Moreno and Beck: Psychodrama and CBT

Aaron T. Beck

Jacob L. Moreno

Jenny Wilson, 2009

A thesis presented to the Board of Examiners of the Australian and New Zealand Psychodrama Association Inc. in partial fulfilment of the requirements towards certification as a psychodramatist.

This thesis has been completed in partial fulfilment of the requirements toward certification as a practitioner by the Board of Examiners of the Australian and New Zealand Psychodrama Association Inc. 2009 Jenny Wilson. The Australian and New Zealand Psychodrama Association has the right to publish. All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no reproduction, copy or transmission of this publication may be made without written permission from the author or the Australian and New Zealand Psychodrama Association Incorporated. No paragraph of this publication may be reproduced, copied, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, save with written permission of Australian and New Zealand Psychodrama Association Incorporated or the author. The development, preparation and publication of this work have been undertaken with great care. However the publisher is not responsible for any errors contained herein or for consequences that may ensue from use of materials or information contained in this work.

Enquiries: Jenny Wilson, Christchurch New Zealand. E-mail jenny@blennerhassett.gen.nz or to ANZPA, PO Box 232, Daw Park, South Australia 5041, Australia

Photographs: Photo of Aaron T. Beck used with permission, photo of Jacob L. Moreno is in the public domain.

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Table of Contents
Abstract...........................................................................................................................................iv Preface............................................................................................................................................vi Acknowledgements......................................................................................................................viii INTRODUCTION...........................................................................................................................1 How does a therapist combine two vastly different therapies?...................................................1 Literature review: Therapists who have combined CBT and Psychodrama...............................2 The Men......................................................................................................................................4 PHILOSOPHY, THEORY AND PRACTICE................................................................................7 Philosophy...................................................................................................................................7 Therapy Goals.............................................................................................................................8 Basic description.........................................................................................................................9 Spontaneity, Creativity and Surplus Reality.............................................................................10 Warm up....................................................................................................................................11 Roles, Schema Modes and Personality.....................................................................................12 Psychopathology.......................................................................................................................13 Therapeutic relationship and encounter....................................................................................16 Group considerations................................................................................................................18 Catharsis....................................................................................................................................19 Action........................................................................................................................................20 Thoughts ...................................................................................................................................21 Therapy content and therapist stance........................................................................................22 Techniques................................................................................................................................25 A CBT PSYCHODRAMA............................................................................................................25 CBT enriched with Psychodrama.............................................................................................25 Philosophy and theory behind the techniques...........................................................................29 IMPLICATIONS...........................................................................................................................33 Clinical practice........................................................................................................................34 Research and future directions..................................................................................................34 CONCLUSION..............................................................................................................................37 REFERENCES..............................................................................................................................38

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Abstract
This thesis introduces the work of Jacob L. Moreno, founder of Psychodrama, and Aaron T. Beck, a key founder of Cognitive Behaviour Therapy (CBT). I propose that although Psychodrama and CBT are vastly different therapies they have enough similarity and compatibility that Psychodrama can enrich CBT and CBT can make a contribution to Psychodrama. Introducing the founders and considering philosophy, goals, and theory lays the foundation for successful integration of CBT and Psychodrama as demonstrated in an example of supervised therapy.

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We give thanks for the invention of the handle. Without it there would be many things we couldnt hold on to. As for the things we cant hold on to anyway, let us gracefully accept their ungraspable nature and celebrate all things elusive, fleeting and intangible. They mystify us and make us receptive to truth and beauty. We celebrate and give thanks. AMEN Michael Leunig

Preface
My friend Tania and I are walking on the ridge above Kaiteriteri. The walk is easy, companionable with just a little pleasant exertion on the uphill bits. With our eyes on the golden beach far below, we miss a junction in the track. We continue to the point of the ridge until the track peters out. There is a rough track of sorts heading straight down. It is steep, greasy with mud and deeply channelled. We push branches out of the way and hold tightly to shrubs and stalks to halt our downward decent. Then there is gorse, dead and prickly and we soon find that the track runs underneath it in a grooved slippery slick. Should we continue? Can we get back? We turn around and find the way back easier than expected; climbing up is easier than the downward slide. Laughing we make our way to the top, backtrack a short distance and find easy steps cut into the hillside that take us to the beach. My Psychodrama track has been ill formed at times, muddy, scratchy and prickly. Detours and false trails have kept goals tantalisingly out of reach. Some stretches of this path have been joyous and pleasurable, some extremely difficult but made bearable by the company. I have been an Information Prospector for as long as I remember with a tendency to be goal focused, persistent, efficient and wanting to get a handle on things; qualities that became overdeveloped during my clinical psychology training. Psychodrama training assisted me to develop strong complimentary abilities, so I can also be an Easy Companionable Explorer, highly valuing relationship, being more accepting of not knowing, more willing to try a variety of ways and even find pleasure in the surprises of detour. When I first started training in CBT and Psychodrama in the 1990s, distrust between the two camps was evident in dismissive comments made by senior people and peers on both sides. In response I automatically put something of myself aside as I entered the university buildings or the Psychodrama group room. My employment as a research therapist, an asset in my identity as a clinical psychologist, initially complicated my Psychodrama identity. I am trained in three different research protocol therapies (Cognitive Behaviour Therapy, Interpersonal Therapy and Schema Therapy). For several years I worked in a research setting and was required to use each of these therapies in a way that emphasised their unique characteristics and minimised overlap a situation that I found interesting and satisfying but at odds with the holistic approach of vi

psychodrama. This background influenced me to ask the specific questions about theory and practice that have structured my thesis. Now a clinical educator in a university clinic, my background contributes to me being a well informed, confident and influential advocate of Psychodrama. I have found reading about Psychodrama akin to reading the musical score of a great symphony; a complex and unsatisfying linear representation of a most complex multi-sensory endeavour. I find Morenos writing hard work with its specialised language, comparisons with psychoanalytic theory and reference to various historic and public figures whom I am unfamiliar with. Looking for answers to my curious questions, hoping for clear definitions, distillations of theory and clear direction, I have found the answers elusive. My love of the Psychodrama method has kept me searching and trying to understand while simultaneously trying to appreciate what is not knowable or explainable. I have continued to steadily travel to and fro between Psychodrama and CBT, between Moreno and Beck. Steadily building up credibility and strong networks in both communities and offering cross-cultural gifts: A sociodramatic enactment as I teach interview skills to clinical psychology students; a presentation of myself and my CBT work to our local ANZPA meeting; an action warm-up to assist clinical psychology staff and students build positive connections on orientation day; co-leading a Psychodrama professional development day for health professionals with a Psychodrama colleague; an article introducing Psychodrama to CBT practitioners (Wilson, 2009). Gradually the track has become clearer and more well formed. I strongly value both Psychodrama and CBT and believe that each can enrich the other. I invite both CBT and Psychodrama companions to travel with me as they read.

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Acknowledgements
I have been well supported on both my Psychodrama and CBT journey. I give my heartfelt thanks to those who have been involved with me, particularly those who have contributed to this thesis. Thank you Clare Elizabeth and Paul Baakman my main Psychodrama trainers, and Eileen Britt and Janet Carter who supported and supervised my CBT training. Thank you to my friends and peers who have shared my dramas and my work, particularly Chris Bloomfield and Sonja Bakker who have sustained a lively interest in the topic and process of my writing. Tania Oolders thank you for your helpful suggestions at the difficult end stages. To Don Reekie, my Psychodrama primary trainer and thesis supervisor, this thesis owes much to your generous, perceptive and timely reflections. I deeply appreciate the commitment you have to my development. To my partner Eliot Blennerhassett and my daughter Emily Blennerhassett, thank you for your love, practical support and encouragement.

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INTRODUCTION
How does a therapist combine two vastly different therapies?
Personal experience in Psychodrama groups has convinced me that the methods are effective. The techniques make sense, are user friendly, and easy to demonstrate. Committed attention to relationship and process creates warm, emotionally moving and playful sessions. Participants engage their whole body, feelings, spirit and intellect, and there is a vast repertoire of interventions that do not rely on the written or spoken word. However Cognitive Behaviour Therapy (CBT) is the major therapy practised and recommended by New Zealand trained clinical psychologists.* CBT has a well grounded theoretical base and is extensively researched. In many public or insurance funded settings it is the only therapy available and there is pressure for psychologists and others to follow manualized CBT treatments. This trend for CBT to dominate is set to continue (e.g., see the recommendations made by the New Zealand Guidelines Group http://www.nzgg.org.nz or United Kingdoms National Institute of Health and Clinical Excellence http://www.nice.org.uk ). This approach will result in Psychodrama eventually being excluded from mainstream providers unless psychodramatists can find a way to work alongside CBT or assertively provide rationale for their independent inclusion. My vision is for Psychodrama to survive and flourish as an option in the mainstream not just as a few borrowed techniques but with its original spirit intact. Active collaboration and work with CBT practitioners is one way to achieve this. Relative to other treatments, CBT works well for clients with straight-forward single diagnoses (e.g., depression, and phobias). But CBT is not effective for all clients. For example Gortner, Gollan, Dobson, and Jacobson (1988) and Dimidjian et. al. (2006) found that only 40-50% of depressed clients made a full and sustained recovery. My own experience confirms that CBT is less successful for clients with personality difficulties and chronic psychiatric problems and CBT's reliance on the written and spoken word makes it unsuitable for some clients. Therapists need to have alternatives to offer clients who do not respond to traditional CBT.

*Although there are other founders of CBT, it is the work of Beck that has most influenced my work. Beck calls his therapy Cognitive Therapy, however as I and many others include a substantial portion of behavioural strategies I have adopted the commonly used term CBT as I believe it more accurately describes my work.

It is their differences that make CBT and Psychodrama potentially complimentary companions. Yet how does a therapist bring them together to make a coherent whole for clients and supervisees? This exploration will have particular relevance for psychodramatists working in or with mainstream organisations where CBT is the predominant therapy model. This thesis compares and contrasts the work of Moreno and Beck. After reviewing relevant literature I introduce Moreno and Beck, their philosophies, goals, and fundamental principles from their theories. A sample of techniques from both modalities is combined in an example from my work as clinical psychologist, supervisor and therapist.

Literature review: Therapists who have combined CBT and Psychodrama

Therapy schools each have their own specialised constructs and language; being able to read and understand those texts is important if sharing of ideas is to occur. Many of Moreno's ideas about Psychodrama and psychotherapy can be found in Moreno 1939, 1953:1993 and 1946:1977; those new to Psychodrama may find it easier to read secondary sources include Blatner (1996, 2000) and Dayton (1994). Beck's original work is detailed in his 1964 and 1979 writings; CBT is presented in an updated and more easily read form by Westbrook, Kennerley, & Kirk (2007). A number of therapists have blazed a trail before me by combining Psychodrama and CBT. Reading their work made me feel less isolated, gave me hope in my own journey. The following selection illustrates some of the ways in which Psychodrama and CBT have been combined and at what level (technique, theory or philosophy). Jacobs (2002) saw the potential for enhanced CBT for two individual adolescent girls who had been sexually abused. Adapting psychodramatic role play, she brought the girls together for three sessions that used Psychodrama techniques to complement and deepen the CBT they had done. Flemming (2000) describes how he uses Morenian role theory in a programme for sexual offenders. Hamamci (2002, 2006) uses Psychodrama techniques to demonstrate concepts related to CBT, noting that they ease the tasks of CBT and provide concrete opportunities to generate new thoughts and behaviours. Many CBT writers have adopted Psychodrama methods such as role-play and family of origin imagery. These methods are particularly likely to be suggested when the basic CBT strategies don't work. However even when Psychodrama is mentioned, (which is rarely) authors are 2

unaware of, or do not acknowledge its origins. Padesky (1994) and Edwards (1990) focus on changing cognitive schema and mention Psychodrama but neither author acknowledges Moreno's contribution, Edwards attributing the method to Perls and Padesky omitting to reference it at all. Beck reports My employment of enactive, emotive strategies was influenced, no doubt by psychodrama and Gestalt therapy (Beck, 1991, p.196) but does not mention Moreno. Several Psychodrama practitioners bring CBT techniques and theory to Psychodrama. Treadwell, Kumar and Wright (2002) explain CBT theory, noting the utility of the goal-focused, problem solving, self-reflection and mood regulation aspects, and describe CBT techniques that can be used to enhance Psychodrama. Similarly Kipper (2002) endorses the usefulness of identifying and exploring irrational beliefs and distorted thoughts, adapting and describing specific Psychodrama techniques to facilitate this. Fisher (2007) reflects that psychodrama "lacks the full development that an academic following would have provided", noting that some of the best Psychodrama directors combine Psychodrama with another psychotherapy theory. Baim (2007), referring to his personal experience at the Beck Institute in the USA , notes significant commonalities in the approach of CBT and Psychodrama. Both Fisher and Baim write how CBT and Psychodrama theory can enrich each other, each observing the ways in which Psychodrama could be considered a cognitive therapy. A number of writers who combine CBT and Psychodrama utilise CBT's tradition of empirical research, adopting standard CBT measures and experimental psychology methods. Boury, Treadwell and Kumar (2001) refer to the ...considerable research dedicated to testing the effectiveness of CBT. In an exploratory study they use a psychology research design and CBT measures to evaluate the effects of participating in a group course that combines elements from Psychodrama and CBT. Hamamci (2002) trialled a therapy that integrated aspects of CBT and Psychodrama specifically targeting cognitive distortions related to interpersonal relationships. She demonstrated that the integrated therapy was effective in reducing cognitive distortions. In her (2006) study of moderately depressed students, Hamamci compared three groups: Psychodrama integrated with CBT, CBT alone and a control (no treatment) group. Although she found no statistically significant differences between treatments in terms of effectiveness at the end of sessions, she 3

found that the integrated therapy group was highly motivated and continued to improve on a number of measures from post-test to 6 month follow-up, whereas the CBT alone group showed decline. Her findings are important as they provide evidence to suggest that integrating CBT with Psychodrama may assist engagement in therapy, facilitate ongoing improvement and offer protection against relapse. Griffith (2003) notes that in a era of managed care and limited resources brief therapy approaches, such as CBT, are receiving more attention. Attempting to utilise the most powerful elements from both CBT and Psychodrama, Griffith created a brief intensive therapy for difficult-to-treat clients and made innovative suggestions for presenting schema-focused cognitive therapy (a newer variant of CBT) in a Psychodrama group. The writers mentioned have all considered it useful to combine techniques from CBT and Psychodrama. However many (with the exception of Baim, Fisher and Griffith) detail only one theoretical perspective and none provide more than hints about the philosophy behind CBT or Psychodrama. To address this omission, this thesis will consider the theoretical and philosophical position of each, before presenting a case vignette where the methods are applied together.

The Men
The way in which Moreno and Beck each developed a therapy in keeping with his own personality intrigues me. It helps me to understand why I feel so comfortable with the writing and therapy developed by Beck; I can easily identify with his anxiety, diligence, focus and quest for understanding and order. It also explains some of my difficulties with the writing of Moreno and my fascination with his method; I find the man, viewed through his writing, rather alarming in his exuberance, disorganisation, megalomania and intensity, yet I am compelled by the breadth of his vision and the startling innovation of his method. Highlights from the lives of Moreno and Beck are introduced to illustrate the context in which each of the therapies evolved. In common Aaron T. Beck and Jacob L. Moreno share Jewish heritage and 20th Century arrival in the United States. J. D. Moreno, editing his father's writing in 1989 notes that J. L. Moreno was born in 1889 from a line of Sephardic Jews (Moreno, 1989a, p.4). He was raised in Vienna and emigrated to the United States in 1925 as racial hatred mounted in Europe. Beck was born in

1921, and raised in the United States by Russian Jewish immigrant parents (Weishaar, 1993, p.3) who are likely to have experienced similar political turmoil to Moreno. Each man was exposed to a variety of political and social views. For example Moreno lived in a mixed neighbourhood and was exposed to a wide range of influences (Moreno, 1989a, p.22) and lived in Vienna during the beginnings of Nazism, communism and existentialism (Moreno, 1989a, p.45). Beck's father was a free thinker who introduced his son to literature, theatre and poetry and regularly hosted a group of men in his home to exchange philosophical, political and literary opinions (Weishaar, 1993, p.7). Each had early personal experience of life at the emotional extremes and each explicitly brought this to his work. Beck had a childhood history of extreme anxiety and phobias and Moreno experienced periods of grandiosity and heightened creativity during his teens and twenties. Interestingly the style and confidence of each man appears to have moderated over time. Beck anxious and unsure of himself at the start has become more self assured over time e.g., claiming that CBT is "the integrative therapy(Beck, 1991, p.191, italics in the original), while Moreno, extremely self confident during his youth, is reported as being more self reflective towards the end e.g., my megalomania is shattered (Moreno, 1989b p.124). Both men commenced medical training and initially started working with psychiatric patients almost by chance; Beck being required to do a rotation in psychiatry against his wishes (Weishaar, 1993, p.15) and Moreno choosing to work temporarily with mental patients due to the difficulty in retaining professional actors in his theatre of spontaneity (Moreno, 1989b, p. 76). Both Beck and Moreno disagreed with the Kreplinian diagnostic approach common at the time. Beck saying I found the Kreplinian approaches to be nihilistic and unrewarding (Weishaar, 1993, p.14), and Moreno reporting that psychoanalysis and Kreplinian psychiatry left me cold (Moreno, 1989b, p.62). Moreno never went through psychoanalytic training, rebelling against it early on, he worked independently from mainstream psychiatry of the time. He developed his own psychiatric hospital, Beacon Hill Sanatorium, from 1936 to1967 (Marineau,1989, p.134) and introduced psychodrama to St Elizabeth's psychiatric hospital in Washington DC in 1934 (Blatner, 2000, p.19). Beck completed his analysis and psychoanalytic training and later rebelled against it. Beck worked as an original thinker within mainstream psychiatry. Developing strong links with academic psychologists who were more receptive to his ideas than psychiatrists, Beck had an 5

affiliation with a major university. Moreno chose not to work within the constraints of a university system instead founding his own institute at Beacon Hill. Both men had ideas which were initially seen as rebellious or novel compared with mainstream thought at the time. Each man developed the seeds of all subsequent ideas in his early writings (Beck writing his seminal works in 1962 and 1964 and Moreno writing Words of the Father in 1923), ideas that continued to develop and mature with the man and that have been developed by others. Beck met many individual patients who had entered psychoanalytic therapy. Moreno's experience was with groups of people on the street and in their homes, in their natural surroundings (Moreno, 1989b, p.61) as well as psychiatric patients. It is likely that these different observation points influenced the development of their theory and methods for explaining and changing human experience. Beck has focused on the individual and the primacy of thought; Moreno has focused on the group and the primacy of action. Moreno and Becks own words open each of the following sections, with quotes chosen to offer a glimpse of the men before I introduce aspects from the philosophy, theory and practice of Psychodrama and CBT.

PHILOSOPHY, THEORY AND PRACTICE

Philosophy
Moreno: Two contradictory principles are operating in the therapeutic investigation. One is the utterly subjectivist and existentialistic situations of the subject; The other is the objective requirements of the scientific method (Moreno and Moreno, 1959:1975, p.216). Beck: The cognitive perspective is often misunderstood as taking only a realist perspective. However, the cognitive perspective posits at the same time the dual existence of objective reality and a personal, subjective, phenomenological reality (Alford and Beck, 1997, p.22). Both Beck and Moreno recognised the tension between fully entering the client's world and the need for objectivity. Beck has a long association with mainstream academic institutions that tend to promote reductionism and rationalism at the expense of holistic and spiritual values. CBT has been the subject of many studies in these institutions, and at times has been reduced to structured treatment manuals and narrow outcome measures. Beck's own writing however indicates that he appreciates the complexity of human experience. Beck aligns himself with the constructivist perspective that states that human beings actively construct their personal realities and create their own representational models of the world (Meichenbaum, 1993, p. 203, cited in Alford and Beck, 1997). Moreno's emphasis on the subjective nature of psychological truth places him philosophically alongside the phenomenologists (Blatner, 2000). Both writers reject determinism and see clients as meaning makers in their own world, providing a common footing in the foundations of these therapies. Moreno had a strong existential and spiritual belief system, identifying with existentialists and religious figures from an early age. (Moreno, 1989a, p. 45). The early existentialists emphasised existence itself as something sacred. Central to existential philosophy is the valuing of spontaneity and creativity and the urgency of immediate experience (Moreno, 1989a, p. 45). Moreno gives spontaneity and creativity a spiritual significance, linking them to the experience of God within. He saw psychodrama as an extension of the existentialist movement and a 7

method which could grapple with the big questions; birth, death, sex, and the function of the Creator of the world(Moreno and Moreno 1969:1975, p.19). Moreno developed his existential ideas at a time when the eugenic perspective adopted by the Nazis was gaining momentum in Europe. It is easy to imagine Moreno and his fellows passionately seizing existentialist values as a counter to the empirical classification of humanity embraced by the Nazi. I have found no reference to Beck's spiritual beliefs, and imagine such writing is incongruent with the academic environment in which he works. Nor can I find reference to Beck's views on existentialism, however in notes recorded following a conversation with His Holiness the Dalai Lama, I was delighted to read Beck saying I am struck with the notion that Buddhism is the philosophy and psychology closest to cognitive therapy and vice versa. He notes several similarities between CBT and Buddhism including a view on universality that is consistent with Moreno and with mine We are one with all humankind (Beck, 2005a).

Therapy Goals
Moreno: A truly therapeutic procedure can not have less an objective than the whole of mankind (Moreno, 1953: 1993, p.3). Beck: The goals of cognitive therapy are to correct faulty information processing and to modify dysfunctional beliefs and assumptions that maintain maladaptive behaviours and emotions (Beck and Weishaar 1989, p.28). Moreno's expansive goals are concerned with all aspects of living and the maximising of human potential: Psychodrama enables the protagonist to build a bridge beyond the roles he plays in his daily existence, to surpass and transcend the reality of life as he lives it, to get into a deeper relationship with existence, to come as close as possible to the highest form of encounter of which he is capable, (Moreno 1969: 1975, p. 29). I have found psychodrama to be life enhancing, focused on health and highly valuing the full range of human emotions including joy, celebration, tenderness and love. The focus is wider than symptom relief, extending towards full experience and relish of life.

This thesis focuses on psychotherapy, however Psychodrama goes beyond the therapy room towards development and growth in every human and community sphere. Moreno has written about his methods in many contexts including education, business, and communities. He developed a triadic system and considered Psychodrama, sociometry and group psychotherapy to be inter-related and indispensable to one another (Moreno, 1970). He considered sociometry (his study and measurement of society and relationships) as the foundation of his work and formulated several laws and hypothesis on the basis of his research (see Moreno, 1943 for details). He developed the field of sociodrama as a method of exploring, understanding and intervening in group settings. Beck's initial goals were more narrow. Focused on individual therapy clients suffering from depression, he made observations of clinical data. He tested and developed measures to systematize these observations and formulated guidelines for therapy. He applied this process to a sequence of disorders and problems including suicide, anxiety and phobias, panic, personality disorders and substance abuse, interpersonal problems, anger hostility and violence (Beck, 2005). Beck's theories arose in a clinical context and his tightly focused approach led to specific strategies for particular problems. Relief of symptoms and managing troubling emotions are key treatment targets. When working in a clinical context with individual clients, Becks goals match my own in many ways. However as I consider the whole of my experience engaging in groups, supervision, teaching, meetings and social situations I appreciate the relevance of Morenos vision.

Basic description
Moreno: Drama is a transliteration of the Greek which means action, or a thing done. Psychodrama can be defined, therefore the science which explores the truth by dramatic methods. It deals with inter-personal relations and private worlds (Moreno 1953:1993, p.53). Beck: Cognitive therapy is an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders (Beck, 1967, cited in Beck et. al. 1979, p. 3).

Psychodrama originated as a group action method. Participants in psychodrama enact events from their lives using five main instruments. The stage provides a flexible space for freedom of experience and expression. The psychodrama director (a term used in preference to therapist) functions as counsellor, producer and analyst, assisting the group to build an environment where the protagonist (main actor or client) can experiment freely with the assistance of auxiliaries (group members) who assist the director and protagonist in guiding and exploring the protagonist's world, portraying the actual or imagined people and aspects contained in it. The audience can be a sounding board of public opinion or subject of the drama, they may assist the protagonist or may be assisted by the drama portrayed (Moreno, 1953:1993). CBT was developed primarily as a talking therapy for individuals with psychiatric problems. It is a collaborative process between client and therapist that employs behavioural and verbal techniques to examine the client's cognitions, challenge unhelpful beliefs and provide skills that promote more adaptive cognitive processing (Beck and Weishaar, 1989).

Spontaneity, Creativity and Surplus Reality

Spontaneity, creativity and surplus reality are three intriguing constructs proposed by Moreno, I am unaware of any equivalent concepts in Beck's work. Unfamiliar to CBT therapists and full of promise and hope these constructs have rich potential for enhancing CBT. Moreno: The universe is filled with the products of spontaneity-creativity interaction (Moreno, 1953: 1993, p.11). Surplus reality is ... an enrichment of reality by the investments and extensive use of imagination .... (Moreno 1965, cited in Moreno et. al., 2000, p.2). Crucial to Moreno's theoretical perspective is the principle of spontaneity. He emphasises The root of the word 'spontaneous' and its derivatives is the Latin sponte, meaning of free will (Moreno, 1946:1977, p.81), clearly differentiating it from impulsivity, with which it is often confused. He defines spontaneity as the ability to meet each new situation with adequacy and to develop new responses to old situations (Moreno, 1946:1977, p. 50). He noted that Successful adjustment to a plurality of environments requires a flexible, spontaneous personality make-up (Moreno, 1953:1993, p.193).

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In a spontaneous state, similar to that experienced by children as they play, we are less self conscious, more free to try new things, able to see ourselves and others in new ways and to use our imagination. When spontaneity is high, anxiety lessens and vice versa. Moreno believed that spontaneity can be developed by Psychodrama training (Moreno, 1953:1993, p.195) and that spontaneity is the catalyst for human creativity. Moreno talked of a Godlike or spiritual energy that is fuelled by spontaneity and creativity. He proclaimed that God's voice is in us all, and that he had heard that voice directly inside him. (Moreno, et. al., 2000, p. xiv). His theory suggests that by harnessing spontaneity and creativity we become co-creators in the universe with the God within us all. In Psychodrama the spontaneity and creativity of director, protagonist and group make anything possible. Human imagination flows freely and the group can create anything or any situation. Surplus reality is a world which may never have been nor may ever be, yet it is absolutely real (Moreno et. al., 2000, p.5). Our capacity to dream, to create, to imagine, is a quality that makes us human. This capacity has given rise to painting, sculpture, architecture, drama, dance, music and other arts. It is a quality that has enabled science and technology and resulted in humankind successfully inhabiting the globe. The process of imagining and engaging in something that has never existed or happened before, is highly valued in Psychodrama, termed surplus reality it is harnessed for its healing potential.

Warm up
Moreno: ...learning connected with highly warmed up states establishes special associations. Contents of learning which enter the mind connected with highly warmed up states recur more easily with the recurrence of similarly warmed up states ... learning becomes essentially connected and integrated with [his] acts, not apart from them (Moreno, 1953:1993, p. 199-200). Beck: ...cognitive constellations underlying affect become accessible and modifiable only with affective arousal. In the language of cognitive therapy these are hot cognitions (Beck and Weisharr, 1989, p.29).

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The concept of warm up is used in Psychodrama both in the context of warming up a group, and in the context of an individual warming up. According to Moreno the warming up process manifests itself in every expression of the living organism as it strives towards an act (italics in the original, Moreno 1946:1977, p. 56). Warm up gets us started in a particular direction and can be self initiated or activated by another (Taylor, 1998, p. 50 ). For example, a dinner party host might offer drinks and introduce guests to warm them up to engaging with each other. An individual might warm up to doing more exercise by thinking about sports he used to enjoy. The Psychodrama director uses the group warm up to assist members to become aware of their current experiences and to develop trust and group cohesion. After a well conducted warm up there is a sense of common purpose and involvement with one another and the group is able to move smoothly into enactment. By contrast an inadequate group warm up may result in divided interests, breaches in rapport and a sense of reluctance by some to move into action. Psychodrama techniques function to increase the warm up of the protagonist, increasing ability to be present, intensifying thoughts and feelings and enabling them to act with spontaneity. Following Moreno's guidelines (Moreno and Moreno, 1969b:1975, p. 235) and facilitating a warm up from more superficial to most salient issues assists the group and individual work at deeper and deeper levels. Considering warm up and developing warm-up skills is useful for the CBT therapist. Beck noted that change can only occur if the patient is engaged in the problematic situation and experiences affective arousal (1989, p.29, italics in the original). Adequate warm up assists the client access the deeper thoughts, feelings and behaviours related to the current concern and facilitates the accessibility of emotionally laden cognitions.

Roles, Schema Modes and Personality

Moreno: Role is the functioning form the individual assumes in the specific moment he responds to a specific situation in which other persons or objects are involved (Moreno, 1946: 1977, p. IV). Roles do not emerge from the self but the self emerges from the roles (Moreno, 1946: 1977, p. II).

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Beck: Modes are conceived of as a structural and operational units of personality that serve to adapt an individual to changing circumstances. The modes consist of a composite of cognitive, affective, motivational and behavioural systems (Beck, 1996, p.19). Reflecting and joining in with the play of children Moreno noticed them trying out different ways of being and respond to one another and the adults around them. He planted the seeds for role theory a body of knowledge associated with the interactive functioning of human beings (Clayton, 1994, p. 122) that others have since developed (see Clayton's 1994 review). Roles have an action, feeling and thinking component and Moreno makes them central to personality development; the self is a system of interacting roles (Clayton, 1975). According to Moreno, a healthy adult develops a wide repertoire of roles, has sufficient spontaneity to develop new roles or generalise old roles to new situations and is able to react flexibly to many different situations. Roles described by Moreno sound similar to schema modes as described by Beck who conceptualized schema modes as the basic components of personality (Beck, 1996, p.27). The similarity between roles and schema modes is not coincidental. Influential theorist George Kelly borrowed ideas from Moreno (Stewart and Barry,1991) and Beck was in turn influenced by Kelly (Alford and Beck, 1997). More so than Beck, Moreno firmly places roles in a social context; roles arise in response to others and are thus inseparable from a social system. Moreno suggests that the person's internal psychological systems interlock with the psychological geography of a community and that community is part of the psychological totality of human society itself(Moreno, 1937, p.207 & p. 215). Seeing roles or schema in this way broadens and enlivens my picture of a client. The specialised techniques Moreno developed to measure and address social issues (Sociometry and Sociodrama) create a method that can explicitly address the social context in which an individuals problems lie.

Psychopathology
Moreno: Without this function of spontaneity to facilitate the shift, the warming up process can produce a mental set in one track to the degree that it hampers or harms the relationship of the individual to real

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situations and real objects, or to imagined situations and imagined objects (Moreno, 1946: 1977, p.72).

Beck: ...the cognitive model of psychopathology stipulates that the processing of external events or internal stimuli is biased and therefore systematically distorts the individual's construction of his or her experiences, leading to a variety of cognitive errors.... Underlying these distorted interpretations are dysfunctional beliefs incorporated into relatively enduring cognitive structures or schemas (Beck, 2005b, p.954). Writing extensively about social relationships and personality development Moreno embraces the complexity and normality of human experience. His writing about psychopathology is in the form of case study and explanatory notes, from which some of his ideas about psychopathology can be gleaned. Moreno writes of the social atom the "pattern of interpersonal relations which develop from the time of birth" (Moreno, 1939, p.3). The social atom consists of the "psychological relations of one individual to those other individuals to whom he is attracted or repelled and their relation to him" (Moreno, 1939, p 2). Although constantly changing, the social atom that develops in response to early social relationships (e.g., family of origin) is seen to be particularly influential in later development of relationships with others and with the picture a person has of himself. Moreno recognises in normal development the relationship between self and experience of self (e.g., our ability to have feelings of acceptance, rejection, discord, or indifference to ourselves). He notes that in complex personalities there may be multiple and contradictory relationships with self. In times of psychosis there is a disturbance between all the relationships the patient has with himself and others, and the sense of time and space may also become blurred (Moreno, 1939, p.4). Moreno identified that lack of role flexibility can contribute to difficulties and insufficient spontaneity results in limited responses: The subject in action may often be found to be controlled by remnants of roles which he has assumed in the past, at one time or another, and 14

these conserves interfere with or distort the spontaneous flow of his action (Moreno 1946:1977, p.111). Moreno postulated that a normal split between objective reality and fantasy or subjective reality occurs in early childhood and the more deeply engraved these tracks are the harder it becomes to shift from one to the other on the spur of the moment(Moreno, 1946:1977, p.72). According to Moreno a person with abnormal social atom development may go through life without clinical manifestation of a mental disturbance but these can be rapidly activated as soon as a precipitating cause appears(Moreno, 1939, p.29). Precipitants can include physical illness, psychological states such as feelings of inferiority, or social conditions such as job loss or bereavement. Beck has written extensively about psychopathology and psychological problems. His theory is summarised in Beck and Weisharr (1989, p.21-25) as follows: Cognitive theory is based on the observation that an organism needs to process information in an adaptive way in order to survive. The processing is not necessarily rational; in some circumstances (e.g., mate selection) it may have been advantageous to be overly optimistic, in other circumstances (e.g., risky situations) exaggerating the potential for harm enabled the survival of the individual and contribution to the gene pool. Evolution has thus shaped our information coding systems to have a tendency to bias. Each individual's learning history will contribute to the development of rules, assumptions and attitudes as we appraise our environment and experiences. Negative childhood experiences such as neglectful parents, major losses and trauma, may predispose an individual to psychopathology by activating a more primitive (less flexible and negatively biased) coding system, particularly in times of stress. Cognitions do not cause psychopathology but are an intrinsic part of it. The shift to more primitive information-processing systems is apparent in systematic errors in reasoning called cognitive distortions. Examples of cognitive distortions include a tendency toward dichotomous thinking - categorising experiences into one or two extremes, e.g., I must be the best student in the class or I am a failure, and personalisation - attributing external events to oneself in the absence of any causal connection, e.g.,My friend must be grumpy because of something I have done. Beck noted and described specific patterns of cognitive distortions in several psychiatric disorders.

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According to Beck each person has a set of idiosyncratic vulnerabilities that may predispose them to psychological distress. They are related to personality structure and to fundamental beliefs, values and attitudes about the self and world. The cognitive structures that contain these beliefs are termed schemata. Schemata develop early in life from personal experiences and identification with significant others, they are reinforced and shaped by further learning experiences. In his later writing (1996) Beck formulates his theory of schema modes, integrating cognitive schemata with structures from the affective, behavioural, motivational and physiological systems. Although influenced by the medical model of health and illness, Beck attributes psychopathology to the over-activation of normal information coding systems rather than qualitatively different process, noting that cognitive theory considers personality to be grounded in the coordinated operations of complex systems that have been selected or adapted to insure biological survival (Alford and Beck, 1997, p.29). I appreciate Beck's focused commitment to researching and understanding psychological problems. Collaborating with academic psychologists he has created a well developed and comprehensive theory of psychopathology. The patterns he has observed and written about have assisted me understand why people become unwell and CBT research contributes to specific and detailed recommendations about effective therapy strategies. My desire to understand and explain is usually satisfied by CBT writers who lean towards clear definitions and explanatory models about specific problems. In clinical situations I highly value this approach. I can be even more effective when Morenos writing compels me to also attend to the social and personality context of illness and to see and relate to the person behind the diagnosis. Perhaps most importantly Psychodrama training allows me to tolerate ambiguity and be with the client when I do not understand and can not find a model.

Therapeutic relationship and encounter

Moreno: The fundamental principle underlying all forms of psychotherapy is the encounter (Moreno and Moreno 1959: 1975, p. 234). ... let us consider the encounter in its various forms. On the lowest level are the millions of simple, drab encounters of daily life which everyone

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shares. At the highest level is the rare, penetrating high encounter which happens once or twice in a lifetime, a flash, an encounter with nature, a love relationship or an intense friendship, or a religious experience ... Psychodrama enables the protagonist to ... come as close as possible to the highest form of encounter of which he is capable (Moreno and Moreno, 1969: 1975, p.29). Beck: The general characteristics of the therapist which facilitate the application of cognitive therapy ... include warmth, accurate empathy and genuineness (Beck, 1979, p. 45). The therapist accurately communicates an understanding of the patient's thoughts and feelings. Understanding' refers to how well the therapist can step into the patient's world, see and experience life the way the patient does, and convey this understanding to the patient (Young and Beck, 1980, p.5). It is difficult to express the difference between a Psychodrama encounter and a CBT relationship by just referring to the literature. Both Psychodrama and CBT writers state that relationship is important. In CBT a satisfactory working relationship is the vehicle by which CBT (and CBT supervision and training) can be delivered. In Psychodrama, relationship (with director group members and trainers) is a major, perhaps the major component of the method. Moreno puts relationship at the heart of the therapy process and is talking about something that is qualitatively different from the understanding or stepping into the patient's world which occurs during CBT. In psychodrama, group members are trained, or are coached in the moment, to be assistants to the client (protagonist) by becoming the people in the client's world and inner experiences. In such therapeutic assistance an auxiliary will not just step into the patients world. If the protagonist is weeping and crawling on the ground the auxiliary will weep and crawl on the ground. If the patient is is delicately and gently caressing her child then the auxiliary will delicately and gently caress her child. The skilled auxiliary will be the protagonist. This true role reversal is qualitatively different from empathy in a talking therapy. Psychodrama teaches the auxiliary to fully and completely enter into the experience of the protagonist with all their being. 17

Extensive personal development is one of the reasons Psychodrama training is so lengthy and includes hundreds of hours of group interactions including dramas, sharing, interpersonal conflicts, discussions and personal work. Psychodrama trainers involve themselves in the professional development of trainees and work to enhance the roles called for in particular situations. Trainers directly experience and intervene in the functioning of all members of the training group. Psychodrama trainers and trainees bring this extensive relationship experience and capacity for encounter into training groups, and all engage in ongoing personal development. It is both terrifying and wonderful; it makes the interpersonal environment of Psychodrama groups tremendously challenging and rewarding. Beck emphasises that a good working alliance and collaboration is necessary for a good outcome and makes concrete suggestions about how to achieve this including operational definitions (Young and Beck, 1980). However CBT therapists could maximise the impact of their work by placing much more emphasis on relationship and relationship training. Attending closely to relationship while delivering CBT enhances the potency of the content and tasks of CBT; it potentially makes therapy easier and more satisfying for both client and therapist. For complex clients, relationship may be the essential ingredient that keeps the client engaged in therapy.

Group considerations
Moreno: ....psychodrama represents the chief turning point away from the treatment of individual in isolation to the treatment of the individual in groups (Moreno, 1946:1977, p. 10 ). Moreno (1953: 1993, p.61) noted that modern psychiatry developed out of somatic medicine where the locus of a physical ailment is within the individual. As psychiatry developed this same premise was automatically applied to mental disorders. Changing the locus of therapy from the individual to the group is one of Moreno's major contributions to psychotherapy. Problems are seen as arising in a social context and in relation to others and the creation of a therapeutic environment, including auxiliaries who interact with the patient, is a crucial aspect of Psychodrama. Group members in psychodrama become agents of therapy themselves (i.e., they are both clients and healers/therapists). The therapist/group leader is also seen as a group member. Although he or she has more expertise in the method he or she is not seen as expert and offering a solution to difficulties in the same way as CBT therapists tend to be. 18

CBT is frequently delivered in groups but the groups tend to focus on content rather than process with some leaders actively actively discouraging extensive discussion of emotional experiences, instead focusing on the acquisition of technical skills. (e.g,. Free, 2007, p. 40). Moreno's method teaches group leaders to focus on both content and process, giving clients an opportunity to learn new skills and the opportunity to learn about human relationships and the effect of interpersonal interactions on their difficulties. In individual therapy situations the psychodramatist is aware of group principles. The social context of the issue at hand is highly relevant. Typically the individual Psychodrama therapy room becomes populated with people from the client's life, represented by objects or dolls or in imagery (Hirschfeld and McVea, 1998). Psychodrama literature can provide a model for the CBT therapist to work with the social context even in one-to-one therapy.

Catharsis
Moreno: Mental catharsis is here defined as a process which accompanies every type of learning, not only release and relief but also a catharsis of integration (Moreno, 1953:1993, p.206). Beck: ... it has been found efficacious to produce an affective experience through inducing imagery regarding traumatic childhood experiences, revivifying early memories, and role playing crucial past episodes (Beck, 1991, p.195). The term catharsis originally applied to physical purging, and was first used by Aristotle who related it to the emotional reaction of the audience in Greek theatre (Langley, 1998 p.263). Moreno was more interested in the experience of the protagonist, although he also recognised the therapeutic effects on the audience. Moreno differentiated between catharsis of abreaction - a release or expression of feeling; and catharsis of integration - a cognitive and emotional shift in perception (Dayton,1994, p.15). Catharsis of abreaction with emotional and physical expression is a characteristic feature of psychodramas. What is less obvious to the untrained observer is that each catharsis of abreaction is accompanied by catharsis of integration to ground the learning on a cognitive level (Dayton, 1994, p.16). Catharsis of abreaction does not necessarily involve a noisy outburst of emotion; 19

quiet and delicate expressions can be full and valuable and can also be followed by a reflective catharsis of integration. Psychologists are familiar with the rapid and emotionally charged learning that occurs in a traumatic incident and results in PTSD. Similarly Psychodrama enactments enable corrective and helpful learning to occur in an emotionally charged state. In contrast many CBT techniques focus on the management of emotions and Beck is dismissive of catharsis, particularly when it is simply a release of dammed-up feelings (1979, p.42). Beck does support the use of experiential and emotive techniques, such as role play and imagery combined with a highly organised reality-test of the associated cognitions (Beck and Weishaar, 1989, p.29). Psychodrama experience and theory suggests that there are times when catharsis of abreaction with full expression of emotion is appropriate and therapeutic. It demonstrates a process for cognitive integration to occur following such catharsis.

Action
Moreno: Because of the universality of the act and its primordial nature it engulfs all other forms of expression. They flow naturally out of it or can be encouraged to emerge, verbal associations, musical associations, visual associations, color associations, rhythmic and dance associations (Moreno and Moreno, 1946:1977, p.18). Beck: ...behavioural methods can be regarded as a series of small experiments designed to test the validity of the patient's ideas or hypothesis about himself (Beck, Rush, Shaw and Emery, 1979, p.118). For Moreno action is primary and psychodrama represented a movement away from treatment by talking therapies to treatment by action methods (Moreno and Moreno 1946: 1977, p. 10). Before each of us developed spoken language we could act and according to Moreno it is through action that we learn, change and develop. Moreno developed a wealth of action methods in many different spheres. As an example: Moreno noted how mothers react to infants and recognised the importance of these early interactions (Moreno, 1952). He observed mirroring where the mother, in sensitive face to face relationship with the child, repeats back to the child the sounds and facial expressions that she has observed and doubling where the parent alongside the child assists the 20

child to put words or expression to new or puzzling experiences. He noticed the importance of human touch for the normal growth and development of children. A number of Psychodrama action techniques recreate aspects of this this first encounter. For example, thoughtful mirroring, doubling and caring and ethical touch is healing for a protagonist who had insufficient parental attention in early childhood. Moreno believed that knowledge and insight in itself does not cure. To Moreno it is important to change behaviour, and to change behaviour it is necessary to access spontaneity and creativity (Moreno et. al., 2000 p.13). Psychodrama utilises many forms of creative expression in order to develop new perceptions and change behaviour. Drama is only one aspect of this; music, song, colour, and dance are frequently expressed on the psychodrama stage. Beck advises that the ultimate aim of including behavioural tasks in CBT is to produce change in the negative attitudes (Beck et. al., 1979 p.119). Psychodrama action provides ample opportunities for behavioural rehearsal, behavioural experiments and graded exposure to previously avoided situations. These action strategies with appropriate catharsis of integration can impact on client attitudes and thinking in a powerful and lasting way.

Thoughts
Moreno: I had two teachers, Jesus and Socrates; Jesus the improvising saint, and Socrates, in a curious sort of way the closest to being a pioneer of the psychodramatic format (Moreno,1953, p.xxii).

Beck: Cognitive therapy ... is based on an underlying theoretical rationale that an individual's affect and behaviour are largely determined by the way in which he structures the world (Beck, 1967, cited in Beck et. al. 1979, p. 3). Alterations in the content of the person's underlying cognitive structures affect his or her affective state and behavioural pattern ... correction of

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faulty dysfunctional constructs can lead to clinical improvement (Beck, et. al., 1979, p.8). Moreno was impressed with Socrates, seeing him as unconsciously using the technique of role reversal during his dialogues. Interviewing for role is an opportunity for the director to explorer thoughts and cognitive processes in psychodrama. Using a Socratic questioning the director questions the protagonist during a drama either as him/herself or (in role reversal) as a significant other. This process illuminates the thinking process of the protagonist and his insight into the thoughts and values of others. Note that Moreno also identified with Jesus, seeing Jesus as being able to enter in the totality and essence of a situation. Moreno saw Psychodrama as a synthesis of the approaches of these two great healers (Moreno, 1953, p.xxii). Beck examines thought processes separately and in much greater detail than other aspects of human functioning. For Beck cognition is primary, not because it necessarily comes first, but because he found it most amenable to change. According to Beck the cognitive biases that are present when a person is distressed or psychologically unwell, can be identified by the client and therapist and systematically challenged. Shifts in cognition leads to shifts in affect and behaviour. If more adaptive patterns of cognition are constructed and maintained then the person is less vulnerable to recurrence of problems such as anxiety and depression (Beck, 1991). Contrary to popular belief the CBT therapist does not argue with the client to convince him that his thinking is mistaken. The competent CBT therapist approaches the client open-mindedly using Socratic questioning to guide the collection of data, identifying and exploring themes and patterns collaboratively so that the client learns to identify these assumptions and to consider whether they are valid or logical (Beck, 1979, p.55). Socratic questioning is a fundamental component of both CBT and Psychodrama and an effective intervention to assist clients identify, monitor and change their thinking. Using Socratic questioning in action situations (by interviewing for role) provides immediate access to emotionally relevant cognitions in totality and essence.

Therapy content and therapist stance

Moreno: The objective of psychodrama was, from its inception to construct a therapeutic setting which uses life as a model, to integrate

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into it all the modalities of living, beginning with these universals - time, space, reality and cosmos, - down to all the details and nuances of life and reality practice (Moreno and Moreno, 1969:1975, p.11). Beck: ...symptom relief, distortions in logic and problem behaviours ... ultimately ... to modify underlying assumptions and systematic bias in thinking (Beck and Weishaar, 1989, p.28 ). Moreno identified what he called the four universalia of psychotherapy: time, space, reality and cosmos. Consideration of all these dimensions contributes to the rich multi-layered experience of Psychodrama moving far beyond the concerns of standard CBT. Moreno was interested in the relationship humans have with time noting: Man lives in time past present and future. He may suffer from a pathology related to each (Moreno and Moreno, 1969:1975, p.11). He was concerned about space, including perception of physical space, physical distance and movement. He recognised different aspects of reality including what is happening in the therapy office, what is happening in the client's day to day life, and surplus reality; the intangible, invisible dimensions of intra-and extra-psychic life (Moreno and Moreno, 1969:1975, p.15). Moreno saw man as a cosmic being and psychodrama as a method which can address the dilemma of the existentialist ... how to tie his personal existence into the rest of the world (Moreno and Moreno, 1969:1975, p.19). A skilled director enables the protagonist to see an issue or a relationship in many dimensions; past present and future can all be present, abstract ideas can be made concrete. When fully immersed in a drama the protagonist may be in an altered state similar to light hypnosis. The shift in perspective by reversing roles or standing outside the action as an observer brings new insights, new possibilities and new behaviours and results in a very full experience which may remain strongly in memory for many years. I offer a personal example to illustrate this: Approximately 10 years ago I was directed in a drama in which I had a conversation with my deceased father (who died unexpectedly during my teens). On recalling it, I am strongly aware of a physical and spatial component of the drama (e.g., an awareness of my father standing to my right), a visual component (my mental picture of the auxiliary who played my father) an emotional and verbal cognitive component

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(remembering the grief and the words of sadness and appreciation), a body component (e.g., the sensation of being able to breath freely again). There is surplus reality (the conversation occurred on a stony river bank where my father loved to fish) and a playful spiritual element (my father was fishing in heaven and I wondered if God likes to fish!). There is an existential time component (e.g., I can recall the day my father died more than 30 years ago, the drama 10 years ago and my current thoughts and feelings about my father). I have multi-layered memory access to these and other time periods, and my current experience of the once traumatic death is rich and bitter-sweet. Since that drama I feel peaceful in the presence of all these memories. The Psychodramatist is directive about the process of the session (e.g., giving instruction to move from discussion to enactment or from physical gesture to verbal expression). He or she attends to the spatial aspect of the situation including action and staging, but is entirely flexible about content, noticing subtle clues in the protagonist that guide the flow of the drama. The Psychodrama director learns to value not knowing what will happen next. The situation could be explored at the level of the individual, society or the universe; past present or future; or from any perspective on reality (e.g., dream or fantasy). The possibilities are limitless. For the novice director this is either extremely freeing or utterly paralysing! CBT's content and therapist stance is very different. CBT is focused on current day problems. Little attention is paid to childhood recollections except to clarify present observations (Beck, 1979, p.7). The focus is on everyday thoughts, feelings and behaviour. Goals are established for the course of therapy and within the session. The therapist is directive about the content of the session and will prioritise key activities, thoughts or behaviours that Beck has demonstrated are likely to be effective points for intervention and change. This parameter is both CBT's strength and its weakness. When CBT works well, behaviour change and symptom relief can be rapid. However there are many cases when consideration of a much broader content area such childhood experiences, dreams and existential concerns is highly relevant. Sometimes it is useful for the client to narrow focus to specific content and pre-determined goals, however sometimes it is the therapist's anxiety that narrows the therapy window in this way. It has taken Psychodrama training to help me discover that any session content can provide a door into useful CBT work (as thoughts and behaviours are always involved) and if I hold goals more lightly then sometimes detours get us to a destination more effectively.

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Techniques
Moreno: Psychodrama ... includes all previous technical approaches (Moreno, 1959:1975, p.236). Beck: With the theory of cognitive therapy in place, we can turn to other systems of psychotherapy as a rich source of therapeutic procedures (Beck, 1991, p.191).

Psychodrama has a number of unique techniques (e.g., see Moreno, 1959 & 1969 and Blatner, 1996) however it is debatable whether any technique applied in isolation is Psychodrama. Similarly, although CBT has a proud tradition of specialised techniques (e.g., see Leahy, 2003), CBT therapists would argue that it is the cognitive conceptualisation rather than techniques that make it true CBT. As indicated in the literature review CBT and Psychodrama therapists are already borrowing techniques from one another; Beck and Moreno would support this but probably each would think his was the integrative therapy. Psychodramatists willingly adopt any technique that might seem useful in a specific situation and I have no doubt that most could readily and creatively adopt the techniques of CBT. CBT practitioners are also great borrowers of new ideas. However although willing to try different therapy techniques, many CBT practitioners are wary of experiential situations that require selfdisclosure and the experience or expression of intense emotion. This is a significant barrier to effective use of Psychodrama methods that can only be overcome by training and experience.

A CBT PSYCHODRAMA
The following section describes an example of my integration of CBT and Psychodrama. Use of techniques from both therapies are illustrated, followed by discussion regarding underlying theory and philosophy.

CBT enriched with Psychodrama

This work occurred at the Psychology Centre, a clinic for clinical psychology students to gain practical experience and clients to access psychological assessment and therapy at reasonable

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cost. As a senior clinical psychologist staffing the Centre, I supervise students and conduct assessment and therapy sessions. The main therapy model used at the clinic is CBT. Client and student consented to me using this material; their names have been changed. Margaret is a 28 year old woman who has been suffering from depressive symptoms and body image concerns. She referred herself for therapy and is aware that she will have a student and supervising clinical psychologist working with her. Lisa, the student, has a Bachelors degree in psychology, is studying for a Ph.D., and is in her second year of postgraduate clinical psychology training. Lisa and I decide to work as co-therapists, Lisa taking on as much of the therapy process as she can manage. I will be in the room and will assist as required. In our initial supervision sessions Lisa is relatively relaxed with me. She talks openly and freely. She is a mature student, keen to learn as much as she can during her clinic placement. Prior to commencing clinical psychology training, Lisa was engaged in a variety of occupations and hobbies including competitive sport, hairdressing and parenting. I enjoy Lisa interacting with me as a respected equal. She takes space comfortably in our small clinic rooms. She is selfreflective, curious, excited about meeting people and appears to relish the opportunity to engage with clients and hear their stories. Before her first therapy session with Margaret, Lisa and I discuss the CBT session she has prepared. She is jittery and tense, speaking quickly and fidgeting in her chair. I know she is capable of calmness under pressure. I ask her how she relaxes before a big sports event. Like this she puts her hands to the side of her eyes like blinkers shutting out distractions and focusing on the task at hand. She puts her fingers in her ears shutting out sounds. Her eyes stop darting about and her body stills, she is playing and laughing with this, serious but not serious. Go outside I say, walk around, do what you do to prepare for a sports competition, come back at 11am when your client will be here. She returns calm and focused. Lisa prepares and conducts the majority of three CBT sessions with our client. She forms a warm and attentive relationship with Margaret, teaching and assisting her to explore her world with CBT, using Socratic questioning effectively. I am impressed with her ability to listen and attend, her willingness to enter the client's reality and to be flexible in the therapy session suggesting and encouraging rather than imposing the CBT model. Lisa is still learning about CBT. She struggles and falters at times but manages to maintain a strong relationship with Margaret. She does a substantial portion of the work on her own. I assist her at various choice points. 26

Margaret's depressive symptoms lift quickly, she is bright, motivated and learns easily. She has a potential for healthy psychological functioning (including a good range of roles and cognitive flexibility) that is readily revived with a warm and empathic therapy relationship and a few well targeted CBT interventions. She enjoys the structure of CBT, including making an agenda at the beginning of each session, checking progress, setting goals, responding to didactic teaching of new skills and selecting and checking homework to be done between sessions. She readily brings up relevant items for the agenda, and works on homework tasks such as pleasant event scheduling (bringing back me time into her diary). She is particularly excited about a homework reading that we assign her from Self Esteem (McKay and Fanning, 2000), identifying in herself a critical voice and a more compassionate coaching voice. Lisa teaches Margaret to identify and record her negative automatic thoughts; habitual, involuntary and unhelpful thoughts about herself, the world and others that have a negative impact on her mood. She questions and discusses Margaret's thoughts encouraging her to notice their impact and evaluate them, rather than accept them. Evidence for and against unhelpful thinking patterns is systematically gathered with Margaret, and forms the basis for thought challenges; structured exercises that assist her to develop alternative thinking patterns. For homework Margaret fills out thought challenge worksheets, practising and developing skills to independently record and challenge her negative automatic thoughts. We get to a point in the therapy familiar to many CBT therapists. Margaret can identify thoughts that are unhelpful and probably untrue but they still feel true. Experiential learning can be very useful to facilitate an emotional shift, and in supervision we discuss using a Psychodrama approach to enhance CBT. I talk with Lisa about using experiential work within a CBT framework, and recommend some CBT articles related to this. Lisa is keen to be involved but not confident to do this herself. We plan that I will direct if the opportunity arises in the next session. At the start of the fourth session Margaret puts on the agenda her concern about negative thoughts about herself and her body and states her desire to change these. Lisa is warm and gentle with the client. She is quite directive, writes key points on the whiteboard during the session and follows a standard CBT format, using Socratic questioning to assist Margaret identify her negative automatic thoughts, find evidence that supports and challenges these negative thoughts and develops alternative thoughts based on evidence. She refers to an earlier

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session where the childhood origins of beliefs had been discussed. Margaret is actively engaged in this process, thoughtful, humorous, and able to access a range of thoughts and beliefs about herself including examples. Margaret's automatic thoughts include concerns that she is too fat and blobby, and that her boyfriend will find her unattractive; evidence to challenge these thoughts include many positive remarks made to her by her friends and her boyfriend. At the end she is able to clearly state that sexiness is a state of mind not a body size. She also states that although she knows this intellectually, it does not feel true. As planned I invite Margaret to try a different sort of thought challenge - a type of role play. She agrees. I indicate the stage area where I have placed two chairs. I suggest she take up the role of Young Blobby Margaret who has been cruelly teased by catty girls at her school. She sits in one of the chairs and takes up this role moving into it quite quickly and requiring minimal prompting to talk in the present tense: I'm fat and blobby, no one likes me, I am ugly and pathetic. She is uncomfortable in her body, sitting on the edge of the seat, moving her hands over her hips, and thighs in an agitated way, very conscious of her body and her tummy repeating the names she has been taunted with. She is focused inward, experiencing an earlier childhood time, her constricted voice, small movements of her mouth and eyes holding back tears are evidence of her distress. She does not make eye contact with me. Her level of immersion and arousal suggest that her warm up is high and appropriate for interaction. I stand up, ask her to move out her chair and take the other. I direct Lisa to take Margaret's seat and role of Blobby Margaret. Lisa is initially self conscious, I demonstrate the role to her and she takes up the role strongly, maximising the agitated hands squeezing and pinching and talking in a self deprecating way. The client looks at Blobby Margaret, silent for a minute, her face is set, a little uncertain. Suddenly her face changes and softens she moves forward in her seat, Oh I want to hug her! You poor thing. She looks at me, I ask the auxiliary if it is okay for Margaret to hug her, she consents. Margaret moves her chair towards Blobby Margaret, she does not hug her but sits close. She talks kindly to her, gently and softly she reassures her, she firmly states some of the things we had identified in the early cognitive challenge; those girls were really mean, you look okay, you are fine just the way you are, you are plump, your parents were plump too its okay ...

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We have several role reversals. Blobby Margaret hears the reassurance but has to check out whether Margaret really means it. It is some time before she can make eye contact. There is a deep level of connection in eye and voice but no physical contact. I invite Margaret to let Bobby Margaret know that she will stay in contact, she does this wholeheartedly and we end the enactment. We return to our original chairs. I explain to Lisa the purpose of Psychodrama sharing, when a person has done an enactment such as this they often feel vulnerable. Making a human, rather than 'professional' connection with the people present helps them feel less exposed and helps with the transition back into ordinary life. I am aware that Margaret is listening, she nods when I talk. In sharing I let Margaret know that I feel moved by the gentle relationship she is developing towards herself. Lisa and I each briefly share a little of our own experience of body dissatisfaction, acknowledging that it is difficult to keep liking our bodies when there are so many pressures to look a particular way. Margaret expresses her appreciation for the session, she is bright and animated, stating that she is amazed at this way of working and that she feels very different from when she walked in. In three later sessions we continue with a standard CBT format but the experience of a conversation with yourself is frequently referred to. The client maintains her gains and is consistently more compassionate and gentle with herself. She finished therapy six weeks after the described session.

Philosophy and theory behind the techniques

Preparing the student I am attentive to the relationship between us. Guided by the philosophy and theory of Psychodrama I attend to Lisa's warm up and focus on her healthy functioning. I am delighted at her playfulness as she demonstrates blinkers and ear plugs. Psychodrama experience and theory informs me that using her body in action will greatly assist her. I am aware that playfulness is a glimpse of spontaneity and creativity that this student is capable of accessing within herself. Thanks to psychodrama training I am a spontaneous and creative supervisor. As a co-therapist with the student I recreate the supervised experiential learning style of Psychodrama, rather than CBT supervision that may rely on student report or review of recordings. Within Psychodrama's culture of lifelong personal development I have been both a 29

student and a client in the recent past. This assists me to position myself alongside Lisa and Margaret physically and emotionally at times. Doubling each of them in this way provides a strong experience of empathic attunement that both responded to positively. The self-help reading from McKay and Fanning (2000) is user-friendly CBT for those with a good reading level, and is compatible with Psychodrama. McKay and Fanning illustrate thought challenging using two characters the Pathological Critic and the Encouraging Coach. It is a short step to role enactment. The session described uses Psychodrama elements within CBT structure, however it is Psychodrama training that informs my genuine openness to the content of the session, and a quality of relationship that enables production with sensitivity and depth. The CBT agenda and the initial cognitive challenge exercise serve as warm up for the enactment. The Psychodrama action is integrated into the body of the CBT session. Psychodrama sharing assists the client to transition from the intense internal experience of enactment of childhood experiences, to the present day and current relationships before returning to her working day. Sharing some of our own human experience with the client is consistent with Psychodrama theory as we are all group members, and consistent with CBT it may counter beliefs that her concerns make her abnormal. The structured CBT thought challenge on the whiteboard strongly engaged the client's ability to think and reason, making the most of her intellectual capacities. However it did not convincingly shift her emotions, it still did not feel true. This is a common issue identified in CBT and is traditionally addressed by ensuring that clients engage in changes in behaviour. For CBT homework the client had been engaging in pleasant events, planning breaks from her work schedule and eating regular healthy meals. Other specific CBT homework behavioural tasks for body image issues include exercises such as observing ones body in front of a mirror and developing neutral descriptors (e.g. rounded hips instead of fat and ugly hips), engaging in moderate physical exercise and abstaining from checking behaviours (such as pinching and measuring). A CBT approach may recommend experiential techniques such as imagery or rational-emotive role play to restructure childhood beliefs. However I, and many other psychologists, have received little or no CBT training in how to do this. Psychodrama training provides opportunity to practice a large repertoire of experiential methods. 30

Considering the use of Psychodrama in the session I had thought about staging and had brought in extra chairs for the session. Placing the action on a stage or distinct allocated space is characteristic of Psychodrama. This assists the protagonist by defining the boundary between current day experience and surplus reality, moving from audience to stage is a physical marker of degree of warm up. Unlike CBT's rational-emotive role play, concrete positions are available for different roles. Body positions and spatial relationships between roles (e.g., near or far, higher or lower) provide another layer of information about the quality of relationships. Consistent with CBT, and Psychodrama's role training, the enactment had a clear goal and content in mind; to shift feeling about a particular issue. The Psychodrama director however, primarily directs the process rather than content. We were keen for the client to develop feelings congruent with rational thinking. Psychodrama training has prepared me to hold such goals lightly. If the enactment had taken a different direction, perhaps moving the client towards more unhappiness or arousing feelings of rage, Psychodrama training provides ample preparation for working with client experience (rather than pushing it in a preconceived direction). Psychodrama theory and experience informs me that the spontaneity and creativity of the client, the student and myself would have risen to the occasion and found a progressive direction. I think that those without Psychodrama training would find this difficult. The enactment was simple and effective and the production adequate. True to CBT it focused on the area with most potential for symptom relief. By focusing on two main roles that were congruent with CBT theory there was a clear framework for the student to follow assisting her learning about CBT, and using experiential methods within a CBT framework. The most obvious strength to the enactment was that we had the "blobby" and bullied child present with herself as an encouraging, caring companion. We were able to engage the client with herself in such a way that she responded adequately to the negativity and her own harsh criticism. We did not address the thoughts, feelings and behaviours of the bullying children. Had we done so we would have applied concretisation, the Psychodrama technique that brings alive abstract ideas or characters. We could have set out items such as cushions or dolls to represent the critical girls and the bully, the client could have used coloured fabrics to represent feeling states blobby and pathetic. Effective use of concretisation heightens the warm up for the protagonist and enables multiple aspects of the situation to be experienced simultaneously.

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In asking the client to be herself as a blobby teenager I was picking up on her terminology, accepting and fully entering into her experience of reality, a stance consistent with both CBT and Psychodrama. Drawing attention to body sensations, posture and movement e.g., coaching the auxiliary to maximise the agitated hands, facilitated the visual and spatial experience for the client, heightening warm up and deepening emotional experience and accessing CBT's hot cognitions. By standing up, rather than sitting, I warmed myself up to being a director of action rather than a talking therapist. Role theory has been briefly mentioned in this thesis. Appreciation of role concepts is crucial to Psychodrama theory. Reversing roles is a powerful technique. Physically moving to another position changes ones perspective emotionally and intellectually. Viewing herself as an unhappy teenager markedly shifted the client's experience. This was not just a cognitive shift but a complete shift in role. Compassionate feelings, thoughts and actions were aroused and utilised to good effect. In demonstrating the role of Blobby Margaret I was coaching Lisa to become a spontaneous auxiliary for Margaret, I also facilitated two mirrors for Margaret. She saw an aspect of herself reflected in me the supervisor/teacher and then by Lisa. Multiple views of herself and at least three perspectives (the first from within the role, the second as she eavesdropped on my demonstration to Lisa and the third as she interacted with it) deepened her experience of herself and assisted the shift in affect. Psychodrama training has taught me to attended to the quality of the role, not just the words, during role reversals. I was aware of tone of voice, softening of timbre, softening and moistening of eyes. These and other clues indicated that the client was fully engaged in the enactment with emotions and cognitions heightened. I also was conscious of the client occasionally shifting roles and time frames during her interactions with me. No longer immersed in the enactment she would thoughtfully and calmly ask a question before returning to the action fully present and emotionally expressive towards herself as a teenager. We were in existential time where multiple layers of experience, past and present were happening in the here-and-now. The client was also demonstrating and practising schema mode flexibility, moving easily from one mode to the next and having access to a rational appraisal of the situation. A potent action cue was stated I want to hug her. Encouraged to move closer to the "blobby" teenager the client willing shifted her chair closer but hesitated to actually make body contact. At 32

this point I experienced a role conflict within myself. In Psychodrama, ethical physical contact is valued for its healing potential and to maximise the experience for the client. Psychodrama practitioners do not necessarily use physical touch in individual sessions however as Psychodrama director it could have been appropriate for me to gently assist the client to make physical contact with the auxiliary by coaching her or modelling the action for her. As clinical psychologist I have been discouraged from having physical contact with clients. In this situation the auxiliary had consented and the action cue had been given by the client. Cautious and recognising the good work that was occurring by sitting close together I did not amplify the action at this point. I believe it was a good decision as I have not yet found a way to integrate physical touch in my CBT practice. The session described used aspects of CBT and Psychodrama. Both therapies influenced the techniques used, my stance and thinking. Psychodrama influences are most salient in my attention to therapy and supervision relationship, and in my stance of being directive about process but relatively open about content of the session. I find that nearly every topic of discussion provides ample opportunities to work with cognitive distortions, schema and behavioural patterns, roles and role relationships. I am not bound by the limitations of spoken word, white board, or two column thought challenges, I can work with whatever material emerges including multiple clusters of cognitions and feelings and multiple time-frames. I set therapy goals and focus on symptom reduction but hold these goals lightly, recognising that client led detours sometimes lead to the heart of an issue and that problematic inflexible roles or cognitive patterns will show themselves repeatedly for addressing. The more I become aware of the social context of mental health issues the more I value the theoretical and technical contribution Psychodrama offers for addressing this.

IMPLICATIONS
I have investigated the goals, philosophy, theory and practice of Beck and Moreno, compared and contrasted their work, taken these findings and applied them to a supervised therapy situation. This work has implications for clinical practice, research and future directions.

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Clinical practice
Although CBT is the predominant therapy model in many mainstream organisations, research and clinical experience confirms that many clients will not make full and sustained recovery with CBT alone. One possibility for enhancing the delivery of CBT is to borrow methods from other therapy schools. I have demonstrated that many aspects of Psychodrama enrich CBT. Psychodrama training enables the CBT therapist to maximise use of the therapy relationship. Psychodrama techniques can ease the tasks of CBT for many clients, facilitating access to emotionally charged cognitions and providing opportunities for change. Psychodrama could also be a sequel to CBT. With its focus on experiential learning in a group context, Psychodrama may be particularly useful for clients who have long standing interpersonal difficulties that inhibit progress or contribute to relapse in traditional CBT. For CBT supervision and training Psychodrama offers a complementary training model that is based on health rather than illness and encourages lifelong learning and personal development. Psychodrama normalises the difficulties faced by therapists and provides opportunity to develop intimate and supportive peer relationships where personal and professional development occur side by side. The full potential of combining the therapies will only be realised with training, experiential learning and supervision. For example, lack of training in the therapeutic use of space and physical touch will prevent a CBT practitioner from ever using the full range of Psychodrama action methods and use of any technique will be limited unless the clinician has an appreciation of its theoretical underpinnings. Although there are some similarities there are significant and possibly irreconcilable differences between Psychodrama and CBT at the level of philosophy. Both therapies value the subjective and objective experience of the client and both see human beings as meaning makers of their own world. However there is likely to be tension between the spiritual and existential values of psychodrama and the tight focus on predetermined goals, specific outcomes, and measurable symptom reduction endorsed by CBT and its academic psychology roots.

Research and future directions

Psychodrama's contrasting but largely complementary perspective has the potential to stimulate CBT theory and research. Psychodrama has the potential to increase the effectiveness of CBT 34

with individuals, enhance the effective delivery of CBT in groups and reduce risk of relapse. Promising areas for further exploration and research include: 1. Investigation of role theory and its relation to schema mode theory. This may be particularly useful for CBT practitioners and researchers considering the impact of schema modes in group and social contexts. 2. Enhancing delivery of CBT in groups by drawing on Psychodrama theory related to group process. 3. Consideration of Psychodrama's extensive repertoire of methods that do not rely on spoken or written work for clients with language and literacy problems. 4. Developing CBT's repertoire of experiential techniques to include use of spatial relationships, movement, colour, body sensations, physical objects and ethical use of touch. 5. Development of CBT theory and practice by considering Psychodrama's capacity for dealing with multiple time-frames, and multiple clusters of experience (including several streams of cognition) simultaneously. 6. Consideration of spontaneity and surplus reality in the development of theory and practice and training, particularly in regard to anxiety reduction and motivation to experiment and play with new behaviours. 7. Exploration of alternative styles of CBT training and supervision, including the supervised clinical practice model of Psychodrama (as an adjunct to recordings, student report, or one-way mirror observations). In clinical settings, where Psychodrama therapists are referred clients with a psychiatric diagnosis and expected to assist with symptom relief in short time frames, CBT's focus on psychological problems may provide a useful adjunct to Psychodrama's health-focused model: 1. CBT shares some common ground with Psychodrama, has widespread mainstream acceptance and its language is familiar to many mental health practitioners. Use of CBT language may facilitate acceptance of Psychodrama concepts.

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2. All psychodramas involve cognitions and cognitive change. Consideration of CBT theory could raise awareness of the cognitive aspect of role and sharpen focus particularly in groups in clinical settings and during catharsis of integration. 3. CBT offers a wide range of specifically tailored strategies for clinical problems many of which can be adapted and used in action. Further exploration and research into the area of combining CBT and Psychodrama is warranted. This is likely to initially involve more individual case studies and therapist observations but may eventually result in more controlled trials being conducted. Robust discussion is needed to determine whether this method of research is appropriate for Psychodrama and whether there are better means to explore this complex method. The similarities in the work of Beck and Moreno are intriguing and warrant further investigation. It is heartening that these two men with such different approaches have findings in common. It gives me hope that it may be eventually possible for people of diverse opinions to have a greater degree of shared understanding of the human condition.

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CONCLUSION
This thesis introduced Beck and Moreno as part of quest to address the question: How does a therapist combine two vastly different therapies?. This question is pertinent for experienced therapists who gain expertise in diverse therapy modalities particularly if there is organisational and professional pressure to adhere to a single model. As clinical psychologist, supervisor and therapist with CBT as my main therapy perspective I also apply Psychodrama in my work. In moving beyond borrowing techniques, it has been necessary for me to consider the origins, philosophy, goals, theory and practice of each therapy. I have placed these two radically different therapies side by side for comparison and contrast, appreciating that each is a source of alternative perspectives, differing world views and unique gifts to share. Experiential training, study and practice in both has assisted me to personally integrate this knowledge. By approaching them in this way the two separate therapies become companions rather than adversaries and I have demonstrated that this approach enables the therapist and teacher to draw on the richness of both during therapy and supervision sessions. I have provided description and analysis of a CBT based supervision and therapy situation enhanced with Psychodrama. Outlining the complimentary nature of these therapies I have suggested possibilities for further enquiry and research into combining CBT and Psychodrama in psychotherapy and supervision.

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