Using Psychodrama to Teach CBT

CHALLENGING CASE

Is it possible to add creative twists to proven therapeutic techniques in order to encourage reluctant patients to try safe and effective treatments that we believe can benefit them? After reading the case, tell us what you think in the comments section at the end of this article.

CASE VIGNETTE
"Danny" (identity changed) was a delightful person, and talented to boot, but self-effacing to a fault. The years he spent with embittered parents had taken their toll. Antidepressants increased his energy but did not erase Danny’s negative self-talk. Psychodynamic therapy identified the origins of his self-doubt, but it did not dampen his deafening internal dialogue.

Danny had grown up in the Deep South, not rich, but not as poor as some of his neighbors. When a big box store opened across the river, his family’s small fishing supply shop could not compete. It lost its customer base and closed in 2 seasons. The family store was not large, by Danny’s accounts, but it fed the family and paid for Danny’s after school classes. His father had inherited the store from more enterprising grandparents who were long gone. Now the store was gone, and Danny’s father needed a job.

Father was too proud to accept a job at the big box store and he found no other opportunities. He lacked the spark that had propelled his own father into opening a business. He berated his wife for offering to work as a cashier at that same store. So Dad fished all day, returned home at night, and shouted at his sons, reminding Danny that he would never amount to anything. No wonder Danny left town when he had a chance. He took a job as a stagehand with a traveling theater company. He ended up in New York City.

Danny’s sense of inadequacy continued, unabated. It was obvious that he incorporated his father’s insults into his self-image, but understanding that father projected his own failures onto his son did not relieve Danny’s distress. Danny’s negative self talk seemed suited to a trial of cognitive behavioral therapy (CBT).

When Danny looked skeptical, I elaborated on the value of identifying distorted cognitions and arguing against them. “Ignoring the evidence” is first on a short list of common cognitive errors. (Other recurring cognitive errors include magnifying or minimizing, jumping to conclusions, catastrophizing, and so on.)

The very word, “evidence,” reminded me of Law & Order, a long-running television program that recently celebrated its 25th year on the air. I heard myself saying to Danny, “You know, like on Law & Order.”

I myself was not a diehard Law & Order fan (and am not even a TV watcher), but my sister developed an unnatural affection for the series, in spite of her PhD in epidemiology. Dinner at my sister’s house meant listening to Law & Order playing in the background. As a result, Law & Order started playing in the background of my own mind (not as an hallucination, but as a free association!) as we spoke of “evidence.” Since Danny worked for a theater company, this association became even stronger.

I asked Danny to pretend to be the prosecutor on Law & Order and to poke holes in the witness’ statements. Danny pointed out that he already acted as the “witness” as he “testified” to “facts” about his predicted failures. Since this was not a real court, I convinced him to continue his questioning, without giving up until he-the witness-caves in and admits that his statement contradicts other “evidence.”

In this case, the “allegation” concerned Danny’s alleged inability to hold a job. He always expected to be fired. Yet the “evidence” proved that Danny could indeed hold a job (unlike his explosive father).

To make matters more fun, I suggested that he pretend to be the defense counsel who must support his witness’s assertions, however absurd. That role offers an opportunity to defend reflexive-but maladaptive-responses, and often reveals little or no evidence to support automatic bad thoughts.

We proceeded, “Law & Order-style,” talking about his expectations. The next time he tried to “jump to conclusions,” (which is a common cognitive distortion), Danny was told to jump in like a Law & Order attorney and complain, “Counsel is leading the witness.” At this point, the judge intervenes.

With a little practice, Danny learned to be his own judge and to intervene in his mind’s “courtroom proceedings.” He matched his automatic responses to other distorted cognitions on the list from my APPI-press book on High-Yield Cognitive-Behavioral Therapy,¹ such as “jumping to conclusions,” “over-generalizing,” “catastrophizing” or “expecting their worst,” “all-or-none thinking,” or “personalizing.” Danny did his homework, shared it with friends, and apparently had fun.

[[{"type":"media","view_mode":"media_crop","fid":"34682","attributes":{"alt":"cognitive behavioral therapy","class":"media-image media-image-right","id":"media_crop_1455557610898","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3691","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©jslavy-shutterstock","typeof":"foaf:Image"}}]]How would you proceed?

A. I would try to teach new CBT techniques, even though there are obvious obstacles

B. I would not try CBT before exhausting trials of all available psychopharmaceutical strategies, including adding lithium or second-generation antipsychotics approved as antidepressant adjuncts to his antidepressant regimen or then doing a washout of all medications so he can start monoamine oxidase inhibitors

C. I would refer him for more intensive and longer term therapy at a local psychoanalytic training institute that offers several psychoanalytic sessions per week for up to 2 years, especially since the psychodynamic origins of his self-doubt seem so transparent

D. I accept the fact that some patients can improve only so much and feel fortunate that he is able to hold a full-time job

E. I would “reframe” the CBT techniques in terms that he can relate to, using contemporary media, rather than presenting CBT techniques as demanding educational exercises

[Please include full names names and academic titles in your comments. –Psychiatric Times Editors]

Discussion
There is a lesson to be learned from Danny’s success at this modified approach to CBT. It should not come as a surprise that many patients do not complete CBT homework assignments. Schoolteachers (and perhaps parents) could have predicted this, but health care professionals must measure results. As an example, data show that only a small fraction of patients do CBT “assignments” for substance use.² There is more discord about how much is enough-or good enough-homework.³

Many studies confirm the efficacy of CBT, yet people are people, and even adult patients are not always as diligent as they could be. In contrast, it is common to encounter patients who exclaim, “I can’t believe it-that’s so me!” when handed the list of “Distorted Cognitions,” downloaded from the CBT book referenced below.¹ The next challenge is convincing patients to argue against their automatic thoughts at the time they occur, so that they can extinguish the distorted cognition and substitute a more accurate and adaptive idea, to the point that this becomes habit. Turning this assignment into a game, rather than a task, makes it easier to complete.

Teachers learned a long time ago that “edutainment” succeeds more than ordinary education. They have to engage their students, just as we must engage our patients. We no longer expect school students to memorize long Latin conjugations to “train their minds.” Why should we expect more from our patients, who may be more anxious, depressed, or distracted than average students? By making their CBT assignments fun, we stand a better chance of helping them benefit from scientifically proven techniques. It is unlikely that incomplete CBT assignments are more helpful than unfilled prescriptions.

Admittedly, not everyone likes Law & Order, but enough do, making it worth analyzing. This brief case example suggests that this modified CBT technique deserves further study. However, I must confess: this approach is just old-fashioned psychodrama blended with contemporary CBT-but next to no one knows about psychodrama anymore and almost everyone knows about Law & Order. My next assignment for myself is to find more ways to spruce up CBT to match other patients’ interests.

In spite of prior treatment with psychotropic medications and psychodynamic psychotherapy, this patient’s nagging self-doubt and self-denigration persisted long after the vegetative and affective symptoms of depression remitted. He is skeptical that another type of treatment can relieve his distress. Because he is so self-critical, he is especially uncertain that he can do CBT lessons “correctly” and warns that such failure may worsen his low self-esteem.

Disclosures:

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine in the Bronx, NY. She is the author of several books, including, Cinema’s Sinister Psychiatrists: From Caligari to Hannibal (McFarland, 2012) and Neuroscience in Science Fiction Films (McFarland, 2015). She is in private practice in New York City. She reports that she receives royalties from Neuroscience in Science Fiction Films; A History of Evil in Popular Culture: What Hannibal Lecter, Stephen King, and Vampires Reveal About America (ABC-CLIO, 2014); Cinema’s Sinister Psychiatrists, Movies and the Modern Psyche (Praeger, 2007); and other books that do not relate to the topic at hand.

References:

1. Adapted from Wright JH, Wright AS, Beck AT. Good Days Ahead: The Multimedia Program for Cognitive Therapy. Professional Edition, Version 3.0. Louisville, KY: Mindstreet; 2010, reprinted (with permission) in Wright JH, Sudak DM, Turkington D. High-Yield Cognitive-Behavioral Therapy for Brief Sessions: An Illustrated Guide. Arlington, Va: American Psychiatric Publishing, Inc; 2010.
2. Anton RF, Moak, DH, Waid LR. Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: results of a placebo-controlled trial. Focus. 2003;1:183-189.
3. Schmidt NB, Woolaway-Bickel K. The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder quality versus quantity. J Consult Clin Psychol. 2000;68:13-18.