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Psychodrama is a psychotherapeutic technique that aims to guide patients in expressing their life experiences through dramatic enactments. It is a clinical technique that can also enhance clinical skill learning. According to Avrahami (2003), psychodrama focuses on a “protagonist,” or drama character, to explore life issues, conflicts, unfinished business, and maladaptive behaviors in front of a group of learners or patients. Psychodrama has been shown to be successful because it is action-oriented (Dayton & Nicholas, 2009) and offers discussions of each session between the therapist and the protagonist (played by a client) (Avrahami, 2003; Drakulic, 2010). Jenkyns (2008) suggests that psychodrama can be used as a supervisory tool, as it is a “projective work” approach that encourages professionals to act or observe the enactment of life situations relevant to clients (p. 99). Hinkle (2008) calls this a “parallel learning” process in that a counseling professional learns through the enactment group and appreciates learning from the client’s perspective (p. 401). This article illustrates the experiential use of psychodrama techniques to provide internship orientation and its educational impact on an MSW intern [1]. We analyzed the intern’s notes and the supervisor’s responses for evidence that using psychodrama could provide interns the means to conduct self-reflective learning to prepare them for placement.
Using Psychodrama in Treatment
Recent literature addresses the use of psychodrama in clinical practice and illustrates its dual utility for clinical practice and social work education. A prominent therapeutic issue related to the use of psychodrama as a treatment modality is about clients’ fears to disclose their problems. In order to help clients understand the importance of therapy in a group setting, every group member, including the clinician, participates in a psychodrama to visualize the process of how influential life factors can be examined. Garfield (2003) suggests that life force analysis is best revealed when an action-oriented approach is used, following a role reversal experience to identify life stressors or facilitators that have either negatively or positively impacted the client. When using the action-oriented technique, treatment goals are identified before the action takes place, so that the clients involved can connect learning from observations to therapeutic successes (Haen, 2007). With role reversal, personal inner problems and transpersonal conflicts are experientially examined and confronted by playing another person’s role. The visual impact of personal involvement enables the clients to feel and see changes in the psychodrama moment. The use of these techniques is to encourage clients to experience the “now” moment, which is a visual and experiential way of exploring and analyzing one’s thinking patterns as related to actions and behaviors (Vassilious, Livas, Karapostoli, & Papdakis, 2006).
There are a number of outcomes studies of psychodrama. For example: Kipper and Hundal (2003) use thirty-four cases to illustrate the impact of using role-play psychodrama as an intervention modality. They conclude that the techniques are congruent with psychotherapeutic theories that aim to achieve therapeutic change. In a meta-analysis conducted by Kipper and Ritchie (2003), “role reversal” (stepping into “another person’s shoes”) and “doubling” (inviting another group member to imitate a participant’s role and actions) have been proven effective for promoting a client’s involvement in psychodrama therapy. In another study with twelve adult participants in psychodrama, Kim (2002) found that the most beneficial therapeutic factors were the existential elements of re-enactment and universalization. When clients use their own self by re-experiencing the past in order to understand current feelings, psychodrama produces a positive effect toward change and reduces resistance. In a study comparing 56 Latino families who attended action–oriented skill training to 25 who attended unstructured support groups, Smokowski and Bacallao (2009) found that when using psychodrama techniques in the action–oriented family groups, adolescent clients exhibited reduced rates of problems in terms of oppositional defiant behavior, anxious depression, and parent-adolescent conflict. They also found in the one-year post-intervention evaluation that the action–oriented groups maintained superior effects in these areas, when compared to their unstructured support group counterparts.
Using Psychodrama in Clinical Education
Both role-play and psychodrama have been utilized as educational tools for adult professionals seeking to enter a clinical setting. A 1985 study by Hundsalz describes the use of psychodrama in a group supervision session with social workers. As members of the group experience conflict, personal problems, or other issues, the tools of psychodrama (e.g. role reversal, mirroring, and role feedback) are employed to provide support and guidance. Jenkyns (2008) describes the use of “dramatherapy” in supervision where clinicians experience projective work through transference and counter-transference drama sessions.
Other types of simulated sessions and role-plays are also commonplace teaching methods for clinical professionals. In Hafford-Latchfield’s 2010 study, post-learning reflections were analyzed to evaluate the use of role-play in a classroom setting, in which the students explored the topic of gay adoption. In addition, other qualitative and quantitative studies have confirmed the effectiveness of simulated sessions (Mooradian, 2007; Mooradian, 2008) and role-plays (McGovern & Harmsworth, 2010) for building clinical skills. Some studies have demonstrated the use of professional or trained actors for enhancing the effectiveness of clinical role-plays (Petracchi, 1999; Petracchi & Collins, 2006). Hinkle (2008) also reports that the use of a psychodrama model generates a two-fold experience of a professional, as both a learner and participant simultaneously during the therapeutic process.
This study reports how an MSW intern presented the learning stages and self-development through five psychodrama sessions at the beginning of a specific field placement. The observation notes of one intern are used because they support the use of a case study to demonstrate an entire journey of experiencing psychodrama as a first step of learning. The analysis is based on observations and reflective notes as supervisory tools. Rather than chronicling those specific events, the analyses of these notes focus on the intern’s learning process, during which the student fulfilled the dual role of being a supportive worker and a learner.
Method
A second-year MSW student was selected to enter an internship specializing in psychodrama therapy as the advanced clinical field placement for two semesters. This intern was the only intern representing the first author’s university to work in this placement during this academic year. The intern’s goal was to improve confidence and maximize practice skills for building a clinical career path.
The agency in which the intern was placed is a private counseling agency located in a suburb of Houston, Texas. Through a participatory mode of learning, the intern entered an orientation training program within the agency to learn the psychodrama techniques for self-development. Before any intern starts to work with clients, it is this agency’s educational policy that the field supervisor provides a briefing session about the purpose of this type of clinical training. The intern must complete a weekend psychodrama orientation for staff and interns from social work, counseling and psychology programs. This orientation serves as an opportunity for the intern to experience the format of psychodrama in a protected environment with experienced clinicians and learn how to co-facilitate in future psychodrama sessions. After debriefing this training experience with the field supervisor, the intern then attends at least one client group during the first semester of internship, observing and interacting with clients, as well as preparing for the role as co-facilitator in subsequent psychodrama sessions in the second semester. The intern’s learning through the orientation program and actual psychodrama facilitation takes place within the same agency. This study focuses on analyzing the intern’s data recorded during the orientation to demonstrate the impact of supervisory learning through psychodrama on the intern’s preparedness in clinical work.
In the briefing session with the supervisor, the intern first learned about the dual roles for each participant in this orientation journey: as a protagonist who viewed this process from the client’s perspective, and as a participant who tried the different positions in various psychodrama sessions. The supervisor clearly stated that this training was an orientation to psychodrama, not to psychoanalyze the intern but as an optional opportunity for the intern to reveal life issues in a safe environment with professional guidance. In the orientation, the intern played an active role under the supervision of the agency’s psychodrama director. The intern also wrote observation notes from a first-person perspective. Three licensed supervisors and clinical mentors (two LCSWs and one LPC) processed the notes with the intern and provided written responses. These three mentors were: 1) an on-stage supervisor who provided immediate feedback; 2) a field supervisor, who was an observer in the psychodrama training and identified strengths and limitations of the student in the learning process after the intern shared the learning reflections; and 3) a professor, who taught the intern clinical practice and analyzed the intern’s skills by responding to the observation notes as a part of the intern’s integrative learning between classroom and field.
The intern’s professor found that the orientation training had laid a foundation for successful internship. At the end of the internship, the professor invited two other licensed social work practitioners to utilize a triangulation method to review the notes and found that the words could provide support for the development of an orientation model for a clinical field practicum. In the first round of analysis, keywords associated with the intern’s learning were extracted. Then the intern’s notes with these learning keywords were further analyzed to identify major themes about self and professional development. Finally, these practitioners agreed on seven themes, and the professor shared the information with the intern to ensure best representation of the intern’s learning, as part of the intern’s integrative learning from the internship experience. With permission from the intern and the agency supervisor, the authors applied for an institutional review and received a waiver to publish the findings. It was assured that no personal information was put on the notes when the analysis was conducted, and the results had been used previously for the intern’s learning.
Findings
The use of one intern’s clinical notes allows for longitudinal comparisons of the intern’s learning progresses and helps in designing an internship preparation model. The comparisons focused on the use of psychodrama as a clinical skill, as well as an educational tool. As the intern engaged in reflective learning, observation notes provided evidence that using personal experience as a way to explore vulnerability and acceptability is indeed a powerful tool. The intern kept all the clinical notes (extracted in italics) of this learning process. Major learning notes that do not intrude upon the intern’s privacy are used in this report to illustrate how a parallel learning process takes place from preparation to the final evaluation of this five-session learning. Seven learning themes were found in this process, and the originally designed two-way learning process was found to be three-way — the intern’s learning roles as learner, participant, and clinician, adding the clinical supervision aspects in the learning process. All information disclosed here supports the thematic analysis, which has been shared with the intern and finalized with the intern’s consent.
Theme 1: Prepare for Self-Learning
Clinical Notes: I am developing the clinical skills that will prepare me to perform in the capacity of being a psychotherapist and LMSW. My desire to do this work has been a lifelong dream. While my motivation is sincerely to help others, my personal background and past pains also have fueled this journey. In preparation, I am required to facilitate groups as well as observe and interact with clients in other therapeutic sessions so that I can learn about how a person’s past has affected this person’s present state…
I learned that about every two to three months, the director hosts a “psychodrama weekend.” During these weekends, staff and interns will participate in trainings to learn to co-facilitate these groups and are encouraged to participate for therapeutic reasons if they choose. Because I am fairly unfamiliar with “psychodrama,” I am anticipating the event with curiosity and apprehension.
Supervisory Responses: Learning itself serves as a motivational factor. This intern identifies that motivation to learn is a first step toward the application of an innovative idea of planning an intervention with a group of colleagues. Clinical skill preparation is an essential step prior to participation in psychodrama. Gaining self-awareness is the first step to successful learning and intervention planning. Further, apprehension is also normal, especially when colleagues are participants.
Theme 2: Learn about Professional Boundaries
Clinical Notes: Several of the therapists and long-time clients have described psychodrama as intense, cathartic, powerful, and life changing, but they offer little explanation. Aside from the academic motivation for my participation in this psychodrama, I possess personal and professional reasons for my involvement. Although I am preparing to become a social worker, I also have past personal issues that I have worked hard to overcome… It will be hard to be a clinician with some personal scars in my life. My role as a clinician must be separated from my past issues.
Supervisory Responses: Personal limitations are reflected in this first move. The intern is interested in learning more about psychodrama, knowing that personal issues may be revealed in the sessions. Holding onto past trauma or issues may become an obstacle during the treatment process with clients if the intern does not know how to handle personal self and counter-transference. However, this becomes a strength when the intern shows competence in processing feelings appropriately. The intern is able to relate a great deal of empathy with clients who express past traumatic experiences. As a professional, the intern also gains an understanding about the importance of self-awareness when engaging the same therapeutic process with clients in the future.
Theme 3: Encounter Various Non-threatening Roles
Clinical Notes: The first evening of psychodrama takes place on a Friday from approximately 6:00PM – 9:00PM. This time slot is reserved mostly for professional training purposes for therapists and interns. The director carefully explains the ground rules and various procedures. Some warm-up exercises are done to prepare us to enter the mindset required to successfully participate in the workshop. For instance, the participants are asked to recall a time in their past where they were punished for something they did not do. They are also asked to act out a role where they (perhaps as teenagers) were negotiating with a parent figure with the objective of “just trying to be understood.” Another task in the practice is that of “doubling,” where a participant stands next to a partner, mirrors the hand gestures and body stance, and then verbalizes the messages the partner has transmitted non-verbally as well as cues from verbal communication. The evening progresses quickly and the activities are, for the most part, unthreatening.
Supervisory Responses: Working with interns who do not know the psychodrama procedures can be a difficult task, particularly when they ask a question in the middle of the drama. This intern has learned about the expectations and the importance of observations; therefore, the intern felt comfortable to be engaged in the process. This self-reflective learning method is one that helps clinicians overcome fear and become effective when handling clients’ emotions in a session. In this case, the intern learned about group therapy, where rules and warm-up exercises are essential to the subsequent process of group therapy and helping to achieve that particular session’s objectives.
Theme 4: Experience Relationship Issues in the Group
Clinical Notes: This morning when the group reconvenes, I note that a couple of additional people, who are not mental health professionals, have joined. In total, there are 17 participants. Once some icebreaker activities have been carried out, we listen to the director, who instructs the large group about how to construct a “social atom,” a means of diagramming significant relationships. This activity is carried out in groups of four. I begin my drawing [about my family]. Moving away from the immediate household, I draw in other people… Just like a genogram, various types of lines are drawn to indicate connections and the quality of those relationships. Within the small group, we each take turns sharing information about our social atoms. When I take my turn to present my social atom, I am surprised to find how much I have learned about [me] growing up…. My discomfort originates from my impending explanation of my past issues and my wish to avoid making others feel uneasy.
Supervisory Responses: The intern knew that participating in the psychodrama discussions might be uncomfortable, especially when additional personnel joined in. Discomfort is a natural and typical reaction to past issues, despite having prior preparation and knowing that one will be disclosing personal information to strangers. Re-experiencing past events must be handled with care and psychological preparation. With this experience, the intern realized that this experience would enhance the intern’s professional ability to genuinely use empathic skills and provide insights about how to prepare clients for this type of group activities. It is important to explain to the clients who will attend the session so that there will be no surprises.
Clinical Notes: Soon thereafter, the small groups join to form one large group. At this time, one member indicates that she is ready to work on an issue she has always wanted to resolve. As she goes up on the stage, the director begins to ask her questions about the concern and the family members who would need to be represented in the “role-play” on stage. Various members of the group are selected to go on stage and are strategically positioned…. I am chosen to portray her deceased father with whom she has developed a close relationship. Personally, more feelings begin to arise within me, pulling me back to my childhood. Now I understand how intense this exercise is, even though I am not the person sitting in the hot seat.
Supervisory Responses: Interns can take different roles within a psychodrama session as helpers on the client’s psychodrama stage. This helping relationship encourages the interns to accept their roles and portray the characteristics accordingly. The learning aspect of this role-play opportunity is that the interns can feel mixed emotions within a session, from an intern’s perspective as well as from the client’s point of view. In this case, vulnerability was safely experienced as the intern learned to establish an appropriate identity. Additionally, this counter-transference experience prepared the intern for working with future clients, who may talk about sensitive subjects that may coincide with the intern’s past issues. It is important to have full awareness that this learning process may be evoking personal emotions and risking projection.
Theme 5: Observe Projection
Clinical Notes: We regroup and receive another activity to be carried out in smaller groups of four or five. Within these more intimate gatherings, more role play activities occur. We then “share back” and make comments about a role-play. The role-play consists of a personal issue of some concern to one of the participant actors we have observed. I learn that “share backs” must consist of “I” statements, but our group talks about analysis feedback instead. We finally remark on how our fellow participant’s role-play has affected us personally. The individual who is role-playing is overwhelmed by caring for her demented mother and her need for more assistance from her family. In addition, her sister’s lack of involvement has greatly frustrated her. To share my view, I should have said something along the lines of “I felt frustration and a sense of being overwhelmed in the past when I had to be a caregiver…” Instead, I share that not everyone is able to be a nurturing caregiver. I project my own defense through this role-play because of my past healthcare career for seventeen years. I actually feel blessed to have had a background as a compassionate and competent professional. I feel that certain aspects of my former training as a clinical social worker transfers into my current role with clients. Not only have I developed sensitivity to the emotions of my patients and a sense of empathy, but I have also gained valuable insight into the biopsychosocial issues faced by individuals with physical health issues or disabilities. I believe that I have attained an acceptable point of appreciating and grieving my former career.
Supervisory Responses: The intern is able to connect personal issues with the role-play with sensitivity, because the intern knows that clinical work will connect the worker’s therapeutic skills to the client’s issues. With this exercise, the intern becomes aware of personal limitations and the importance of self-differentiation for providing professional guidance and directions for clients. This learning shows that the intern understands that the client is the priority in this process. Practicing with this mentality will help the intern assume a professional and objective role in the session and not re-experience past issues or vulnerability. Having processed past struggles, this intern has achieved a higher level of self-awareness. The psychodrama role-play has become a way to inform self and others that the clinician has the power to transform past problems or mistakes into learning opportunities.
Theme 6: Understand the Importance of Self-Care
Clinical Notes: Going home, I feel a little vulnerable. For the twenty-minute ride home, I turn on the radio and listen to music and try to relax. I feel tired. I go home, get something to eat, and try to focus on reading some research articles about psychodrama. After a couple of hours, I feel exhausted. I must say that the earlier session has impacted how I will use my past career to my current work as a social worker. This weekend makes me confront my anxiety and the illusion of having recovered from past issues.
Supervisory Responses: Preparing an intern to go through a psychodrama learning process can be time-consuming. The intern was honest about emotional drain and secondary trauma due to the personal disclosure as related to the client’s situations. This journal was a healing and therapeutic tool for the intern to ventilate inner conflict. Once the intern made peace with it, moving on to “getting ready” was not difficult. The intern was able to accept the past as part of life and stand on the client’s side to view the same so that emotionality would not be a factor interfering counseling effectiveness.
Theme 7: Observe the Multiple Roles “On Stage”
Clinical Notes: We begin to set the stage... I explain my past experience and learning through two major concepts: 1) I can take action, and 2) I don’t have to take hits anymore. I invited participants to portray the various people in my life… I also assign another group member to be my “self-respect,” who stands next to the individuals representing “taking action” and “I don’t have to take hits anymore.” I take my seat… and begin to engage in a typical discussion with my family as portrayed by my group members, while a participant stands in front of me [to represent me]. I name this individual “fear.” As I speak with my group, I direct “fear” to slowly approach closer and closer to me… Meanwhile, “fear” keeps moving closer… wrapping around my head… At the director’s command, all action has stopped. I am asked why I allowed fear to do this to me, and what I could have done to change this feeling… Action is halted once more after I am trying to tackle fear alone without any assistance. Then, I tell “Self-Respect,” “I Can Take Action,” and “I Don’t Have To Take Hits Anymore” to stand nearby. With all these strengths, I am able to chase the fear away. This action is empowering to me. The tangible scene has made me realize that I possess the abilities to set boundaries, to not feel guilty, and to have a better sense of faith and belief in myself… On this note, the drama comes to a close.
Supervisory Responses: In this last and central stage of learning, preparation comes around and makes a difference. The intern processed past issues with the supervisor before bringing them onstage. After processing emotions in small groups, the intern is able to identify an additional need for self-care. This psychodrama section is well-planned; therefore, the intern understands the importance of doing a step-by-step process with vulnerability being played out so that the clients can visualize the importance of disclosing personal struggles through a drama. In this parallel process, once the intern visualized own strengths and weaknesses, the supervisors processed the learning outcome with the intern. The intern learned about clients’ perspectives, “transference” mind, and the power of “empowerment.” From this experience, the intern is able to help “walk” the clients through the steps of achieving their therapeutic goals.
Discussion: Evidenced Learning
The original intent of using psychodrama as a learning mode for this intern was to enhance self-confidence by exercising the dual role of learner and professional. It became a three-way learning process through “onstage” experiences as a learner, participant, and clinician, all within one journey for this one intern. The learning effect is maximized because the intern knew that the supervisor and other clinical staff had faith in the intern despite the intern’s difficulties due to certain personal limitations. The intern has learned how to select personal issues that might enhance a social worker’s capacities to effectively serve clients.
This is a case study using the learning and supervisory notes for one MSW intern. It represents a unique clinical experience to explore how a kinetically-oriented parallel learning process can help adult learners achieve major learning objectives in an experiential internship. This learning journey provides evidence to support the use of a three-way learning process for the education of clinical students. Although this information came from only one intern in a first clinical experience in a selected MSW internship program, it provided themes for analyzing major learning lessons in clinical preparation by means of experiential training. From all these notes came three learning lessons, with a focus on teaching clinical skills in the field.
Learning Lesson #1: Reflecting Strengths as a Preparatory Task
The preparation for the journey of psychodrama is a process of self-reflection. Because a clinician must recognize his or her personal limitations in self-disclosure before taking part in a psychodrama session, a few supervisory sessions are essential prior to the psychodrama journey. These sessions help the intern understand what aspects of his or her personal issues can be disclosed for the client’s therapeutic benefit. Taking part in psychodrama from the client’s perspective is a powerful way to prepare social work interns to become effective clinical social workers.
Learning Lesson #2: Affirming Professional Identity
In front of the psychodrama group, the intern must be able to speak about some past and unresolved conflicts in a professional way. Although it can be a challenge to identify one’s past in front of a field supervisor, with this exposure, the intern can appreciate the process when clients reveal their past issues that may have interfered with their current life situation. This process helps adult learners critically assess the connection between unresolved issues and professional self-development. These issues include personal/professional boundaries, self-blaming, and lack of confidence. The intern reported that this learning process had been concrete and experiential and could serve its functions for social work interns to build strong professional identities in front of clients.
Learning Lesson #3: Evaluating Internship Outcome
This psychodrama learning journey provides more than just words of reassurance. This experience can yield tangible results that the intern can visualize with concrete clinical learning outcomes. These outcomes include a change of attitude about self-involvement in learning. Every step taken with a client is a learning opportunity that can occur at three different levels: cognitive, affective, and behavioral. Working with clients who may need intensive guidance, the intern must adopt new perspectives at all three levels before helping the clients making changes.
Conclusion
This study represents the use of a clinically-oriented approach to document the field education preparation process for a MSW intern — through self-exploration in five psychodrama sessions, during an orientation program in a clinical agency. The participation in this integral psychodrama journey takes part in individualized educational supervisions. The intern contributed to the successful outcomes of the sessions by practicing the three major roles in this process-learning approach; being learner, participant, and clinician helped the intern gain the confidence needed to assume the multiple roles of a social worker in future practice. This intern learned clinical skills through the seven themes identified in this study, with the assistance of the field instructor and clinical supervisors. These experiences provided an opportunity for the intern in terms of transforming the intern’s limitations into capacities.
Qualitative data are used in this study to demonstrate how an adult learner connects clinical skill learning to professional self-development through a three-way learning psychodrama process. The intern valued the experiences and feedback from the supervisors, as well as the educational aspects of reflecting learning through these experiences. The outcome of this study implies that a clinical internship must include sound pedagogy of reflective learning. The seven themes from the intern’s notes can help educators design a teaching model that enhances internship success. One caution is that these steps represent a clinical skill learning process, not a means of providing psychotherapy to students. With concrete evidence to support the outcomes of skill-learning and professional self-development, psychodrama can be utilized in an internship setting for students to establish clear professional boundaries and to build practice wisdom with confidence.
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1 The personal identifiers of this intern (such as gender and other demographics) are not disclosed to protect confidentiality. Therefore, no gender specific noun or pronoun will be used to represent the intern.