CBGPT GROUP MODEL1
Cognitive Behavioral Psychodrama Group Therapy
Thomas Treadwell Ed.D., T.E.P., CGP
Deborah Dartnell MA, MSOD
West Chester University of Pennsylvania
Abstract
Cognitive Behavioral Psychodrama Group Therapy (CBPGT) is an effective model for working with the clinical example by Shay (2017) for group therapy. The model incorporates cognitive behavioral and psychodrama interventions, allowing group members to identify and modify negative thinking, behavior, and interpersonal patterns while increasing engagement in positive and success-based experiences (Treadwell, Dartnell, Travaglini, Staats & Devinney, 2016). The CBPGT environment creates a safe and supportive climate where clients can practice new thinking and behaviors and share their concerns freely with group members (Treadwell, Kumar, & Wright, 2004; Treadwell, Travaglini, Reisch, Kumar,2011). Students and clinical populations respond well to this approach and, as a result, are able to develop an awareness of their dysfunctional thought patterns and beliefs that play an important role in mood regulation. One of the most important elements of CBPGT is that it is data driven. CBPGT adds a new dimension to both the fields of cognitive behavior and group therapy and is built on a proven efficacious model. The integration of these methods may be beneficial for clients who have not responded to more traditional approaches.
Key words: cognitive psychodrama group therapy, group therapy, cognitive behavior therapy and psychodrama techniques, group cohesion, automatic thought records, cognitive triad
Code 004
Introduction
Cognitive Behavioral Psychodrama Group Therapy (CBPGT)is an effective model for working with clients depicted in the clinical group vignette. The model incorporates cognitive behavioral and psychodrama interventions, allowing group members to identify and modify negative thinking, behavior, and interpersonal patterns while increasing engagement in positive and success-based experiences (Boury, Treadwell, Kumar, 2001,Hamamci; 2002; 2006; Baim, 2007; Fisher, 2007; Wilson, 2009; Treadwell, Kumar, & Wright,2004;Treadwell, Travaglini, Reisch, Kumar, 2011).
The CBT model is sometimes criticized for being overly structured and intellectually oriented (Young & Klosko, 1994; 1996; Woolfolk, 2000). As a result, some group therapists today use an approach based upon CBT or identify with a less structured approach called eclectic (Kellerman, 1992) that typically employs techniques that come from cognitive behavioral therapy and its related research. CBT is a robust, proven, and very effective treatment approach for many mental disorders, including the big ones like depression and anxiety. Beck reports “My employment of enactive, emotive strategies was influenced, no doubt, by psychodrama and Gestalt therapy” (A. Beck, 1991, p.196). Psychodrama is an eclectic tool to enhance the cognitive and behavioral change.
ThimmandAntonsen (2014) point out that many cognitive behavioral therapy groups’ content is manual driven. According to Free (2007), the groups tend to focus on content rather than process with some leaders actively discouraging extensive discussion of emotional experiences, instead focusing on the acquisition of technical skills. Since the early 2000’s, there have been shifts in the group cognitive behavioral literature, commencing with Yalom and Leszcz’s (2005) description of the eleven relevant therapeutic factors that groups offer and how each of these can be fostered in the group environment to facilitate change. White and Freeman (2002) reference the broad range of clinical populations being treated using group CBT methods and assert that the two defining variables of cognitive behavioral group therapy are cohesiveness and task focus. Subsequently, Bieling, McCabe, and Antony (2006), Wensel, Liese, Beck, and Friedman-Wheeler (2012) concentrated on integrating CBT strategies and the understanding and enhancement of group process to aid in learning and grasping cognitive and behavioral strategies. They concluded that the therapeutic alliance and interpersonal factors are critical elements in cognitive behavioral group therapy. Burlingame, Strauss, and Joyce(2013) have demonstrated there is sufficient data showing that group therapy is as efficient and/or effective as individual therapy.
The CBPGT environment creates a safe and supportive climate where clients can practice new thinking and behaviors and share their concerns freely with group members and provides ample opportunities for behavioral rehearsal, behavioral experiments and in-vivo exposure to situations that have been avoided (Treadwell, Kumar, & Wright, 2004). This concept is shared by Bieling et al. (2006),Wensel et al. (2012),and Burlingame et al.(2013). This approach is consistent with what Beck advises the ultimate aim of including behavioral tasks in cognitive behavioral therapy to be: “to produce change in negative attitudes” (Beck, Rush, Shaw, & Emery, 1979, p. 119). Furthermore, CBPGT affords the opportunity for catharsis (YalomLeszcz, 2005) in contrast to the limited discussion of emotional experiences often found in traditional CBT groups (Free, 2007).
In CBPGT groups, all members are initially assessed using various instruments to establish the nature and severity of presenting issues and to uncover other relevant information. The first one or two sessions are devoted to establishing group norms, explaining Cognitive Behavior Therapy (CBT) and schemas, and describing the session format. The initial didactic sessions are intended to explain the group format as a problem-solving approach for working through various interpersonal, occupational, educational, psychological, and health-related conflicts. The sessions include information about the nature of the structured activities so participants have realistic expectations about how the group will run. Each group member signs informed consent and audiovisual recording consent forms. The audiovisual recordings create an ongoing record of group activities and serve as a source for feedback when needed.
Here’s how the model looks in the clinical example by Shay (2017). In session one, the director, Dr. Newland, introduces the Beck Depression Inventory-II (BDI), Beck Anxiety Inventory (BAI), and Beck Hopelessness Scales (BHS) (A. Beck, 1988; Beck & Steer, 1993; Beck, Steer, & Brown, 1996), and explains the importance of completing each scale on a weekly basis. The instruments are administered before the start of each session and are stored in personal folders to serve as an ongoing gauge of participants’ progress within the group (Treadwell, Kumar, & Wright, 2004).
In the second or third session, additional data on early maladaptive and dysfunctional schemas/core beliefsare obtained when group members complete Young’s (Young, Klosko, & Weishaar, 2003; Young & Klosko, 1994; Young, 1999) schema questionnaire. A list of the definitions of dysfunctional schemas and core beliefs are given to participants during the initial session (Treadwell, Kumar, & Wright, 2004).
Each group session in CBPGT is divided into three sections typically found in psychodramatic interventions: warm-up; action; and sharing (Moreno, 1934). Many CBT techniques (J. Beck, 2011) are utilized in the warm-up, including: identifying upsetting situations, automatic negative thoughts and triggered moods; writing balanced thoughts to counter negative automatic thoughts; and recognizing distortions in thinking and imprecise interpretations of difficult situations. The second portion, action, employs psychodramatic techniques such as role-playing, role-reversal, and mirroring, which facilitate the examination of various conflicting situations individuals experience within the group context. This enables group members to better understand the nature of negative thoughts triggered by situations and their effects on moods. The last stage, sharing, allows auxiliaries and group members to share their experiences with the protagonist. At this stage, the director may provide additional guidance to the protagonist regarding ways to begin resolving the actual situation in real life. Normally, the protagonist will be asked to complete a homework assignment that will be reviewed at the next session.
This case study presents a somewhat frenziedgroupwith little cohesion. Utilizing a specific format with clear expectations of behavior and outcome would promote a better sense of the group and enable the sessions to be more fruitful. In this case study, Diane would emerge as the protagonist and other members of the group serve as auxiliaries andthe audience.
The Cognitive Psychodrama Group Model
Warm-up
Diane would complete an Automatic Thought Record (ATR)(Greenberger& Padeskey, 1995) on a white board during warm-up. Her situation is she took a man home the previous night and put herself in a risky situation. She would identify her moods and, using the downward arrow technique, the director would repeatedly ask her questions to evoke automatic thoughts. The questions force the protagonist to think about whatunderlying thought or belief is causing feelings to arise in this situation, eventually isolating her core belief or schema. Diane’s schemas of insufficient self control and failure emerged as she completed her ATR. Aportion of
Diane’s ATR follows:
SITUATION / MOODS / AUTOMATIC THOUGHTSI took a guy home with me and he stole my credit cards. / Angry 10
Scared 10
Ashamed 10 / Why do I always do this?
I should have been working on my dissertation
I’m a screw up
I am always messing something up
I’m out of control
I’m a failure
Action
The protagonist, Diane, selects a group member, Will, to be her double. The double communicates thoughts and feelings the protagonist is having but cannot express. Since Diane is rather agitated, she may have some difficulty getting into the psychodrama; in this case, the soliloquy technique would be helpful. Diane can walk around the room, thinking aloud, expressing her concerns, discomfort, and hopes, allowing her to relax, focus, and prepare for the psychodrama. This is also useful in helping group members focus on the upcoming action phase. The double,Will, walks with her, expressing thoughts he assumes she is thinking but not expressing.
As Diane talks, she begins to realize her impulsive side is constantly presenting problems in her relationships, her academic progress, and her self-image. Dr. Newland, the director, suggests that Diane talk with her impulsive side to determine how she can begin to manage it. Diane chooses an auxiliary to play the role of her impulsive side. Diane and her chosen auxiliary have a conversation, while group members observe. Her double,Will,is with her, expressing thoughts that he imagines she is thinking but not expressing. Although she tries repeatedly to manage the impulsive role, Diane is never successful. The director employs role reversal several times to allow Diane to experience someone else trying to control her impulsive role, but she continues to have difficulty managing it. The director then brings Ned in to mirror Diane’s role and has Dianewatch the interaction. This technique, called modeling, occurs whena group member demonstrates to the protagonist how he or she would handle the situation.
Diane begins to understand but still cannot shut down the impulsive role. Dr. Newland suggests that she may need to develop another role to manage the impulsive role and asks her to identify the roles she currently plays in her life. Diane readily identifies “the student” role and, more reluctantly, the “party girl”, the “procrastinator”, the “lonely girl”, and the “perfectionist”. She admits that she inhabits the “party girl” to counteract the “lonely girl” and “perfectionist” roles. Her double helps her to realize she feels unworthy of real relationships and is afraid of failing in her academic work. As a result, Diane recognizes that she needs to have a “confident/responsible” role to manage her fears that unleash the “party girl”.Thus, to investigate Diane’s roles we place chairs in the middle of the room and have Diane sit in each role, expressing what she thinks about each role. The double,Will, sits with her in each role, expressing thoughts he imagines she is thinking but not expressing. The auxiliary playing the “party girl” continues to challenge her. Diane then chooses Angela to play the “confident/responsible” role. After seeing Angela model this role, along with the help of her double, Diane begins to exercise some measure of control over the “party girl”. A final step in the action phaseis havingDiane talk to an empty chair representing a man trying to pick her up at a bar, a situation that represents a recurring challenge for her. Speaking from the “confident/responsible” role, she is able to reject his advances and feel proud that she did.
Doubling, modeling, and role-training are crucialin learning how to get unstuck from repeated behavioral patterns. Many protagonists are anxious when learning a new role; therefore, it is important to support them as they try it in the group session.
Sharing
Following the psychodrama enactment, group members share and discuss what occurred, commenting on their experience playing a particular role or on how the situation affected them. Diane took a huge risk exposing her inner struggles; hearinggroup members share similar painful feelings and experiences lead to feelings of acceptance, support, and understanding. Sharing is critical both for the protagonist and for each of the group members as they reflect, share, and learn from each other. Sharing is a fundamental componentin enhancing group cohesion.
At this stage, assigning homework to the protagonist is essential, as it encourages the continuation of work on the new role explored in the session. Role development needs practice for habituation to take place and to move the protagonist to feel safe in her new role.
Alternative Behavior Plan (Homework)
It is the job of the director and the group members participating in the psychodrama to address the protagonist’s core beliefs and schemas with a behavioral strategy that takes the form of homework. Homework (J. Beck, 2011) is a key componentof CBPGT because it encourages members to practice learned strategies in their own environment.
In Diane’s case, it is crucial that she practice the new confident/responsible role. Diane, the group, and the director collaboratively design situations where she can rehearse this new role in her everyday life. For example, situations are designed to focus on developing a schedule to complete a specific section of her dissertation and/or develop healthy relationships and avoid risky ones. To promoteDianein herendeavor, the director asks members of the group to volunteer to provide their support until the next session. Betty and Angela both volunteer to check in with her throughout the week and to be available if she needs them. The protagonist and the group members who have volunteered to check in typically exchange telephone numbers and arrange to either text or call each other during the week (Wenzel et al., 2012; Bieling et. al., 2006).
Summary
Etiology and Treatment
A situational psychodrama was completed and presented as a vehicle for change. Utilizing principles of CBT and psychodrama created a powerful and effective group process, enabling participants to address problematic situations with the support of group members. Clients find CBT helpful in becoming aware of their habitual dysfunctional thought patterns and belief systems that play an important role in mood regulation; the action componentof the psychodrama allows them to actually see and feel the dysfunction.Schema-focused techniques (Young & Klosko, 1994) present an opportunity for a deeper level of insight and merge well with the psychodramatic framework. Schemas and core beliefs provide a window into the etiology of the client’s presenting problem and form the basis for treatment planning. Case conceptualization, which was not presented in Diane’s case, is applied as an ongoing therapeutic tool. After three or four sessions, the group leader takes on a psychoeducational role; explaining main ideas behind the technique and asks group membersto complete the case conceptualization form on an ongoing basis as the group progresses.Group memberstake turns discussing theircompleted form with the group on an assigned day. Case conceptualization may help group members reflect on their various rules, conditional assumptions, beliefs, and means of coping (J. Beck, 2011). It is also a good way of introducing the cognitive triad to group members who characterize their situations to reflect themes of loss, emptiness, and failure. Typically, this characterization is distorted,makingcase formulation useful in challenging the client’s view of self, the world, and the future (J. Beck, 2011). Presenting it in the group may serve as a warm up for action and provides structure for the group, ensuring all members feel heard. The cognitive triad (Beck, 1967) is best conveyed to group members using this visual representation:
Thoughts
Behavior Feelings
The cognitive triad readily reveals thoughts, emotions and behaviors at a glance and is useful data for exploring the various struggles in the action format. The psychodramatic triad, warmup, action, and sharing, with its emphasis on action, enables the protagonist to virtually engage in a safe environment with the presenting issue.
Multi-cultural Considerations
In our experience, multi-cultural issues can be addressed in the CBPGT modelutilizing techniques of role interview and surplus reality to present another’s point of view. Additionally, during the warm-up, the protagonist, Diane, hadthe opportunity to expand on what was important in herculture. The genogram(McGoldrick, & Gerson, 2008,)although it was not presented in this case, is often created during the warm up stage and is useful in capturinga picture of family and cultural relationships. The genogram,combined with the Automatic Thought Record, allows the group to become educated and gain insight intothe protagonist’s values and beliefs. The psychodrama takes place within the cultural context the protagonist defines.For example, when acting out the scene, Dianehadcontrol over who she choseas auxiliaries and provided, through role interview and role reversal,insights into her reality. The protagonist can continue providing direction to the auxiliaries as the psychodrama unfolds. This ensured that the psychodrama accurately depicted herenvironment and culturalrealities (Nien-Hwa & Hsin-Hao, 2014;Remer Remer,2003).