Arthur L. Caplan, PhD: Welcome to Close-Up. I'm Art Caplan, from the Division of Medical Ethics at the New York University (NYU) Langone Medical Center. I have a great guest with me today: Jonathan Moreno, a professor at the University of Pennsylvania in the Department of Medical Ethics. He's also a PIK [Penn Integrates Knowledge] professor, a lofty honor that is given to few. You have a new book.
Jonathan D. Moreno, PhD: I have a new book. The book is about my dad [J.L. Moreno] and his influence on the theater, psychotherapy, and social network theory. My dad died just a few months before you and I met in 1974. We have talked about him and his work a lot in the past 40 years.
Dr Caplan: Your book is on Amazon and in bookstores everywhere?
Dr Moreno: It's in virtual bookstores everywhere. It's called Impromptu Man and it's published by Bellevue Literary Press, which is technically part of NYU.
Dr. Caplan: Let'stalk about that. You had a very interesting youth. Your dad was older when he had you. How old was he?
Dr Moreno: He was 63.
Dr. Caplan: He came from Europe. He had fought long and hard about the connection between psychotherapy, the theater, and Freudianism. When he came here, he put some of that into practice. What did he do when he got here?
Dr Moreno: He came here in 1926. He was already 35 or 36 years old. He had gone to medical school in Vienna. Freud was one of his lecturers. He wasn't interested in psychoanalysis except as his bête noire. What he was really interested in, in medical school, was the whole idea of God. He was a mystic. He was very interested in theater and was part of a literary movement called Viennese Expressionism while he was in medical school. I don't know how he had time for these things. I guess there was a lot less medicine to learn in those days. He also was a medic in a couple of refugee camps. He was pressed into service for the Austro-Hungarian Army during World War I. He was a medic in the Austro-Hungarian Army, which is kind of hard to relate to. He had questions about playing the role of God, questions about our relationships to one another ("the Encounter," he called it) and how things play out on the stage, whether it was the stage of life or his experimental theater, which he called the theater of spontaneity. He saw these things as all of a piece. He had done all of these things by the time he got here in 1926.
Moving Beyond Freud
Dr Caplan: When he came, mental health care was very much under the influence and ideology of Freud. Were people doing psychoanalysis at that time?
Dr Moreno: There was asylum care. The big focus, when he was in medical school and in the 1920s and 1930s, was Kraepelin and the diagnostic categories. Psychoanalysis was starting to penetrate among the intelligentsia. His best friend was Alfred Adler. My father was not opposed to all psychoanalysis by any means, but he thought that psychoanalysis was insufficiently interpersonal.
Dr Caplan: The lying on the couch with the listener.
Dr Moreno: Yes, not facing each other and not interacting. It was the idea of transference—that I project my feelings toward my father on you as the analyst. Let's have the analyst play the role of the father. Let's have that encounter. Let's see what it's like to be dad. Let's have you feel your way into dad's role. He wanted to push. This was the expressionism. He wanted to push these internal dynamics out onto something like a theater stage.
Dr Caplan: There is a lot of emphasis in our medical schools now on trying to teach doctors to be more humane. There are humanism courses—not ethics, but the notion that you can teach physicians to be kinder and gentler, and more empathetic.
Dr Moreno: How to have a difficult conversation.
Dr Caplan: How did your dad fit into that? What might he have said?
Dr Moreno: He would have loved that. He thought that role-playing—what he called psychodrama—should be part of all education. Any profession in which there is a relationship with another human being could benefit.
The Invention of Role-Playing
Dr Caplan: He thought that you could learn, practice, and get better?
Dr Moreno: Absolutely, but he started early, in 1926. His ideas were fully formed by World War II. His first job in the United States was at Mount Sinai in the mental hygiene clinic after he got off the boat, where he did role-playing with kids.
Dr Caplan: We still see some of that today in our child guidance centers. People who deal with kids with various problems and challenges are following those techniques.
Dr Moreno: They give the child a doll to play the doctor or an abuser. The second place that he did his role-playing in this country was at R.H. Macy, where they were teaching the people on the staff how to relate to the customers. Now this is standard practice.
Dr Caplan: Today, everyone wants to make medicine adopt the techniques used at the Four Seasons.
Dr Moreno: Anything that involves feeling your way into the skin of the other person, trying to understand their point of view, involves what he calls role reversal.
Dr Caplan: If people read the book, would they have a better understanding of the techniques, ideas, and theories that generate empathy? Will it give us some idea about how to teach or even construct our own interpersonal practice, and improve on it?
Training in Spontaneity
Dr Moreno: He thought that the two most important ideas in the 20th century were spontaneity and creativity. It sounds paradoxical, but he thought that you could train people to be spontaneous.
How do you do that? What we are doing right now has a level of spontaneity. We have never had this exact conversation before. When you enter a real interpersonal environment, you have to be somewhat spontaneous and creative. He thought—and this was his connection to, for example, the Stanislavski method in method acting—that you could train people to be spontaneous by putting them in new situations. It's like a muscle. It needs to be used. Creativity, he thought, was an infinite reservoir. There is no limit to creativity, in principle. But people get stuck in roles, so I'll just name-drop. People will remember the actor Peter Lorre, who, by the time we were kids, was literally a cartoon caricature.
Dr Caplan: They turned him into a cartoon.
Dr Moreno: My dad discovered Peter Lorre in his spontaneity theater in Vienna. László Löwenstein was his real name. He was so good at playing the creepy role that he stuck with it.
Dr Caplan: He was the Spock of his time.
Dr Moreno: He couldn't get out of the role. He went to Bertolt Brecht and kept the role. Then he went to Fritz Lang and made a famous movie called M in 1931, in which he plays a child abuser and murderer. My dad warned him that he would get stuck and that he needed to learn how to play other roles. If you know Peter Lorre's story, it was very compelling and painful. He couldn't get out of that role. My dad's idea was that you could learn how to warm up to other roles if you had a safe place to do it, such as the stage or the theater.
From Boxing Matches to Improvisational Comedy
Dr Caplan: What happened to your dad's reception as Freudianism began to take off? We got out of the asylum. Did he get left behind? Was he so far ahead of his time that some of these creative approaches to role-playing and theatrical-ness got lost in mental health care?
Dr Moreno: This is exactly where I entered the picture in 1952, when I was born. He was famous. He was in the newspapers. It was fascinating.
Dr Caplan: You told me he predicted boxing matches.
Dr Moreno: He predicted boxing matches. He was never wrong. He did it based on the interpersonal relations in the training camp. The press loved him. He was Viennese with the accent, sandy hair; he was a psychiatrist, and he loved actors. The actors liked him. What happened to him, though, in the 1960s was kind of sad. This was much of my experience with him when I was little. The culture adopted his ideas and cannibalized his ideas. Role-playing is everywhere. Social networks are everywhere now. The basis of the Internet is the social network, and it generates new social networks. He saw ideas being cannibalized and taken away through the human potential movement, places like Esalen.
Dr Caplan: They are direct descendants, almost.
Dr Moreno: They were direct descendants and people knew that at the time. There were new population therapies—Gestalt therapy, transactional analysis, and EST [Erhard Seminars Training]. I interviewed Werner Erhard for the book. They were inspired by psychodrama. But [my dad] was so far ahead that the ideas were taken and he was left behind. He wasn't cool anymore at a certain point. That's the sad part of the story. The great part of the story is that his ideas live on in education, medical schools, business schools, and even law schools. There is role-playing everywhere, experimental theater, and Second City. The old improvisational actors knew where it came from. They knew where the inspiration was.
Dr Caplan: Our comedy is shaped very much by that.
Dr Moreno: Comedy is shaped by it. We see people like Tina Fey, who said that she has used psychodrama in her shows.
Dr Caplan: I still meet children who are going to therapists who have the dolls out and use acting.
Dr Moreno: Yes, it's role-playing and role reversal. I wrote an op-ed about Clint Eastwood's speech at the Republican Convention when he used the empty chair. I explained where the idea of the empty chair came from. It makes perfect sense that an older actor-director would get the idea of the empty chair.
Action vs Lying on a Couch
Dr Caplan: Do you think your dad was a psychiatrist from another era? He comes to us now. We are all talking about evidence-based medicine, outcomes based medicine. What would he have said about that?
Dr Moreno: He thought that psychoanalysis was too abstract to be a therapy. He thought that you had to get into action. We live with other people. We live in the world. We don't live on the couch. He believed that the real evidence is what he called existential validation. If you do a psychodrama, if you resolve the relationship, you find a new way to deal with a problem you have in your family or at business, or whatever it is. Take it into the world and see how it works. To him, that is the real evidence that a therapy works.
Dr Caplan: If you are doing better in real life, that's what counts.
Dr Moreno: It's not a questionnaire, not intellectualizing, not taking forever to dig through your neuroses. He thought that was very abstract. In fact, many psychoanalysts who do group therapy (and he was the first person to use the term "group therapy" in print, in 1932) use his techniques. They assess the situation intellectually, and theoretically, using psychoanalysis. They actually use role-playing. In cognitive-behavioral therapy, which is the big movement now, there is a lot of role-playing.
Dr Caplan: The Aaron Beck movement.
Dr. Moreno: Yes, Aaron Beck, who has said that, of course, we know all about psychodrama.
Return to the Asylum Era?
Dr Caplan: We have a group of people now in mental health who are saying that maybe it's time to rethink the asylum. You practically grew up on the grounds of one. Your dad operated one.
Dr Moreno: He had a 30- to 40-bed mental hospital in the Hudson Valley.
Dr Caplan: We have a lot of people in prison with mental illness. We have a lot of folks on the streets with mental illness. Where do you think we should be going? I'm saying this in part to channel your father, but I'm interested in your view, too. Where are we with respect to the world of the asylum that he presided over and which then disappeared?
Dr Moreno: He practiced largely before there were the psychoactive medications that we have now. But he wasn't opposed to them. He did live in an asylum world. He would say that there is a place for people who are vulnerable and defenseless to be in a protected environment. The word "asylum" now has become pejorative, but it merely means a protected environment. He had a patient for almost 20 years when I was growing up who was very psychotic and had schizophrenia. He was a danger to nobody but himself. My friends would come over to play in the 20-acre sanitarium. They would hear this howling. I would say, "That's Joe." My father didn't give up his license for several years and he didn't give up his insurance in the late 1960s for several years because he didn't want to send Joe to the public hospital. He was afraid that Joe would be abused.
Dr Caplan: That was at a time when we were "Willowbrooking."
Dr Moreno: Exactly. It was the late 1960s and people were beginning to become aware of the problems in these total institutions. Of course, Erving Goffman, who wrote the book Asylums, saw psychodrama at St. Elizabeth's Hospital in the 1950s. It was considered very progressive. But the asylums were, at that point, becoming snake pits, as they had several times in our history. He would have said that there are some people who need this kind of cloistered situation.
Dr Caplan: I understand what your dad might have said. What do you think? Is there a case to be made for returning more mentally ill persons to asylum-like settings?
Dr Moreno: I would say the same thing.
Dr Caplan: You would?
Dr Moreno: I think most people in the world of psychiatry and clinical psychology agree that we are not doing this well. We have failed.
Dr Caplan: There are too many people out on the streets, rotting with their rights on.
Dr Moreno: When you and I were in graduate school 40 years ago, 30%-40% of people in prisons had a diagnosed mental illness. If they don't, it's exacerbated or created by being in the prison environment. We have failed and he would see that as a real social tragedy.
Defining the First Social Networks
Dr Caplan: One of the things I found startling in the book is your claim that your father, in a way, was the forerunner of Facebook. Tell me about that.
Dr Moreno: He was working in one of those refugee camps during the First World War. He saw that the families were being forced together, different cultures, different languages, and different ethnicities. It's all connected. He saw the whole society as invisibly networked.
In organizations, there were these formal relationships in the hierarchies but there are also the informal relationships. There are these social networks. When he got to the United States in 1926, he started to think more about this stuff. In the early 1930s, he was invited to engage in a massive psychotherapy assessment of Sing Sing prison. He started to see the social networks in the prison. Then he went to a girls' reform school in upstate Hudson, New York. He reorganized the whole place, which was having terrible problems with runaways and bad behavior in terms of who would like to live in which cabin. Who would like to work in the laundry together? Who would like to work in the kitchen together? Who would like to be in the class together? Suddenly, people were getting along. The institution was functioning.
Dr Caplan: So he was making the connections that we hear about even now, in terms of the influence of your friends on your behavior, and influence of your social network.
Dr Moreno: Exactly. Even a national agency had gotten into the act, which consulted him in the mid-1950s. He started drawing maps of these relationships, which he called sociograms. Today they are called social graphics. If you look at your friend's network, it's what he would have called a sociogram. He saw the whole society as invisibly networked.
Dr Caplan: There are lessons here for healthcare and medicine that we ignore, at our peril, because whether you are trying to modify a person's behavior or convince someone to vaccinate their children, it very much matters who they are hanging around with and who are they influenced by.
Dr Moreno: Right, and Facebook knows all about this social epidemiology. There was an experiment a while ago in which they manipulated the positive and negative messages. It's all the stuff that [my dad] perceived but he did not have the technology to do it. He had to use pen and paper. Now you can do it online.
Dr Caplan: Impromptu Man is a wonderful book. You will see the career of a physician, a pioneer, someone who was way ahead of his time; someone we could say still has lessons to teach us, although he might want us to act through them rather than to just be a one-way street. I have read the book. I found it fascinating. I hope you found the interview interesting and will go out and get the book as well. I'm Art Caplan. Thanks for watching.
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Cite this: Psychodrama, Role-Play, and Social Networks - Medscape - Mar 13, 2015.