Roleplay in Psychotherapy

7

General effects of roleplay techniques in psychotherapy
by Roger Schaller

In numerous meta-analyzes of therapeutic efficacy studies no therapeutic method has proven to be superior, which is why a figure from Alice in Wonderland has been chosen as the metaphor for this result of therapy research: the bird Dodo, who calls for a competition in which it is forbidden to win which is why everyone wins. So if you want to express that all therapy schools or methods are equally effective, it is called the “validity of the Dodo-bird verdict”. It is said that no therapy school and no psychotherapeutic method wins but all win somehow. It is believed that the effect is not due to individual therapy techniques but to common factors found in each therapy situation.

Orlinsky, Grawe & Parks (1994) use the general model of psychotherapy (Generic Model of Psychotherapy) for a broad approach to the collection of psychotherapeutic principles. The aim of this general model is to offer a research-based metatheory of psychotherapy that lists all the therapy variables mentioned in the research literature. The therapeutic factors are summarized in six aspects:

  • The formal aspect. These are features of the therapy agreements and the definition of what the therapist and what the patient should do. Questions of the fee and the regulation in case of failure of a therapy play a role, but also the type of therapeutic setting (in the group or individually).
  • The technical aspect. This means the expertise of the therapist and the application of expertise. This aspect includes the specific therapeutic methods (e.g., stool technique), but also the basic therapeutic approach (e.g., more related to the symptoms in the here and now or more to the cause of the problem).
  • The interpersonal aspect. This refers to the therapeutic relationship through which only the therapeutic techniques can be effective. Only when the patient feels understood, a further therapeutic impact is possible.
  • The intrapersonal aspect. Here the self-living of therapist and patient plays a role. These include issues of self-esteem, self-control and openness.
  • The clinical aspect. This is about the effect of the therapy session on the patient. For example: has insight, self-understanding and encouragement grown in the patient?
  • The temporal aspect. This refers to all time constraints, such as the number of sessions, the frequency (several times a week, once a week, less frequently) but also the duration of a single session.

Orlinsky and colleagues do not distinguish between the more general impact factors and the specific individual techniques. For example, there is the general factor “appreciation and empathy of the therapist” as well as the quite specific role-playing method “chair technique”; for both positive correlations with the therapy success are reported.

This raises the question: What impact factors exist, and with which techniques are they realized? Tschacher, Junghahn & Pfammatter (2014) made an important contribution in the definiton and conceptualization of common factors of psychotherapy by analyzing their differential associations to standard techniques. They conducted a survey in which 68 psychotherapy experts gave their judgements about the relation between 22 general efficacy factors found in the pertinent literature and 22 psychotherapeutic standard techniques found at various therapy schools. It has been shown that therapy experts believe that a certain general effect factor can be realized with the help of several therapy techniques. Conversely, it also holds true that a particular individual technique is considered effective for different impact factors. The single technique that has been considered effective for most general impact factors is the roleplay technique. This technique is more closely defined in the study of Tschacher and colleagues than in psychodrama, namely only in the sense of behavioral training: (according to Tschacher et al., 2014): “Therapist simulates difficult social interactions in a play with patient as participant, and instructs, models and corrects the performance. ”

In the following, those impact factors are listed that were considered by the respondents to be realizable through this roleplay technique.

Table: Common factors realizable through roleplay technique (according to Tschacher et al., 2012; significance: p <.0001)

In the study by Tschacher, Junghahn and Pfammatter various other therapy techniques are listed, which are also used in psychodrama, namely role playing with chairs, the role-playing ritual, the verbalization of emotional reactions and the sculpture and constellation work. As a result of this Expert Survey we can say: roleplay seems to be an essential ingredient of change in psychotherapy. So it is worth to look more closely at roleplay: What is the specificity of roleplay? Are there different forms of roleplaying?

From rigid reaction to creativity

We will start the discussion of these questions with a digression into the world of temperature and heating regulation:

The aim of psychotherapy is the promotion of health and well-being, whereby an unwanted actual state is to be converted into a desired target state. With role play this process from the actual to the target state as well as possible obstacles can be modeled and thus explored and trained in a simulated situation. This corresponds to the biological data processing of the human brain, which can be described as a kind of “prediction machine” (Jäncke 2015). Based on already stored information, current sensory inputs and individual characteristics, our brain constantly develops predictions about the environment and possible consequences of our actions. According to these predictions, we regulate our body activities and behaviors – and also our inner physical states as for instance the body temperature. Similar to our brain, home automation also works to regulate temperature of a house. Heating control in a house works in the following way: a thermostat equipped with various temperature sensors to record the current room temperature (actual value) calculates  the difference between the current room temperature and the desired room temperature (target value) and derives therefrom an instruction to the burner which is turned on or off as needed.

According to Widmer (2013), the elementary scheme underlying all technical and biological regulatory systems (“prediction engines”) has four components:

  1. Representation of an actual state: The organism delivers electrical impulses as information about a current condition; for example, in a house over the room temperature or in humans about the body temperature; or also information about our sensitivities (for example: “I am feeling cold“ or ” I am anxious, I think I could disturb the others“)
  2. Reference (target state): For what the information represents, there is a reference value in the brain; in the heating system of residential buildings this is the room temperature 21 degrees; in the example about social anxiety this could be: “I am self confident and calm”
  3. Control logic: The deviation of the current from the reference value results in a voltage that is converted into an instruction by a logic; in the house-example the instruction to the burner is calculated; In the example of social anxiety different emotions or thoughts can be activated
  4. Instruction: Is automatically derived from the calculations or sensations and thoughts and is done directly, without any further adjustment and reflection processes. In the example of social anxiety this could be: “I will go and ask if I may join them” or “No, I prefer to stay alone ….”

For control processes such as keeping the temperature constant in a residential building, a few signals are sufficient. However, every second, our brain processes an incredible number of electrical impulses as information about the current biological state, about sensory perceptions and about the simultaneously occurring thought processes and emotional states. Human existence is more complex than a heating system. There is a huge amount of information about the current state associated with memory, needs, intentions and expectations. How do humans handle this huge amount of data? How can humans prevent themselfs from always making their calculations according to the same regulatory logic and again and again showing the same behavior almost automatically? How does a person get to a new instruction for a new behavioral response?

Widmer (2013) describes the regulatory logic according to which an instruction is given to maintain or change an actual state in three stages:

I.    Rigid reaction is based on the “if-then principle”, e.g. “If hungry, then scream” or “If I come across an obstacle, I’ll wait           and see” or “If I see my colleagues sitting at a table I will avoid them”.
II.  Variation allows a more flexible behavior in case of problems, e.g. “Not only can I wait for an obstacle, but I can imagine         and try out different possibilities (going around left or right, skipping over, pushing the obstacle away, etc.)”. If the                 possibilities are more complex, evaluation functions are added: “What is socially desirable? What is riskier?” For                     example: “If they look at me friendly I will go to their table and ask if I may join them”.
III. Simulation also contains the evaluation of different variations of behaviours but goes much further: we do internally as           if we were carrying out a possible behavior and visualize the situation in question, the objects and the sequence of                   states, and experience in the so-do-as-if mode. Simulation goes beyond the momentarily visible and represents a virtual         testing of options. In our example of social anxiety, I could imagine what will happen when I go there and ask to join               them : “They will say Yes, but I will see in their faces that they are not pleased and so I will be inhibited.”

Human regulatory systems are highly complex and difficult to access for therapeutic intervention. Roleplay techniques can empower patients to explore their own experiences and the motives of their actions in relation to the world, other people, their own body, their own values and their own biography. Central concern of the method roleplay is in this sense the promotion of the creativity of the control scheme of a human being. According to Widmer (2013), creativity is made possible by the increasing complexity of regulatory logic. The more flexible a human being is in his world, the more open his regulatory system must be for generating new behaviours. By roleplay techniques the patient can come to a better understanding of his difficulties and how to change his behaviour.  In order to understand a problematic actual state, we must be able to recognize what makes it so stressful and why previous attempts at change in the direction of target state did not work. Therefore in therapy often unsuccessful attempts at solution have to be reenacted in order to find out why they do not work. In roleplay the patient has the freedom to experiment with different behaviours and perspectives. This high degree of freedom in roleplay creates spaces and creative energy for personalised care and autonomy to ensure bioethical self-determination and openess.

 

Roleplay in CBT

Cognitive behavioral therapy (CBT) has a disorder-specific approach, which is oriented to recognizable and changeable mental and behavioural processes and tries to influence them by pointing out possible variations. It is assumed that every emotional disorder becomes recognizable on the basis of cognitive content and so becomes accessible for therapeutic processing. The basic premise of CBT is that cognitions play an important role in the maintenance of emotional disorders – mainly due to the assumption of a causal influence of cognitions on one’s own emotions and behaviour. Accordingly in CBT the therapist is engaged with the patient in a collaborative exploration of the patient’s inappropriate cognitions and emotions usually with conversation techniques.

In CBT roleplay is mainly used in interpersonal skills training and in treatement of anxiety disorders.  In CBT roleplay is practiced in several runs and gradual variation of the target behaviour. Here a brief overview of the different steps of roleplaying in CBT:

  1. Therapist and patient discuss the rationale for the specific skill and the therapist models the target skill in a roleplay or by a detailed description of the target behaviour.
  2. The target behaviour will be broken down into different behavioural components and the patient will try to perform one part of the chosen target behaviour in a first roleplay run. The therapist plans the first roleplay in a way so that the patient will be able to perform it with a good probability of success.
  3. The therapist gives positiv feedback about what the patient did well and provides corrective feedback with suggestions for how the client could do the skill better. The patient repeats the roleplay until the first step oft he target behaviour is reached and then the other behavioural components of the target behaviour are integrated.
  4. After each roleplay the patient receives positive feedback and the patient is asked to define what difficulties and variations could gradually be introduced in the training situation.
  5. Finally an assignment for the patient is developped to practice the skill on his own until the next therapy session.

As example for this procedure we take the case study a patient with a anxiety disorder: the patient fears scrutiny by other people and therefore avoids social situations at work. For example, he reports that he always sits down alone at lunch in the canteen because he is reluctant to sit down with other colleagues. In a first step unfavorable thoughts and feelings were identified and named (“I’m probably too boring for the others – probably they would not like if I take place at their table”) and new positive thoughts and feelings were developped. Then the therapist proposes to experiment with the new positive thoughts and feelings in roleplay where the the difficulty level of the target behavior is gradually increased.

Therapist : „We will start with a little exercise: imagine here is the canteen and here at this table are already sitting somme colleagues of us and I will show you now how I would go there and ask if I may take place at their table“.

In a second step, the patient is asked to imitate the behavior shown. To facilitate the roleplaying task for the patient the therapist takes care to focus only on singular aspects of behavior: vocabulary, speech melody, eye contact, posture, etc. In several repetitions of short role-playing sequences, the patient will now gradually approach the target behavior. If necessary, the therapist can play again the target behavior as a model. If it seems necessary, variations will be introduced which better correspond to the person of the patient and the specificity of the situation. At the end of this behavioral training the patient is given the task to try this behavior in the real life situation at least once before the next session and to write down the thoughts and feelings that arise.

In CBT roleplay is mostly used in a very simple form with very general and banal instructions, as described in the example above. Accordingly in CBT literature and manuals the attention is rarely directet to any technical consideration about role play. This runs the risk of obtaining superficial and meaningless behavoural trainings and non-generalizable therapeutic experiences. There is one major tradition of psychological treatement that involves techniques of role play to a significant degree: psychodrama.

 

Roleplay in Psychodrama

While in CBT the patient explores new ways of thinking and behaviour by imitation and variation of a modelled behaviour, in Psychodrama the patient is instructed to play with the reality by simulation. The Psychodrama therapist uses techniques to help the patient to experience the roleplay as if he was “really in the canteen”and the patient is engaged in a spontaneous and creative roleplay. Let us go back to the above case study and look how the Psychodrama therapist  will approach this case:

Therapist : „We will start with a little experiment: please stand up and imagine here is the canteen….what do we need to make it real….a table….chairs?“
Patient:  „Yes, a table and some chairs.“
Th: „Okay, let us put here a table and chairs and what else do we need? What is here around the table?“
P: „This is a large canteen, there are many tables and back there is the buffet”
Th: “Good, we imagine back at this wall is the buffet and where is the entrance? Where from do you enter the canteen?”
P: “Here is the entrance.”
Th: “I will mark the entrance with two books I put on the floor. And who is sitting already at this table here?”
P: “Oh, here are three colleagues from my department.”
Th: “Can you please briefly stand behind each of this three chairs and tell me who is this person sitting there? Just the name and one or two sentences about this person and the relation you have with this person.”
P: (gives some brief informations about these imagined persons)
Th: “Very goog, thank you! And now we start our experiment: you go there to the buffet and we imagin that you just do what you usually do.”

The patient does as if he takes his lunch tray and then he looks briefly at the table but then goes in a other direction. In this moment the therapist stops the roleplay and asks the patient to come out of his role and to go back with him to the meeting chairs to discuss what now just happened in the roleplay. Together they try to identify  and name unfavorable thoughts and feelings and define a target behaviour. Then they go back to the roleplay stage and the patient tries to play the target behavior in an second roleplay. The patient gets stuck in his previous pattern of behavior. The therapist will interrupt the role play again and ask the patient to join him on the border of the stage.

Th: „It seemed to me that this was not a new behavior.“
P: „Yes, I don’t know why….“
Th: „I had the impression that your mind wanted to go to join the colleagues at that table, but your body did not follow.“
P: „May be….I don’t know…yes, I somehow felt stiff“
Th: „Would you please go back in these scene and just play this moment, when you feel this stiffness?“

The patient takes again his role in the canteen and after second the therapist freezes the scene („Stop, stay just there were you are and try to verbalize what you are feeling, what you are thinking.“). Then the therapist invites the patient to leave his role and go back to the meeting chairs for a discussion. It turns out that the patient worries a lot about what could go wrong and why he could be rejected by the others. The therapist suggests first of all to stay on the physical side and try to strengthen the well-being of the body.

Th: “To explore this bodily aspect in this canteen situation I propose to do a little imaginative exercise, its okay for you?”
P: “Okay.”
Th: “Please sit down comfortably, close your eyes and breathe in and out calmly….. and now we enter in your fantasy world and wer are looking for a strong figure, a hero, a heroine… what person comes in your mind….a peson with high self esteem…who is a person who is confident, friendly and open to others…. you can find such a person in your memory…. in your imagination?”
P: “Yes…..Roger Federer.”
Th: “Oh yes, Federer, the magical tennis player. Now you can leave your fantasy-world and come back with your thinking in the here-and-now. What do you imagine: what would Roger Federer think, feel and do in your problem-situation?”
P: “May be he would say: If I play my game, If I continue calmly to do what I wanted to do I can win!”
Th: „That’s beautiful: I play my game, I can win! And now we will continue our little experiment and go back again to the canteen. Please stand up and take the role of Federer there at the buffet in the canteen. You don’t need to act, just stand there like a statue of Federer: how would he stand there…please try to take the role of Federer in the canteen eventually meeting his colleagues.“
(The patient takes the role of Federer in the canteen.)
Th: „Thank you, that is enough, please join me here an the border oft he stage, you are not Federer any more, you are yourself here in therapy….what did you experience in this role as Federer?“
P: „It is a good feeling to know: If I play my game, if I do what I want to do then I can win. I was kind of carefree, I felt light.“
Th: „Do you think you can go back in this canteen scene and try to take your role with this bodily sensations: carefree and light?“

The therapy session will now be continued with further role-playing sequences to gradually guide the patient to the target behavior. We can see in this case study that the procedure of roleplaying in Psychodrama is very similar to roleplaying in CBT. In both approaches the therapist is engaged in cooperation with the patient in experimental trainings and in a collaborative empiricism concerning the interpretation of the cognitive and emotional causes of a specific behaviour. The Psychodrama therapist does in action what is done in CBT by talking and drawing out formulations or diagrams on a whiteboard or on a paper (Hammond 2014, Schaller 2014, Dumpert & Schaller 2017). As I mentioned above in psychodrama the patient acts in a simulation-roleplay and uses various techniques to move away from the physical reality of the therapeutic situation and to do as if the scene and the role played in therapy would be real. This gives the patient the capacity to play with reality. I will now put the focus on three central psychodrama techniques and demonstrate how these specific techniques differentiate roleplay in Psychodrama significantly from roleplay ind CBT. These three techniques were also used in the case described above.

The stage: In a psychodramatic role play, it is important to distinguish between three different stages. Stage 1 is the stage of therapeutic encounter where patient and therapist usually sit in their chairs and discuss a problem. For the role play, the patient is asked to move to an open space in the therapy room. In this way a clear distinction between the space for the therapeutic conversation and the room for the scenic play – the play with reality. This special area for roleplay is called stage 2. There is also a stage 3: the patient is asked to try out a special new behavior in their everyday life and to observe himself during this exercise. The stage enabels therapist and patient to separate physiscally the role playing from the ordinary interactions between therapist and patient. “The stage concretizes the idea that certain behaviors are meant to be unterstood as exploratory ‘as-if’ dramas rather than final conclusions.” (Blatner & Cukier 2007) In the ‘canteen’-case therapist and patient move from stage 1 where they encounter and discuss the problem to stage 2 where the roleplaying takes place. They also move to the border of the stage for the director’s talk.

The directors talk: The central technique in individual psychodrama is the director’s talk (Schaller 2016, 2017). The psychodrama director makes the client play only very short sequences of roleplay and constantly interrupts the roleplaying. By inviting the patient to join him on the border of the stage for a conversation about what is happening the therapist turns the role play into a workshop of consciousness: The client receives time, space and interaction possibilities, to realize that his thinking, feeling and acting in this situation not only determined by real external conditions but also by conscious and unconscious mental and physical processes. The art of role-playing is to empower patients to mentally relate to their inner states during role-play. We call this process: awareness in simulation. The director’s talk offers an important opportunity for this mentalization process: The scene is “frozen” and the patient is asked for a brief discussion on the border of the stage. In the ‘canteen’-case a example of director’s talk is given.

Variations in role-taking: The therapist can initiate three different forms of role-taking through targeted guidance and questions (Gallese, Migone & Eagle 2006,  Schaller 2016, Dumpert & Schaller 2017):
Imitation: When a person tries to play the role of another person he/she can do this by imitating an observed behavior of the other person. Imitation is a powerful form of learning commonly used by children. A child’s enthusiasm for imitative behavior prompts parental attention and interaction, and provides a mechanism for transmitting appropriate cultural and social behavior.
Cognitive Simulation:  Taking the role of another person is also possible by simulation of what he/she would do in the other’s place. He/she does this simulation by representing the way of thinking and the mental states of the other and then using the own decision-making systems to operate on these foreign mental states to predict the behavior, feelings and thinking of the other. This cognitive simulationprocess refers to the concept of Theory of Mind (ToM): one’s ability to infer and understand the beliefs, desires and intentions of others.
Embodied Simulation:  When a person tries to play another role it may also happen by an embodied simulation. Embodied Simulation is a crucial functional mechanism of intersubjectivity by means of which the actions, emotions, and sensations of others are mapped by the same neural mechanisms that are normally activated when we act or experience similar emotions and sensations.  While in Imitation and Cognitive Simulation the process of role-taking is conscious, this simulation process is direct and ecapes conscious access. Without thinking the client is instantly able to  reproduce de bodily position and movements of the other person.

In CBT usually roletaking is done by a cognitive simulation. In the psychodrama-‘canteen’example the therapist activated the patient to take a role by imitation (“You don’t need to act, just stand there like a statue of Federer: how would he stand there…“) and by embodied simulation („Do you think you can go back in this canteen scene and try to take your role with this bodily sensations: carefree and light?“). In psychodrama roletaking is usually done by variation. The patient learns to play not only with reality but also to play with different forms of taking a role.

 

Conclusion

The common-factor approach in psychotherapy has been discussed in the first section of this article. This survey has shown that roleplay is often and widely used in psychotherapy. But Tschacher & Pfammatter (2016) emphasize that the role of the body, of nonverbal behavior and reciprocity of mind and body is neglected in psychotherapy and especially in CBT. Currently CBT is integrating humanistic ideas and techniques by its so-called third wave. The third-wave approach (Hayes, Follette, & Linehan, 2004) includes Schema Therapy, Mindfulness-Based Cognitive Therapy, Compassion-Focused Therapy, Dialectical Behavior Therapy, Metacognitive Therapy, Acceptance and Commitment Therapy and others. These approaches seek to blend traditional CBT principles with concepts new to behavioral psychotherapies such as mindfulness, acceptance, compassion, metacognition, spirituality and the therapeutic relationship. Third wave therapies prioritize the holistic promotion of health and well-being and are less focused on reducing psychological and emotional symptoms. Third wave therapies also focus more on bodily and sensory experiences. But still roleplay is used in CBT in a very simple form with little involvement of body and movement. In the following sections I have described how simulation and different psychodrama techniques can develop roleplay in psychotherapy: they implement the movements, postures and overt behaviors of patients right in the therapy setting. Psychodrama employs ‚as if’-techniques to help the therapist to better understand the problem of the patient and also to help the patient to master stressful life events vicariously within the protectet world of the stage. The patient is encouraged to withdraw temporarily from the real world and to let imagination and fantasy get real. In a paradoxical way the psychodrama techniques make the roleplaying more artificial and in the same time more matching the ‚real’ world.

 


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Informationa about the author:
Roger Schaller Psychotherapeut für Kinder, Jugendliche und Erwachsene und als Verkehrspsychologe.  Leitung des Institutes für Psychodrama und Aktionsmethoden www.ipda.ch (seit 2013)