Running head: CBPGT MODEL
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Cognitive Behavioral Psychodrama Group Therapy
Thomas Treadwell Ed.D., T.E.P., CGP
Deborah Dartnell MA, MSOD
West Chester University of Pennsylvania
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Abstract
Cognitive Behavioral Psychodrama Group Therapy (CBPGT) is an effective model for
working with the clinical example by Shay (2017) for group therapy. The model incorporates
cognitive behavioral and psychodrama interventions, allowing group members to identify and
modify negative thinking, behavior, and interpersonal patterns while increasing engagement in
positive and success-based experiences (Treadwell, Dartnell, Travaglini, Staats & Devinney,
2016). The CBPGT environment creates a safe and supportive climate where clients can practice
new thinking and behaviors and share their concerns freely with group members (Treadwell,
Kumar, & Wright, 2004; Treadwell, Travaglini, Reisch,& Kumar, 2011). Students and clinical
populations respond well to this approach and, as a result, are able to develop an awareness of
their dysfunctional thought patterns and beliefs that play an important role in mood regulation.
One of the most important elements of CBPGT is that it is data driven. CBPGT adds a new
dimension to both the fields of cognitive behavior and group therapy and is built on a proven
efficacious model. The integration of these methods may be beneficial for clients who have not
responded to more traditional approaches.
Key words: cognitive psychodrama group therapy, group therapy, cognitive behavior
therapy and psychodrama techniques, group cohesion, automatic thought records,
cognitive triad
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Code 004
Introduction
Cognitive Behavioral Psychodrama Group Therapy (CBPGT) is an effective model for working
with clients depicted in the clinical group vignette. The model incorporates cognitive behavioral
and psychodrama interventions, allowing group members to identify and modify negative
thinking, behavior, and interpersonal patterns while increasing engagement in positive and
success-based experiences (Boury, Treadwell, & Kumar, 2001, Hamamci; 2002; 2006; Baim,
2007; Fisher, 2007; Wilson, 2009; Treadwell, Kumar, & Wright, 2004; Treadwell, Travaglini,
Reisch,& Kumar, 2011).
The CBT model is sometimes criticized for being overly structured and intellectually oriented
(Young & Klosko, 1994; 1996; Woolfolk, 2000). As a result, some group therapists today use an
approach based upon CBT or identify with a less structured approach called eclectic (Kellerman,
1992) that typically employs techniques that come from cognitive behavioral therapy and its
related research. CBT is a robust, proven, and very effective treatment approach for many
mental disorders, including the big ones like depression and anxiety. Beck reports “My
employment of enactive, emotive strategies was influenced, no doubt, by psychodrama and
Gestalt therapy” (A. Beck, 1991, p.196). Psychodrama is an eclectic tool to enhance the
cognitive and behavioral change.
Thimm and Antonsen (2014) point out that many cognitive behavioral therapy groups’ content
is manual driven. According to Free (2007), the groups tend to focus on content rather than
process with some leaders actively discouraging extensive discussion of emotional experiences,
instead focusing on the acquisition of technical skills. Since the early 2000’s, there have been
shifts in the group cognitive behavioral literature, commencing with Yalom and Leszcz’s (2005)
description of the eleven relevant therapeutic factors that groups offer and how each of these
can be fostered in the group environment to facilitate change. White and Freeman (2002)
reference the broad range of clinical populations being treated using group CBT methods and
assert that the two defining variables of cognitive behavioral group therapy are cohesiveness
and task focus. Subsequently, Bieling, McCabe, and Antony (2006), Wensel, Liese, Beck, and
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Friedman-Wheeler (2012) concentrated on integrating CBT strategies and the understanding
and enhancement of group process to aid in learning and grasping cognitive and behavioral
strategies. They concluded that the therapeutic alliance and interpersonal factors are critical
elements in cognitive behavioral group therapy. Burlingame, Strauss, and Joyce (2013) have
demonstrated there is sufficient data showing that group therapy is as efficient and/or effective
as individual therapy.
The CBPGT environment creates a safe and supportive climate where clients can practice new
thinking and behaviors and share their concerns freely with group members and provides
ample opportunities for behavioral rehearsal, behavioral experiments and in-vivo exposure to
situations that have been avoided (Treadwell, Kumar, & Wright, 2004). This concept is shared
by Bieling et al. (2006), Wensel et al. (2012), and Burlingame et al. (2013). This approach is
consistent with what Beck advises the ultimate aim of including behavioral tasks in cognitive
behavioral therapy to be: “to produce change in negative attitudes” (Beck, Rush, Shaw, &
Emery, 1979, p. 119). Furthermore, CBPGT affords the opportunity for catharsis (Yalom &
Leszcz, 2005) in contrast to the limited discussion of emotional experiences often found in
traditional CBT groups (Free, 2007).
In CBPGT groups, all members are initially assessed using various instruments to establish the
nature and severity of presenting issues and to uncover other relevant information. The first
one or two sessions are devoted to establishing group norms, explaining Cognitive Behavior
Therapy (CBT) and schemas, and describing the session format. The initial didactic sessions are
intended to explain the group format as a problem-solving approach for working through
various interpersonal, occupational, educational, psychological, and health-related conflicts.
The sessions include information about the nature of the structured activities so participants
have realistic expectations about how the group will run. Each group member signs informed
consent and audiovisual recording consent forms. The audiovisual recordings create an ongoing
record of group activities and serve as a source for feedback when needed.
Here’s how the model looks in the clinical example by Shay (2017). In session one, the director,
Dr. Newland, introduces the Beck Depression Inventory-II (BDI), Beck Anxiety Inventory (BAI),
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and Beck Hopelessness Scales (BHS) (A. Beck, 1988; Beck & Steer, 1993; Beck, Steer, & Brown,
1996), and explains the importance of completing each scale on a weekly basis. The
instruments are administered before the start of each session and are stored in personal
folders to serve as an ongoing gauge of participants’ progress within the group (Treadwell,
Kumar, & Wright, 2004).
In the second or third session, additional data on early maladaptive and dysfunctional
schemas/core beliefs are obtained when group members complete Young’s (Young, Klosko, &
Weishaar, 2003; Young & Klosko, 1994; Young, 1999) schema questionnaire. A list of the
definitions of dysfunctional schemas and core beliefs are given to participants during the initial
session (Treadwell, Kumar, & Wright, 2004).
Each group session in CBPGT is divided into three sections typically found in psychodramatic
interventions: warm-up; action; and sharing (Moreno, 1934). Many CBT techniques (J. Beck,
2011) are utilized in the warm-up, including: identifying upsetting situations, automatic
negative thoughts and triggered moods; writing balanced thoughts to counter negative
automatic thoughts; and recognizing distortions in thinking and imprecise interpretations of
difficult situations. The second portion, action, employs psychodramatic techniques such as
role-playing, role-reversal, and mirroring, which facilitate the examination of various conflicting
situations individuals experience within the group context. This enables group members to
better understand the nature of negative thoughts triggered by situations and their effects on
moods. The last stage, sharing, allows auxiliaries and group members to share their experiences
with the protagonist. At this stage, the director may provide additional guidance to the
protagonist regarding ways to begin resolving the actual situation in real life. Normally, the
protagonist will be asked to complete a homework assignment that will be reviewed at the next
session.
This case study presents a somewhat frenzied group with little cohesion. Utilizing a specific
format with clear expectations of behavior and outcome would promote a better sense of the
group and enable the sessions to be more fruitful. In this case study, Diane would emerge as
the protagonist and other members of the group serve as auxiliaries and the audience.
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The Cognitive Psychodrama Group Model
Warm-up
Diane would complete an Automatic Thought Record (ATR) (Greenberger& Padeskey, 1995) on
a white board during warm-up. Her situation is she took a man home the previous night and
put herself in a risky situation. She would identify her moods and, using the downward arrow
technique, the director would repeatedly ask her questions to evoke automatic thoughts. The
questions force the protagonist to think about what underlying thought or belief is causing
feelings to arise in this situation, eventually isolating her core belief or schema. Diane’s
schemas of insufficient self control and failure emerged as she completed her ATR. A portion of
Diane’s ATR follows:
SITUATION
MOODS
AUTOMATIC THOUGHTS
I took a guy home with
Angry 10
Why do I always do this?
me and he stole my
Scared 10
I should have been working on my
credit cards.
Ashamed 10
dissertation
I’m a screw up
I am always messing something up
I’m out of control
Hot Thoughts
I’m a failure
Action
The protagonist, Diane, selects a group member, Will, to be her double. The double
communicates thoughts and feelings the protagonist is having but cannot express. Since Diane
is rather agitated, she may have some difficulty getting into the psychodrama; in this case, the
soliloquy technique would be helpful. Diane can walk around the room, thinking aloud,
expressing her concerns, discomfort, and hopes, allowing her to relax, focus, and prepare for
the psychodrama. This is also useful in helping group members focus on the upcoming action
phase. The double, Will, walks with her, expressing thoughts he assumes she is thinking but not
expressing.
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As Diane talks, she begins to realize her impulsive side is constantly presenting problems in her
relationships, her academic progress, and her self-image. Dr. Newland, the director, suggests
that Diane talk with her impulsive side to determine how she can begin to manage it. Diane
chooses an auxiliary to play the role of her impulsive side. Diane and her chosen auxiliary have
a conversation, while group members observe. Her double, Will, is with her, expressing
thoughts that he imagines she is thinking but not expressing. Although she tries repeatedly to
manage the impulsive role, Diane is never successful. The director employs role reversal several
times to allow Diane to experience someone else trying to control her impulsive role, but she
continues to have difficulty managing it. The director then brings Ned in to mirror Diane’s role
and has Diane watch the interaction. This technique, called modeling, occurs when a group
member demonstrates to the protagonist how he or she would handle the situation.
Diane begins to understand but still cannot shut down the impulsive role. Dr. Newland suggests
that she may need to develop another role to manage the impulsive role and asks her to
identify the roles she currently plays in her life. Diane readily identifies “the student” role and,
more reluctantly, the “party girl”, the “procrastinator”, the “lonely girl”, and the “perfectionist”.
She admits that she inhabits the “party girl” to counteract the “lonely girl” and “perfectionist”
roles. Her double helps her to realize she feels unworthy of real relationships and is afraid of
failing in her academic work. As a result, Diane recognizes that she needs to have a
“confident/responsible” role to manage her fears that unleash the “party girl”. Thus, to
investigate Diane’s roles we place chairs in the middle of the room and have Diane sit in each
role, expressing what she thinks about each role. The double, Will, sits with her in each role,
expressing thoughts he imagines she is thinking but not expressing. The auxiliary playing the
“party girl” continues to challenge her. Diane then chooses Angela to play the
“confident/responsible” role. After seeing Angela model this role, along with the help of her
double, Diane begins to exercise some measure of control over the “party girl”. A final step in
the action phase is having Diane talk to an empty chair representing a man trying to pick her up
at a bar, a situation that represents a recurring challenge for her. Speaking from the
“confident/responsible” role, she is able to reject his advances and feel proud that she did.
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Doubling, modeling, and role-training are crucial in learning how to get unstuck from repeated
behavioral patterns. Many protagonists are anxious when learning a new role; therefore, it is
important to support them as they try it in the group session.
Sharing
Following the psychodrama enactment, group members share and discuss what occurred,
commenting on their experience playing a particular role or on how the situation affected
them. Diane took a huge risk exposing her inner struggles; hearing group members share
similar painful feelings and experiences lead to feelings of acceptance, support, and
understanding. Sharing is critical both for the protagonist and for each of the group members
as they reflect, share, and learn from each other. Sharing is a fundamental component in
enhancing group cohesion.
At this stage, assigning homework to the protagonist is essential, as it encourages the
continuation of work on the new role explored in the session. Role development needs
practice for habituation to take place and to move the protagonist to feel safe in her new role.
Alternative Behavior Plan (Homework)
It is the job of the director and the group members participating in the psychodrama to address
the protagonist’s core beliefs and schemas with a behavioral strategy that takes the form of
homework. Homework (J. Beck, 2011) is a key component of CBPGT because it encourages
members to practice learned strategies in their own environment.
In Diane’s case, it is crucial that she practice the new confident/responsible role. Diane, the
group, and the director collaboratively design situations where she can rehearse this new role
in her everyday life. For example, situations are designed to focus on developing a schedule to
complete a specific section of her dissertation and/or develop healthy relationships and avoid
risky ones. To promote Diane in her endeavor, the director asks members of the group to
volunteer to provide their support until the next session. Betty and Angela both volunteer to
check in with her throughout the week and to be available if she needs them. The protagonist
and the group members who have volunteered to check in typically exchange telephone
numbers and arrange to either text or call each other during the week (Wenzel et al., 2012;
Bieling et. al., 2006).
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Summary
Etiology and Treatment
A situational psychodrama was completed and presented as a vehicle for change. Utilizing
principles of CBT and psychodrama created a powerful and effective group process, enabling
participants to address problematic situations with the support of group members. Clients find
CBT helpful in becoming aware of their habitual dysfunctional thought patterns and belief
systems that play an important role in mood regulation; the action component of the
psychodrama allows them to actually see and feel the dysfunction. Schema-focused techniques
(Young & Klosko, 1994) present an opportunity for a deeper level of insight and merge well with
the psychodramatic framework. Schemas and core beliefs provide a window into the etiology of
the client’s presenting problem and form the basis for treatment planning. Case
conceptualization, which was not presented in Diane’s case, is applied as an ongoing
therapeutic tool. After three or four sessions, the group leader takes on a psychoeducational
role; explaining main ideas behind the technique and asks group members to complete the case
conceptualization form on an ongoing basis as the group progresses. Group members take
turns discussing their completed form with the group on an assigned day. Case
conceptualization may help group members reflect on their various rules, conditional
assumptions, beliefs, and means of coping (J. Beck, 2011). It is also a good way of introducing
the cognitive triad to group members who characterize their situations to reflect themes of
loss, emptiness, and failure. Typically, this characterization is distorted, making case
formulation useful in challenging the client’s view of self, the world, and the future (J. Beck,
2011). Presenting it in the group may serve as a warm up for action and provides structure for
the group, ensuring all members feel heard. The cognitive triad (Beck, 1967) is best conveyed
to group members using this visual representation:
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Thoughts
Behavior
Feelings
The cognitive triad readily reveals thoughts, emotions and behaviors at a glance and is useful
data for exploring the various struggles in the action format. The psychodramatic triad,
warmup, action, and sharing, with its emphasis on action, enables the protagonist to virtually
engage in a safe environment with the presenting issue.
Multi-cultural Considerations
In our experience, multi-cultural issues can be addressed in the CBPGT model utilizing
techniques of role interview and surplus reality to present another’s point of view. Additionally,
during the warm-up, the protagonist, Diane, had the opportunity to expand on what was
important in her culture. The genogram (McGoldrick, & Gerson, 2008,) although it was not
presented in this case, is often created during the warm up stage and is useful in capturing a
picture of family and cultural relationships. The genogram, combined with the Automatic
Thought Record, allows the group to become educated and gain insight into the protagonist’s
values and beliefs. The psychodrama takes place within the cultural context the protagonist
defines. For example, when acting out the scene, Diane had control over who she chose as
auxiliaries and provided, through role interview and role reversal, insights into her reality. The
protagonist can continue providing direction to the auxiliaries as the psychodrama unfolds. This
ensured that the psychodrama accurately depicted her environment and cultural realities
(Nien-Hwa & Hsin-Hao, 2014; Remer & Remer, 2003).
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Research Support
Cognitive Behavioral Therapy (CBT) is an evidence based therapy which has been used
extensively in the treatment of depression, anxiety, and personality disorders. With the
increasing popularity of CBT techniques, especially those developed by Beck and his colleagues
(A. Beck, 1995; Beck, Rush, Shaw, & Emery, 1979), the treatment has been applied to a wide
range of disorders from anxiety and depression to schizophrenia in both individual
psychotherapy and group therapy settings. There is an increasing interest in applying
techniques unique to the cognitive behavioral model to group modalities (Bieling, et al., 2006;
Wenzel, et al., 2012). Psychodrama has been explored as a means of personal development and
as a therapeutic tool in group settings since the early 20th century and Moreno was credited
with first practicing group therapy (Yalom & Leszcz, 2005). Although traditional psychodrama is
conceptualized in terms of three main techniques—warm up, action and sharing—there is no
dearth of techniques that may be applied in those three phases (Treadwell, Kumar and Wright,
2004). The versatility of psychodrama stems from the variety of techniques that have been
borrowed or adapted from various individual and group psychotherapy modalities (Wilson,
2009; Hamamci, 2002; 2006; Baim, 2007).
Drawbacks
Clients with severe social anxiety may initially find CBPGT too demanding and may opt to seek
individual therapy prior to joining a group. Anecdotal evidence supported by our clinical
experience indicates that while their experience may be trying, they will likely benefit from the
group interaction and support and will, ultimately, choose to participate as a protagonist.
It is important that the director be cognizant of participants’ BDI, BAI, and BHS scores to ensure
a client is ready to act as the protagonist. Additionally, the director must be prepared to
address any spin off dramas that occur as a result of the protagonist’s psychodrama. There is
limited empirical support for the combination of cognitive behavioral and psychodramatic
group therapy. Nonetheless, there are a studies, (Hamamci, 2002; 2006; Baim, 2007; Fisher,
2007; Avinger & Jones, 2007; Wilson, 2009) focused on the similarities, both philosophical and
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methodological, between cognitive therapy and psychodrama and make a case for their mutual
enrichment. Although psychodrama has not been empirically studied; practitioners, in the
spirit of Freud and Moreno, have relied on clinical experience rather than experimental data. In
addition, psychodrama is rarely approached with “that combination of hopeful curiosity and
scientific skepticism that has served to develop social casework and psychotherapy to their
present stages” (Polansky & Harkins, 1969, p.74). The purpose of the CBPGT model is wedding
psychodrama, an eclectic tool, with CBT, a proven effective and efficacious model.
The following exclusions are recommended for a CBT/Psychodramatic approach:
(a) Individuals with self-centered and aggressive disorders display strong resistance to
group work (Gupta, 2005; Treadwell, Kumar & Wright 2004). They tend to lack spontaneity and
are rigid in their portrayals of significant others; that is, they either insulate or attempt to
dominate others in the group;
(b) Individuals with narcissistic, obsessive compulsive (severe), and antisocial personality
disorders for whom individual therapy is more suitable; and
(c) Individuals with cluster A personality disorders and impulse control disorders have
difficulty functioning in a group (Gupta, 2005; Treadwell, Kumar & Wright, 2004).
Conclusions
CBT and action techniques can be used effectively within the context of psychodrama.
From our experience, students and clinical populations respond well to this approach and, as a
result, are able to develop an awareness of their dysfunctional thought patterns and beliefs
that play an important role in mood regulation. Other CBT techniques, not discussed in this
chapter, such as coping cards and the advantages/disadvantages matrix, are easily integrated
into CBPGT during role play or as homework. Although some resistance from group members
can be expected, particularly around ATR’s being completed on time or disclosed in the group,
this diminishes as trust and cohesion grow (Yalom & Leszcz, 2005). As group members
recognize the usefulness of the structured CBT and action techniques, intimacy and spontaneity
tend to increase, creating and supporting a safe space for sharing.
One of the most important elements of CBPGT is that it is data based (Beck, J. 2011;
Treadwell, Travaglini, Reisch, & Kumar, 2011). Group members keep track of their dysfunctional
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thoughts and depression, anxiety, and hopelessness scores from week to week. They can easily
see changes resulting from group therapy that make the therapeutic process a worthwhile one.
The use of CBT techniques allied with psychodrama provides a balance between an exploration
of emotionally laden situations and a more concrete, data-based, problem solving process.
CBPGT adds a new dimension to both the fields of cognitive behavior and group therapy and is
built on a proven efficacious model. The integration of these methods may be beneficial for
clients who have not responded to more traditional approaches.
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