a sign that more support is needed.
I have found that one advantage of beginning with the double is that it needs little explanation and can quickly transform a talk session into an action experience. From there, a couple that is inexperienced in experiential work can be introduced to a wider variety of psychodramatic techniques. For the clinician who is comfortable with doubling, its advantage is its range. Doubling can be quiet and close to the therapeutic voice or provide a dramatic, emotional contrast to it. The technique can further inner work, or it can be used to augment an interpersonal dialogue. Although it is a powerful technique that can quickly bring a client to an unanticipated emotional expression, this method can also be used to de-escalate an emotional situation with quiet reflection (Leveton, 2000).
One of the issues often raised in applying psychodramatic techniques with individual and couples therapy is the question of the therapist’s taking on a role while working with a couple. In psychodramatic groups, the director does not take a role in an enactment. Although couples therapy is different from a psychodramatic group, relevant criticisms of the therapist’s role playing center around therapeutic boundaries, transference complications, creating dependency, and the possible perception that the therapist is taking sides. Kipper (1986) suggested that the therapist leaves the scene without a director.
These are all valid points for discussion and consideration. Because a search of the literature has produced very little about these topics, the following is a summation of my own clinical experience and that of my students. In the hands of an experienced, well-trained professional with experience in a wide variety of roles, taking on a role can be an effective intervention devoid of the obvious dangers or pitfalls cited earlier. In my view—and I am aware that this will stimulate controversy—the issue of therapeutic boundaries is resolved not only by following the observable, established roles of therapist and client, of director and protagonist, but also by taking the personality and individual style of therapist and client into account. The therapist’s taking a role in an enactment depends on such characteristics as role flexibility, expressiveness, tolerance of expressiveness, and the trust residing in both participants. The dangers, of course, are always there, just as they are with any other form of therapeutic intervention. The therapist must take care to separate personal agendas from the client‘s material (Hayden-Seman, 1998). The therapist must follow, rather than lead, the client (Moreno, Blomkvist, & Ruetzel, 2000). The therapist must check the intervention against the client‘s response in order to judge its effectiveness.
In one of the first family interviews in which I tried doubling, I was worried about the possibility of taking sides when I doubled for an adolescent who had been silent during the initial three sessions. Doubling for her for a good part of the hour, I was afraid that other family members would feel left out or unattended. I was surprised to learn that the opposite was true: The others expressed relief at hearing the adolescent’s concerns, first in my voice, then in her own. Further role plays encouraged my joining in the enactments of families and couples when I thought it appropriate.
All therapeutic techniques that deal with surplus reality require flexibility. Perhaps the challenge to the director’s role as the expert or the authority figure is most difficult to accept. It flies in the face of convention. A patient without a doctor? A protagonist without a director? But a director who takes a role is still a director, as theater and film, where the shift is also debated, have proven on many occasions. It is possible, with many clients, to shift between directing and participating, just as it is possible, in family therapy, to join the family part of the time and remain outside the family in the role of the observing expert authority part of the time. The question becomes one of ability. Can the director shift back and forth? Can the client tolerate and benefit from the shift? Leaving the couple without a therapist, in the sense of a person who remains obviously in charge of the session and its direction, is definitely a concern. A client who has developed strong dependency feelings for the therapist may not be able to tolerate a shift in roles. Clients may indeed feel abandoned by a therapist who leaves the expected situation and enters a role play. If the therapist senses that one or both members of the couple need to be working with someone who takes a strong and consistent role, role taking is not advised.
The client’s needs must determine the use of any therapeutic technique. There are clients who need the therapist to remain impersonal and in the background; it is unlikely that they would tolerate a therapist’s taking a role in a personal enactment. Others look for any signs that reveal their therapist’s personality: the greater range of expression allowed to the therapist who takes a role can provide enrichment and relief for such a client. Flexibility is a requirement; clients who have not achieved role flexibility themselves are seldom able to tolerate it in a therapist. Both therapist and client need the ability to play. The therapist must be capable of assessing the client’s ability to tolerate a role shift and of understanding the subtle cues that signal trouble. Any sign of disorientation or anxiety when a new technique is introduced should alert the therapist to question its appropriateness. Confusion and anxiety are often related to the amount of ambiguity in a situation. In order avoid confusing the client, the therapist must make a clear shift between behavior as a talk therapist and director, and joining in an enactment. The therapist must be able to vary behavior and language enough for the client to experience a new and different role. There must be a clear signal, however subtle, that tells the client when the role-playing begins and when it ends.
Transference issues may arise. A therapist playing an antagonistic mother may fear that the role will affect the client’s view and consequent relationship. Any role taken by the therapist offers the possibility for new transference projections. Countertransference is equally important. In identifying with husband or wife, the therapist must work for awareness of personal agendas. Because role playing provides an avenue of direct, feelingful expression, the therapist must take care to express feelings appropriate for the client instead of using the opportunity to express personal needs. Like any clinician, I have learned over time to track several levels of the client’s experience simultaneously, and have trained my students to do the same. When role playing in couples or individual therapy, the therapist must assess the effects of the role play, much as the actor assesses the audience’s reaction. The couples’ sense of security, any signs of confusion, irritation, anger, or sadness that fall outside the dimensions of the role play must be noted and filed for later discussion.
One of the advantages of couples therapy is that psychodramatic sharing can be augmented with an ongoing, complex discussion of the role-play. On the therapist’s part, openness to discussing process and possible transference and dependency issues is of primary importance in helping to resolve such issues as they arise. The client’s feelings about the therapist’s taking on a role can be addressed when appropriate. In addressing the process and helping to bring conflictual
- Leveton, Eva. Escaping the Blame Frame: Experimental Techniques with Couples. Journal of Group Psychotherapy, Psychodrama, & Sociometry, Summer 2005, Vol. 58, Issue 2.
Reflection Exercise #2