The Drama Therapy Decision Tree

Connecting Drama Therapy Interventions to Treatment

Paige Dickinson, Sally Bailey

• Publisher: Intellect Books
• Year: 2021
• Print ISBN: 9781789382471
• eBook ISBN: 9781789382495
• Topic: Medicine
• Subtopic: Drama

This book provides the reader with a thorough understanding of drama therapy methods through the provision of examples so therapists can select the most appropriate methods and apply them themselves. The authors provide a common language for communicating what drama therapists do in terms of diagnoses and interventions, especially for new students in the field.

There has been no systematic method developed for drama therapists and drama therapy students for selecting the most appropriate drama therapy technique or method for clients. Typically, students leave university and have to work out how to plan treatment through trial and error. This book is not intended as an instruction manual, but the authors of this book have identified and analysed how they approached this task themselves, and they explain how the theory learnt at university can be put into practice. Their desire is to give early career drama therapy professionals a reliable and effective tool for making the best clinical decisions they can. This book is not only an educational tool, but also a practitioner's reference tool for planning how to address the socio-emotional needs of their clients. Readers will find this timely book offers structure to drama therapy teachers and students alike.

It explains the basic tools that drama therapists use in all therapy situations, starting with the therapeutic process, then moves on to identify the core healing concepts that make drama therapy so powerful and unique. The diagnostic systems used by all mental health professionals (DSM-5 and ICD-11) are integrated by relating the core healing concepts and tools to the symptoms of diagnoses. The basic treatment planning process is also discussed. The book then explains how these components are used together systematically through a series of questions (that the therapist asks themself) in order to identify the most appropriate type of intervention for the client. Finally, the book offers several examples of how this system can be applied to a variety of common diagnoses. The appendices provide resources about drama therapy in terms of theory, approach and specific population.

Of primary relevance to teachers and students of drama therapy, and drama therapists and integrative arts therapists in training and early career stages. May be useful for other professionals interested in drama therapy and related creative or therapeutic practices where theatre and drama are used.

Note: in the US context there is a wider range of related practices, which are often regarded as part of drama therapy.

Section 1

Foundations

1

Foundational Principles of the Therapeutic Process

There are no new ideas. All knowledge is built on the thoughts, experiences, and experiments of the practitioners that came before. The drama therapy decision tree is built on theories and philosophies that originate from theatre, psychology, psychotherapy, and drama therapy. Within and across these disciplines, ideas overlap, complement, and are integrated with each other. Each of the following foundational principles in Chapters 1, 2, and 3 have been integrated to create the drama therapy decision tree. Before presenting the decision tree, the authors believe that each of the foundational principles need to be understood and appreciated for what they contribute. This chapter focuses on the principles and processes of individual and group therapy. There are many similarities between an individual therapeutic process and a group one; however, because there are some differences, they will be discussed separately. In later chapters, as the book unfolds, how each set of principles is used will become apparent.

Individual Therapeutic Process Model

The individual therapy process does not originate from one specific theorist. Most textbooks divide the process into four stages; a few theorists divide it into five (Brammer & MacDonald, 2003; Egan, 2013; Okun & Kantrowitz, 2015). For clarity’s sake, five will be identified here.

Intake/Assessment

The initial step of treatment is focused on the therapist getting to know the individual and building the therapeutic relationship. Often there is an intake form that guides the questions asked in the first session. The first session can also include a series of assessments. In certain environments, such as private practice, assessment and intake forms may not be as formal, allowing the therapist to ask open-ended questions. During the assessment the therapist collects two types of information: symptoms and dysfunctions. The therapist wants to explore why the individual is seeking treatment and what type of symptoms have been experienced. Gathering symptom information tends to be related to diagnosis of a particular problem, whereas identifying dysfunctions focuses on what problems the person feels are burdens. Sometimes these are the same, and sometimes they are different. Symptoms are important because labeling them leads to insurance approval, so sessions can be paid for. However, exploring what the participant believes is the most important issue can help build the therapeutic relationship and pinpoint what might need to be addressed first in treatment.

Research has shown that as much as one-third of the healing factors of therapy come from the therapeutic relationship (Miller, Duncan, & Hubble, 1997). An early part of the therapeutic relationship involves creating a safe environment by setting up the rules of treatment: cost, cancellation policies, informed consent, boundaries, and other rights and responsibilities of the participant. Another part is the verbal and nonverbal behavior of the therapist that helps the participant understand that empathy, listening, and engagement in the participant’s problems are genuine.

Exploration/Goal Planning

During this stage the therapist and participant explore what they are going to work on in the therapeutic process. Together they examine patterns and identify specific emotional, behavioral, or cognitive changes that the participant wants to make. Once the exploration has started, they can define specific goals that can create change. During this stage the theoretical orientation of the therapist comes into play. For example, a therapist who comes from a cognitive-behavioral background may set detailed objectives about certain thoughts the participant needs to dispute, in order to change thinking and behavior, in order to meet the therapeutic goals.

Action Plan/Working

The majority of the therapeutic work is accomplished in this stage. This is also when resistance, transference, and other defense mechanisms can arise to interfere with the process. This happens not because the participant does not want to change, but because of the participant’s fear of the unknown. If trust has been developed between the therapist and participant, these obstacles to moving forward in the change process can be dealt with successfully.

Reflection/Connection

This stage is sometimes combined with or split between stages three and five. The focus of this stage is reflecting on the work that has been done and on any adjustments that need to be made in order to reach the therapy goals. During this stage the participant begins to make connections between the work done in therapy and life. Time is also spent reflecting on the meaning of the relationship that has developed with the therapist. The therapist can become a re-parenting figure for the participant as past wounds are healed.

Termination

This can be a difficult stage for the participant and the therapist, because the relationship must come to an end. The therapist must handle this parting without making the participant feel abandoned. The participant needs to be able to verbalize what has been accomplished and what work needs to continue as therapy ends. A plan needs to be in place for what the participant should do if difficulties arise in the future. For someone with an addiction, this would be called a relapse prevention plan. For someone who had been sexually abused or depressed, it could be called a safety plan. Lastly, but most importantly, actually saying good-bye needs to be done. In Western culture many relationships are not terminated in a formal way; endings tend to be avoided because they feel uncomfortable. Respect and value are shown to a participant when the therapist takes the time to say good-bye in a genuine, therapeutic manner.

Irvin Yalom’s Theory and Practice of Group Psychotherapy

One of the foundational theorists for group psychotherapy is Irvin Yalom. Yalom identified a number of core concepts of group development that all groups go through to create cohesion and functionality (Yalom & Leszcz, 2005). His ideas are in alignment with any therapeutic process no matter the theoretical outlook. Yalom is not studied directly in drama therapy courses, and we feel he should be. Through careful observation and thought about his therapeutic groups and those of other practitioners, he identified a pattern of group development that appears to be universal (see Figure 2). His model of group development consists of five stages: orientation, conflict, cohesiveness, working, and termination.

FIGURE 2: Comparison Chart: The Stages of Group Process. 2000. © Sally Bailey.

Stages of Group Development

Stage One: Orientation

The therapist’s role is in the spotlight during stage one because the group looks to the leader to set up the purpose of the group and provide the rules and norms by which everyone will abide. The therapist is a model of how to behave, so the group is shown, rather than told, what is expected of them. If the therapist is not willing to “walk the walk,” the group members may not feel compelled to either and can lose respect for the therapist as the one in charge.

Group members in this stage tend to be guarded, because they do not trust each other, the therapist, or the process yet. This is particularly true for first-time participants who have never been in a therapy group. Often group members will be fearful of revealing their true selves for fear of criticism and humiliation. Sometimes they deflect from the issues of the group to complain about outside situations over which they have little control, such as the weather, the state of neighborhood schools, or the displacement of refugees.

Defensive and resistant are the traditional terms used for group members who refuse to participate or remain critical and remote. A good therapist expects this at the beginning as a natural reaction and must find ways to engage group members. Trust must be developed, as well as a belief in the group as a safe place to explore psychological issues. If a therapist responds to resistance by fighting it, often more resistance is created. Therapists can develop their own style of engaging resistant participants through careful warm-up, humor, playful challenge, and showing genuine interest.

In this first stage, group members are exploring the roles they will take on in the group. Will they be leaders or followers? Will they jump into activities and discussions fully or just dip their toes in the water? Will they connect deeply with the others in the group, or will they continue to hold back from personal intimacy?

When the group is ready to move to the next stage, the therapist will notice that the group members have accepted and are following the group rules and norms; they have begun to develop trust with each other and report feeling safe, and interactions among group members have become more open, respectful, and caring.

Stage Two: Conflict

The therapist continues to be a role model to demonstrate to participants how to self-disclose, how to be genuine and real, and how to talk in concrete and concise ways, rather than in vague abstractions or disorganized meanderings. Once participants have shared their general story, the therapist asks pointed questions to probe into more specific details. While group members know the purpose of the group at this point, they can still be inconsistent in their behavior. They may react to the therapist’s push for more disclosure by creating conflicts between members to distract from the issues or by alternating between open self-disclosure and holding back. They may test boundaries to see if the therapist will hold firm on the rules and regulations. Sometimes they will be willing to listen to others, but if they feel uncomfortable or crave attention, they could block others or respond inappropriately. In short, they are still building the skills necessary to become a productive, effective therapy group. If the therapist continues to model appropriate interaction behavior and skillfully intervenes when group members are ignoring the rules, the group matures.

The therapist knows the group is ready to move to stage three when members begin reporting that they feel closer to their fellow participants. Verbal and nonverbal reactions become more respectful, sensitive, and thoughtful. More group members demonstrate the willingness to take risks in terms of sharing personal struggles.

Stage Three: Cohesiveness

In this stage, group members have become close enough to share willingly. However, if one participant is not being honest or respectful, the rest will tend to avoid confrontation. Psychotherapeutic work slows down when all are on their best behavior and wait for the therapist to intervene. While this can be frustrating for the therapist who wants to forge ahead, the work of this stage must focus on its name: creating cohesion in the group before moving to deeper levels in stage four. If time is not spent on the creation of bonds among the group members, relationships will fall apart when the work begins to deepen later. The therapist knows the group is ready to move to the next stage when conflict has receded, confrontation is appropriate when it happens, cohesion is solid, and members are showing genuine emotional attachments.

Stage Four: Working

At stage four, group members will have internalized the rules, norms, and purposes of the group and know how to function within them. Ideally, they become more active than the therapist and are even able to set goals for the group. This does not mean that therapists sit back and put their feet up; they need to continue to keep the group on track by modeling how to confront and pointing out discrepancies and dissonances that group members may be missing or may not have the courage to address. At this stage participants are ready to change and willing to hold each other accountable to their commitment to change. Participants can mutually aid each other through support, empathy, listening, sharing ideas, and teaching each other skills.

In the best of all possible worlds, participants would remain in stage four until all of their issues were resolved, but this is unrealistic. The therapist may intuit that the work of the group has progressed enough so that staying together longer would create stagnation. More often the fourth stage may need to give way to the fifth stage because the number of sessions that were approved for the group by insurance or grant funding are coming to an end.

Stage Five: Termination

There are many reasons for termination. Currently, most groups are time limited. In this situation, several sessions before the final meeting, the therapist must move the group into the work of closure or termination. In a group that is not time limited, indications that the group is ready to terminate is when participants have developed the ability to practice their discoveries and insights outside of the group, experience a certain amount of success (or make adaptations for behaviors that did not quite work), and understand the changes they have made.

Ambivalence in the behavior and attitudes of group members often returns as the end of the therapy series approaches. The job of the therapist in this stage is to validate and reinforce what the group members have identified and accomplished, so they are clearly aware of the distance they have traveled. Yalom stresses that when a group closes, feelings of grief and loss are experienced by participants and therapist alike. The more successful a group has been, the more feelings of loss there will be. The best way to address these feelings is to deal with them in a reflective and positive manner, sending participants out into the world with a sense of accomplishment and hope. Yalom feels that therapists need to address their feelings about termination as well.

Eleven Therapeutic Factors

Yalom and Leszcz (2005) have identified eleven therapeutic factors that help group members heal during the course of the therapeutic process: installation of hope, universality, altruism, the corrective recapitulation of the primary family group, development of socializing techniques, imparting information, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. These factors also relate to participants in individual therapy, but working in a group increases the effectiveness of the factors. These eleven therapeutic factors are ingredients that all therapists, no matter what their theoretical orientation, should include in their practice. Research has shown that the work that the participant does in therapy is responsible for 40 percent of improvement, and the psychothera...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Prologue
• Section 1 Foundations
• Section 2 The Drama Therapy Decision Tree
• Section 3 Diversity and Ethical Considerations
• Appendix A The Drama Therapy Decision Tree
• Appendix B Global Outcomes Connected to Drama Therapy Intervention Suggestions
• References
• Index