Disorder-Specific Psychodrama Therapy in Theory and Practice

Front matter

Reinhard T. Krüger

Disorder-Specific Psychodrama Therapy in Theory and Practice

OPEN ACESS A Springer

Foreword

During the last half of the century, the use of psychodrama has spread all over the world. A great deal has been done to teach this method and to give people a chance to experience it in action. But since most directors are not committed to the written word, not enough has been done in conceptualizing this practice. Until psychodrama directors start to describe in detail what they do and formulate the theory on which their approach is based, they will not be able to demonstrate its value to the fullest.

Still, there are a lot of fine books about the practice of psychodrama out there. What makes this new book so special? I can think of two reasons. Firstly, this book focuses on the application of psychodramatic techniques to specific mental disorders, and secondly, it emphasizes the importance of creative mentalizing activities within the therapeutic process. These two aspects make this comprehensive book both unique and innovative. It is a long-awaited contribution to the literature on psychodrama that I hope will widen the acceptance of psychodrama as a viable alternative psychotherapy method within psychiatry and psychotherapy.

Even though psychodrama originated as a therapeutic method for alleviating mental suffering, it is not used widely in clinical settings today. One reason for this may be that psychodramatists have committed a relatively small proportion of their scientific literature to the analysis of the mechanisms by which psychodrama therapy achieves its well-known therapeutic effects. Many procedures of psychodrama therapy have been described. Yet these procedures have not yet been embedded in an inherently systematic, comprehensive theory of psychodrama techniques, nor have their specific individual effects been associated with the various mental disorders known to us. That is why it has been difficult for psychodramatists to establish whether patients are suited to psychodrama therapy and to identify the indication for a particular psychodramatic approach. For the same reasons, comparing the outcome of psychodrama therapy with other research and treatment methods has also been challenging. This book now closes this gap in psychodrama literature. It establishes a connection between the diagnostic categorization of patients and specific psychodramatic approaches. By illustrating this connection, this book can help to introduce our knowledge of the unique therapeutic possibilities presented by psychodrama into the science of mental health and the process of knowledge accumulation in cooperation

Vii viii Foreword with institutions. At the same time, this book makes it easier for psychodramatists to adopt new knowledge from other fields of psychiatry and psychotherapy and integrate it into their psychodrama therapy work.

The present work makes a tremendous contribution to explaining the therapeutic value of psychodramatic work with the inner relationship images and the mentalizing processes of people. Moreno wrote: “Psychodrama is a way to change the world in the here and now using the fundamental rules of imagination without falling into the abyss of illusion, hallucination, and delusion” (J. L. Moreno “Magic Charter of Psychodrama”, 1972). As an image-based method, psychodrama focuses on the ability of human beings to create a symbolic representation of the inner world which is continuously manifested in our dreams and play. The concept of ‘as-if’ has a central place in the methodology and philosophy of psychodrama. Its use of role-playing, auxiliary egos, the stage, warm-up exercises, props, and deliberate distortion of time and place is based on the mentalization ability of the protagonist. Role-playing encourages participants to re-enact situations from the past ‘as-if’ these events were happening in the present. Participants relate to inanimate objects ‘as-if’ these were alive, and they talk to other group members ‘as-if’ they were old acquaintances or significant persons from their lives. But there is a need to explain how such intentional activities within psychodrama help to move the therapeutic process forward. The present book improves our understanding of how such techniques may be applied to various clients, all of whom may not easily enter the imaginative ‘as-if’ world.

Ever since my first personal experience of psychodrama, I have been impressed by the quick process in which the initial ‘as-if’ quality of role-playing is transformed into a genuine sense of emotional relief. But even more powerful was the feeling that such abreaction of pent-up tension was often accompanied by a kind of empowerment, a sense of having uncovered a secret, and a feeling that “now I can be as I am”.

When I later observed talented psychodrama therapists at work, I was amazed. Their sensitivity, intuitive skill, and creative use of dramatic art were extraordinary. It looked almost magical, I felt. But they said: “No. It can be learned. You can also learn it!” And so my arduous training began. After many years, however, I still had many questions about how it worked and what each concept meant. I tried to read Moreno’s books and discussed the various therapeutic aspects of psychodrama for many hours with Zerka Moreno. Slowly, I wrote about one or the other aspect to clarify what was happening during a psychodramatic session. One of my conclusions was that psychodrama seemed especially effective for people who had experienced a specific trauma. But I also observed that psychodrama might not always help everyone in the same way. While psychodrama may be suitable for many people at various points in their life, some cannot enter into the imaginative world of role-playing or have great difficulties doing so. As a result, I feel there is a need to continue to study and investigate psychodrama.

In this context, the present book is a step in the right direction. It brings a fresh understanding to the art of psychodrama by an author with significant experience in psychodrama therapy. This volume creates a sounder conceptual basis for

Foreword ix one’s actions in psychodrama therapy and will inspire new discussions of Moreno’s contribution to the development process of psychotherapy.

Israel, Amcha Peter Felix Kellermann

Foreword of the Second Edition German Language

Reinhard T. Kriiger’s book Disorder-Specific Psychodrama Therapy: Theory and Practice by Vandenhoeck & Ruprecht is now in its second edition. This book is a stroke of luck in many ways. It is impressive not only because of the extensive psychotherapeutic experience that the author has gained in more than 40 years of psychiatric practice. This experience is also felt in the psychodramatic case descriptions with which he illustrates his theoretical considerations. A significant new addition is Kriiger’s integration of the psychoanalytic mentalization theory into an understanding of psychodrama. He describes the psychodramatic play as a process of mentalization. This process starts from the direct identification of the protagonist with what he experiences in the play through several differentiated intermediate steps in psychodrama to a level of reflection. This process enables a new perspective of reality and new ways of acting. In doing so, this book has given psychodrama, which was mainly based on Moreno’s role theory up until now, a new theoretical basis. This makes the psychodramatic action methods compatible with other psychotherapeutic approaches.

According to Fonagy, a well-known British psychoanalyst, mentalization is the human ability to understand interpersonal behavior in terms of mental states. In this way, the individual not only answers the question of what the other person or he himself is doing but also how and why. This is only possible under the prerequisite that the person concerned distances himself from his actual experience to such an extent that it is eventually possible to reflect on his experience. This is not as obvious as it might sound. Up to the age of about 3, children consider their internal experience of the world to be the actual reality. The child’s experience, therefore, changes externally from situation to situation without the child being able to establish a connection between the associated internal states of experience. In the further course of development, however, the difference between wishes and reality grows increasingly. As a result, the child’s play gains its typical as-if quality (‘I act as if I am a police officer. But Iam not’). At the age of about 4, it finally becomes possible to represent these different experiences psychologically. In a further mentalization step, the child finally thinks about them reflexively.

xi xii Foreword of the Second Edition German Language

The psychodrama play is designed on the basis of this same pattern. Here, too, the protagonist is initially fully identified with his inner experience. The processing of the play using psychodramatic methods such as setting up the scene, doubling, role-playing, changing roles, changing scenes, role feedback, identification feedback, and sharing enables the gradual mentalization of what has been experienced. This allows those affected to view the contrived experiences from a different perspective.

But that’s not all. The shift in attention from role theory to the mentalization of the patient also makes it possible to understand the patient’s structural disorders, which provide information about the extent of the patient’s ego integration. Today, one will no longer confront a patient with their inner conflicts in psychoanalytic therapy if they are not yet able to recognize them as belonging to him or herself. Similarly, in psychodramatic play, one wouldn’t confront the patient with situations he is not yet able to cope with internally, as the enacted situations would only have a re-traumatizing effect. The disorder-specific psychodrama therapy that Reinhard T. Kriiger develops in this book considers this requirement. One example of this is the recommended way of dealing with traumatized patients. With the help of the psychodrama play, they must first acquire the necessary inner stability before they can carefully approach the traumatic situation. Another example is the recommended way of dealing with the patient’s self-injurious behavior, which can briefly give a pleasurable feeling of liberation in crises, but at the cost of a lasting adverse effect in real life. The symbolization of the dysfunctional inner processes with additional chairs makes it possible for the patient to recognize them as dysfunctional, perhaps for the first time, and to develop an awareness of dysfunctional self-regulation.

Iam a psychoanalyst as well as a psychodrama therapist. In addition to my work as a psychoanalyst, I have also worked with psychodramatic groups in the course of my professional career. I did this out of the joy of understanding the latent scene that gets enacted in psychoanalysis in the therapeutic relationship between the analyst and the patient. I wanted to understand it as a psychodramatist through the actual setting up of the scene in the psychodramatic play and not just through the exploration of one’s countertransference. The different experiences I gained in this way have enriched me in many ways. And yet, while reading this book, I have learned some things I would not want to miss in my wealth of experience.

I wish that the readers of this book will have a similar experience when they read it.

Hannover, Germany Christa Rohde-Dachser

Preface

My patients, through our human encounters and their therapeutic processes, have helped me to recognize how healing takes place in psychodrama therapy. For this, I am incredibly grateful to them. In the case studies in this book, stemming from forty years of psychiatric-psychotherapeutic practice, I have changed the names and some of the facts to preserve the patients’ anonymity. I have asked many of them for permission to publish my account of their process.

Beginning in 1971, I learned the intuition-guided, process-oriented style of directing from Grete Leutz. From Heike Straub I received important impulses for the therapeutic application of psychodrama. Karl Peter Kisker taught me, as a psychiatrist, to think and work with the person, not the symptom, in my encounters with patients. Karlfried Graf Diirckheim helped me, with his existential psychological work, to recognize that healing is more than merely the sum of the individual mechanisms that lead to healing (Kriiger, 1997, p. 11 f.). Many thoughts about the content of this book arose in discussions with participants and co-directors in training seminars and with psychodrama friends, and in recent years in the training seminars in Budapest that took place as a result of the cooperation with Teodöra Tomcsänyi. My 40 years of work with the Moreno-Institut Uberlingen and my 25 years of editorial work in both the Psychodrama magazine and the Zeitschrift fiir Psychodrama und Soziometrie (Magazine for psychodrama and sociometry), currently being published by Christian Stadler and Sabine Spitzer, have allowed me to pose questions and find answers. Stefan Gunkel collaborated with me on Chaps. 1-3 and 5, and other chapters were contributed to by Gudrun Beckmann, Hans Benzinger, Giinter Biichner, Krisztina Czäky-Pallavicini, Birgit Koerdt-Brüning, Annelie Kolbe-Krüger, Volker Kollenbaum, Zsuzsa Marlok, Anne Möhring, Maren Möhring, Cameron Paul, Alfons Rothfeld, Gudrun Runge, Zs6fia Safran, Kristina Scheuffgen, Ingrid Sturm, Gabor Török, Gunhild Warbende, Kurt Weber, Stefan Woinoff, and Birgit Zilch-Purucker. I thank Giinter Barke for the production of the illustrations.

In the interest of gender equality in the terminology and to preserve the readability of this book, the individual chapters refer either to a female therapist and a male patient or a male therapist and a female patient.

xiii xiv Preface

The first edition of this book was published in 2015, and a second revised edition in 2020 by Verlag Vandenhoeck & Ruprecht in Göttingen. I thank Günter Presting and Ulrike Rastin for their immense help with the publication. The book has since been translated into Hungarian (2017, Budapest: L’ Harmattan) and Russian (2017, Moscow: KLAAS). The second edition of the German text has been largely updated and supplemented for the English translation. I am very grateful to Shama Parkhe and Jochen Becker for their great help in organizing and translating this book. It was a joint marathon and adventure over five years, where we could only reach the goal together.

Burgwedel, Germany Dr. Reinhard T. Krüger

Reference

Krüger, R. T. (1997). Kreative Interaktion. Tiefenpsychologische Theorie und Methoden des klassischen Psychodramas. Vandenhoeck & Ruprecht.

1 What is Psychodrama?

References

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Chapter 1 A) What is Psychodrama? get

Jacob Levy Moreno (1889-1974), who developed Sociometry and psychodrama, emigrated as a psychiatrist from Vienna to the USA in 1925. He is one of the founding fathers of group therapy and has been significant in promoting its development in the USA from 1931 onward. According to Moreno, group therapy is not to be equated with psychodrama (Moreno, 1959, p. 69 f.). Instead, he understood “group therapy” to be “simply” a group process in which “the immediate and sole focus is on the psychological health of the group and its members” (Moreno, 1959, p. 53). With this in mind, Moreno worked with existing groups in social institutions such as schools, dormitories, and prisons from 1932 onward. He supervised the employees there, provided organizational consultation, and worked sociotherapeutically using sociometric methods (Moreno, 1974) and role-plays.

In 1936 he founded a small psychiatric clinic in Beacon/New York. At that time, psychotherapy was still in the early stages of its development worldwide. In his 12- bed sanatorium, Moreno treated his mentally ill patients based on the fundamental principles of a therapeutic community. He integrated into the treatment of his patients his earlier experiences of role-playing with children and improvisational theater with adults in Vienna (Moreno, 1970), as well as his insights from his work in social institutions in the USA.

As a psychotherapist, Moreno treated his patients primarily in an individual setting (Straub, 2010, p. 28) (see Sect. 2.6.1) and used role-plays. He let patients develop their own roles or those of others on stage, initially without any role reversal (Moreno, 1945, p. 11 ff.; 1959, p. 221 ff.). Assisting therapists supported the patients as auxiliary egos in the various complementary roles. It was not until later that Moreno (1959, p. 210) integrated role reversal between the protagonist and an auxiliary into his therapeutic work. That was the birth hour of psychodrama as a psychotherapy method as we know it today.

The psychodrama psychotherapy described in this book is based on the concept of the creative human.

© The Author(s) 2024 1 R. T. Kriiger, Disorder-Specific Psychodrama Therapy in Theory and Practice,

2 1 What is Psychodrama?

The concept of the creative human is based on understanding humans as living beings who are constantly adapting to external living conditions. However, in doing so, humans have to maintain their own complex structures in order to be not adversely affected. For this purpose, humans use an internal creative process of self-development. This includes the systemic development of internal self-image and internal object image in the current external situation. These development processes control their external behavior in the current situation. Humans perform these processes of self-development through mentalizing. As a result, they become an actor in their own internal conflict processing.

This view of the creative human ascribes “great importance to the self-regulating processes on all levels of human living and experience” (Kriz, 2012, p. 318). It sees humans as “systemically organized holistic structures” (Kriz, 2014, p. 128 ff.). Psychodrama accomplishes this mentalizing in the as-if mode of play. In this way, psychodrama therapy proves to be a method of humanistic psychotherapy (Kriz, 2012). Psychodrama therapists do not find suitable approaches for their current practical work with their patients in books. Instead, they find the appropriate psychodrama technique within themselves as the patient’s implicit doppelganger. They playfully identify with the patient as an implicit doppelganger and want to ‘understand themselves’. They want to find an appropriate solution in ‘their own’ conflict on the patient’s behalf and therefore use the appropriate psychodrama technique in the patient’s play (see Sect. 2.5).

Psychodrama promotes the internal self-development of humans in external conflicts. Therefore, a theory of psychodrama is also a theory of self-development of humans applicable across all psychotherapy methods.

All psychotherapy methods try to understand persons in psychological distress and to jointly work on finding solutions to their conflicts. Therefore, there are similarities in the thinking and the approaches between various psychotherapy methods. For example, mentalization-oriented psychodrama therapy (see Sect. 2.2) also incorporates depth psychology, behavioral, systemic, and transpersonal therapy.

1. The psychodrama therapist uses, for example, depth psychological concepts when she connects and justifies currently inappropriate behavior or an inappropriate affect with difficult childhood experiences through scene change. She uses the concepts of transference, countertransference, and resistance when dealing with disturbances in the therapeutic relationship (see Sect. 2.7). But the psychodrama therapist also thinks systemically in mentalization-oriented psychodrama therapy.

2. The therapist helps the patient to further develop his inner self-image and object image through role reversal and, thus, dissolve blockades in internal conflict processing. In doing so, she views the patient’s conflicts (see Sects. 8.4.1-8.4.7) and the therapeutic relationship (see Sect. 2.7) systemically (see Sect. 2.4.3).

3. Elements of behavioral therapy can also be of value. Once the patient understands his old ways of dysfunctional self-regulation, he practices discarding the old way and looking for new, more appropriate behavioral opportunities depending on

1 What is Psychodrama? 3 the situation. In the therapy of persons diagnosed with personality disorders, the therapist changes metacognitive processes through psychodramatic chair work, similar to the work in schema therapy (see Sects. 4.74.11). For example, she represents the patient’s self-censorship with a chair symbolizing his ‘inner blind soul killer’. The patient should symbolize it with a hand puppet and lock him up in a cupboard at home. He is supposed to look at it once daily and write down a list of his sadistic superego’s statements. Over time, this helps him notice the ‘soul killer’ actions quicker.

4. Many psychodramatists also make use of transpersonal psychological knowledge. For example, the therapist actively recognizes and supports the patient’s passage through initiatory experiences (Dürckheim, 1984, p. 39 f.). These are profound inner changes that can occur when passing through one of the primary fears of man: the fear of death, the fear of absolute loneliness, the fear of becoming crazy, or the fear of absolute emptiness (see Sects. 5.9, 5.10.5, 5.13, 5.14, 8.8, 9.5 and 10.7). The passage through these basic fears can evoke a feeling of the specialness of life, the experience of security in extraordinary love, the knowledge of greater meaning, or the experience of the fullness of being.

Depending on the current situation, the therapist in mentalization-oriented psychodrama therapy focuses her practical psychodramatic work on.

the patient’s cognitive thought content

the metacognitive processes of mentalizing the individual identity of the patient

his systemic identity

his social identity or

his transpersonal identity.

NED

Figure 1.1 depicts these different focus areas as the poles of the diagram. In this way, the patient potentially develops his personal and ideal identity further. The focus of the work is not an either-or but a both-and approach. I have therefore illustrated the movements between the different focal points of the work as circles.

Over time, various schools of psychodrama have developed different focus areas in their work. Classical psychodrama, according to Moreno, works metacognitively, without really saying it (see Sect. 2.14). It promotes the concept of spontaneous and creative humans and the progressive development of individual groups and the whole society. It is often determined by transpersonal values. The mentalization-oriented, metacognitive psychodrama presented here follows the overarching concept of mentalizing. It justifies the disorder-specific application of psychodrama techniques against the background of a holistic systematic theory.

The composer Gustav Mahler (1860-1911) once said: “Following tradition is not to preserve the ashes, but to pass on the flame.” The mentalization-oriented theory in psychodrama helps preserve Moreno’s passion and pass it on. However, mere admiration of Moreno’s ashes prevents us, psychodrama therapists, from being spontaneous and creative. The therapist must find and admit Moreno’s creativity in herself.

4 1 What is Psychodrama?

Cognitive Identity Social Identity

Individual Personal Ideal Systemic Identity Identity Identity Identity

Metacognitive Identity Transpersonal Identity

Fig. 1.1 The focal points of therapeutic work in mentalization-oriented psychodrama

Since my first encounter with psychodrama, I have concerned myself with two questions: “How does psychodrama work?” “How does healing occur?” I came a step closer to answering these questions when I discovered the analogy between the central psychodrama techniques and the mechanisms of nocturnal dreams (Kriiger, 1978, see Fig. 3 in Chap. 2, Circle C). [had a creative breakthrough in 1995, which helped me further understand the effects of psychodrama techniques (Kriiger, 1997, S. 11 f.). In five months, I developed a cross-sectional theory of metacognitive processes. The uniqueness of psychodrama lies in the fact that the psychodrama techniques used in a play implement the internal metacognitive tools of the patient, which produce their thoughts and feelings. They release these tools from their blocked state and further develop conflict processing (see Chap. 2). Psychodramatists work directly metacognitively using psychodrama techniques.

“Metacognition” is thinking about the processes of thinking. In my understanding, the therapist works in a metacognitive manner when she, together with the patient, uses psychodrama techniques to change the metacognitive process, which creates the patient’s thought contents. In doing so, she does not focus simply on the content of the patient’s thoughts, for example, his feelings, the events, and his memories of his marital conflict. Together with him, she also improves the functioning of the tools he uses in creating these thought contents (see Sects. 2.2 and 2.7). In psychoanalysis, metacognition finds application in defense mechanisms, dream analysis, and mentalization theories. In behavioral therapy, firstly, therapists oriented themselves toward the patient’s external behavior and then developed cognitive-behavioral therapy. This approach attempts to alter the contents of thinking, detect dysfunctional presuppositions and convictions, and replace them with more appropriate thought contents. In the third wave of behavioral therapy, therapists are now focusing their attention on the metacognitive processes that create the dysfunctional content of the client’s thinking. It is, for example, the core concept in Schema therapy.

The mentalization-oriented theory of psychodrama helps us understand ‘what we do in Psychodrama when we do what we do’ (Marineau, 2011, p. 43). This understanding leads to a flexible, metacognitive disorder-specific therapy (see Sect. 2.14). The encounter between the therapist and patient or the group becomes the starting and end point of therapy.

In this book, I first describe theoretically what we do in psychodrama when we do what we do. Then, I explain disorder-specific psychodrama methods for different illnesses based on this theoretical foundation. The mentalization-oriented theory makes it possible to apply psychodrama in individual as well as in group therapy settings (see Sect. 2.6.1).

Diirckheim, K. G. (1984). Von der Erfahrung der Transzendenz. Herder.

Kriz, J. (2014). Einladung zu einer Begegnung. Morenos Werk aus der Sicht der Personenzentrierten Systemtheorie. Zeitschrift fiir Psychodrama und Soziometrie, 13(Suppl. 6), 121-135.

Kriz, J. (2012). Antrag der Arbeitsgemeinschaft Humanistische Psychotherapie (AGHPT) an den wissenschaftlichen Beirat Psychotherapie. Zeitschrift Für Psychodrama Und Soziometrie, 11(2), 311-330.

Kriiger, R. T. (1978). Die Mechanismen der Traumarbeit und ihre Beziehung zu den heilenden Vorgängen im Psychodrama. Gruppenpsychotherapie Und Gruppendynamik, 13(2), 172-208.

Krüger, R. T. (1997). Kreative Interaktion. Tiefenpsychologische Theorie und Methoden des klassischen Psychodramas. Vandenhoeck and Ruprecht.

Marineau, R. F. (2011). Die Integration von Morenos Erbe. Zeitschrift fiir Psychodrama und Soziometrie, 10(1) [Supplement 3: »Psychodrama—Empirische Forschung und Wissenschaft«, herausgegeben von C. Stadler, M. Wieser, VS Verlag fiir Sozialwissenschaften], 35-44.

Moreno, J. L. (1945). Psychodrama and the psychopathology of inter-personal relations. Beacon, N.Y.: Beacon House.

Moreno, J. L. (1959). Gruppenpsychotherapie und Psychodrama. Einleitung in die Theorie und Praxis. Thieme.

Moreno, J. L. (1970). Das Stegreiftheater (2nd ed.). Beacon House. Original work published 1923, Gustav Kiepenheuer.

Moreno, J. L. (1974). Die Grundlagen der Soziometrie. Wege zur Neuordnung der Gesellschaft (3rd ed.). Westdeutscher Verlag.

Straub, H. (2010). Seit fiinfzig Jahren arbeite ich mit dieser spannenden Methode. In D. Ensel, & G. Stiegler (Eds.), Ein Stück im Himmel. Psychodramatikerinnen begegnen sich (pp. 25-42). Zeitschrift für Psychodrama und Soziometrie 9 (Suppl. 2).