A Review of Psychodrama and Group Process

In recent years, group work therapy has been expanded rapidly throughout the world in helping professionals. Psychodrama, as a form of group psychotherapy, has already shown the potential for bringing about positive change in participants for almost 80 years. However, while psychodrama is primarily a form of group psychotherapy, psychodrama practitioners and researchers have seldom recognized it as a group work. Hence, the connection between psychodrama and group process has rarely been addressed. This review examines the development of research in the connection between psychodrama and group process. An extensive literature search including books, reports, monographs and journal articles has been conducted. It is found that before the new century, psychodrama practitioners and researchers have largely ignored the group process. In addition, most research findings were not published in peer-review journals. Encouragingly, in the last ten years, most empirical studies of psychodrama have incorporated group process in their analysis or discussion. Moreover, most of these studies are reported in peer-reviewed journals. However, there is still a lack of research studies which examine the interaction of psychodrama and the group process. It is hoped that the results of this study will stimulate further research in this area and can increase the awareness among psychodrama practitioners, trainers, and researchers of the need to be equally cognizant of both psychodrama processes and group work.


Introduction
Psychodrama had been developed as a form of psychotherapy for almost 80 years (Blatner, 2007). Psychodrama has shown potential for bringing about positive change in participants and is considered as a valid and effective form of psychotherapy. Both psychodrama practices and researches have been expanded rapidly in the recent decades.
Currently, in recent years, group interventions have been expanded throughout the world in helping professionals (Nuttman-Shwartz and Kleinberg).
However, while most psychodrama practices are conducted in a group work context, psychodrama practitioners and researchers mainly concentrate on the psycho-therapeutic effects of the enactments of the individuals only. They seldom recognized it as a group work. Hence, the connection between psychodrama and group process have rarely been addressed.
This review examines the development of research in the connection between psychodrama and group process. An extensive literature search including books, reports, monographs and journal articles has been conducted.

Process of Classic Psychodrama suggested by Dayton
The Warm-up Phase Prior to this phase, it is necessary to ensure that an adequate level of group cohesion and safety has been achieved. It is the responsibility of the group therapist/psychodrama director to assist the group/individuals to become warmed up to each other and the group as a whole. In this context, warm-up means being mentally and/or emotionally and/or physically ready to carry out the work of the group. Where individual are concerned, it means they are ready to work on a personal issue.
There are three ways to select a protagonist: a group member may put themselves forward; a number of group members may put themselves forward simultaneously and the director will get the group to choose which one it wants to be the protagonist; or, the director will select a protagonist.
Frequently the issue arising in the protagonist is also a current hidden group theme/issue. This means, the drama will not only benefit the protagonist but will also benefit the group as a single entity.

The Action Phase
After the protagonist is warmed-up, the director will invite him or her to create a scene on the stage. A scene consists of a time, a place, people and objects. Audience members will be chosen by the protagonist to play all the elements in the scene.
The director will use role-reversal to deepen the protagonist's warm-up. Once all the auxiliaries have learned their roles, the director will chose an auxiliary to take the place of the protagonist on stage. The director will then withdraw the protagonist to a place where they can observe the whole scene and instruct the auxiliaries to take up their roles and play out the scene. This is called mirroring. It enables the protagonist to be an observer of their issue and the scene surrounding it. This technique can have a strong integrative cathartic effect.
Other techniques used to assist the protagonist to increase their warm-up are doubling and soliloquy. In doubling, an audience member is chosen to become the protagonist's alter ego and remain physically close to, and slightly behind, them. They mimic everything the protagonist says and does. The double can also say out loud all the thoughts that they believe the protagonist is repressing. In soliloquy, the director will suggest that the protagonist walk around the stage saying out loud any thoughts that come into their awareness. The physical action of walking can facilitate the expression of thoughts and emotions that can be repressed when being still.
When the director senses that the drama is completed, he or she will say so to the protagonist and, if they agree, the action phase is ended. It is not necessary for an issue to be resolved in a single drama. Many dramas may be required.

The Sharing Phase
After the stage is cleared, the director and protagonist remain on the stage sitting together facing the audience. This the first step towards returning to being a group. The director invites the other group members to share experiences from their lives that resonate with the drama. This self-disclosure helps bring the protagonist back from their drama, in another place at another time, to the present moment in the group (Dayton, 2005).

Group Psychotherapy
At a theoretical level, it is believed that in group therapy the major agent for change is the group itself. This is opposed to individual therapy where the therapist is seen as the major change agent (Bakali, Wilberg, Hagtvet, & Lorentzen, 2010).

Group processes
In group psychotherapy, group processes are classified as nonspecific factors as opposed to specific factors which are the active interventions of the therapist. When exploring group processes the question is whether group psychotherapy contains unique non-specific factors that make it more effective than individual therapy? If this is true, which factors make it so? (Hornsey, Dwyer & Tian, 2007) Hornsey, Dwyer, and Tian (2007) list 12 non-specific therapeutic factors involved in group process: "instillation of hope, altruism, cohesiveness, guidance, identification, interpersonal learning (input), interpersonal learning (output), self-understanding, universality, catharsis, collective recapitalization of the primary family, and existential factors" (p. 568). They point out that all of these factors are held in common with individual therapy except cohesiveness. They also state that there is little theoretical or empirical research into the factors that mediate the connection between group processes and therapeutic outcomes.
Group psychotherapy has suffered from a lack of a universally accepted theoretical framework in regard to group processes and outcome prediction. This has led to researchers having to make their own theories (Hornsey, Dwyer & Tian, 2007).

Group Development
Group development researchers assume that there is a common understanding about the meaning of the term group development. In reality, group development is poorly defined and can mean many things. For example, it can mean changes in group cohesiveness, the leader-member relationship, the goals of the members, or task orientation. There are nearly as many theories of group development as they are group development researchers. (Chang, Duck, & Bordia, 2006). Kipper and Hundal (2003) list four different approaches to defining group structure: (1) Rutan and Stone, in 1993, described the phases as the formation of the group, the reactive phase, the mature phase, and the determination phase; (2) Yalom, in 1995, described them as: the beginning, the advance group phase and the termination phase; (3) Corey and Corey, in 1997, described them as the initial stage, the transition stage, the working stage, and the ending stage; and, (4) system-centred group therapy, described by Agaraziann in 1997, which classified three phases characterised by authority, intimacy and dependency.
Group development research began in the late 1940s and continued strongly into the 1970s. Most research studied therapy, training and personal development groups. The theoretical models that were constructed saw the progress of a group's development as being linear. In the late 1980s, linear models were disputed following research on task-oriented groups, work groups and problem-solving groups. These groups showed evidence of non-linear development paths. This indicated that a linear model of group development were not universally applicable. Group researchers, therefore, need to consider which type of model applies to the type of group being studied (Chang, Duck, & Bordia, 2006). Marmarosh, Holtz, & Schottenbauer (2005) liken group cohesiveness to the therapeutic relationship, between the therapist and client, in individual psychotherapy. They also maintain that, in the literature, the concept of group cohesiveness is varied and more studies are needed to examine how it contributes to changes in group members.

Group Cohesiveness
International Journal of Social Work and Human Services Practice 107 Vol.1. No.2 December, 2013, pp. 105-114 This view is also supported by Burlingame, McClendon, & Alonso (2011). Marmarosh, Holtz, & Schottenbauer (2005) state that cohesiveness has not yet been consistently or clearly defined. They maintain that it is a multidimensional construct rather than one-dimensional. They also consider that most group factors are an element of cohesiveness.
Burlingame, McClendon, & Alonso (2011) described the complexity of group structures as follows: From the perspective of a group member, relationships are comprised of three structural components: member-member, member-group, and member-leader. From the perspective of the therapist, relationships include the same three components as well as two additional: leader-group and, in the case of a co-therapist, leader-leader. The complexity of these multilevel structural definitions coupled with the dynamic interplay among them has created an array of competing cohesion instruments and an absence of a consensual definition.
They see cohesion as having two basic dimensions. Namely, relationship quality and relationship structure.
Relationship quality consists of two factors. The first is acceptance and belonging. The second is work alliances and group climate. Work alliances can be between a member and the group and/or between individual members (Burlingame, McClendon, & Alonso, 2011).
The structure of cohesion involves relationship function and direction. Vertical cohesion occurs between members and the leader. The horizontal cohesion exists from member to member and from member to the group as a single entity. The function of cohesion involves willingness to cooperate in tasks, and the degree of emotional support felt (Burlingame, McClendon, & Alonso, 2011).
The structure and quality model of cohesion is an empirically-based definition of group relationships. It effectively addresses the "who", "what", and "how" of group relationships. In spite of this, the research findings linking cohesion to therapeutic outcome remain inconclusive. These correlational studies do not address the question of causality (Burlingame, McClendon, & Alonso, 2011). Fullagar & Egleston (2008) found that there was strong evidence that performance predicts cohesiveness rather than the opposite. Hornsey, Dwyer & Tian (2007) indicate that there is much disagreement about how to define and measure cohesiveness. They see it as a multidimensional group construct. Hornsey, Dwyer & Tian (2007) note that it is difficult to synthesise the group cohesiveness research literature because of the lack of agreement on how to define it.
The group research's fuzzy definitions of cohesiveness has led to a situation where any variable that correlates positively with outcome is deemed to be a measure of cohesiveness (Burlingame, McClendon, & Alonso, 2011). Hornsey, Dwyer & Tian (2007) state that clinical research is blurred about what creates cohesiveness, what are its outcomes, and what are its constituent parts. They imply that researchers have not been able to effectively define this construct. They propose alternative constructs that are unique to group psychotherapy and which, they believe, would be easier to define, namely "identification, homogeneity, interdependence". They also believe that these variables provide a way to establish causality.

Objective
This review examines the development of research in the connection between psychodrama and group process.

Method
In order to have the review as comprehensive as possible and gain a more complete understanding of the state of psychodrama research., this study includes secondary and as well as primary sources.
An extensive literature search including books, reports, monographs and journal articles has been conducted. Literature were searched through using keywords search from major academic databases, tracing of reference lists and citing articles in identified articles, and searching of common internet search engines.

Results
From our analysis of the literature, it is found that before the new century, psychodrama practitioners and researchers have largely ignored the group process. In addition, most research findings were not published in peer-review journals. Some of the comments of important authors are as follows: Nicholas (2008) comments that psychodrama practitioners and researchers have largely ignored the general field of group psychotherapy. She believes this attitude had its origins in the feud between the founder of psychodrama, J. L. Moreno, and the American Group Therapy Association in the 1950s. Treadwell & Kumar (2002), 10 years ago, lamented that the lack of sufficient scientifically rigorous psychodrama research published in peer-reviewed journals has contributed to its lack of visibility amongst contemporary psychotherapy modalities. Kipper and Hundal (2003) noted in their meta-analysis of the 34 English language, peer-reviewed quantitative psychodrama studies published from 1970 to 2002, that 66% were published prior to 1980. They concluded that, since most psychodrama clinical studies involve single sessions only, this must be the prime mode of treatment. This is in contrast to other forms of group psychotherapy which see the whole group developmental phase structure as being the treatment process. It is as if psychodrama researchers considered the contribution of group process to therapeutic outcomes to be negligible in comparison to that of the psychodrama enactment. They also noted the absence of any discussion of group structure, or the stages of group development, from peer-reviewed psychodrama research studies. They were not able to explain this phenomenon.
There are many case studies published in psychodrama association journals and monographs. These, however, do not have the scientific rigour required for publication in peer-reviewed journals. The majority of these studies were published prior to 1980.
Since then, developments in quantitative research methods have made it possible to achieve the required rigour. Authors of psychodrama case studies, since 1980, have rarely used these methods (Kipper & Hundal, 2003;McVea, 2004).
A search of English language, peer-reviewed journals revealed 25 psychodrama studies published in the past 10 years (see Table 1). Nine of these acknowledged the influence of group process in a psychodrama group in addition to the influence of classic psychodrama or psychodrama techniques. However, none of these studies explained what they meant by the term 'group process'. Two  Gatta et al., (2010), in their study assessing the use of psychodrama groups for the treatment of adolescents with psychiatric disorders, state that a study comparing the therapeutic effectiveness of psychodrama groups with other forms of group psychotherapy is needed in order to gauge the magnitude of the contribution of group process in psychodrama group outcomes.
Although the McVea, Gow, and Lowe (2011) study stated that "The Client Change Interview… [was] adapted for this study to include group impact items" these items were not mentioned in the results or the discussion. Also, in their discussion they state "Group cohesion is widely recognized as a core enabling factor in effective group work… and in this study strong group cohesion in the middle and latter life of the group contributed to the protagonists' readiness" yet no mention is made of how the strength of group cohesion was assessed or measured. They also failed to recommend further studies of the impact of group process in psychodrama groups.

Discussion
While psychodrama is primarily a form of group psychotherapy, it is found that before the new century, psychodrama practitioners and researchers have largely ignored the group process. In addition, most research findings were not published in peer-review journals. Nevertheless, in the last ten years, most empirical studies of psychodrama have incorporated group process in their analysis or discussion and most of these studies are reported in peer-reviewed journals.
One the other hand, this review has shown that there is still a lack of research studies which examine the interaction of psychodrama and the group process. This is a gap in psychodrama.
It is hoped that the results of this study will stimulate further research in this area. It may also increase awareness among psychodrama trainers, trainees and practitioners of the need to be equally cognizant of both group work and psychodrama processes.