I conducted six years
doctoral research into dramatherapy and psychodrama as psychotherapeutic
interventions with people who hear voices (auditory hallucinations)
being registered at the Manchester Metropolitan University. That
research, whilst building on the work of previous therapists and
researchers, was ground breaking because there had not been previous
focused research into what people who heard voices found helpful
or not helpful in dramatherapy and psychodrama.
The Research in brief:
The research was carried out between 1996 - 2002 in two adjacent
N.H.S. psychiatric services: over the years I gradually received
a total of 42 referrals. I saw all referrals individually: some
people chose not to follow through after the first meeting, others
were seen several times and either they or I decided not to proceed
for a variety of reasons. Just half of the 42 people referred, 21
people: 9 women (aged 24 - 44) and 12 men (aged 20 - 50), completed
an assessment of six sessions and chose to enter the study, taking
up offers of individual or group therapy. Six (4 women and 2 men)
were offered 44 sessions of individual therapy. Another woman was
offered 40 sessions of individual therapy. Three men who were waiting
for a group were given 17 sessions of individual therapy. (All individual
therapy was in weekly one hour sessions.) There were three groups
(20 weekly sessions of up to two hours duration) offered sequentially:
a men’s group and two mixed gender groups. Two men chose to
attend two groups (of these, one man dropped out of the second group)
and one woman chose to join a group after her individual therapy
had ended. The low drop out rate (one woman and three men) suggests
the long and careful assessment had built up a sufficient therapeutic
alliance to sustain the person through the therapy. The first group
suffered one drop out, the second group two drop outs, the third
none. Only one person left individual therapy (after 30 sessions).
Three people (two men and one woman) had experience of both individual
and group therapy. For this study I was not able to gather the opinions
of those who dropped out, except in one case: so the results of
the study are based on the opinions of 18 people.
Not counting assessment sessions the research comprised 349 possible
individual therapy sessions (of which 293 were actually attended)
and 60 group sessions (60 x 17 clients = 340 client sessions (of
which 237 were actually attended). This shows that people were more
likely to attend individual therapy (which suggests the therapeutic
alliance was stronger in individual therapy).
The following description of the characteristics of the participants
reveals the rich diversity of the study, including people of different
ages, ethnicity, sexuality and ability.
Age (at time of entry into the research)
range from 20 - 50: 6 in their 20s; 10 in their 30s; 4 in their
40s, one aged 50.
Ethnic Diversity: One African; one
S.E. Asian; one Asian; one half Jewish; one descendant of 2nd World
War Ukrainian immigrants; one half Spanish adopted at birth by British
couple: all of these had experienced the impact of racism; three
experienced the dislocation of being a refugees from violent political
upheaval: they had survived terrorism and genocide.
Disability: One wheelchair user.
Sexuality: one lesbian, one bisexual
man, the others heterosexual.
Schizophrenia: 7: five women, two men (2 survivors
of rape, 3 of sexual abuse, 1 of physical abuse.)
Paranoid schizophrenia: 7: five men, two women
(2 survivors of sexual abuse, 2 physical abuse.)
Depression: 3: two women, one man (1 survivor
of rape, 2 of physical abuse, 1 of sexual abuse)
Paranoid psychosis: 2: men (1 survivor of
physical abuse, 1 of bullying)
Drug induced psychosis: 2: one man, one woman
(both survivors of physical abuse)
Organic psychotic illness: 1 man (survivor
of physical abuse)
Personality disorder: 2 women (both survivors
of rape, 1 of sexual abuse)
‘Neurotic with voices’ (originally diagnosed schizophrenic
when 21): 1 man (bullied)
Several had more than one diagnosis. Two people did not have any
diagnosis of a mental illness: both were survivors
of abuse. Once diagnosed with a mental illness other elements of
a person’s experience, such as experiences of childhood physical
or sexual abuse, may not be attended to: however there is evidence
to suggest that hearing voices is a response to traumatic experiences
(Romme & Escher, 2000).
Experiences of trauma:
Survivor of sexual abuse as a child: 7 (women)
Survivor of rape as an adult: 4 (two women,
Survivor of physical abuse as a child: 7 (five
men, two women)
Survivor of bullying as a child/young person: 3
There were many other traumas: the death of
siblings, assaults, head injuries, near death experiences, witnessing
murder, other losses and the traumas of mental illness. There were
traumas in the parents’ and grandparents’ lives.
It is possible, even likely, that there were some traumas that
were not disclosed: in the case of two men I had some evidence that
they had been sexually abused: they did not disclose. Abuse may
be disguised in psychotic/dissociative experiences.
The results of my research are reported in my PhD thesis, a copy
of which is available on CDRom (£ 15.00: apply to firstname.lastname@example.org).
They are summarised in my book: Drama, Psychotherapy and Psychosis:
Dramatherapy and Psychodrama with People who Hear Voices published
by Brunner-Routledge. A brief summary of the main benefits of these
creative action methods, properly applied, is as follows:
THE BENEFITS OF DRAMATHERAPY AND PSYCHODRAMA
The emergence from isolation is therapeutic and leads to a reduction
of voices. Social skills can be learned and practised. People can
be encouraged to become more assertive, to voice feelings and opinions.
These activities lead to an improvement in a person’s relationship
with themselves and in their relationship with others.
Relief from tension:
Since stress exacerbates voices, the person can benefit from relieving
tension through relaxation, being able to express self, feelings,
frustrations/aggression. Being creative raises self-esteem, and
expands people’s role repertoires, freeing them from debilitating
constraints. Laughter resulting from having fun relaxes people.
Insight and integration:
Therapy can enable people to gain insight into the sources of voices
in earlier experiences. Working through these enables the person
to own their voices and previously split off feelings, and thus
achieve some resolution/integration of the intrapsychic difficulties
that were the origin of the voices. Creative activity facilitates
the integration of unconscious material, strengthens the ego, and
promotes personal development.
Rehearsing a future:
Recovery must be a possible future: the instillation of hope is
in itself therapeutic. But hope cannot just be given to people:
they must discover hope for the future through their own practical
efforts and experiences. Dramatherapy and psychodrama offer the
possibility of rehearsing situations and practising behaviours to
achieve competence and confidence.
Distance and empowerment:
Essential to safe and effective work are the therapeutic relationships
(with the therapist and other group members) and the degree of distance
the person needs at any one time so as not to be overwhelmed and
further disempowered. The method can empower through choices and
decisions being made by the people who hear voices. Their creative
expression of will and responsibility for what is co-created is
empowering. In dramatherapy and psychodrama people can experience
being in control or letting go of control.
Prevention of suicide and self-harm:
There is some evidence in my study that therapy reduces self-harm
and suicidal behaviour as a result of the opportunity to express
feelings and receive support. Therapeutic relationships hold people
back from the brink.
Overall the research results suggest that dramatherapy and psychodrama,
for the majority of participants, promoted intrapsychic and interpersonal
change. From what participants said it is possible to assert that
dramatherapy and psychodrama tended to reduce voices and their impact;
to change the voices so that those that remained were less aggressive
and threatening; to improve people’s coping ability, enabling
personal change and a change of attitude towards the voices in the
direction of people feeling more in control.