,

PSYCHODRAMA AND THE TREATMENT OF BULIMIA

Monica Leonie Callahan
This is Chapter 6, pp 101 – 120, in L. M. Hornyak & E. K. Baker (Eds.),
Experiential Therapies for Eating Disorders. New York: Guilford, 1989.)

Since 1981, I have been exploring ways of using psychodrama as part of individual and group psychotherapy with bulimics in an outpatient setting. Almost all of my clients are women; their ages range from the late teens to the early 50s. Psychotherapy is only one part of the treatment.

I encourage clients, as needed, to consult with a physician, meet with a nutritionist and attend meetings of support groups such as Overeaters Anonymous (OA). I do not require a commitment to specific changes in eating behavior in order to begin treatment; indeed, the ambivalence about such a commitment is often the issue that must be dealt with first.

This chapter introduces the reader to psychodrama in the treatment of bulimics. “Bulimia” here refers to the DSM-3 (American Psychiatric Association, 1980) definition of the disorder, which is less restrictive than the definition of bulimia nervosa in the DSM-3R, (American Psychiatric Association, 1987). In particular, the women I describe may or may not meet the DSM-III-R criterion of, regularly engaging “in either self-induced vomiting, use of laxatives or diuretics,  strict dieting or fasting, or  vigorous exercise in order-to prevent weight gain.”

 Others have written extensive reviews of the literature focusing on: psychodrama (Bischof, 1970; Buchanan, 1984; Haskell, 1975; Kipper, 1986; Z. T. Moreno, 1959; Starr, 1977; Yablonsky, 1976) and on the treatment of bulimia (Emmett, 1985; Garner & Garfinkel, 1985; Neuman & Halvorson, 1983). A number of authors (Boskind-White & White, 1983; Browning, 1985; Neuman & Halvorson, 1983; Roy-Bryne, Lee-Renner, & Yager, 1984; Shisslak, Schnaps, & Swain, 1986; White & Boskind-White, 1984) refer to action methods, such as role playing; gestalt techniques, and assertiveness training used to treat eating disorder, but none of these applications utilize psychodrama: as a primary methodology.

The chapter begins with an overview of the basic principles, objectives, and techniques of therapeutic psychodrama. I discuss how psychodrama is best applied to the treatment of people with bulimia and then demonstrate the use of these techniques to address four central clinical issues. For each issue, I present a psychodramatic group exercise and a reconstruction of a full-blown psychodrama pertaining to that theme. A general discussion follows.

Psychodrama

Psychodrama is a form of therapy and education that uses a wide range of action methods to examine subjective experience and to promote constructive change through the development of new perceptions, behaviors, and connections with others. Participants enact past situations, present dilemmas, future expectations, dreams, fantasies, emotions, and ideas—all occurring in the “here and now” of a special sort of heightened reality. It is the job of the “director”/therapist to help create an atmosphere conducive to such experiences and to develop therapeutic action structures jointly with the “protagonist,” or central character, and with the members of the group. (Psychodrama is usually conducted in groups, but it has been adapted for use with individuals as well (Stein & Callahan, 1982).

Psychodrama was formulated by Jacob L. Moreno (1946, 1953, 1973; Moreno & Moreno, 1959, 1969) during the years 1908-1925 in Vienna and was brought by him to this country in 1925. Over the next half century, Moreno further developed and published his ideas for psychodrama, sociometry, role theory, social systems theory, and group psychotherapy. He also founded a residential center for the practice and training of psychodrama in Beacon, NY.

Moreno was an idealist. Drawing from a background in philosophy and theology, he viewed people as possessing a transcendent ability to create through the workings of an inexhaustible inner energy that he termed “spontaneity.” Spontaneity is defined as the ability to generate novel, appropriate responses to old situations and effective responses to new ones. Spontaneity is also the ability to infuse the familiar with new life and to live in general with vitality and authenticity. The goal of psychodrama therapy is to remove existing blocks to spontaneity so that the natural creativity fundamental to psychological health and -growth can flourish. This goal is best accomplished by creating a context that approximates real life and by treating spontaneity as it emerges in observable behavior.

Along with spontaneity and creativity, Moreno emphasized the basic interconnectedness of people; in particular, he stressed their need for one another in order to establish an identity and to lead a meaningful life. He postulated a natural flow of feeling perceptions between people that, when left unencumbered, can greatly enhance spontaneity. This occurs, for example, in the ideal situation of role reversal, when one person is able accurately to grasp on many levels the subjective experiences of the other by putting herself in the other person’s place.

Moreno studied spontaneity in its moment-to-moment behavioral manifestations. He believed there is a continuous process of “warming up” or preparing for a particular act or feeling state. People use “starters” to warm themselves up, such as mental images, anticipatory physical movements, or the external aspects of an unfamiliar role. Some starters enhance spontaneity, while others, including addictive substances, only appear to do so; instead, they have destructive effects and prevent the healthy development of “self-starters.” An example of the use of such dysfunctional starters is the way some people rely on food to coax themselves through anxiety-producing tasks or to produce desired emotional states. The therapeutic goal would be to help them develop alternative starters for achieving the same outcomes.

Another major component of Moreno’s thinking was his conception of roles. Moreno viewed people as natural role players. According to him, the self emerges from a constellation of roles, and the status of an individual’s role repertoire—for example, the variety of roles available and whether these roles are congruent with inner experience—is an important indication of psychological health. Roles are formed in an interpersonal context and develop differently depending on how they are reciprocated and influenced by the roles of others. Spontaneity is curtailed when people are locked in a rigid system of roles that won’t permit growth or change. Thus, for example, some bulimics become quite adept at role playing in the process of adapting their behavior to accommodate others. But beneath an outer expressiveness and flair for the dramatic, these-women are often cut off from their inner experience and they feel empty and confused.

 Learning new roles occurs in three stages: (1) “role- taking,” trying on the externals of a role; (2) “role playing,” gaining comfort and spontaneity in a role, and (3) “role creating,” changing a role: by infusing it with unique, personal elements. The power and effectiveness of psychodrama stems from the fact that roles can be assumed, at least initially, without being experienced as part of the self. In this way, role taking and role playing provide a kind of psychological protection that helps an individual explore unfamiliar, threatening, or otherwise unacceptable areas of concern.

Moreno believed that the goal of psychodrama is to achieve a “catharsis of integration” through action experiences in the here and now. This form of catharsis produces change not only through releasing pent-up anxieties and emotions, but also by bringing about new perceptions and, at least potentially, a reorganization of the self. In the words of Z. T. Moreno (1971), “The greatest depth of catharsis comes . . . from embodying those dimensions, roles, and interactions which life has not, cannot, and probably never will permit.”

In J. L. Moreno’s view, catharsis does not attain its full therapeutic impact unless it occurs in an interpersonal context. The importance of connectedness with others underlies the three-part structure of a traditional psychodrama session in which the enactment is sandwiched between the “warm-up” and “sharing” phases. During the initial warm-up, central themes emerge and the group develops the underpinnings of trust and mutual involvement needed to support the “action” phase. Following the action, in the sharing phase, the protagonist is reintegrated into the group as members speak in turn of their identification with the psychodrama. This phase may also be a time for “de-roling” (helping people relinquish particularly compelling roles), for giving feedback to the protagonist, for making interpretations, and/or for contracting for further work.

Along with producing catharsis, psychodrama may heighten the effects of more general curative factors in group psychotherapy. For example, participating together in the enactment of an individual’s drama can be an experience of considerable intimacy, especially when the therapist, role players, and group members are able to accurately sense and portray the protagonist’s inner world, follow her lead, and facilitate a spontaneous release of emotion. In this way, psychodrama can enhance the group’s function as a “self-object” by providing a special sort of mirroring, as Kohut (1977) described it.

Psychodrama can also be a means of highlighting and working through transferences occurring in the group process. For example, the choice of someone to play a significant role may reveal transferential feelings toward that person and may provide an opportunity to work through those feelings. Transferences and projections that emerge in the group’s overall interaction can also be dealt with psychodramatically. For instance, a particular member may dominate a number of sessions with one emotional crisis after another, drawing forth repeated attempts to help from some members while alienating others. Psychodrama techniques can be used to help the other group members discover the function this person is serving for them, both individually and as a group.

Psychodrama’s curative effects depend on how it is used. If the goal is behavioral learning or role training, action can be structured to emphasize the use of modeling, anxiety reduction, behavior rehearsal, feedback, and positive reinforcement. A client might enact a stressful situation known to trigger bingeing and purging and then try out alternative ways to cope with the situation. Alternately, if the goal is bringing into awareness and counteracting destructive internal objects, action can be structured to help the protagonist personify her inner voices, release repressed emotions, and affirm the weakened parts of her self. In bulimia, such self-destructive internal dynamics are often played out in the relationship with food, as in the emotional responses during an episode of bingeing and purging.

Detailed descriptions of the wide array of psychodrama techniques and action structures have been provided elsewhere (Blamer, 1973; Hale, 1981; J. L. Moreno, 1946; Z. T. Moreno, 1965). The following are five basic techniques that appear in the clinical examples. These are simplified definitions, as each technique has many nuances and variations.

The “soliloquy” is a monologue in which the protagonist expresses inner thoughts and feelings as if she is talking to herself, but out loud. This technique may be used to help the protagonist warm up to a situation or to help break through resistances and emotional blocking (see case 1 and 3 later in the chapter).

In “doubling,” a group member physically joins the protagonist and attempts to give voice to unexpressed feelings and thoughts as the drama proceeds. The protagonist is given the option of rejecting or accepting and incorporating any expression and action by the double. Doubling may be used to provide support, to elicit emotions, to stimulate thinking, or to offer a gentle sort of confrontation (see case 3 and 4).

In “role reversal,” the protagonist exchanges parts with the person with whom she is interacting in order to perceive the world—and, more importantly, to perceive herself—from the other’s point of view (see cases 1, 3, and 4).

In the “mirror” technique, another group member portrays the protagonist and duplicates as accurately as possible her actions in the previous enactment. This gives the protagonist an opportunity to observe her own verbal and nonverbal behavior and to consider how it affects others (see case 1).

In the “aside,” the action is stopped in midstream, and the protagonist is asked to express her feelings and thoughts at that moment. This technique may be used to stimulate insight and the awareness of emotions or to help break through unproductive patterns in the drama (see- case 3).

When I invite someone in my group for bulimics to act as the protagonist in a psychodrama, the response may be great enthusiasm or thinly veiled terror, but it is invariably intense. Reactions often stem from fears of being forced to reveal a vulnerable inner self that is felt to be unworthy or to express intense emotions that are experienced as unmanageable.

Psychodrama may seem like an improbable treatment of choice for the bulimic, who isolates herself from others, maintains a tight hold on her emotional life, and, above all, fears a loss of control. The idea of enacting in front of others a behavior that produces so much shame and self-doubt is almost unthinkable. Furthermore, people with so many negative feelings toward their bodies would be expected to resist something involving so much movement in proximity to others.

Nevertheless, I have found psychodrama techniques to be highly effective for many bulimic clients, in particular, helping people in their efforts to overcome blocks to emotional experience and to gain access to hidden parts of the self. This is facilitated by the use of multiple nonverbal and imaginal cues that engage participants on many levels simultaneously. Psychodrama also provides opportunities to experience, practice, and strengthen the healthier aspects of the self, and sharing such intense experiences with others can help counteract the isolation so characteristic of people with bulimia.

There are ways of adapting psychodrama techniques to the special needs of the bulimic. Some individuals in the group may only be able to work on their own issues indirectly by playing roles in other people’s dramas or by doubling other members. The therapist can make good use of the playfulness of some psychodrama techniques, as in the personification of favorite binge foods. For example, someone could take the role of “ice cream” and interact with various group members as a way of exploring the function ice cream serves for them. With respect to the bulimic’s sensitivity about her body, techniques may be altered so that they are less threatening. For example, bulimics can be given the option of sitting rather than standing in a particular exercise, or methods can be used that require only limited movement, such as speaking to an empty chair that represents a person or a part of the self.

Case Studies

The following clinical examples were selected to demonstrate the use of psychodrama to address four major areas in the treatment of bulimia: (1) eating behavior and the relationship to food; (2) body weight and body image; (3) intimacy issues; and (4) self-experience and self-structure. The examples consist of group exercises and reconstructions of psychodramas based on actual sessions.

Eating Behavior and the Relationship to Food

The Clock Exercise : Group members are asked to imagine the face of a clock with specific positions for 12, 3, 6, and 9 o’clock spread out on the floor of the room. They walk silently in a circle, mentally passing through the hours of the silently passing day, and then stop at a time when food typically becomes a problem for them. When everyone has stopped, each person is asked in turn to talk in the present tense about what she is doing, thinking, and feeling. This procedure is repeated several times. Finally, people are asked to focus instead on a time of day when they feel particularly strong emotionally and untroubled about food. Everyone then sits down and discusses the exercise.

The clock exercise can also have a more specific focus, for example, how group members feel about their bodies at different times of day. Along with talking at each stopping place, each person could assume a physical position to express her feeling. The clock exercise often produces material for further exploration during the same or later sessions.

Case 1: Laura’s Psychodrama

Laura was a 44-year-old woman, about 80 pounds overweight, who had been through a long series of weight-loss programs; however, she was unable to complete any of them. She was never able to stay slim for very long and attributed this difficulty to problems in her marriage and to feelings about her abusive, alcoholic father. She talked of her fear that if she lost weight she would have to face her husband’s lack of physical responsiveness and the overall emptiness in their marriage of 18 years. She also blamed her inability to lose weight on her father, who had called her “fat and ugly” throughout her childhood. He had often accused her of being just like his overweight mother, a mentally ill woman who had neglected and abused him. Laura was in reality a talented and appealing woman, but she suffered from deep feelings of shame, self-doubt, and loneliness. She felt best when she took part in performances at a community theatre, for which she had won some local acclaim.

At the time of her psychodrama, Laura had attended individual therapy for a year and a half and she had been in the group for 9 months. Her initial depression had subsided, and she had begun to deal with feelings about her family and about her past. She still felt isolated, however, and had not yet made any real changes in her use of food. She had participated in psychodramas focused on others and had herself worked as protagonist on career and family issues, but she had never before worked directly on her eating behavior. This session was a turning point for Laura, as she herself spoke of it later. Subsequently, she began attending OA and a women’s support group at her church. More significantly, soon after, on her own initiative, she began to experiment with changing her eating habits by eliminating sugar from her diet. She was able to sustain this for several months before a family crisis necessitated the interruption of therapy.

During the warm-up, Laura said she felt hopeless about her bingeing, a behavior that usually occurred late at night when her family had gone to sleep and she was finally alone. I suggested that she use this session to take a look at her experience of that vulnerable time and to try to come up with alternatives to bingeing. The action began with Laura using furniture and other objects to set up her living room and kitchen. As a warm-up to the situation, I asked her to imagine that it was a typical night and soliloquize about her day.

LAURA: My body feels tired, but my mind is still awake. I spent the whole day chauffeuring my daughter around and talking to people on the phone about the flea market for the church. Everybody wants me to do things. I should never have volunteered, even though it’s once a year. Now it’s nice and quiet, and I just want to forget about everything. I feel kind of antsy—I think I’ll see what’s in the refrigerator.

Laura continued to speak as she went through the motions of searching the refrigerator, sitting down in front of the television with her favorite binge foods, and eating. She performed this scene with less spontaneity than she had shown up to that point, and she seemed embarrassed. With the idea of helping Laura learn to anticipate and interrupt her compulsive behavior, I asked her to select someone to represent herself and replay the whole scene as a kind of mirror. Laura would observe in the role of a wise and compassionate counselor to herself. The woman she chose to portray herself played the scene of bingeing in front of the television very effectively. Using small boxes piled high in her lap to represent the food, she eagerly stuffed cookies, cupcakes, and chocolate into her mouth. I stopped the action and asked Laura as counselor to reflect out loud.

COUNSELOR/LAURA: That’s disgusting! You’re a fat, lazy pig. Is that all you can do with your time? No wonder you’re all by yourself!

Laura had not been able to warm up to the assigned role, scolding and abusing herself instead as she habitually did internally. As a way of providing more guidance, I aligned myself with the counselor and asked her to try to see through Laura’s outward behavior to the sensitive person inside and to help her find another way to deal with her feelings. The counselor/Laura then suggested that Laura take a walk in her flower garden, listen to the birds, and write in her journal.

Laura returned to her original role and followed this advice. As she took a walk in her garden, which she described in vivid detail, she spotted a family of birds. She chose someone to play the mother bird, then reversed roles with her and sent a message to Laura, the gist of which was as follows:

BIRD: I am part of nature and I am beautiful, and so are you!

Finally, Laura returned to her own role and listened to the bird repeat her words so that she could feel the full impact of her own message and, it is hoped, begin to internalize it.

Body Weight and Body Image

The Mirror Exercise: Group members stand facing an area of the wall that serves as their imaginary mirror. They are given the option of closing their eyes and are asked to visualize themselves in the mirror. One by one, they describe what they “see” and then address their image. Responses are typically negative descriptions and distortions of their bodies, followed by harsh criticisms and demands for change. Each person then takes one step back and speaks from the role of someone significant in her life who might say or think similar negative things about her.

Following this, each person takes another step back and speaks from the role of someone significant in her life who appreciates and supports her struggle. Finally, everyone takes two steps forward and speaks again as herself to her image in the mirror. What is said this last time usually reflects what was said in the second, more supportive role. Everyone then sits down and talks about the experience.

One variation of this exercise is to ask people to reverse roles with their image after they speak from each assigned role and respond to what was said. This method requires that people face outward; a darkened room or private corner may help them feel less self-conscious.

Case 2: Bonnie’s Psychodrama

Bonnie was a 35-year-old woman, about 60 pounds overweight, who had a history of alternate bingeing and restricting, with wide fluctuations in her weight. Her periods of thinness had been achieved through extreme dieting and compulsive exercise. The last such period had occurred during the early years of her brief marriage to an up-and-coming, status-conscious businessman to whom her appearance was very important. After the first year of marriage, Bonnie began to suspect that her husband was having affairs during business trips, though he repeatedly denied her accusations. When the affairs started to become known around town, she initiated divorce proceedings. A bitter battle ensued over the division of property, and her husband used Bonnie’s occasional bouts of compulsive spending to claim that she had squandered their money. The day after the divorce became final, her husband married an 18-year-old model.

Bonnie spoke of feeling humiliated, but she showed little emotion aside from a disdainful tone of voice. She talked wistfully about having been thin and attractive but seemed ambivalent about losing weight. She had been divorced for 2 years but hadn’t dated at all, though several men had shown interest in her. Bonnie talked very little about her large family, but she did mention how afraid she and her siblings were of her minister father, who had been very strict and protective of the girls.

At the time of this session, Bonnie had been in group therapy for about 4 months; it was close to the end of the time-limited group. My hope was to help her move closer to resolving her ambivalence about changing her eating behavior by focusing on her weight and its defensive function. The psychodrama could also provide opportunities for her to express her accumulated anger.

I asked Bonnie to choose group members to represent her extra weight and to “physically surround herself with them. She chose six people and had them form a tight ring around her. I asked how she felt. She said, “Very comfortable,” and everyone laughed. When asked what or who was outside the circle, she said, “People, especially men who are interested in me, and some people in my family.” I asked her to choose someone to represent a hypothetical “interested” man. She took this role first while the person she had chosen stood in her place temporarily. As the man, Bonnie was quite seductive.

MAN: I’ve been watching you ever since you started working here, and I can’t take my eyes off you. Are you busy Saturday night? Or what about the weekend—why don’t we go down to the shore? My friend has a beach house, and he’s not using it.

Bonnie resumed the role of herself, and the person chosen to play the man repeated these words, adding to them in the spirit of the role. When asked how she was feeling, Bonnie said she felt safe where she was and did not even acknowledge what had just been said. As the man came closer and became more aggressive, she responded more directly: “Forget it! Leave me alone! Find someone else to take advantage of.”

I then asked Bonnie to think of a family member she would place outside the circle, and she chose her sister, who had been her running partner in her latest thin phase. She selected someone to play her sister, but began by portraying the role herself.

SISTER: Look at all that weight you’ve put on! Honey, just trust me. I’ll get you back on a diet, and you’ll be skinny in no time. We can run around the track like we used to. And look at your hair—you’ve really let it go. You’ve got to stop feeling sorry for yourself!

When Bonnie resumed the role of herself, I had the person playing her sister speak these words and at the same time try to pull her out of the “weight” circle. As Bonnie resisted and moved away from her sister, she asked the circle to come with her, at which the group laughed sympathetically.

This seemed like a good point to turn the focus of the drama to the function of the weight encircling Bonnie. I asked her to reverse roles with someone in the circle and tell “Bonnie” inside the circle what she, as the weight, was doing for her. The other members of the circle would follow her lead. At first Bonnie and the others told the inside “Bonnie” how they protected her from disappointment, from abusive relationships, from sexual exploitation, from her family’s high expectations, and from painful emotions in general. Bonnie then returned to the center of the circle and people repeated what had just been said. At this point one member of the circle began to speak of the positive things Bonnie was missing in life by hiding behind her weight.

CIRCLE MEMBER: We keep you from experiencing all of what it is to be alive. We keep you from knowing the joys of sexuality and a loving relationship. We keep you from letting people know all the good things you have to offer as a person. We keep you numb and preoccupied so that you don’t feel the ups and downs, the sorrows and joys that give meaning to life.
Bonnie was moved to tears and later referred to this message as having been very meaningful and encouraging.

As a form of closure, I asked Bonnie to do something with her circle of weight to signify where she stood at that moment. She pushed against the circle (people had locked arms) with some force but without enough to break through. I encouraged the members of the circle to let her easily push her way through, as it seemed important to leave Bonnie with a true sense of her remaining ambivalence.

Intimacy Issues

A Self-Presentation Exercise: In this exercise, group members think of a significant person in their life, past or present, who has had something to do with their relationship to food. One by one, each takes the role of that person and “visits” the group in that role. People are given two options: either they can stand outside the group, warm up to the role, and then enter as the visitor, or they can sit in a chair facing away from the group while preparing for the role and then turn their chair back when they are ready to begin. In the role of the visitor, each person is asked to tell the group about himself or herself and then to talk about the group member he or she is introducing (her actual self). During this time, the therapist may ask questions and may invite group members to do the same. The visitor is then thanked for coming and walks away (or turns the chair back around). The group member becomes herself again and is invited to talk about the experience, including feelings toward the person whose role she played.

This exercise can be altered to define the visiting person more specifically or to include more than one role. For example, each member could choose someone she believes has been part of her problem with food and then someone who has been helpful with respect to that problem.

Case 3: Donna’s Psychodrama

Donna was a 38-year-old low-weight bulimic and the unemployed mother of two teenage children. Her first marriage had ended in divorce after 3 years and she was now “happily” remarried. She had never developed job skills or pursued her career interests as she had married and become pregnant soon after high school and had been supported financially ever since.
Donna had been secretly bingeing and purging since high school, when she had been a beauty queen and quite popular. While suffering inwardly during that time, she had maintained a pleasing and confident manner, especially in social situations with her parents, who were active in politics and highly visible in the community.

Donna spent her days chauffeuring her children, following an intensive regimen of exercise, fixing up her house, cooking elaborate meals, and attending work-related social functions with her husband, a prominent lawyer. Her life felt empty to her and she had no close friends in her area. Donna had been in therapy intermittently for the previous 10 years, but she had been open about her bulimia only during the last 3. She had attended a number of groups for eating disorders but, by her own admission, she had dropped out too soon for them to be of any help to her.

At the time of her psychodrama, Donna had been attending group therapy for 6 months. At the beginning of this session, she expressed feelings of hopelessness about ever being able to stop bingeing and purging. Her husband’s attempts to be supportive left her feeling confused and frustrated. I invited her to explore her feelings toward her husband with the idea that these might somehow be connected to her bulimia.

Donna began by portraying a typical scenario preceding a bulimic episode. She had spent hours that day planning and cooking dinner. Now everyone had eaten, and she was in the kitchen cleaning up and picking at the leftover food on the plates. I asked her to soliloquize.

DONNA: Another boring day. I hate this life. Why do I even try to cook something special for him? He takes it for granted. He asks me how things are going with my “problem,” but does he really understand? Then again, at least he asks me; he really does make an effort. I shouldn’t be so critical. Why am I so worried about what he thinks of me? Why am I so insecure about his feelings toward me—like at those awful parties?

“Those awful parties” were cocktail parties connected with Donna’s husband’s work. I invited her to show us what happened at a typical party. She chose people to play the roles of her husband, his male colleagues, their wives, and some female colleagues. I also asked her to choose someone to be her double.

The scene began with her husband, played by Donna, talking confidently, while drinking, about his successes at work. He began flirting with one of the women, complimenting her and acting intensely interested in what she was saying. Donna then resumed her own role while the scene was replayed with a group member representing her husband. I stopped the action and asked her for an aside. Donna spoke of feeling older and less attractive than the other women. Her double was much more able than she to express anger about her husband’s flirtatious behavior, accusing him of needing to prove that he could still attract women. I asked Donna what it would be like to tell her husband how she felt, and she said she didn’t know how to do that without jeopardizing their relationship.

I then invited Donna to use the psychodrama as a chance to try talking with her husband in a new way. In the previous scene she had acted in a subservient manner toward her husband, so I had her place him standing on a chair looking down at her in the hope that such exaggeration would help stimulate the expression of her feelings. Donna was better able to express her anger toward her husband with him so obviously “above” her, and she did so with a chorus of other group members who had all been invited to double her.

DONNA: I hate your flirting! I don’t know why you need to do that. And I hate always being the one to compromise, to make things comfortable for you, to support your career. I have needs too, and I need to take the time to do some things for myself. I am thinking about going to OA meetings and I may not be at home as much at night. You’re going to have to understand. You ask me about my bulimia as if ‘you’re expecting a quick solution—like it’s just a matter of self-control and why do I keep doing it if I’m happy with you. Well, there’s a lot more involved in my problem, and maybe you don’t want to hear about it because you wonder if you have an addiction yourself.

Donna reversed roles with her husband, and the group member playing her husband repeated what she had said. She then returned to her own role and considered out loud how she had sounded and which things she might actually say to her husband. Donna was surprised to hear herself be so confident and expressed relief at having vented her feelings. She decided to talk to her husband about going to meetings and about her bulimia, though she was still unsure about showing her anger.

Donna reported some positive changes in her marriage that she related to this session. With more time, it might have been helpful to explore whether Donna’s difficulties with her husband harkened back to problems in earlier relationships; my suspicion was that unresolved issues with her parents, now emerging in her marriage, were somehow connected to her eating disorder.

Self-Experience and Self-Structure

A Self-Projection Exercise:  A chair is put in a central location and group members are asked to use their imagination and place in the chair the part of themselves that is afraid of change and doesn’t want to give up the bulimia. One by one, each person is given a chance to enact an inner dialogue with that part of herself, either alone or with the help of another group member. Each member begins by sitting in the empty chair and taking the role of the part of herself that she projected—assuming its body position, thoughts, and feelings—and then soliloquizing. Following that, the therapist guides each person in a series of role reversals between the part in the empty chair and the part of herself that emerges in the original chair. There is some advantage to performing the exercise in dyads, as this gives each person a chance to view and hear the different parts of herself.

This exercise can be used to highlight other inner conflicts as well, depending on how the initially projected part of the self is defined. For example, group members could be asked to begin with the part of themselves that is afraid of close relationships. Another variation is to have each person choose two group members to role play the two sides of the conflict so that she herself can stand back, observe her own struggle, and find a way to intervene.

Case 4: Individual Psychodrama with Fran

Fran was a 26-year-old single woman who had been bulimic for 11 years. She had also had periods of cocaine and alcohol abuse and some stealing to support her addictions. She was close to finishing her master’s degree in a helping profession but was not sure whether she wanted to work in that field.

Fran had always occupied a special position in her family. Even after her family knew she was bulimic, she continued to be held up to her sisters as the strong, successful, and thin one. In her early teens, she had served as confidante to her mother, who was depressed and very unhappy with her marriage. Fran had always desired a better relationship with her father, who was a workaholic, critical toward himself and others, and emotionally distant.

Fran’s family, though living far away, continued to be involved in her life through frequent phone calls, packages, and visits. Their style of closeness left little room for individuality, and, as a result, Fran had become an expert at assuming roles to accommodate others. She felt that her family and friends didn’t know the “real” Fran, and she herself was unsure of who she was or what she wanted.

Beneath her cheerful and confident exterior, Fran was quite fearful and periodically would be overcome by intense surges of emotion. She had a repetitive: history of self-destructive relationships with men, in which she would feel overpowered and demeaned and, at the same time extremely dependent. It was the turmoil of one such relationship, along with the worsening of her bulimia, that led her to seek treatment.

Fran’s psychodrama occurred after 5 months of individual therapy. She had begun to attend OA and to keep a journal, but she had yet to establish control over her bingeing and purging. I had introduced the possibility of using psychodrama techniques at the start of therapy, and we had used them in two previous sessions.

In this session Fran talked about how she walked around most of the time feeling like the devil was perched on her shoulder, watching and commenting upon her every move. She acknowledged that this figure probably represented a part of herself and, that sometimes she felt like two people. I invited her to explore this duality by acting it out. My hope was to strengthen her ability to counteract what seemed to be a highly rejecting and self-destructive inner voice. I asked Fran to stand behind her chair in the role of the devil and talk to “herself’ in the empty chair:

DEVIL: You never do anything right! Sit up straight! All you do is talk, talk, talk, and then you go home and eat, eat, eat. You’re disgusting! Serves you right if you gain weight—your stomach looks bigger already. No wonder you haven’t been exercising enough! You’re lazy, and I caught you cheating again with those reports. They’re skimpy, and you know you should be much more thorough. And that journal of yours—you should be embarrassed reading that to Dr. Callahan. You don’t even write in complete sentences!

Fran then sat in the chair and became the other part of herself, a part that sounded and acted like a lively and rebellious child. To help Fran make the transition, I suggested that she first move around in the role, at which point she got up and paced nervously back and forth. The words soon followed, encouraged by an occasional doubling statement from me.

FRAN: I can’t stand this anymore! I can’t live up to your standards. Leave me alone! I’m tired of everything I do and say being wrong—why can’t I just live my life? I don’t care anymore. I’m so tired of everything. Why shouldn’t I eat if I want to? [Fran was getting more and more agitated at this point.] I want some ice cream right now, and I hope you’re satisfied! I’m going to get two gallons and turn on the television and eat. I’m so mad! I don’t know what to do.

Fran reversed roles a few more times, alternating between herself and the devil. At this point, sensing that it would be acceptable to her, I joined in the role playing. I wanted to help Fran develop a more accepting and nurturing attitude toward herself. The belief that her own needs were legitimate would be a first step toward finding constructive ways to meet them. I took the role of the part of herself she had just played and gave her the task of trying to calm “me” down, to reassure me, to help me feel better about myself, and to help me consider the possibility of giving up bingeing and purging.

At first it was difficult for Fran to respond to the role I was playing with anything other than her accustomed self-criticism and punitiveness. I used my role to help her warm up to her assignment by asking for help in various ways and by responding warmly to her positive efforts. Fran eventually became quite confident and calming in this new role, and her remarks suggested the beginnings of a new perspective on herself.

FRAN/ NEW ROLE: You have a right to be angry—the way you never give yourself a break. You don’t have to be perfect! You’re doing the best you can, especially when you consider all those years you depended on bingeing and vomiting to deal with things. But it’s time to stop hurting yourself and to start using the resources you have. It’ll be hard but you can do it! Try to do what they’re telling you in OA—take 1 day, even 1 minute, at a time and call someone when you’re upset—maybe even find yourself a sponsor. You’re important! You’re worth it!
The action ended with me reversing roles with Fran and repeating what she had said so she could experience the effect of her words.

It was not long after this session that Fran became much more involved in OA and began to be “abstinent” for several days at a time—the first major step on her road to successful recovery. She often referred back to this psychodrama, in particular when she tried to understand what had precipitated a loss of abstinence.

DISCUSSION

These case studies present a somewhat idealized and oversimplified picture of psychodrama and its application. The sessions from which the examples were drawn evidenced a good match between the client’s readiness, the group’s receptivity, and the methodology. An effective psychodrama is often the culmination of a series of preparatory individual and/ or group sessions, and a number of sessions following the psychodrama may be needed to integrate its effects with the rest of the protagonist’s experience. Closure is particularly important with bulimics, who are prone to dissociation. The intense experience of an emotional psychodrama may be temporarily “forgotten.” But if the emotions generated by a psychodrama are not worked through sufficiently during the sharing phase, the resulting emotional tensions may be acted out subsequently in an episode of bingeing and purging.

The portion of the session following a psychodrama is important for other reasons as well. For example, transferences among the group members may be heightened by the enactment and, with the help of some discussion, brought to a new level of awareness. Psychodrama can also have a powerful impact on transference toward the therapist, especially as the therapist moves in and out of the active role required to direct the drama. The greater involvement of the therapist in psychodrama, relative to other therapies, may be jarring to some and reassuring to others—in any case, it can provide meaningful data for therapeutic work.

Psychodrama at its best requires more than the skillful use of techniques. Its effectiveness depends on the clinical sensitivity and maturity of the therapist, on the relationship between the therapist and client, and, in the case of group therapy, on the evolution of the group. Such factors can determine whether, for examples, a particular psychodrama is experienced by the protagonist as an invasion of privacy or as a freely chosen opportunity to share and explore private experiences. A sense of control is particularly important for bulimics who are beginning to risk the letting go of long-established defenses. The factors mentioned above can also determine whether the protagonist experiences the psychodrama as the product of the therapist and/or the group, or whether she feels it to be her own personal, creation. A sense of ownership Bs crucial for bulimics, who are experts at accommodating others at the cost of failing to develop a secure sense of self. In my experience directing bulimics, it is a good idea to check frequently with the protagonist concerning her experience of the psychodrama at that moment and to offer the protagonist as many choices as possible regarding the structure and progress of the action.

Psychodrama is not intended for everyone, and certain techniques should be used with discretion. Not all people, for example, have the capacity to tolerate the features of psychodrama that require a well-developed ability to separate fantasy from reality and to differentiate the self from others. For example, clients with a borderline personality organization may have difficulty distinguishing between a psychodrama experience and reality or maintaining a secure sense of themselves while taking on the role of others. It may be difficult for them to relinquish roles and role perceptions of others following an enactment. Techniques that involve rapidly switching roles, enacting parts of the self, or personifying objects can be confusing and frightening for more disturbed clients. Also, the emotional intensity of techniques such as doubling demands a tolerance for a certain degree of intimacy that some people find overwhelming.

A final note of caution: Psychodrama is a powerful method not only for the client but for the clinician and may heighten the effects of countertransference. For example, the therapist may become narcissistically identified with a particular psychodrama as a production, especially if the protagonist is accommodating and the therapist has unmet needs for creative expression, recognition, or control. Also, in working with bulimics, the therapist directing a psychodrama may experience the client’s own perfectionism and performance anxiety.

There are a number of applications of psychodrama other than those described here that are relevant to the treatment of bulimics. For example, psychodrama can be employed effectively in an inpatient setting, where the immediate availability of other staff and other groups may permit more intensive, confrontational psychodramas. Furthermore, psychodrama need not focus solely on the concerns of individuals but can also be used to examine and work through key moments in group development. For example, in a case of frequent absences by an ambivalent group member, other members might be asked in turn to reverse roles with her and then consider how they identify with her and what function she serves for the group. Such absences can stimulate fears of the group disintegrating, and the group might explore this in a dramatized future scenario or “future projection” (Z. T. Moreno, 1959). Another possibility is the use of sociodrama, which employs psychodrama techniques to examine issues more generally rather than focusing on the specific experiences of individuals. One sociodrama, for example, might explore- societal expectations concerning thinness and their ramifications for bulimics. Group members could take the roles of people, institutions, or other sources of expectations and direct messages to several people representing “all bulimics.” The group could then explore in action the effects of these messages and attempt to generate constructive ways of coping with them.

Empirical studies of the clinical effectiveness of psychodrama are limited (Kipper, 1978), and I am not aware of studies focusing specifically on the use of psychodrama with bulimics. Research is needed in particular to address the questions of which bulimic clients benefit most from psychodrama, when psychodrama is contraindicated, and which psychodrama techniques are effective at particular phases of treatment.

In summary, psychodrama techniques, in the hands of a skilled and clinically sensitive therapist, appear to have a great deal to offer the treatment of people with bulimia. Psychodrama works on many levels simultaneously and is able to accommodate diverse theoretical orientations. Thus, as shown in the case studies, psychodrama techniques can be directed toward the goals of both cognitive, behavioral and psychoanalytic approaches—a frequent combination in working with bulimics. Psychodrama, may be particularly useful in helping clients overcome blocks to emotional experience and in helping them work through internal conflicts that help sustain their eating disorders.

REFERENCES

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author.
Bischof, L. J. (1970). Interpreting personality theories New York: Harper & Row.
Blatner, A. (1973). Acting-in. New York: Springer.
Boskind-White, M., & White, W. C_ (1983). Bulimarexia: The binge/purge cycle. New- York: W. W. Norton.
Browning, W. N. (1985). Long-term dynamic group therapy with bulimic patients: A clinical discussion. In S. W. Emmett (Ed.), Theory and treatment of anorexia nervosa and bulimia (pp. 141-153). New York: BrunnerlMazel.
Buchanan, D. R. (1984). Psychodrama. In T. B. Karasu (Ed.), The psychosocial therapies, Part II of the psychiatric therapies (pp, 783-798). Washington, DC: American Psychiatric Association.
Emmett, S.W. (Ed.) (1985).Theatre? treatmmt of anorexia nervosa and bulimia. New York: Brunner/Mazel.
Garner, D. & Garfinkel, P. E. (Eds.). (1985). Handbook of and. bulimia. New York: Guilford Press.
Hale, A. E. (1981). Conducting- clinical sociometric explorations: A manual for and sociometrists. Roanoke, VA. Author.
Haskell, M. R. (1975).. Socioanalysis: Self-direction via-sociometry and           psychodrama.  Long Beach: sociometry and psychodrama CA: Role Training, Associates of California.
Kipper, D. A_ (1978). Trends in. the research on. the effectiveness of psychodrama: Retro-
spect and prospect. Group Psychotherapy Psychodrama and Sociometry, 31, 5 – 17.
Kipper, D. A. (1986). Psychotherapy through clinical role playing. New- York Brunner/Mazel. Kohut, H. (1977). The restoration or the self. New York: International Universities Press.
Moreno, J.L. (1946). Psychodrama (Vol. 1). New York: Beacon House.
Moreno, J. L. (1953). Who shall survive? New York: Beacon House.
Moreno, J. L..(1973). Theatre of spontaneity. New York- Beacon House.
Moreno, J. L., & Moreno, Z. T. (1959). Psychodrama (Vol. 2). New York: Beacon House. Moreno, J. L.’ Moreno, Z. T. (1969). Psychodrama (Vol. 3). New York: Beacon House.
Moreno, Z. T.  A survey of psychodramatic techniques. Group Psychotherapy, 12, 5–
Moreno, Z T. (1965). Psychodramatic rules, techniques and adjunctive methods. Group Psychotherapy, 18, 73-86
Z. T. (1971). Beyond Aristotle, Breuer and Freud: Moreno’s-contribution to the concept-.of catharsis. Group Psychotherapy and Psychodrama, 24, 34-43.
Neuman, P. A., & Halvorson, P. A.(1983). Anorexia nervosa and bulimia: A handbook for counselors and therapists. New York: Van NostrandReinhold.
Roy-Bryne, P., Lee-Benner, K., & Yager, J. (1984). Group therapy for bulimia: A year’s experience. International Journal of Eating Disorders, 3, 97-116.
Shisslak, C. M., Schnaps, L., & Swain, B. (1986). Interactional group therapy for anorexic and bulimic women. Psychotherapy, 23,’598-606
Starr, A. (1977). Rehearsal for living. Psychodrama. Chicago: Nelson Hall.
Stein, M. B., & Callahan, M. L. (1982). The use of psychodrama in individual psychotherapy. Journal of Group Psychotherapy, Psychodrama. and Sociometry, 35, 118-129.
White, W. C., & Boskind-White, M. (1984). Experiential-behavioral treatment program for
bulimarexic women. In R. C. Hawkins, W. G. Fremouw, & P. F. Clement (Eds.), The
binge-purge syndrome: Diagnosis, treatment, and research (pp. 77-103). New York: Springer.
Yablonsky, L. (1976). Psychodrama: Resolving emotional problems through role playing. New York: Basic Books.