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APA Article Division 49 Newsletter October 2022

Experiential Group Psychotherapy & Psychodrama Column

This is an author preprint, published article available at:

Giacomucci, S. (Oct 2022). Psychodrama as a Treatment for Complex PTSD. Experiential Group Psychotherapy & Psychodrama Column. The Group Psychologist. Division 49: Society of Group Psychology & Group Psychotherapy. American Psychological Association. Washington, D.C. Accessible at – https://www.apadivisions.org/division-49/publications/newsletter/group-psychologist/2022/10/issue.pdf#page=13

Psychodrama as an Effective Treatment for Complex PTSD

By Scott Giacomucci, DSW, LCSW, BCD, CGP, FAAETS, TEP

Complex trauma and Complex Post-Traumatic Stress Disorder (CPTSD) are increasingly becoming recognized as commonly presenting clinical issues in group therapy. Though it has not been recognized in the DSM-5 as a mental health disorder, it was recognized in the ICD-11. CPTSD is caused by repeated experiences of trauma and is characterized by disruptions in 1) sense of self, 2) relationships, and 3) emotional regulation – in addition to the PTSD symptom clusters of reexperiencing, avoidance, and arousal, reactivity, and current sense of threat. CPTSD most often manifests as a result of reoccurring relational trauma in childhood while PTSD is more often caused by single incident traumas and shock trauma such as an experience of violence, a natural disaster, or motor vehicle accident. Preliminary research on CPTSD suggests that it may be even more common than PTSD in some clinical samples (Karatzias et al., 2017).

The unique nature of CPTSD strongly reflects many of the primary concerns of clients who seek psychotherapy and group psychotherapy services – struggles related to sense of self, relationships, and emotional regulation. Chances are good that every group therapist has participants in their groups (and likely also staff on their team) who are survivors of complex trauma and/or experiencing CPTSD symptoms. As such, it is important that clinicians be familiar with the treatment of CPTSD in group settings. In my own experience facilitating groups in inpatient substance abuse treatment and at an outpatient trauma therapy center, the majority of clients seeking services are survivors of complex trauma.

The neurobiology of trauma points to its impact to non-verbal parts of the brain (and body) that are only marginally impacted by cognition or talking (van der Kolk, 2014). Trauma is largely stored in the right hemisphere of the brain and coded in implicit memories. This may be particularly true for complex trauma, relational trauma, and attachment trauma – and especially when the memories are pre-verbal or repressed. Many trauma survivors are unable to remember their trauma or unable to tolerate the overwhelming emotions that accompany retelling the stories. Group therapists are faced with the same limitations of talk therapy in the treatment of trauma and are encouraged to also consider integrating action methods into their group processes.

This article focuses on psychodrama as one of the oldest group therapies (developed in 1921) and the first formalized creative arts therapy or body-oriented psychotherapy. Psychodrama emerged within Jacob Moreno’s triadic system – sociometry, psychodrama, and group psychotherapy – each of which parts can be effective in addressing complex trauma. Group therapy, with its emphasis on relationships and social learning, provides complex trauma survivors with significantly more opportunities to renegotiate relational trauma and what Yalom and Leszcz (2020) describe as the “recapitulation of the primary family group” in their therapeutic factors. This essentially describes the process by which the therapy group, and the matrix of relationships within it, can provide a safe holding environment and corrective renegotiation of internalized relational trauma from childhood.

Sociometry offers various action-based group tools for group leaders that may be useful when working with complex trauma – such as spectrograms, step-in sociometry, locograms/floor checks, and sociograms (which were detailed in previous articles of this newsletter column). Sociometry is intrinsically focused on the nature of relationships within one’s life and within the group itself. Considering that complex trauma primarily is experienced through harmful interpersonal relationships, it makes sense that sociometric analyses and interventions targeting the sociodynamics within groups would be important to consider. Experiential sociometry tools offer participants with a multitude of opportunities to reflect on their social choices, better understand themselves and others, see how others experience them, prevent retraumatization or unhelpful reenactments in the group sociodynamics, and consider the patterns of attractions and repulsions in their social life. Action sociometry provides the group with opportunities to move around the group and interact with each other in new ways while uncovering shared identity and experiences in an emotionally titrated manner that promotes emotional regulation (for a more in-depth description of action sociometry, see Giacomucci, 2021a).

The surplus reality of psychodrama affords limitless potentialities for renegotiating complex trauma (Giacomucci & Stone, 2019). Courtois & Ford (2016) outline a three phase approach in the treatment of CPTSD – 1) safety, stabilization, and engagement, 2) processing trauma, and 3) (Re)Integration. Following this triphasic model of trauma treatment, we might focus initial psychodrama sessions on developing strengths and resources to face trauma, promote affect regulation, and reconnect to a sense of safety beyond the hyperarousal (Giacomucci, 2018, 2021c). Trauma-informed psychodramatic interventions such as the double, mirror, and role reversal directly address CPTSD symptoms including reexperiencing, avoidance, arousal and reactivity, distorted sense of self, disruptions in relationships, and emotional regulation (Giacomucci, in-press). Once phase 1 objectives have been accomplished, psychodrama can be used to revisit moments of complex trauma, psychodramatically undo, then redo the memory in a new and corrective way. This provides clients with an embodied experience of completing survival responses that were unfulfilled in the moments of complex trauma while renegotiating traumatic memory networks with developmental repair and healing (Giacomucci, 2019, 2021b). As part of phase 3 trauma work, psychodrama can be used to envision and embody posttraumatic growth and role train or rehearse future templates for life situations that may trigger CPTSD symptoms. This provides a client with the opportunity to develop new social skills, confidence, spontaneity, and reformulate attachment styles and ways of being with others and the world.

Currently, there are very few research studies on the effective treatment of CPTSD (especially group therapy treatments of CPTSD), however some suggest that research on PTSD can guide our understanding of effective treatments for CPTSD as well (Karatzias et al., 2019). The emerging research on psychodrama as a treatment for PTSD continues to support its effectiveness with various traumatized populations (Giacomucci, 2021b). My own ongoing research on psychodrama and PTSD in an inpatient drug and alcohol center is primarily with complex trauma survivors and suggests high treatment effects (Giacomucci & Marquit, 2020; Giacomucci, Marquit, Miller Walsh, & Saccarelli, in-press). Interestingly, when past treatment outcome data using the DSM IV PTSD criteria are compared with newer (yet to be peer-reviewed or published) data from the same program using the updated DSM-5 PTSD criteria, the treatment effect nearly doubled from a mean decrease in PTSD of 20-25% to a mean decrease of about 45%. There may be other reasons for this change, but a primary reason appears to be the use of the updated PTSD diagnostic criteria. The primary change in the new DSM 5 PTSD symptomology is the inclusion of a new symptom cluster of “Negative Cognitions and Moods” which appears to overlap with the ICD-11 CPTSD symptoms of disruptions in sense of self, relationships, and emotional regulation. This suggests that psychodrama may be an effective treatment for CPTSD, but more research is needed to validate this hypothesis.

References

Courtois, C. A. & Ford, J. D. (2016). Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach. New York, NY: The Guildford Press.

Giacomucci, S. (2018). The trauma survivor’s inner role atom: A clinical map for post-traumatic growth. Journal of Psychodrama, Sociometry, and Group Psychotherapy. 66(1): 115-129

Giacomucci, S. (2019). Social group work in action: A sociometry, psychodrama, and experiential trauma group therapy curriculum. Doctorate in Social Work (DSW) Dissertations. 124. Retrieved from https://repository.upenn.edu/cgi/viewcontent.cgi?article=1128&context=edissertations_sp2

Giacomucci, S. (2021a). Experiential sociometry in group work: Mutual aid for the group-as-a-whole. Social work with groups, 44(3), 204-214.

Giacomucci, S. (2021a). Social work, sociometry, and psychodrama: Experiential approaches for group therapists, community leaders, and social workers (Vol. 1). Springer Nature.

Giacomucci, S. (2021b). Traumatic stress and spontaneity: Trauma-focused and strengths-based psychodrama. In J. Maya & J. Maraver (Eds), Psychodrama Advances in Psychotherapy and Psychoeducational Interventions. Nova Science Publishers

Giacomucci, S. (in-press). Trauma-Informed Principles in Group Therapy, Psychodrama, and Organizations: Action Methods for Leadership. Routledge.

Giacomucci, S., & Marquit, J. (2020). The effectiveness of trauma-focused psychodrama in the treatment of PTSD in inpatient substance abuse treatment. Frontiers in Psychology, 896.

Giacomucci, S., Marquit, J., Miller-Walsh, K. & Saccarelli, R. (in-press). A Mixed-Methods Study on Psychodrama Treatment for PTSD and Depression in Inpatient Substance Use Treatment: A Comparison of Outcomes Pre-Pandemic and During Covid-19. Arts in Psychotherapy.

Giacomucci, S., & Stone, A. (2019). Being in two places at once: Renegotiating traumatic experience through the surplus reality of psychodrama. Social Work with Groups, 42(3), 184-196.

Karatzias, T., Cloitre, M., Maercker, A., Kazlauskas, E., Shevlin, M., Hyland, P., … & Brewin, C. R. (2017). PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. European journal of psychotraumatology, 8(sup7), 1418103.

Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., … & Hutton, P. (2019). Psychological interventions for ICD-11 complex PTSD symptoms: Systematic review and meta-analysis. Psychological medicine, 49(11), 1761-1775.

Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking Press.

Yalom, I. D., & Leszcz, M. (2020). The theory and practice of group psychotherapy. Basic books.

APA Div 49 Column Oct 2022 revised2

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Psychodrama as an Effective Treatment for Depression

By Scott Giacomucci, DSW, LCSW, BCD, CGP, FAAETS, TEP

Published July 2022 in The Group Psychologist – newsletter of APA Division 49: Group Psychology and Group Psychotherapy – https://www.apadivisions.org/division-49/publications/newsletter/group-psychologist/2022/07/newsletter-july-2022.pdf

Depression is one of the most common mental health conditions impacting millions of people each year. Studies in the early phases of the covid-19 pandemic suggested that the prevalence of depression tripled in samples in the United States from 8.5% pre-pandemic to nearly 27.8% in 2020 and 32.8% in 2021 (Ettman et al., 2020, 2022). Prior to the pandemic, depression was already a significant mental health concern; yet covid-19 has increased the need and demand for effective interventions in the treatment of depression. Group therapies, including psychodrama, offer practitioners with effective and efficient interventions for treating depression. The demand for mental health services and increased isolation from the pandemic position group therapy approaches as ideal due to their cost effectiveness, ability for one professional to provide treatment to multiple clients at once, and inherent emphasis on social connection. Experiential group methods not only highlight connection but also promote action, spontaneity, and playfulness which many find as important qualities in overcoming depression.

Depressive symptoms include changes in mood and appetite, diminished interest, pleasure, movement, activity, energy, and ability to think or concentrate, as well as an increase in depressed feelings, suicidal ideation, guilt, and worthlessness (APA, 2013). Depression is often paralyzing and debilitating. It impacts one’s ability to cultivate meaningful relationships, function in life, and maintain a positive sense of self. The feelings of hopelessness and worthlessness that come with depression are prone to fueling thoughts of suicide. Prolonged and chronic depression also leads to a layered experience of loss and ambiguous loss in that relationships, opportunities, and time tend to pass by unfulfilled. An individual experiencing depression is weighed down by the heaviness of a disheartened mood, slowed cognitive processing, fatigue, and the lack of interest or pleasure in activities. Depression results in a divorce of spontaneity, a disengagement from life, a rupture in one’s relationships with humor, joy, and playfulness.

Group therapy is an effective treatment for depression (McDermut, Miller, & Brown, 2001). There are unique benefits to group work compared to individual work when treating depression as groups offer a multiplicity of social interactions that are absent in individual work. A group for folks experiencing depression offers a sense of normalization, validation, and cohesion that would be tough to cultivate anywhere other than in a group setting. The worthlessness, isolation, and hopelessness related to depression can be alleviated by the connective group process. Groups provide opportunities for connection, cohesion, and solidarity. Group work actively counter acts depressive symptoms through psychoeducation, mutual aid, collective empowerment, and the eradication of loneliness. Groups help depressed clients see that they are not alone. The all-in-the-same-boat phenomenon that emerges in groups initiates existential validation and interpersonal comfort.

Group psychotherapy is part of Jacob Moreno’s triadic system – sociometry, psychodrama, and group psychotherapy (Giacomucci, 2021). Psychodrama is primarily a group approach, though it can be used in individual settings as well. As such, the benefits of general group therapy are as present in psychodrama group therapy. Psychodrama psychotherapy, however, includes more active, creative, dramatic, and body-oriented interventions than traditional group therapy. The action methods involved in psychodrama may be particularly useful in combatting symptoms of depression that include a reduction in physical activity, loss of energy, and diminished interest and pleasure in activities. These three specific depressive symptoms are actively addressed through the experiential nature of psychodrama groups which warm participants up to action through spontaneity training, improv games, experiential sociometry, and role-playing techniques. Moreno’s tombstone reads “the man who brought laughter into psychiatry” (Nolte, 2014), a notion which is further supported by recent research findings demonstrating that participants experience the psychodrama groups as fun (Giacomucci & Marquit, 2020). The inherent incorporation of playfulness, humor, and spontaneity in psychodrama treatment may further contribute to its effectiveness in treating depression. The current research literature on psychodrama psychotherapy as a depression treatment supports its effectiveness, though more research is needed (Costa et al., 2006; Dehnavi, Hashemi, & Zadeh-Mohammadi, 2016; Erbay et al., 2018 Giacomucci, Marquit, Miller-Walsh, & Saccarelli, under-review; Souilm & Ali, 2017; Wang et al., 2020). Furthermore, some evidence has emerged depicting an inverse relationship between spontaneity and depressive symptoms (Testoni et al., 2016, 2020). While more research is needed in this area, the relationship between spontaneity and depressive symptoms deserves further exploration.

Spontaneity is the curative agent in psychodrama psychotherapy (Moreno, 1953). Spontaneity is defined as an energy that helps us facilitate new responses to old, reoccurring situations, and adequate responses to novel situations. The emerging spontaneity research demonstrates spontaneity’s positive relationships to various measures of well-being and social functioning, as well as its inverse relationship to other psychosocial problems or mental health disorders (see summary of the spontaneity research in Giacomucci, Marquit, & Miller-Walsh, 2022). Depression, through the lens of spontaneity theory, would be conceptualized as an absence of spontaneity – stuckness, inability to live freely, and reoccurring response to the often chronic symptoms of depression. The infusion of spontaneity, accessed through a warming-up process, helps patients reconnect to the vitality of life and develop new responses to their inner experience and social circumstances. Spontaneity seems to be a remedy for depression and other mental health conditions.

Spontaneity is only accessed through a warming-up process – this is depicted through Moreno’s Canon of Creativity (Moreno, 1953). In psychodrama practice, the warm-up phase of a group most often involves spontaneity games and/or sociometry processes (see Giacomucci, 2021 for a comprehensive overview of experiential sociometry and the Canon of Creativity). Simple sociometry processes, such as locograms, floor checks, spectrograms, and step-in sociometry, can be employed in groups focused on the topic of depression to provide psychoeducation, connection, normalization, and develop new insight for clients. One example is to employ a floor check of depression symptomology. This would entail printing out the symptoms of depression on different pages and distributing them throughout the group room while providing brief psychoeducation (Dayton, 2015). Then, asking participants to physically place themselves at the symptom that answers a prompt – for example, “which symptom do you experience the most often?”, “which symptom feels the most disruptive to your life?”, “which symptom do you experience least often?”, “which symptom do you feel you have gotten better at coping with?”, etc. With each new prompt, a new constellation of clustered group members emerges. In between prompts, participants are directed to share with the group-as-a-whole, or to share with each other about their choices. This promotes mutual aid, connection, validation, self-awareness, and group cohesion (Giacomucci, 2020). These sociometry processes can be employed as stand-alone group processes or as warm-ups to a psychodrama or other group activity.

The psychodramatic process has the power to help participants access their spontaneity, address underlying issues, confront their depression, and develop hope for the future. In a psychodrama enactment, patients could externalize the negative beliefs related to their depression to renegotiate their relationship to core beliefs and actively or symbolically replace them with new positive cognitions. Strength-based psychodrama vignettes can help clients enlist their personal strengths and develop new strengths or resources that may be needed to recover from depression and related hopelessness or unworthiness. A client could have a direct conversation with their depression in psychodrama, explore their relationship and practice new intrapsychic responses to depressive symptoms in the safety of the group with the support of others. Psychodrama allows patients to travel into the future and engage with themselves in remission/recovery from their depression – embodying a new self, living with hope, peace, and purpose. The interpersonal focus of psychodrama and sociometry provides clients with opportunities to practice implementing new social skills, role train for future situations, and experiment with new versions of self in the group.

The very nature of depressive symptoms impacts an individual’s sense of interest, pleasure, energy, and physical movement. With this in mind, it makes senses that interactive, engaging, and action-based approaches would be desired in the treatment of depression. Sociometry, psychodrama, and group therapy provide clients with tools for combating the stigma, isolation, shame, guilt, and loss often associated with depression. Experiential sociometry processes allow group workers to bring the process to life through dynamic and engaging psychoeducation and inherently connecting group activities. Psychodrama offers participants with opportunities to externalize parts of self, develop new roles or strengths, practice for future social situations, and envision a hopeful future.

References

American Psychiatric Association, D. S., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5). Washington, DC: American psychiatric association.

Costa, E. M. S., Antonio, R., Soares, M. B. D. M., & Moreno, R. A. (2006). Psychodramatic psychotherapy combined with pharmacotherapy in major depressive disorder: an open and naturalistic study. Brazilian Journal of Psychiatry, 28, 40-43.

Dayton, T. (2015). NeuroPsychodrama in the treatment of relational trauma: A strength-based, experiential model for healing PTSD. Health Communications, Inc

Dehnavi, S., Hashemi, S. F., & Zadeh-Mohammadi, A. (2016). The effectiveness of psychodrama on reducing depression among multiple sclerosis patients. International Journal of Behavioral Sciences, 9(4), 246-249.

Ettman, C. K., Abdalla, S. M., Cohen, G. H., Sampson, L., Vivier, P. M., & Galea, S. (2020). Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA network open, 3(9), e2019686-e2019686.

Erbay, L. G., Reyhani, İ., Ünal, S., Özcan, C., Özgöçer, T., Uçar, C., & Yıldız, S. (2018). Does psychodrama affect perceived stress, anxiety-depression scores and saliva cortisol in patients with depression?. Psychiatry investigation, 15(10), 970.

Ettman, C. K., Cohen, G. H., Abdalla, S. M., Sampson, L., Trinquart, L., Castrucci, B. C., … & Galea, S. (2022). Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of US adults. The Lancet Regional Health-Americas, 5, 100091.

Giacomucci, S. (2020). Experiential sociometry in group work: Mutual aid for the group-as-a-whole. Social work with groups, 44(3), 204-214.

Giacomucci, S. (2021). Social work, sociometry, and psychodrama: Experiential approaches for group therapists, community leaders, and social workers (Vol. 1). Springer Nature.

Giacomucci, S., & Marquit, J. (2020). The effectiveness of trauma-focused psychodrama in the treatment of PTSD in inpatient substance abuse treatment. Frontiers in Psychology, 896.

Giacomucci, S., Marquit, J., & Miller Walsh, K. (2022). A controlled pilot study on the effects of a therapeutic spiral model trauma-focused psychodrama workshop on post-traumatic stress, spontaneity and post-traumatic growth. Zeitschrift für Psychodrama und Soziometrie, 21(1), 171-188.

Giacomucci, S., Marquit, J., Miller-Walsh, K. & Saccarelli, R. (under-review). A Mixed-Methods Study on Psychodrama Treatment for PTSD and Depression in Inpatient Substance Use Treatment During Covid-19.

McDermut, W., Miller, I. W., & Brown, R. A. (2001). The efficacy of group psychotherapy for depression: A meta‐analysis and review of the empirical research. Clinical psychology: Science and practice, 8(1), 98-116.

Moreno, J. L. (1953). Who shall survive?. Beacon House.

Nolte, J. (2014). The philosophy, theory and methods of JL Moreno: The man who tried to become god. Routledge.

Souilm, N. M., & Ali, S. A. (2017). Effect of psychodrama on the severity of symptoms in depressed patients. American Journal of Nursing Research, 5(5), 158-164.

Testoni, I., Bonelli, B., Biancalani, G., Zuliani, L., & Nava, F. A. (2020). Psychodrama in attenuated custody prison-based treatment of substance dependence: The promotion of changes in wellbeing, spontaneity, perceived self-efficacy, and alexithymia. The Arts in Psychotherapy, 68, 101650.

Testoni, I., Wieser, M., Armenti, A., Ronconi, L., Guglielmin, M. S., Cottone, P., & Zamperini, A. (2016). Spontaneity as predictive factor for well-being. In C. Stadler, M. Wieser, & K. Kirk (Eds.), Psychodrama. Empirical research and science 2 (pp. 11-23). Springer, Wiesbaden.

Wang, Q., Ding, F., Chen, D., Zhang, X., Shen, K., Fan, Y., & Li, L. (2020). Intervention effect of psychodrama on depression and anxiety: A meta-analysis based on Chinese samples. The Arts in Psychotherapy, 69, 101661.

Psychodrama as a Treatment for Anxiety

By Scott Giacomucci, DSW, LCSW, BCD, CGP FAAETS, TEP

Published March 2022 in The Group Psychologist – newsletter of APA Division 49: Group Psychology and Group Psychotherapy – https://www.apadivisions.org/division-49/news-events/anxiety-treatment

Psychodrama is an experiential psychotherapy approach that utilizes role playing techniques and other action methods to address psychosocial issues. Psychodrama appears to be a promisingly effective treatment for anxiety disorders and can be particularly useful in reducing fear and anxiety (Abeditehrani et al., 2020; Erbay et al., 2018; Tarashoeva, Marinova-Djambazova, & Kojuharov, 2017; Wang et al., 2020). The philosophy and practices within the triadic system of sociometry, psychodrama, and group psychotherapy offer helpful instruments for conceptualizing and addressing anxiety in action. Some of these tools include spontaneity theory, the warming-up process, group therapy, sociometry, psychodrama, and role training.

Psychodrama’s founder, Jacob Moreno, theorized nearly 100 years ago that anxiety and spontaneity were inversely correlated (1934). He writes that when our anxiety is high, our spontaneity is low; and when we are able to increase our spontaneity, our anxiety diminishes (Moreno, 1953). In psychodrama theory, spontaneity is defined as the capacity to respond to new situations with adequacy and to respond to reoccurring situations with novelty (Moreno, 1946). The term spontaneity has a specific meaning in the psychodrama community. It is less associated to the pop-culture use of the term which has become somewhat related to impulsivity. Instead, psychodramatists approach spontaneity more as a competence for skillful living and aliveness (Giacomucci, 2021a).

Moreno’s spontaneity theory affirms that spontaneity can only be accessed through a warming-up process (1953). The warming-up process manifests differently based on the situation at hand but often involves a warm-up on multiple levels such as physically, emotionally, psychologically, socially, spiritually, and warm-up specific to the content and process at hand (Giacomucci, 2021b). The lack of attention to the warming-up process may be a major shortcoming in work with anxiety. Anxiety can start to feel like resistance. However, in psychodrama, ‘resistance’ is reframed as a lack of warm-up or a suggestion that the individual is simply warmed-up to something else. This reconceptualization of anxiety and resistance can help group workers respond to anxiety with an extended warm-up to help mobilize clients to action. It seems likely that someone struggling with anxiety would need even more focus on the warming-up process as their anxiety or stress is likely to prevent a quick and efficient warm-up (Giacomucci, 2021b). Remembering this can help group therapists support their groups by meeting them where they are at and extending patience for their slower warm-up process.

Though some clients may struggle with groups due to their anxiety, group therapy research has highlighted its effectiveness in treating anxiety disorders (Barkowski et al., 2016; Barkowski et al., 2020). Group therapy is unique compared to individual therapy due to its more dynamic social elements. The ‘group’ aspect of group therapy may initially be a barrier for clients with social anxieties but with increased warm-up and preparation many clients with social anxiety are successfully able to participate in groups. Group therapy offers the ability to actively combat isolation which tends to characterize the experience of clients with anxiety disorders. The group atmosphere provides opportunities for clients to see others demonstrate social skills and also to practice implementing new social skills. The support system within the group often becomes an important modulator of anxiety for clients whilst also offering them opportunities to help others which increases their sense of confidence in themselves. While group therapy is an effective approach for treating anxiety, the other aspects of Moreno’s triadic system (sociometry and psychodrama) offer avenues for advancing the group process.

The clinical practice of sociometry focuses on utilizing an enhanced sense of group dynamics, sociodynamics, group assessment, group development, and interpersonal phenomena to implement interventions that promote cohesion, healing, inclusion, equity, mutual aid, and interpersonal learning (Giacomucci, 2020; Hale, 2009). Sociometry practice involves particular attention to the system of attractions and repulsions between group members and the distribution of social wealth – both of which are likely to fuel the anxiety of group members if uncontained by the facilitator. A sociometrist works towards group goals by employing various experiential sociometry tools such as sociometric tests, spectrograms, sociograms, locograms, step-in sociometry, and small group work (see Giacomucci, 2021a for detailed explanations on each of these sociometry tools). Though it can be used alone, experiential sociometry is most often used as a warm-up to a psychodrama enactment.

Psychodrama can be used to fortify the client in the here-and-now through intrapsychic scenes focused on engaging the strengths needed to face anxiety. Psychodrama offers multiple avenues for addressing anxiety, perhaps two of the most significant include 1) using psychodrama to find closure with unresolved past experience that may be a source of present anxiety, and 2) using psychodrama to enact future situations and provide role training to quell anxiety about anticipated experiences. With the first avenue, psychodrama allows us to revisit the underlying fueling factors of anxiety, such as childhood trauma or past adversity, to renegotiate how those experience have been internalized (Giacomucci, 2018; Giacomucci & Stone, 2019). For example, we could facilitate a client, who experienced childhood physical abuse, to psychodramatically nurture and protect themselves as a defenseless child while standing up to the perpetrator and the associated negative cognitions introjected from the perpetrator. In the second approach, psychodrama can be used to develop future scenes that provoke anxiety to help clients practice responding to them before being confronted with them in real life. This is called role training in psychodrama. The role training process allows clients to experiment in the safety of the group and try multiple methods of responding to the situation. The role training experience helps to mitigate anxiety while increasing spontaneity and confidence so that clients feel better prepared to face future situations having role played multiple responses already.

Moreno’s triadic system offers a multitude of methods to address anxiety and anxiety disorders. The integrated application of sociometry, psychodrama, and group psychotherapy provides group therapists with a theoretical framework and actionable interventions for dynamic groups while cultivating safety, spontaneity, cohesion, connection, social skills, mutual aid, healing, integration, resolution, growth, and role training for group participants. While psychodrama would benefit from more research to further validate its effectiveness as a treatment for anxiety, it offers group psychotherapists innovative tools to enhance group practice.

References:

Abeditehrani, H., Dijk, C., Toghchi, M. S., & Arntz, A. (2020). Integrating cognitive behavioral group therapy and psychodrama for social anxiety disorder: An intervention description and an uncontrolled pilot trial. Clinical Psychology in Europe, 2(1), 1-21.

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J. (2016). Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. Journal of anxiety disorders, 39, 44-64.

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., & Rosendahl, J. (2020). Efficacy of group psychotherapy for anxiety disorders: A systematic review and meta-analysis. Psychotherapy Research, 30(8), 965-982.

Erbay, L. G., Reyhani, İ., Ünal, S., Özcan, C., Özgöçer, T., Uçar, C., & Yıldız, S. (2018). Does psychodrama affect perceived stress, anxiety-depression scores and saliva cortisol in patients with depression?. Psychiatry investigation, 15(10), 970.

Giacomucci, S. (2018). The trauma survivor’s inner role atom: A clinical map for post-traumatic growth. Journal of Psychodrama, Sociometry, and Group Psychotherapy. 66(1): 115-129

Giacomucci, S. (2020): Experiential sociometry in group work: mutual aid for the group-as-a-whole, Social Work with Groups, Advanced online publication. https://doi.org/10.1080/01609513.2020.1747726

Giacomucci, S. (2021a). Social Work, Sociometry, and Psychodrama: Experiential Approaches for Group Therapists, Community Leaders, and Social Workers. Springer Nature. https://doi.org/10.1007/978-981-33-6342-7

Giacomucci, S. (2021b). Traumatic stress and spontaneity: Trauma-focused and strengths-based psychodrama. In J. Maya & J. Maraver (Eds), Psychodrama Advances in Psychotherapy and Psychoeducational Interventions. Nova Science Publishers

Giacomucci, S., & Marquit, J. (2020). The Effectiveness of Trauma-Focused Psychodrama in the Treatment of PTSD in Inpatient Substance Abuse Treatment. Frontiers in Psychology, 11, 896. https://dx.doi.org/10.3389%2Ffpsyg.2020.00896

Giacomucci, S., & Stone, A. M. (2019). Being in two places at once: Renegotiating traumatic experience through the surplus reality of psychodrama. Social Work with Groups. 42(3), 184-196. https://doi.org/10.1080/01609513.2018.1533913

Hale, A.E. (2009). Moreno’s sociometry: Exploring interpersonal connection. Group, 33(4): 347-358.

Moreno, J. L. (1934). Who Shall Survive? A new approach to the problems of human interrelations. Washington, DC: Nervous and Mental Disease Publishing Co.

Moreno, J. L. (1946). Psychodrama Volume 1. Beacon, NY: Beacon House Press.

Moreno, J. L. (1953). Who shall survive? Foundations of sociometry, group psychotherapy and sociodrama (2^nd edition). Beacon, NY: Beacon House.

Tarashoeva, G., Marinova-Djambazova, P., & Kojuharov, H. (2017). Effectiveness of psychodrama therapy in patients with panic disorders: Final results. International Journal of Psychotherapy, 21(2), 55-66.

Wang, Q., Ding, F., Chen, D., Zhang, X., Shen, K., Fan, Y., & Li, L. (2020). Intervention effect of psychodrama on depression and anxiety: A meta-analysis based on Chinese samples. The Arts in Psychotherapy, 69, 101661.

When Talking Isn’t Enough: Action Methods in Addiction (and Trauma) Recovery

By Scott Giacomucci, DSW, LCSW, BCD, CGP, FAAETS, PAT

Published November 2021 in The Group Psychologist – newsletter of APA Division 49: Group Psychology and Group Psychotherapy – https://www.apadivisions.org/division-49/news-events/action-methods-addiction

Addiction, substance use, and overdose rates have significantly increased in recent years, particularly during the covid-19 pandemic. Relapse rates are high and many clients struggling with substance use disorder have been to treatment multiple times. Most of these clients have accrued significant knowledge about addiction and recovery – they could probably present a lecture on addiction just as well most addiction counselors! The problem is, however, that knowledge alone does not lead to change – it must be put into action. This very concept is reiterated by the popular Alcoholics Anonymous saying that “self-knowledge availed us nothing.” Families understand this just as well as others as they have heard their addicted loved one apologize and verbally commit to recovery many times, only to experience them continue to drink, use drugs, and engage in the same behaviors. When it comes to addiction, words so quickly become meaningless unless followed with action. Psychodrama and other experiential therapies have a unique capacity to engage clients in addiction treatment, addressing underlying fueling factors of addiction, and role training clients for the life skills needed for sustained recovery (Dayton, 2005; Giacomucci et al., 2018).

Many addiction experts have asserted trauma to be one of the primary causes of addiction – some research studies indicate self-reported histories of trauma in over 80% of inpatient addiction populations (Cohen & Hien, 2006). Post-Traumatic Stress Disorder (PTSD) is one of the most common co-occurring disorders for folks with a substance use disorder (Creamer et al., 2001; Roberts et al., 2015). Trauma and addiction exist in a cyclical relationship. Trauma survivors often turn to alcohol or drugs (or other addictive behaviors) to self-medicate the stress, feelings, or physical sensations related to prior trauma, loss, neglect, or abandonment (Morgan, 2019). Furthermore, the lifestyles often associated with addiction makes someone much more vulnerable to experience more trauma, which in turn creates more adverse feelings to fuel substance use. All addiction treatment is trauma treatment; addiction recovery is incomplete without trauma recovery. Maintaining long-term recovery from addiction requires that we address underlying causes which often include trauma, loss, neglect, and abandonment. Otherwise, we are simply engaging in symptom control and avoiding the causes of the addiction.

When it comes to addiction and trauma, words and talking is limited. Many people in recovery and trauma survivors have no words for their trauma, avoid talking about it, or talk about their trauma but are clearly dissociated from the associated feelings. Research even shows that the Broca’s Area, the language and speech center of the brain, (and the entire left brain hemisphere) is largely inactive when one remembers a traumatic memory (Rauch et al., 1996; van der Kolk, 2014). Similarly, addiction involves the hijacking of survival systems and choices which often appear absent of rational thought (Morgan, 2019). Neurobiologically, both trauma responses and addictive behaviors operate below levels of consciousness, rational thought, or cognition. Trauma impacts the body and the nervous system in implicit and unconscious ways. Even when one doesn’t consciously remember a traumatic event, the nervous system may still be impacted and imprinted by it. Both trauma and addiction impact an individual biologically, psychologically, socially, and spiritually (or existentially) (Giacomucci, 2021). Breaking these cycles requires new experiences that can create new neural pathways in the brain. Experience changes both the brain and the mind – this is the most important neuroscience finding of the century (Siegel, 2012). The brain maintains neuroplasticity, or the ability to change, throughout the entire lifespan. This means that new experiences have the power to renegotiate and change the impact past experiences have had upon an individual. Experiences in treatment, therapy, and recovery can be corrective and effectively repair the damage done from past experiences of trauma or addiction (Giacomucci & Stone, 2019).

Psychodrama and other action methods actively engage the whole person in the therapeutic process. Instead of relying only on talking or cognition, experiential therapies involve the body. Psychodrama, the first body-oriented therapy, integrates role-playing techniques into group therapy allowing clients to move beyond talking and into action (Giacomucci, 2021). Experiential sociometry methods from the field of psychodrama quickly cultivate mutual aid, cohesion, and connection (Giacomucci, 2017, 2020b). Rather than verbally discuss a future relapse prevention plan, we can role-playing scenes related to relapse prevention in the safety of the group to practice for the real world. Instead of just talking about a deceased loved-one, psychodrama allows us to talk directly to that person and find closure (Giacomucci, 2020a). Rather than talk about addiction, with psychodrama we could talk directly to addiction. In psychodrama, a client could have a dialogue with their self in the past or with a vision of themselves in recovery in the future. The lynchpin of psychodrama is the role reversal, which is when the client assumes the other role(s) in the scene and responds to themself from that role. This allows for avenues of resolving grief/loss, instilling hope, cultivating understanding, accepting forgiveness, or simply putting oneself in the shoes of another. The psychodramatic experience can be both fun and powerful at the same time – it offers new corrective emotional experiences to clients that may be impossible otherwise (Giacomucci & Marquit, 2020).

Many addiction counselors intuitively try to make their groups and programs more engaging through creative exercises. Psychodrama training offers a time-tested and systematic approach to using action methods in addiction treatment and beyond. Experiential therapies and psychodrama in particular have had a long relationship with the addiction treatment world tracing their connections back to psychodrama’s use in the original addiction therapeutic communities or prominent trainers such as Virginia Satir, Sharon Wegscheider-Cruse, or Tian Dayton who were very active in teaching psychodrama to addiction counselors (Dayton, 2005). As the addiction treatment community continues to evolve it has been further adopting trauma-informed principles, philosophies of empowerment, and holistic approaches – all of which are congruent with psychodrama (Giacomucci, 2021). In my own experience integrating psychodrama at Mirmont Treatment Center, an addiction treatment center, we found that the patients respond very well to it. It was one of the most requested therapies on their patient satisfaction surveys propelling us a few years before covid-19 to significantly expand our use of experiential therapies and psychodrama throughout the entire inpatient clinical program. The trauma-focused psychodrama group that I run is in such high demand that it almost always has a waitlist of patients wanting to join.

Trauma and addiction result in repetitive patterns, reenactments, helplessness, frozenness, and stuckness. Talking about it is often simply not enough to promote change or healing. Clients often state that their addiction treatment groups (inpatient, PHP, IOP, and OP) feel no different than a free 12-step meetings or other support groups. Many clients are sick of talking about it again and again throughout their treatment experiences and have lost hope in the ‘talking cure’. Breaking free of the cycles of addiction and trauma requires action and more action. The experiential nature of psychodrama and experiential therapies helps to get clients into action – exploring new roles, rehearsing new behavior, role training new skills, renegotiating somatic imprints of trauma, releasing frozen emotion, and developing action insights throughout the process.

References:

Cohen, L. R., and Hien, D. A. (2006). Treatment outcomes for women with substance abuse and PTSD who have experienced complex trauma. Psychiatr. Serv. 57, 100–106. doi: 10.1176/appi.ps.57.1.100

Creamer, M., Burgess, P., and McFarlane, A. C. (2001). Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-Being. Psychol. Med. 31, 1237–1247. doi: 10.1017/s0033291701004287

Dayton, T. (2005). The Living Stage: A Step-by-Step Guide to Psychodrama, Sociometry, and Experiential Group Therapy. Deerfield, FL: Health Communications Inc.

Giacomucci, S. (2017). The sociodrama of life and death: young adults and addiction treatment. Journal of Psychodrama Sociometry, & Group Psychotherapy, 65(1): 137–143.

Giacomucci, S. (2020a). Addiction, traumatic loss, and guilt: a case study resolving grief through psychodrama and sociometric connections. Arts Psychotherapy, 67:101627.

Giacomucci, S. (2020b). Experiential sociometry in group work: mutual aid for the group-as-a-whole. Social Work with Groups 33, 53–68. doi: 10.1080/01609513.2020.1747726

Giacomucci, S. (2021). Social Work, Sociometry, and Psychodrama: Experiential Approaches for Group Therapists, Community Leaders, and Social Workers. Springer Nature. https://doi.org/10.1007/978-981-33-6342-7

Giacomucci, S., Gera, S., Briggs, D., and Bass, K. (2018). Experiential addiction treatment: creating positive connection through sociometry and therapeutic spiral model safety structures. Journal of Addiction & Addictive Disorders, 5, 17.

Giacomucci, S., & Marquit, J. (2020). The Effectiveness of Trauma-Focused Psychodrama in the Treatment of PTSD in Inpatient Substance Abuse Treatment. Frontiers in Psychology, 11, 896. https://dx.doi.org/10.3389%2Ffpsyg.2020.00896

Giacomucci, S., & Stone, A. M. (2019). Being in two places at once: Renegotiating traumatic experience through the surplus reality of psychodrama. Social Work with Groups. 42(3), 184-196. https://doi.org/10.1080/01609513.2018.1533913

Morgan, O. J. (2019). Addiction, Attachment, Trauma and Recovery: The Power of Connection. New York, NY: W. W. Norton & Company Publishing.

Rauch, S.L., van der Kolk, B.A., Fisler, R.E., et al. (1996). A Symptom Provocation Study of Posttraumatic Stress Disorder Using Positron Emission Tomography and Script-Driven Imagery. Arch Gen Psychiatry. 53(5): 380–387.

Roberts, N. P., Roberts, P. A., Jones, N., and Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis. Clin. Psychol. Rev. 38, 25–38. doi: 10.1016/j.cpr.2015.02.007

Siegel, D.J. (2012).  Developing mind:  How relationships and the brain interact to shape who we are. New York: Guilford Press.

van der Kolk, B. A. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. New York: Viking Press.

The Phoenix Center offers low-cost trauma therapy and EMDR sessions through our graduate internship program. We are invested in training the best experiential trauma therapists in the field. You can trust that you will experience excellent quality clinical services provided by Phoenix Trauma Center interns. Our interns receive regular training and 2-3 hours of weekly supervision from our director Dr. Scott Giacomucci, DSW, LCSW, BCD, CGP, FAAETS, TEP. Interns also receive weekly supervision from an additional supervisor at the Phoenix Center – in addition to supervision provided by their university program (professors and field placement liaison). They participate in regular trainings and professional development to increase their understanding and expertise of trauma. Each of our interns are offered opportunities for training in EMDR, psychodrama, and Internal Family Systems (IFS). Our interns support our therapists co-leading psychotherapy groups and are engaged in leading their own free or low-cost community groups.

Intern’s sessions start at $85 (with a very flexible sliding scale)
Contact us to secure your spot – Support@PhoenixTraumaCenter.com | 484-440-9416

SEE OUR CURRENT GRADUATE INTERNS OFFERING LOW-COST THERAPY HERE

Benefits of Working with an Intern

As noted, by our friends at Spilove Psychotherapy, there are many benefits to working with a graduate intern which includes lower costs, receiving the expertise of multiple supervising therapists, the benefits of ‘beginner’s mind’, increased passion, and up-to-date practice standards.

Lower-Cost Therapy Sessions – Our interns are all masters-level students towards the end of their programs and getting ready to enter the field. Nevertheless, their session fees are half or one-third of what other therapists charge; and they can be very flexible with their sliding scales.

Receiving the Expertise of Multiple Supervising Therapists – All interns are receiving supervision, training, teaching, and oversight from multiple experienced therapists. This includes weekly supervision with Phoenix Center’s director and another therapists from our center – as well as oversight and/or teaching from multiple professors and a field placement liaison from their university graduate program. Most interns are actively engaged in more reflection, training, supervision, and professional development than other professionals who have already graduated. This means that your intern therapist is spending hours each week reading, writing, reflecting, discussing, and reviewing their work – actively trying to be the best that they can be.

The Benefits of ‘Beginner’s Mind’ – Though many of our intern therapists have experience in the mental health field already or have years of experience in another field, they are starting a new chapter in their professional journey and becoming a therapist. Interns are just starting out so they aren’t just going through the motions of being a therapist. Interns are exploding with curiosity, excitement, passion, and creativity!

Increased Passion and Energy – Interns aren’t weighted down by years of vicarious trauma or burnout that sometimes impact experienced therapists. Instead, intern therapists are bringing new energy, spontaneity, and passion into their work each day. They are excited to begin a new career that they have been preparing for and eager to offer the compassion, connection, and validation that you might be craving.

State-of-the-Art Practice Standards – Graduate students are actively engaged in intense learning through reading, discussions, reflection, and supervised practice. Our field is evolving rapidly (especially with new research findings related to trauma and the brain). Most therapists in PA are only required to complete 15 hours of continuing education each year which simply isn’t enough to stay current on all the new findings in the field. Graduate students however are learning state-of-the-art practice standards. Intern therapists enter the field while continuing to pursue rigorous studies providing current information about the practice of psychotherapy.

This video presents an introduction to the 4 ‘R’s of Trauma-Informed Care:
-Realize
-Recognize
-Respond
-Resist Retraumatization

Each of the 4 are described in detail by Dr. Scott Giacomucci, a Fellow of the American Academy of Experts in Traumatic Stress (FAAETS). These four ‘R’s are essential knowledge for all trauma-informed practitioners, providers, and organizational leaders. The four ‘R’s provide a simplified framework for applying trauma-informed principles from the SAMHSA. See other videos on this channel for additional context including:
SAMHSA’s 6 trauma-informed principles – https://www.youtube.com/watch?v=ANRlWfuWOGQ&t=1s
What is Trauma? – https://www.youtube.com/watch?v=R4Js6VTu9yw&t=
What is PTSD? – https://www.youtube.com/watch?v=LbpdG2tiX8c&t=
Post-Traumatic Growth – https://www.youtube.com/watch?v=uFGJI1o-ciQ&t=

Visit our website to learn more about how we can help your organization implement trauma-informed principles and trauma-focused group work – https://www.phoenixtraumacenter.com/training-for-your-team-in-experiential-trauma-therapy/

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