Another Color in the Psychiatric Crayon Box

An Expert Interview With Adam Blatner, MD

Bret Stetka, MD; Christine Vuolo; Adam Blatner, MD

Disclosures

August 30, 2012

In This Article

Putting Psychodrama Into Practice

Medscape: What sort of training is involved in learning psychodramatic methods?

Dr. Blatner: Rather extensive training is needed to learn the method well. Candidates for certification as practitioners are required to have at least a master's degree in some form of counseling or psychology. Most people take several years to attain the number of hours of supervised training required. Because this is not just intellectual knowledge, but rather becoming actively proficient, directing classical psychodrama is a bit like learning brain surgery. On the other hand, just as family physicians can use modern techniques derived from advances in the field of surgery in their offices, so too can many psychodramatic techniques be adapted to and integrated with other types of psychotherapy and counseling.

Medscape: How familiar are most psychiatrists with psychodrama today?

Dr. Blatner: Most psychiatrists are quite uninformed or are only slightly aware of this as a type of therapy. There was a bit more awareness of the method in the 1960s, when psychodrama was seen as a major alternative to psychoanalysis and included in major textbooks; however, as the number of alternative therapies proliferated, psychodrama became only 1 among many.

Because psychodrama is taught as a group therapy method, very few psychiatric residents continue that type of practice after leaving their training and enter private practice or a clinic. As for inpatient treatment, let's just acknowledge that the economic mandate for shorter stays and active pharmacotherapy has generally diminished many types of adjunctive psychotherapy.

Medscape: So your average psychiatrist does not receive very much, if any, formal training in this?

Dr. Blatner: Hardly in the United States, and there are almost no faculty that I know of psychiatric residency programs that train psychiatrists in action methods. (There are numerous psychodrama training programs around the country, but they are run by certified trainers; see the American Board of Examiners in Psychodrama, Sociometry and Group Psychotherapy Website.) In contrast, there are many more psychiatrists who are also psychodramatists in Europe and South America, and the method's popularity is growing in Asia and the Middle East. So I do want to acknowledge the international movement.

Medscape: How could psychiatrists/therapists benefit from the use of psychodrama?

Dr. Blatner: Psychodrama offers a goodly number of tools for supporting a wide range of therapeutic goals. As I mentioned above, there are techniques that can be used in 1-to-1 sessions. For example, sometimes it is useful to have the client "role reverse" -- the therapist asks the person to "become" the person they are talking about and to imagine what that person might be thinking/feeling and to say it out loud. The patient is then asked to return to themselves and comment on what they heard or imagined the other person saying.

Often in more conventional types of talk therapy, clients get bogged down in their own thoughts. Psychodramatic techniques generate an inner metaphor of the actor choosing how he or she can play the role differently, perhaps better. It establishes a bit of psychic distance between the chooser of how the role is to be played and old habits of reaction. The client has more room to see themselves and the other person in ways other than how they tended habitually to perceive and react.

New ways of interacting can be considered and even experimented with using "role taking" or "role rehearsal." The doubling technique can be used by therapists as a form of active empathy, in which the therapist says, "If I were you (the patient) in that situation, I might be feeling _____." This can help a patient who is having trouble verbalizing something to start their own stream of expression. To differentiate this from mere "interpretation," I continually check in with the patient by saying, "Am I close to what you'd say? Correct me." This establishes a more positive therapeutic alliance.

Therapists are thus perceived as someone who's trying to help discover the dynamics of the problem. It breaks down the cliché that the therapist-as-authority figure presumes to or does know all the answers or that the therapist is judging the patient.

There is also the concept of warm-up.Warm-up is something that in the 20th century was not considered in most schools. You're supposed to be prepared and ready to answer questions. But that's not how 95% of people work in most situations. With warm-up, the psychiatrist says, "You can take your time; we'll warm up to this. I assure you we'll get there." It's very reassuring.

People feel so embarrassed because they can't find the words for all their feelings when they walk into the doctor's office, and they feel like they're supposed to tell the whole story cleanly. They can't. But saying, "We're warming up, and we're going to talk around it a bit, and I'll help you," is such a nice thing. It's also the opposite of sitting there silently, which is isn't helpful.

Medscape: So, you acclimate the patient to the situation, which leads to a healthier interaction and therapy session?

Dr. Blatner: Yes, acclimating and having a healthy, happy interaction. If I trained psychiatrists now, I would spend the first year just teaching them to be nice. Empathy is so important, and an empathetic psychiatrist is already ahead of the game when they walk in to see a patient. However, it's rarely taught because there are no right or wrong answers. It's a matter of using your imagination and sometimes being approximately right. That's very different from most of US schooling, which operates under the assumption -- which is fundamentally flawed -- that there are always right answers. It turns out that in 5% of your life, there are precisely right answers, but in 95% of your life, answers are blurry and negotiable.

These and other psychodramatic techniques add immeasurably to the repertoire of treatment strategies for therapists, adjusted to what the client needs. In this sense, psychodrama is to general psychotherapy what the introduction of new technologies, such as laparoscopes, are to surgery. Once one learns to use these tools properly, they can be integrated in many different kinds of procedures. In this sense, learning to psychodramatic methods might be analogous to a carpenter learning to use electrically powered tools.

Medscape: So you're not advocating psychodrama over other therapies or interventions necessarily, but more as 1 potential component of a multimodal approach?

Dr. Blatner: That's correct. I consider myself a psychiatrist with multiple ways to approach any given problem. It's kept me energetically engaged with my patients. I know that I have the basic medical specialty skills that are required for Board certification, and I've learned so many other ways to try to help them as we explore their problems together.

Medscape: And I imagine that like most therapies, its use and effectiveness is case-specific? In certain cases, psychodrama is going to be far more effective, and in certain cases another technique might be far more effective?

Dr. Blatner: Yes. Too many people -- including some psychodramatists -- make claims for their own approach, as if it were a panacea. Again, I want to clarify that a full psychodrama with a person is very powerful. Like a surgical procedure, you need a team to help and definitely follow-up care. I remind practitioners that there need to be plausible indications for the use of this procedure. Psychodrama is not necessarily good for everyone and is unnecessary for some people. Nonetheless, I am an active proponent of psychodramatic methods (not the whole classical process) being more widely integrated into a professional practice.

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