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Psychodrama and Systemic Therapy

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It is now increasingly recognized that psychodrama provides a valid and useful tool in many different contexts; equally, practitioners in a wide variety of fields are acknowledging the benefits that a systems thinking approach can bring to their work. This book unites the two by describing the author's work over a number of years. Dr. Farmer provides a lucid exposition of his own systemic approach to psychodrama, both theoretically and in practical clinical terms. The final section, which discusses systemic approaches to psychiatric care in general, puts the book in a wider context, and will make it of interest to a wide range of mental health professionals.

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CHAPTER ONE. Psychiatry systems and drama

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SYSTEMIC FAMILY THERAPY

Family therapy looks at the system as it appears to the therapist and to the family members as they interact in a session. I say “it appears” because “it” does not exist, except in the minds of the individual members. Each member and therapist would regard the system from a different viewpoint; if it were a psychodrama and not a family therapy session, each would present his own distinct individual representation of the family. There is no “correct” portrayal. The “family system” is an abstraction that is derived from each individual’s perceptions and formulations as these evolve together in the minds of the family members and the therapists while they participate together in dialogue (Anderson et alv 1987).

Systemic family therapy seeks to enable the family to define itself in such a way as is congruent for the individual members. The feedback gained from such techniques as circular and reflexive questioning helps each person to see himself more clearly in relation to other family members. Together they utilize the knowledge of differences that feedback provides to construct a redefinition of the family system that encompasses the descriptions of each individual member. Thus, at the end of a period of systemic family therapy, one would in theory expect that if each individual member were to enact a psychodrama, it would portray a family picture that is more akin to that of other family members than it would have been before family therapy began.

 

CHAPTER TWO. A psychodrama in action

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The following is a record of a psychodrama undertaken immediately before this chapter was written; it illustrates a number of systemic features of what might be considered a “typical” or random psychodrama. It would be inappropriate to term it “representative”, as psychodramas are so difficult to compare, there being no easily recognized standard except in very broad outline. For simplicity, the warm-up is not described in this following narrative (on many occasions, however, its significance for the later phases can be considerable). Psychodramas are best related in the present tense.

SUE

After the group is warmed up, the transition to the action phase takes place with the selection of the protagonist. Sue, aged 28, is chosen, partly because this may be her last session. She has not been a protagonist before; for two weeks she has been giving out strong signals of her ambivalent feelings about “doing” a psychodrama.

This ambivalence, which proves later to be an important feature throughout the psychodrama, is first apparent in the task of deciding whether to volunteer. She says she will be the protagonist if others decide that she “should”. In spite of the apparent ambiguity, the director points out that she has actually made the decision (a very important step for Sue), albeit a conditional one. It is, however, unclear whether she would have “decided” without encouragement (possibly expressed or perceived as pressure) from other group members. The significance of this indecisiveness becomes clearer later.

 

CHAPTER THREE. The psychodrama tic exploration of transgenerational psychiatry: “sins of the fathers”

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In this chapter I illustrate the way psychodrama can be applied to a particular conceptual model of family systems theory, rather than to systemic therapy in the more general sense, as used in the Milan approach. The “multi-generation transmission process” as expounded by Bowen (1978) conceives family dysfunction as arising from the operation of a family’s emotional system over several generations.

Much family therapy involves working with family-of-origin issues and some practitioners consider these to be the most fundamental concerns. Bowen (1978) originated this field of study which has been developed by his followers, including Guerin (1976) and Fogarty (1978). Framo (1982) brought object relations theory to bear on the subject and Boszormenyi-Nagy (1981) introduced the concept of a ledger of ethical obligations extending across generations. Lieberman (1979) in England and Roberto (1992) in the United States have reviewed transgenerational theories and therapies. These clinicians and many others have emphasized the importance of patients addressing these topics directly with the family members concerned wherever this is possible.

 

CHAPTER FOUR. Strategic psychodrama: helping an abusive mother to converse with her children’s social worker

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Strategic psychodrama” is a term used by Williams (1989) to emphasize psychodrama’s pragmatic, problem-solving functions, as distinct from the aesthetic, self-revelatory, and cathartic qualities derived from its theatricality. I use the term to denote a psychodrama undertaken with a specific goal in mind, over and above the more general aims of releasing a patient’s spontaneity, developing insight, gaining a greater sense of self, or acquiring new roles. The following psychodrama was carried out with the intention of moving towards a particular objective in the overall management plan of a patient

DAWN

Dawn had reached an impasse in her dealings with a social worker who had had to remove Dawn’s second baby into care after alleged physical mistreatment. Dawn had been devastated, but the social worker had felt that there was no choice: she had given Dawn a great deal of support over some years, especially when Dawn’s first child was fostered. It appeared that Dawn had come to regard the social worker, Ruth, as her only confidant, and she had felt bitterly betrayed, refusing all further contact.

 

CHAPTER FIVE. Psychodrama as a source of information

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FORMULATING A SYSTEMIC HYPOTHESIS IN THE MANAGEMENT OF A SCHIZOPHRENIC IN-PATIENT

Psychodrama can be useful in securing background information from psychotic patients who, when an ordinary case history is undertaken, are not able to associate present-day experiences with past events. When a patient is released from the question-and-answer format of the formal case history-taking and given action methods as an accessory language, then, through the associated changes of role, he can recall and describe events that are otherwise inaccessible to the conscious mind.

This section demonstrates how clinical signs and family involvement, linked with material from the case history and from the patient’s psychodrama, enable a systemic hypothesis to be made and to be tested by action at the ward level. The process is illustrated in Figure 5.1 (pp. 84-85).

* * *

Edith, a middle-aged lady with chronic schizophrenia, is asked during her psychodrama (Fig. 5.IF) to take on the role of her slightly older brother, who died as a young child; she speaks as if he had been brought back alive to the age that he would be in the present day, had he not died. In her role as the brother, she describes the way that Edith’s two older sisters had doted upon him, and how important he was to them in view of the fact that their mother, overwhelmed by their alcoholic, tyrannical father, was not emotionally available to them. The sisters were devastated when the brother died, and they switched their attention to Edith to fill the gap. One of the sisters later had an illegitimate child, presumably in an attempt to have someone of her own to love rather than to have to share Edith with her sister. This was before the Second World War. Two close relatives had committed suicide, one out of grief following the death of her own child. The family shame at what, at the time, they felt to be unspeakable events—illegitimacy and suicide—isolates them from other people. They had also found these matters impossible to speak about as children, even within the family.

 

CHAPTER SIX. Summary: the effect of one therapy role upon another in a public mental health service

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This book presents clinical material from the viewpoint of a psychiatrist, a psychodrama practitioner, or a family therapist depending upon the stance required at any particular time. Situations might arise with one individual patient, a therapy group, or a family. Reference was made in chapter one to the ways in which individual team members, also, can adjust their roles according to the task with which the clinical team is presented. One manifestation of isomorphism (see de Shazer, 1982, for an account of this phenomenon) is the propensity of a therapeutic team, or of a network of agencies, to replicate the conflicting attitudes that operate in the presenting family.

Awareness of this phenomenon is helpful in the diagnosis or understanding of how the family operates, not only in relation to the team members or agencies, but within the family system itself, and particularly how the family might function if the agencies did not exist. A similar operation was applied in Balinf s (1964) groups of family doctors, where the feelings engendered within the group during the discussion of a case were utilized to assist the casepresenter in understanding his own response to the patient and in adopting the appropriate therapeutic stance.

 

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