A Psychodrama Group for Substance Use Relapse Prevention Training

Article Citation:

Somov, P. G. (2008)
A Psychodrama Group for Substance Use Relapse Prevention Training.
The Arts in Psychotherapy, 38 , 151-161.

Abstract

The article reviews utilization of psychodrama group therapy in the context of drug and alcohol treatment and introduces a specific application of psychodrama group therapy for the purposes of relapse prevention. The proposed psychodrama group format features facilitator guidelines for directing relapse prevention behavioral role plays, substance-use specific role plays, and a format for post-role-play processing of group participants’ experiences.

Psychodrama is Group Therapy

Psychodrama is an action method pioneered by Moreno, one of the founders of group psychotherapy (Corsini, 1955). A therapeutic modality in which “people enact scenes from their lives, dreams or fantasies in an effort to express unexpressed feelings, gain new insights and understandings, and practice new and more satisfying behaviors” (Garcia & Buchanan, 2000, p. 162), psychodrama would appear uniquely positioned to allow individuals in substance use treatment to practice relapse prevention skills. And yet psychodrama, as a clinical modality, appears to be underutilized by the mainstay of substance use group work. For example, Brook and Spitz, in their otherwise comprehensive review of group modalities in the field of substance use treatment, “ The Group Therapy of Substance Abuse” (2002), did not include a description of psychodrama. Their book makes a few “one-word mentions” of psychodrama in passing and devotes only one free-standing paragraph on the history of psychodrama with substance use population tucked away at the end of the book. Robert Landy, professor and director of the Drama Therapy Program at New York University, in his 1997 pre-millennium status report article entitled “Drama Therapy – The state of the Art,” enumerates at least sixteen specific client populations but fails to mention the population of substance use. Similarly, Frances, Miller & Mack, in their authoritative and much anticipated 2005 “Clinical Textbook of Addictive Disorders, Third Edition” fail to mention psychodrama. Coombs and Howatt, the authors of “The Addiction Counselor’s Desk Reference” (2005), a truly panoramic resource, offer only a two-line definition of psychodrama in the back-matter of the four hundred plus pages book. Their definition of psychodrama as “adjunct to psychotherapy in which the patient acts out certain roles and incidents” (p. 373) offers a clue to the short shrift given to psychodrama in the substance use literature: despite a rather substantial history of the use of psychodrama with the substance use population, psychodrama is still viewed as an “adjunct to psychotherapy” for substance use, not as a bona fide group treatment modality.

One possible explanation for the underutilization of psychodrama in the group-work driven drug and alcohol rehabilitation field might be a failure to appreciate that psychodrama is, unambiguously, a form of group therapy. Another possible explanation is that while some attempts have been made to extend the practice of psychodrama to the field of addiction treatment, the psychodrama literature has largely failed to crystallize a psychodrama application that is specific to the goals of relapse prevention. Furthermore, psychodrama has historically relied on psychoanalytic and interpersonal frame of reference which places psychodrama, as a clinical modality, somewhat at odds with the fact that most of the present drug and alcohol treatment, in general, and relapse prevention training, specifically, in the U.S. appears to be informed by the cognitive-behavioral paradigm. Avrahami’s 2003 article on the interplay between CBT and psychodrama is an encouraging but largely isolated attempt to formally shift the vector of psychodrama practice and psychodrama literature towards the cognitive-behavioral orientation. Finally, psychodrama in its classic form, both in its conceptual postulate of spontaneity and creativity as well as in its theatrical and improvisational logistics, does not quite fit in with the outcome-oriented rehabilitation culture that emphasizes canned protocols.

The present article proposes a psychodrama application that is specifically designed for the purposes of substance use relapse prevention training, that has been adapted to the cognitive-behavioral frame of reference, and that offers the director (group facilitator) more ways to direct and manage the outcome of what happens on the psychodramatic group stage. The proposed modality, originally described in Somov & Somova (2003) and piloted in a residential correctional drug and alcohol treatment program in an American county jail, represents a psychodramatic treatment modality that can be used as a relapse prevention skill-practice group as part of the overall relapse prevention training curriculum or as a stand-alone relapse prevention group modality.

An Incomplete Evolution of Psychodrama in Addiction Treatment

Since Moreno conducted the first psychodrama session on April 1st, 1921 in his Vienna Theatre of Spontaneity and throughout the 20th century, psychodrama evolved from a kind of broad-band psychoanalytic action method (in which “audiences suggested topics” and “the troupe” of professional actors “enacted them to explore and resolve the underlying social issues”) to a set of progressively population-specific “practical applications for everyday use” (Garcia & Buchanan, 2000, p. 162). The evolution of psychodrama, however, appears to be somewhat incomplete. In theory, the unique clinical promise of psychodrama is that it is both analytical (awareness-building) and behavioral (behavior-modifying) as it offers a “significant advantage in changing behavior both through exploratory, healing role play and through role training or practicing more functional behaviors” (Dayton, 2003, p. 179). While Rustin and Olsson (1993, p. 12) note that “psychodrama has been widely used in the treatment of addiction patients” and that Moreno himself “treated alcoholics in psychodrama,” the applications of psychodrama in addictions treatment has remained primarily analytical and focused on “exploratory, healing role play” to foster insight into one’s inter- and intra-personal addiction dynamics rather than focusing on “role training or practicing” relapse prevention behaviors and skills to directly effectuate behavior- and habit-modification.

An example of such incomplete evolution can be found in Woodward’s “Acting for Change: the evolution of a psychodrama group” (2004). Woodward describes Acting for Change, a psychodrama group that was offered from 1994 through 2001 at ACCEPT, a London agency that started out as an alternative to (if not a refuge from) AA and provided abstinence-based day programs and a therapeutic community for individuals with problematic alcohol use. Woodward (2004) offers a description of an evolution of a psychodrama group for alcohol abusers as a function of the evolution of the agency’ treatment philosophy that changed from an approach that originally focused on “insight and underlying issues” of alcohol abuse to an approach that focused on “self-management, negotiation of boundaries, and containment” (p. 133). Woodward notes that the original Acting for Change psychodrama for alcohol abusers was psychoanalytically-informed and “often concentrated on childhood issues and the development of insight leading to a catharsis” (p. 137). As the agency’s treatment philosophy evolved away from the psychoanalytic perspective towards a “more contemporary psychodynamic model” (p. 133), which also introduced “didactic and cognitive elements” offered “in the informative sessions such as the alcohol and therapy seminar, the self-management group, and relapse prevention” (p. 140), the new Acting for Change psychodrama for alcohol abusers appears to have remained largely insight-oriented and awareness-building rather behavior- and habit-modifying in its scope. And indeed, as the agency’s treatment philosophy shifted from psychoanalytic, insight-oriented frame of reference towards at least partial focus on skills of self-regulation and relapse prevention, the new Acting for Change psychodrama still remained insight-oriented in its vector. Woodward writes that in “rethinking the delivery” of this psychodrama for alcohol abusers he felt that the “real value was the externalization of internal issues through enactment” (p. 142). This new and reformed psychodrama included such enactments as having clients “talk to the ‘bottle’ and reverse roles with it briefly” and “externalization of internal splits” designed to raise “personal awareness of ambivalence” (p. 143). Aside from this awareness-building role play, the new psychodrama did include role training which involved “brainstorming past and current roles” and giving clients an opportunity to “think of a role they would like to be in, then speak from that role” (p. 144). While this kind of brainstorming of roles suggests a significant evolution from the “old school” emphasis on spontaneous enactments that reveal the unconscious by way of transference to a “new school” approach of consciously thinking through the parameters of a desired role, Woodward’s description of this role training does not, however, suggest that this role training evolved far enough to include specific practice of recovery oriented interpersonal stances or behavioral rehearsal of relapse prevention skills.

The “Sobriety Shop,” a psychodrama exercise for use with the substance use population pioneered “in the early 1950s” by Hannah Weiner, a student of Moreno’s (Rustin & Olsson, 1993, p. 12) , is another example of an analytically- rather than behaviorally-oriented application of psychodrama to the problems of substance use. While Rustin and Olsson note that the exercise “helps patients learn new behaviors needed for maintaining abstinence and anticipate the problems patients will face in their recovery,” this psychodrama exercise “in which personal qualities that have contributed to the patient’s addictive illness are exchanged for desirable qualities that will help the patients stay sober,” (1993, p. 12), to my analysis, is primarily insight-oriented. Despite the behavior-modifying mandate of the exercise, the “Sobriety Shop” remains more of an exploration and an assessment than a behavior-modification training. Rustin and Olsson in the conclusion of their paper summarize the benefits of the “Sobriety Shop:” the exercise “offers an opportunity for several patients to explore their issues in a single session;” the exercise “allows for wider group participation;” allows patients to “enjoy the spontaneity and playfulness” and to “drop their defenses, which permits them to deal more authentically with their issues;” and from the facilitator’s perspective, the exercise “provides an avenue for participation evaluation” (1993, p. 21).

Dayton (2003), in writing on the application of psychodrama in the treatment of addiction and trauma in women, speaks clearly about the role training value of psychodrama: “We learn through experience. Psychodrama can provide an arena where anticipated, desired, needed, or feared roles can be explored and new behaviors ‘tried on for size.’ One of psychodrama’s important uses is to provide practice in underdeveloped roles so that the anxiety and newness of a role can be explored and worked through in a clinical environment” (p. 193). Dayton, like Woodward and other psychodrama clinicians that operate in the addictions context, appears to be unambiguously clear about the value of practicing recovery behaviors. And yet, despite this clearly behavioral mandate of skill practice, the actual practice of psychodrama in the field of addiction appears to be conspicuously void of any substantive emphasis on relapse prevention. A case in point is Dayton’s (2003) set of three goals designed to leverage the role training benefits of psychodrama in treating addicted female trauma clients; these goals are: “to provide practice and training in adapting to a new role,” “to explore the nuances of a role as it relates to the self,” and “to explore the impact of the role from the position of the other” (p. 193). The goal that is conspicuously absent from this addiction-oriented application of psychodrama is “to practice a substance use recovery oriented role and relapse prevention skills.”

Psychodrama for addictions has, indeed, evolved from its historically exploratory, diagnostic unraveling of the unconscious dynamics behind substance use to motivation-leveraging and ambivalence-clarifying dialogues with the “bottle” and up to a threshold of change at which substance use clients “try on for size” a recovery role. This is an incomplete evolution: the above examples of psychodrama for addiction highlight the fact that psychodrama remains underutilized as an excellent behavioral supplement to relapse prevention training. Despite its two-fold benefit of exploratory role play and role training, all too often, the former takes precedence over the latter. Psychodrama, in its original mandate, is both analytical (awareness-building) and behavioral (habit/role/behavior-modifying). Consequently, it would appear that as long as psychodrama for addictions continues to be primarily focused on exploratory, awareness-building role play to the exclusion of behavior-modifying role training of such specific recovery skills as relapse prevention, the evolution of psychodrama for the treatment of addictions is incomplete.

Dysfunctional Spontaneity of Relapse Prevention

In trying to make sense of the resistance of the psychodrama movement to prescriptive role rehearsal of specific relapse prevention behaviors, it helps to examine Moreno’s canon of spontaneity and creativity. Moreno (2000) postulated that the spontaneous and creative have the survival advantage and that “all dysfunction is caused by a lack of spontaneity and/or creativity” (p. 172). This spontaneity dysfunction can manifest as either paralysis of spontaneity (becoming “frozen and unable to act” when faced with a novel situation), or impulsivity (“action without reflection”), or reactivity (“reflection without a here and now action,” i.e. a re-enactment of an old action that might have been appropriate for a situation in the past but might not be an appropriate response to the current situation) (p. 172). Moreno’s emphasis on spontaneity and creativity shaped the vector of psychodrama development: from the days of the Vienna-based Theatre of Spontaneity to the present, psychodrama emphasizes being in the moment, “living in complete harmony and unity while staying connected to the social realities of the here and now” (Garcia & Buchanan, 2000, p. 172), in a state of here-and-now mindfulness and absorption, in a state of “flow” (Csikszentmihalyi, 1991) characterized by peak spontaneity and disappearance of ego. In short, psychodrama emphasizes here-and-now action and, in its classic form, resists rehearsal which is a prescriptive re-action/re-enactment of a previously agreed upon role. In this, Morenean psychodramatic theatre of spontaneity stops being theatre per se since theatre, in its classic form, is nothing other than a re-enactment of an internalized role, the word that “draws its origin from the Latin rotulus, which is the name of the roll of paper or vellum upon which the actor’s part was written” (Pittruzzella, 2004, p. 92). Pittruzzella clarifies the function of a role: “role makes us think, therefore, of a prescribed sequence of behavior – words, gestures, expressions, bodily attitudes and other communication signs – coherent with a definition of the character moving within given circumstances” (p. 92). While this kind of role training would be ideal for a relapse prevention application of psychodrama in which a client protagonist could be exposed to hypothetical recovery-challenging circumstances in order to practice a “prescribed sequence” of relapse prevention behaviors, such re-enactment of a recovery role would appear incongruent with the Morenean emphasis on real time spontaneity. The result, unfortunately, is the kind of psychodrama application to addiction that results in dysfunctional spontaneity of relapse prevention. Substance use clients that participate in psychodrama applications for addiction, even when confined to the “framework of a vignette” that involves a possible recovery-specific scene (Woodward, 2004, p. 143), are essentially left to improvise their way through a relapse prevention response.

Whereas the theatre-of-spontaneity approach to psychodrama applications for addiction may be invaluable in terms of its diagnostic, awareness-building value, the use of psychodrama for relapse prevention cannot afford improvisation. To be exact, the improvisation of relapse prevention has to be re-calibrated to the spontaneity and creativity of the application of a prescribed relapse prevention cluster of behaviors and interpersonal stances, not to the spontaneity and creativity of the character per se. The distinction between the improvisation of the recovery character and the improvisation of how this recovery character acts when presented with various scenes of life is a paramount one. For psychodrama to remain psychodrama and not be reduced to an oversimplified behavioral role-play, the protagonists do have to practice spontaneity and creativity of the behavior; however, if psychodrama applications for addiction are to offer more than exploratory role training of the recovery persona, psychodrama has to offer clients a prescribed recovery role that, among other things, includes a specific relapse prevention algorithm, with an encouragement that the protagonist practice the spontaneity of application of the recovery behaviors while remaining in character (of recovery). In short, for good performance, an actor has to have a method and to apply it with spontaneity.

Relapse Prevention Psychodrama

Relapse prevention psychodrama, proposed here, was piloted by the author in the context of a residential non-medical drug and alcohol correctional treatment program housed in a county jail. The Lapse/Relapse Prevention Group, as it was listed on the program’s clinical curriculum, was, in fact, a culmination of an overall prevention skill-power training module that began with a didactic introduction of the distinctions between Slip, Lapse and Relapse, and, then, proceeded with a systematic introduction of four separate prevention plans, namely, those of Slip Prevention, Lapse Prevention, Relapse Prevention and Relapse Termination plans (Somov & Somova, 2003). Following the initial didactic introduction of Slip Prevention, Slip Prevention was practiced in the context of a peer-led Slip Prevention Self-Help Circle. This peer-led Slip Prevention group ran parallel to the introductory Prevention Skill-Power Training Group. When the Prevention Skill-Power Training Group concluded with the presentation of all four use prevention and use termination plans, the correctional substance use clients “graduated” to Lapse/Relapse Prevention Practice Group, which constituted use prevention oriented psychodrama (to be referred to henceforward as LP/RP Psychodrama).

Rationale

The rationale behind the LP/RP Psychodrama is three-fold. First, this addiction-specific psychodrama group allows clients to practice their use prevention and use termination plans through a variety of role-plays and recovery vignettes. This psychodrama also group allows clinicians to engage in direct observation of clients’ prevention skills and to provide clients with constructive/corrective feedback. Finally, the LP/RP psychodrama group enhances clients’ sense of membership in a kind of recovery-oriented “social atom”(a network of recovery-significant relationships) with the hope of enhancing clients’ overall treatment compliance and aims to increase the possibility of exporting the program-established recovery network to clients’ post-discharge/post-release lives.

The Instruments and the Process of LP/RP Psychodrama

Moreno (2000) elaborated the following five instruments of psychodrama: the stage (setting), the director (the therapist), the protagonist (the client in treatment who is the focus of the given psychodramatic enactment), the auxiliary egos (the supporting actors that reveal various aspects of the protagonist’s phenomenology), and the audience (the group). Furthermore, psychodrama offers several distinct processes: the so-called warm-up, the casting (the selection of the protagonist and auxiliaries), the action, and the post-action processing or sharing. The following is a review of these items of format as they apply to the LP/RP Psychodrama group.

The Stage

The setting has to at least vaguely parallel the architecture of the theatre space. In practice, this is merely an issue of a boundary between stage space and audience space. Consequently, any space can be arbitrarily divided into these two realms. In the case of this particular pilot, the LP/RP Psychodrama took place in an essentially triangular room that had been previously divided in half for the purposes of a visitation room. On the author’s request and with the help of the program’s administration, the jail administration was gracefully willing to knock this wall down which yielded a sizeable triangle-shaped auditorium for most of the program’s group activities which opened directly into the housing pod and also featured on one side a wall of windows with a view of the open air gym and, on the other side, featured a door window into a “slider” lock port that, on occasion, provided an element of random audience of the jail staff that would be awaiting passage in the “slider” from one area to another. From the psychodramatic perspective this arrangement allowed for a degree of transparency that essentially set the stage of this psychodrama on the backdrop of reality.

The Director and Director’s Roles

Kellerman (1992) deconstructed the role of the psychodrama director into four roles: analyst, producer, therapist, and group leader. Woodward (2004), in his writing about a psychodrama for newly abstinent alcohol abusers, and building on the role theories of Moreno and Clayton, defined the roles of a psychodrama/group therapist as excavator, container, parent, advocate and cheerleader. Given the behavior-modifying rather than awareness-building focus of the LP/RP Psychodrama, the roles of its Director can be conceptualized as essentially two-fold: the producer and the group therapist. The LP/RP Psychodrama Director is expected to switch back and forth between these two roles depending on the specific psychodrama process. It stands to reason that during the warm-up, the Director is the group therapist in charge of leading a psychodrama group into an action phase. During the casting, the Director may intermittently assume the role of a producer or a group therapist depending on whether the dynamics of the protagonist and auxiliary ego selection require any interpersonal processing. In the action/enactment phase, the Director again alternates between the roles of a producer (should additional acting resources, for example, need to be recruited and quickly role-trained from the audience) and a group therapist (if the enactment is paused for real time feedback or processing). Finally, in the post-action phase of sharing, the Director is back to being the group therapist in charge of processing clinical material and intra-group dynamics as he or she leads the psychodrama group session to closure.

The Protagonist and the Psychodrama Group Size

The protagonist of LP/RP Psychodrama is a substance use client that either self-selects for an enactment or is selected by the Director. Whereas in classic psychodrama the protagonist is encouraged to be spontaneous “rather than being an actor in a play who must follow a script,” (Garcia & Buchanan, 2000, p. 178), in lapse/relapse prevention psychodrama the protagonist is offered a particular recovery oriented vignette and is expected to stay in the recovery character while aiming for a real time spontaneity and creativity of application of previously discussed substance use prevention plans.

Feasey (2001) recommends to use closed psychodrama groups as the “security of tenure is a must for a psychodrama group” and, in regard to the number of participants, suggests that “psychodrama can be very effective in groups much larger than eight” (p. 20).

In the case of the present pilot program, the LP/RP Psychodrama group consisted of approximately twenty correctional male inmates. The drug and alcohol program in question had a typical census of twenty five inmate clients at any given time, five of which typically constituted new arrivals who did not participate in the LP/RP Psychodrama until they completed a peer-led Slip Prevention Self-Help Circle (group). While this LP/RP Psychodrama group was not technically closed, the actors’ “troupe” tended to remain largely the same for substantial periods of time and only varied with the natural turn-over of the program participants. Given the fact that this particular LP/RP Psychodrama group was offered in the context of a residential correctional context, it was offered on a daily basis Monday through Friday for a period of several weeks. Following the run of the group, this psychodrama would be re-introduced at a later point as the composition of the program participants turned over enough for the bulk of the residents to be new admissions. As such, some of the clients that remained in the drug and alcohol program for a longer period of time would have a second opportunity at participation in the LP/RP Psychodrama group. These second-timers would typically prove to be an invaluable resource as these “old” actor-members would be already indoctrinated to the process of psychodrama and would model the group culture for the new arrivals. Feasley (2001, p. 16) writes about the similar experience of an open psychodrama group in a hospital setting: “the group was stable, but it was a slow, open, permanent group, admitting new members as patients left. This made for a somewhat different culture. Mostly it was signified by ‘old’ members of the group introducing new members to the culture.” Unlike in Feasley’s case where as a result of this open and rotating membership format there formed a “pecking order of experience and seniority, which had to be taken into account by the director” (p. 16), in the present case no such pecking order appeared evident. The “old,” second-time psychodrama participants appeared willing to come to the rescue, so to say, in the absence of volunteers for the role of a protagonist, but did not necessarily feel entitled to the psychodramatic limelight. Another advantage to having these second-timers was their willingness to publicly process their past hesitations for volunteering to be a protagonist for psychodrama, which tended to normalize the self-conscious inhibitions of the new group members.

Auxiliary Ego: The Voice of Craving

Auxiliary Ego is a psychodrama term for a supporting actor whose role is to enact an aspect of the protagonist’s phenomenology. “The auxiliary ego brings life to the protagonist’s world” (Garcia & Buchanan, 2000, p. 179). One of the key aspects of a substance user’s phenomenology during a situation that challenges his or her commitment to recovery and may potentially result in a lapse or a relapse is an experience of a craving. Craving is often described as consisting of a combination of the behavioral impulse to use a given substance, possibly accompanied with a degree of somatic arousal, and of a cognitive element in the form of self-talk that advocates substance use at a given moment. The proposed LP/RP Prevention Psychodrama utilizes the craving aspect of a substance user’s experience through the so-called Voice of Craving.

The Voice of Craving is thus a psychodramatic device that is specifically designed to allow a substance use client protagonist to externalize an aspect of his or her experience in order to practice an application of a lapse/relapse prevention plan despite the craving. The Voice of the Craving distracts, complicates, tantalizes and, as such, inoculates the protagonist to this often inevitable internal liability of a person in early substance use recovery. On a practical note, a psychodrama group member that volunteers to enact the protagonist’s Voice of Craving, in essence, narrates craving sound-bites into the protagonist’s ear as those kinds of craving thoughts would be expected to emerge as the protagonist deals with a given prevention scenario.

The Voice of Craving auxiliary ego actor is, in essence, a supporting actor who role-plays the nagging voice of sabotage. It is recommended that the Voice of Craving auxiliary ego actor should be physically positioned behind the protagonist to facilitate a sense of an invisible voice in the back of the mind. As such, the Voice of the Craving experientially illustrates the sense of confusing overwhelm and distraction that occurs when an individual battling with lapse or relapse prevention attempts to multi-task. The protagonists are instructed to engage in craving control as soon as they hear the Voice of the Craving. Furthermore, the protagonists are asked to announce that they are initiating craving control.

At the sound of this announcement by the protagonist the Voice of the Craving supporting actor lowers down his or her voice to illustrate the fact that craving control works and the craving subsides and eventually vanishes. The added benefit of this element is that easily-distractible clients are, in fact, taught to utilize the method of self-instruction by verbalizing to themselves out loud what they are about to do in order to successfully navigate a given situational challenge to their recovery. As the protagonist maneuvers through a role-play scenario, the Voice of the Craving emerges at logical junctions (for example, whenever the protagonist comes in contact with such craving eliciting external stimuli as people, places and things, as well as whenever the protagonist might be triggered to crave by internal stimuli of boredom, dysphoria, anger, anxiety or any other significant deviations from emotional baseline). At such points, when the Voice of the Craving becomes louder, the protagonist once again resumes craving control as necessary.

Other Auxiliary Egos in LP/RP Psychodrama: Double, Sponsor, Support Figure, Dealer, P.O.

LP/RP Psychodrama utilizes other auxiliary egos that are pertinent to the theme of substance use prevention. The Double is a stand-in auxiliary ego that represents the Protagonist. The role of a Double may be useful in several ways. For example, in a stage-within-a-stage production, the Protagonist, who is in the process of role-playing a lapse prevention vignette, might be also observing another role-play on the periphery of the clinical stage in which his or her Double is role-playing the protagonist’s past handling of a similar situation in which the Protagonist ended up lapsing and/or relapsing. This allows for real-time self-reflection as well as for an experiential reference of the Protagonist’s behavior that had been previously ineffective. The Double may also carefully watch the Protagonist’s lapse/relapse performance and “play it back” afterwards to help the Protagonist critique his or her act. The auxiliary egos of Sponsor, Support Figure, Dealer, or P. O. (probation officer) represent the “others” from the protagonist’s support and “use” networks.

Psychodrama group members that role-play the Protagonist’s auxiliary egos are protagonists in their own right as well. In role-playing the Voice of the Craving, or the roles of Support Figure or the roles of a Sponsor or a Dealer or a Double, these supporting actors support their own recovery both through vicarious and direct practice of anti- and pro-recovery roles that are just as relevant for their recovery as they are for that of the Protagonist. Moreover, the practice of anti-recovery roles of the Voice of the Craving or that of a Dealer or a Drinking Buddy, the supporting actors often find themselves in motivationally leveraging states of cognitive dissonance. Furthermore, this role-play of anti-recovery roles with its resultant dissonance about one’s impact on another’s well-being also serves as a form of empathy-training that is of additional benefit in the correctional substance use rehabilitation setting.

The Audience: Membership in Recovery

The psychodrama audience is an interactive and validating witness to the Protagonist’s stage-life. In my experience of conducting the LP/RP Psychodrama in a correctional drug and alcohol program, I came to appreciate the importance of allowing for spontaneous interaction between the acting troupe and the audience. Aside from corrective and celebratory applause and cheer-leading, the group participants in the audience often volunteered themselves as provocateurs and supporters of the Protagonist’s recovery struggle in mid-play. While at times such outbursts of audience activity appeared to create an element of chaos, the participation – regardless of its vector – appeared to be of greater clinical significance than its dramatic utility. The spontaneous engagement of a given audience member on either side of recovery leaked streams of process-rich information both about his readiness for change and the sociometry of group dynamics. More often than not, the audience – which is typically comprised of substance clients with varying degrees of ambivalence about going “clean” – invested their sentiments with the protagonist, in support of his recovery. And in so doing, the audience would inadvertently unite around the common denominator of change and recovery, thus becoming a kind of unofficial pro-recovery microcosm, ready to be internalized both by the protagonist and the audience members themselves.

LP/RP Psychodrama Process: The Warm-Up

As noted above, the psychodrama offers several distinct processes: the warm-up, the casting, the action, and the sharing. Psychodrama action begins with the warm-up. Garcia & Buchanan (2000) note that “the warm-up is the time when group members begin focusing on the issues that they may wish to explore during the session.” The specific nature of warm-up and its extent vary by the setting. Psychodrama conducted on an outpatient setting, in a psychodrama group without a specific population focus, would appear to require more extensive and more exploratory warm-up than a psychodrama group that meets several times a week in a problem-specific rehabilitation setting. Woodward (2004), in writing about a psychodrama application for substance users, writes that clients in a therapeutic community are “likely to be ‘warmed-up’ to ongoing issues most of the time” (p. 142). This was certainly the case in the example of this LP/RP Psychodrama group. Consequently, the warm-up typically involved a brief discussion of a client’s “hypotheticals” (in which clients are instructed to problem-solve hypothetical prevention opportunities on their own, as homework) or a discussion of clients’ “prevention memos” ( in which clients are asked to audio-tape revelations about their craving triggers from their participation in the Slip Prevention Self-Help Circle, as well as the audio versions of their LP, RP and RT plans) (Somov & Somova, 2003). Thus, the 5-10 minute warm-up would usually involve hearing out a couple of client reports about how they had handled a “hypothetical” challenge to their recovery and/or listening to a play-back of someone’s “prevention memo” cassette.

LP/RP Psychodrama Action: 20 Recovery Vignettes

LP/RP Psychodrama action would begin with casting: the Director would call for volunteers. The Director would typically avoid casting anyone by appointment and reduce his or her authority in selection only to an occasional suggestion to a given group member about trying this or that role. In the rare event that no one volunteered, the Director would proceed to process the meaning of this non-participation until motivation for participation would be re-leveraged or until the end of the psychodrama session. Following the casting, the Director would “walk and talk” with the respective members of the cast to set up a recovery oriented vignette that would at a minimum provide an opportunity for practice of lapse prevention (LP) but could also be easily converted to an opportunity for relapse prevention (RP). The following is a sample of twenty-one such recovery vignettes to role-play in substance use prevention oriented psychodrama. The vignettes below, in part, reflect the correctional nature of the rehabilitation context in which this LP/RP Psychodrama was piloted. Clinicians are naturally advised to tailor the LP/RP vignettes to the specifics of their target populations.

“Sponsor Gone Bad.” Client discovered that his sponsor has lapsed or relapsed. Alternatively, a client who is struggling with a lapse or relapse prevention task invites his or her sponsor on the scene and the latter develops a craving of their own.

“Found a Stash.” Client is instructed to role play a LP after he or she finds a stash of cash and/or drugs from the previous run.

“To Sell or Not to Sell.” Client has been unsuccessful in trying to get a job and has been approached with an offer of selling drugs. Alternatively, the client has been doing well for some time but lacks money to send the family on a trip to Disneyland. Consequently, he ponders “flipping one or two Gs” from his savings to fill up the deficit in his budget.

“Street Come-on.” Client is instructed to role play a bread-and-butter classic of being offered drugs on the street. He might be waiting for a bus, or coming back from work, or just sitting in a park.

“Meeting Got to Me.” Client, after a self-help meeting, has heard too much about other people’s bottoms and is pondering a peek into his own abyss.

“Pay Day.” Client came into some cash and/or has been asked to go to a bar or to celebrate the end of the work week with his or her work buddies.

“Downsizing.” Client has been fired with or without severance pay. Severance pay essentially synthesizes the Pay Day scenario with the Got Fired scenario.

“Communication Break-Down.” As the client enacts his role-play, the facilitator suddenly signals to him that the client cannot access his support for one of the following reasons: he forgot the phone number; he does not have a cell phone or change to use pay phone; the support person is not answering or is not emotionally available; the support person answers the call, asks to call back, but does not call back.

“Disabled Enabler.” The client is offered a situation of pseudo-support in which his or her “support” person enables substance use.

“Back on the Set.” Client is instructed to role play a LP after he found himself back on the “set” (in his/her substance use environment, i.e. back in the “old company” of using friends, or back in the neighborhood, etc.).

“Using Peer.” Client has been offered drugs by a halfway house roommate or a self-help meeting peer or a fellow participant in the substance use treatment program.

“Walking off the Paper.” Client is instructed to role play a LP after he has completed the conditions of his parole or probation or after release from the correctional setting. In short, the client has met his legal obligations and entertained the idea of celebrating.

“Drugs and Sex.” Client is instructed to role play a LP which involves any number of situations in which clients’ partners are either current or former users. Alternatively, client is triggered to use in the course of or after a sexual encounter due to his or her past combination of using and intimacy.

“Righteous Child.” Client is instructed to role play a LP which involves an altercation with his or her adolescent child who is either caught using or selling and righteously excuses his or her behavior by blaming the parent for modeling the very behavior in question.

“Giving a Lift.” Client is instructed to role play a LP after he or she, in good faith, gives a ride to a fellow person in recovery to a self-help meeting; as the passenger exits the client’s car, the driver discovers that his passenger inadvertently dropped a vile of crack or a stamp bag. Alternatively, the passenger offers client, the driver, drugs “for old time’s sake,” or as a form of repayment.

“Family Function.” Client is instructed to role play a LP after he is offered alcohol and/or drugs in the course of a family function (reunion, birthday, holiday, wedding, etc.).

“Relationship Trouble.” Client experiences a loss of relationship (break-up, quarrel, separation, divorce).

“Home-Coming.” Client discovers that his or her partner had been unfaithful while client had been in a residential treatment facility.

“Devise Your Own Role-Play.” Clients are invited to role-play a vignette of their own. They are asked to ponder the types of situations they are likely to encounter upon completion of treatment, or while in treatment, and to role-play the corresponding scenarios.

“Change the Future by Changing the Past.” In this psychodrama clients are offered an opportunity to think of a pivotal moment in their recent history that resulted in their current circumstance or in the break-down of their recovery. They are offered to re-do what had happened, to enact a chain of events that would have allowed them to prevent the chain of events that resulted in their current predicament. This role-play typically, but not always, involves a re-enactment of the antecedents of the situation in question without substance use.

The guidelines for the behavioral role-plays involve an emphasis on acting in real time. If, for example, enacting the specific steps of their lapse or relapse prevention plans, clients are

encouraged to do so in real time and not compress these personalized use prevention protocols in time. For example, clients are encouraged to do their craving control in real time (i.e. to actually take six to twelve deep abdominal breaths and to actually take time to use their previously established craving control self-talk) (Somov & Somova, 2003). The guidelines for protagonists involve permission to create “obstacles” and to “throw in curve balls.” The supporting actors agree to respond to real-time instructions from the Director (usually non-verbal signals). This is used in the situation in which a given Protagonist appears to be easily distraught or confused. For example, when the Protagonist enacts calling a support figure on the phone, the facilitator may signal to the auxiliary ego that role-plays a Dealer or Using Peer to “pull back” for a time being. Alternatively, if the Protagonist appears to be “on the ball,” the Director may nonverbally or inconspicuously signal a supporting actor to create an additional obstacle for the Protagonist. For example, if a Protagonist role-plays calling a Sponsor for support, the Director may signal to the Sponsor to not answer the phone or to act like a “sponsor that went bad.” This technique of Curve Balls parallels the complexity of life and as such has the value of generalization and realism. The strategy of creating obstacles is in contrast with often naïve expectations that substance use clients in recovery have about the ease of access to, utility and dependability of their support network. In directing LP/RP role-plays it is important to let the primary actor experience at least some frustration as a process of inoculation against future stress. Both didactically and through group process (in the sharing phase), the Director in his/her Group Therapist role emphasizes that the presence of lapse/relapse prevention plans is not an automatic assurance of stress-free recovery. The group leader aims to harness Protagonists’ frustration from these “curve balls” as motivational leverage to increase clients’ commitment to the practice of recovery skills. It should be noted that the LP/RP Psychodrama in question is informed by an approach to recovery that emphasizes self-sufficiency of use prevention skill-power (Somov & Somova, 2003).

The value of this obstacle strategy, however, has to be balanced against the therapeutic goal of enhancing clients’ self-efficacy. With this in mind, another guideline for LP/RP Psychodrama is the principle of “Always a Happy End.” What this means is that a given psychodrama is not complete until the Protagonist demonstrates a successful resolution of the prevention challenge in hand. This may involve having the Protagonist pause, process the lessons of the experience, and redo the role-plays until the recovery objectives are met. In some cases, this principle meant that the particular psychodrama would last more than one session.

LP/RP Psychodrama Sharing: Processing Group Dynamics and Lessons of Prevention

Sharing is the concluding phase of the psychodrama process. In its classic form it involves the processing of group participants’ personal experiences. Feasey (2001) suggests that the Directors give the protagonists an opportunity to process the material on their own immediately following the enactment. Feasey (2001) recommends that the Director first attend to the auxiliaries. In Lapse/Relapse Prevention psychodrama the group leader would explore the “lessons of prevention,” triggered memories or feelings, revelations and epiphanies of the supporting actors as well as the audience. Questions along the lines of “In what way was this about you?” help engage the audience in sharing ways in which they identified with the action on stage.

Feasey (2001, p.74), in writing about the closure in sharing, also speaks of the importance of “de-roling” in which the protagonist, for example, in exiting the stage and returning to the circle of the group, i.e. in “moving from one reality to another,” would “de-role,” for example, a prop of a paperback book from its role as a diary back to being but a paperback. Similarly, Feasey (2001) feels it is necessary to have the auxiliaries to formally “de-role:” If, for example, a psychodrama group member named Fred role-played John, then Fred needs to say that he is Fred, not John. Lipman (2003) also acknowledges the importance of “de-roling” as a means of shedding “immediate sociometric links to the protagonist’s world” (p. 12) but proposes a less formal method for “de-roling” through merely processing how auxiliaries’ roles pertained to their own experience.

Lipman (2003) notes that following a psychodramatic enactment there might be shifts in the sociometry of the group. While some psychodrama theorists object to the use of post-action sharing for discussion of such sociometric shifts in group dynamics, the majority of psychodrama authors appear to be in consensus on the utility of this kind of interpersonal processing. In my experience, exploring the sociometric/group-dynamic valence of such psychodrama events as the frequency (or lack thereof) of the self-selection into the role of protagonist, protagonist’s choices of auxiliaries, the audience’s response to a specific psychodrama (that might be at times more reflective of the interpersonal dynamics between the audience members and the specific individuals on stage than of the actual clinical value of the performance) is clinically valuable, particularly for understanding group dynamics of a cohort-driven rehabilitation treatment in which clients are grouped on the basis of the timing of their admission to the program. In my experience, I have also observed that “de-roling” of both protagonists and auxiliaries helps actors process any interpersonal sentiments towards each other elicited by the enactment. This is particularly valuable in lapse/relapse psychodramatic enactments in which auxiliaries that enact the anti-recovery roles (of Voice of the Craving, Dealer, Using Peer, etc.) improvise additional obstacles or “curve balls” for the protagonist as part of challenging the protagonist’s spontaneity of application of use prevention know-how.

In “de-roling” the Protagonist, I have found it helpful to follow a particular sequence of questions that allows the Protagonist to first focus on the what he or she had appreciated about his/her performance, followed by questions to the Audience and the Auxiliaries about what they had appreciated or liked about the Protagonist’s performance. Having elicited positive feedback, the Director opens the door into constructive feedback: “What in your opinion could have been improved upon?” I find that having a standard format to the processing of the role-play puts clients at ease and gives them a sense of control over how the feedback will be given.

Conclusion

Psychodrama, as a clinically rich group therapy modality, has been underutilized in the substance use/addictions treatment setting. The present article explored a particular application of psychodrama for the purposes of substance use lapse and relapse prevention training. The proposed skill practice/role training oriented application of psychodrama is not intended to replace the more traditional exploratory applications of psychodrama with substance use populations. Instead, the application of psychodrama proposed in this article is offered as a stand-alone clinical treatment modality designed to augment the overall lapse/relapse prevention curriculum of the drug and alcohol rehabilitation treatment. The particular emphasis of the proposed psychodrama for use prevention is on minimizing the dysfunctional spontaneity with which substance use clients are left to improvise their way through recovery-challenging situations. Whereas Moreno’s Theater of Spontaneity served the purpose of exploration of inter- and intra-psychic realities of the participants, the proposed Theatre of Relapse Prevention is intended to be used as a means of internalizing a behavioral algorithm of relapse prevention through the modality of psychodramatic role-play.

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