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THE HEALING EXPERIENCES OF WOMEN:

PSYCHODRAMA AND EATING DISORDERS


by
Nancy Bailey

CHRISTOPHER LUCIES, EdD., Faculty Mentor and Chair


MEE-GAIK LIM, PhD, Committee Member
CRYSTAL NEAL, PhD, Committee Member

David Chapman, PsyD, Dean, Harold Abel School of Social and Behavioral Sciences

A Dissertation Presented in Partial Fulfillment


Of the Requirements for the Degree
Doctor of Philosophy

Capella University
August 2012

UMI Number: 3539139

All rights reserved


INFORMATION TO ALL USERS
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In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.

UMI 3539139
Copyright 2012 by ProQuest LLC.
All rights reserved. This edition of the work is protected against
unauthorized copying under Title 17, United States Code.

ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346

UMI Number: 3539139

All rights reserved


INFORMATION TO ALL USERS
The quality of this reproduction is dependent on the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.

UMI 3539139
Copyright 2012 by ProQuest LLC.
All rights reserved. This edition of the work is protected against
unauthorized copying under Title 17, United States Code.

ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346

Nancy Bailey, 2012

Abstract
This generic qualitative research study articulates the experiences of women who were
diagnosed, and in recovery from an eating disorder and received psychodrama therapy as
a component of their eating disorder treatment. Psychodrama is a therapeutic intervention
and theory developed by Jacob Moreno, created out of the existential theoretical age.
Although there is documented research to support the use of psychodrama therapy with
women who are diagnosed with substance dependence and trauma, there has been little
research to support the use of psychodrama therapy as a therapeutic intervention for
women diagnosed with eating disorders. To investigate this issue, 10 female participants,
ages 18-65 years old, diagnosed with anorexia nervosa, bulimia nervosa, or eating
disorder not otherwise specified who participated in psychodrama therapy as part of their
eating disorder treatment experience were interviewed. The findings of this study
demonstrated that the participants described positive experiences with psychodrama as a
treatment modality for the diagnosed eating disorder proving them with a significant
internal shift and accelerated recovery from their illness. The participants also identified a
significant theme connected to the facilitation of psychodrama related to this particular
population. Results from this research add to the current level of professional literature,
as well as leads to suggest improved treatment modalities for the adult female eating
disorder population.

Dedication
This research paper is dedicated to the many women struggling with
eating disorders and the professionals assisting in their treatment and healing.
This paper is also dedicated to my parents who provided a foundation in the
importance of education, especially my father who always told me I could do
whatever I put my mind to.

iii

Acknowledgments
First and foremost I would like to thank my Higher Power for steadfast guidance
and nurturing.
I would like to thank my mentor, Dr. Christopher Lucies, whose knowledge,
support, and encouragement kept me forging ahead on this extraordinarily difficult, but
rewarding path. Thank you for all of your patience and persistence.
I would like to thank my committee members Dr. Mee Gaik-Lim and Dr. Crystal
Neal for their hard work and support.
I would like to thank my husband and children for their love, support, and belief
in me throughout this process. Without their understanding of the need for focus and
writing time/space, I would not have been able to complete this journey. Also to my fourlegged fur family for their unconditional love.
Thank-you to my gang of cheerleaders friends, family, co-workers,
colleagues, and professionals who kept my feet to the fire, dried my tears, kicked my
butt, listened, read and re-read, all along the way. What a ride thanks for hanging in
there with me!
Finally, I would like to thank all of the women who agreed to be interviewed and
became vulnerable in my presence for the purpose of research. I was honored and
privileged to share in their experiences of recovery. Thank-you.

iv

Table of Contents
Acknowledgements

iv

List of Tables

ix

CHAPTER 1: INTRODUCTION
Introduction to the Problem

Background of the Problem

Statement of the Problem

Purpose of the Study

Rationale

Research Questions

Significance of the Study

Definition of Terms

Assumptions and Limitations

11

Theoretical/Conceptual Framework

12

Organization of the Remainder of the Study

13

CHAPTER 2: LITERATURE REVIEW


Introduction to the Literature Review

14

Theoretical Framework

15

History and Development of Psychodrama

15

The Process of Psychodrama

17

Psychodrama, Trauma, and Addiction

19

Psychodrama Used with Addictions and Trauma

21

Historical Treatment Usages of Psychodrama

23

Contemporary Psychodrama

25

Psychodrama Therapy with Eating Disorders

26

Diagnostic Classifications and Criteria for Eating Disorders

28

Dynamics and Causative Factors for Eating Disorders

30

Research in Other Fields of Study Related to Eating Disorders

32

Group Practice in Therapy

33

Crucial Theoretical/Conceptual Debates

37

Bridging the Gaps or Resolving the Controversies

39

Review of the Critical Literature

39

Morenos Impact

39

Cognitive Behavioral Therapy and Dialectical Behavioral Therapy

40

Art Therapy with Eating Disorder Patients

43

Movement Therapy with Eating Disorder Patients

44

Summary

45

Evaluation of Viable Research Designs

45

Chapter Two Summary

47

CHAPTER 3: METHODOLOGY
Introduction

48

Research Questions

48

Research Philosophy

49

Research Design

50

Sampling Procedures

51

Recruitment Strategies

52

vi

Data Collection Procedures

52

Results of Field Testing Interview Guide

54

Data Analysis Procedures

55

Limitations of Research Design

56

Qualitative Validity and Reliability

57

Expected Findings

58

Ethical Issues in the Proposed Study

58

Conclusion

60

CHAPTER 4: DATA COLLECTION AND ANALYSIS


Introduction

61

Central Research Questions

61

Data Analysis Procedures

61

Participant Profiles

62

Findings

66

Fear of Connection

70

The Need for Safety in Therapy

79

Summary of Findings

84

CHAPTER 5: RESULTS, CONCLUSIONS, AND RECOMMENDATIONS


Introduction

87

Summary of the Results

87

Discussion of the Results

90

Discussion of the Conclusions

95

Limitations

98

vii

Recommendations for Future Research or Interventions

98

Conclusion

99

REFERENCES

101

APPENDIX A INFORMATIONAL RESEARCH PACKET PARTICIPANT


ASSESSMENT AND DEMOGRAPHIC FORM

120

APPENDIX B: PARTICIPANT INTERVIEW GUIDE REVISED

122

viii

List of Tables
Table 1 Participant Demographics

65

Table 2 Experience of Participants

67

ix

CHAPTER 1: INTRODUCTION
Introduction to the Problem
Psychodrama has been considered on the fringe of therapy with little research to
support its use, especially with persons diagnosed with eating disorders (Cassin, von
Ranson, Heng, Brar, & Wojtowicz, 2008; Treadwell & Kumar, 2002). Patients who
obtain treatment for eating disorders are usually engaged with their treatment providers
by using Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy
(DBT); (Binford et al., 2005; Treadwell & Kumar, 2002; Wilks, 2006; Yager, 2008).
Psychodrama, by nature, is spontaneous and less directive than CBT and DBT,
emphasizing the here and now role-playing in therapy that is recommended for patients
who struggle with experiencing their feelings, such as those diagnosed with eating
disorders (Kipper & Matsumoto, 2002; Wilson, Grilo & Vitousek, 2007).
The patients desire to be emotionally disconnected, utilizing their eating disorder
as a method of control, distracts the patient from feelings allowing the patient to focus on
cognition or thoughts (Claes, Witteman & van den Bercken, 2009; Kipper & Matsumoto,
2002). Binfor et al. (2005) suggest that individuals diagnosed with bulimia nervosa
should have adjunct therapies combined with CBT for relapse prevention and long term
recovery. Utilizing psychodrama therapy in the treatment of women diagnosed with
eating disorders may be a positive adjunct providing longer-term recovery because of
psychodramas ability to integrate the cognitive, behavioral, and emotional components
of healing (Dayton, 2007; Fisher, 2007; Hagedorn & Hirshhorn, 2009; Yager, 2008).

Background of the Problem


The field of eating disorder treatment is young, and after an exhaustive review of
the literature, there is limited research on the topic of psychodrama therapy used in the
specific treatment of eating disorders. Wilson, Grilo, and Vitousek (2007) discuss some
progress in the psychological treatment of eating disorders over the past twenty years
especially in the areas of family therapy and cognitive therapy, but point out a need for
identification and application of treatment approaches beyond the current methods. The
National Institue of Mental Health, Chavez and Insel (2007) in this study, also identify
the need for research in both adolescent and adult populations affected with eating
disorders. The modality most commonly used to treat this population is Cognitive
Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT); (Wilks, 2006).
Alternatives to the CBT and DBT methods are psychodrama and experiential
interventions to aid in emotional regulation.
A central part of DBT is learning to regulate emotions (Linehan, 1993).
Emotional regulation methods of therapy should be offered to this population who are
very cognitively oriented because of the patients lack of desire to be emotionally
connected contributing to their relapse rates (Binford et al., 2005; Greenberg, 2008;
Kipper & Matsumoto, 2002;). Research has produced correlation with those diagnosed
with eating disorders having difficulty experiencing, expressing, and describing
emotional responses, known as alexithymia (Blodgett et al., 2007; Piran & Cormier,
2005; Zonnevylle-Bender, van Goozen, Cohen-Kettenis, van Elburg, & van Engeland,
2002).
2

Emotional regulation or lack of feeling is a common problem of women


diagnosed with eating disorders (Cockell, Geller, & Linden, 2003; Piran & Cormier,
2005). Restricting, binge eating, and purging offer a way for those diagnosed with the
disorder to negatively cope with painful emotions and societal pressures (Blodgett et al.,
2007; Cassin, von Ranson, Heng, Brar, & Wojtowicz, 2008; Johnson, 1995; Sassaroli &
Ruggiero, 2005). These eating disorder coping mechanisms are also methods used as an
attempt to self-soothe emotions that are overwhelming (Dayton, 2007). Dayton (2000)
posits, in work with women being treated for substance abuse, that because women are
considered to be more relationship oriented, trauma elicited from emotional pain or loss
in relationships trigger the use of self-medication. Action-oriented methods of treatment,
such as psychodrama, are thought to be better suited for women because of their tendency
to be relationship focused; therefore, reconnecting the patients to the emotional pain of
the issues rendering healing (Dayton, 2000; Johnson, 1995; VanBoven & Espelange,
2006; Uhler & Parker, 2002). However, limited studies (Baratka, 1994; Hornyak &
Baker, 1989; Hudgins, 2002; Scott, 2000, & Widlake, 1997) have been written to support
this connection related specifically to the treatment of women diagnosed with eating
disorders. Moving from intellect or thought focused therapy to emotional and experiential
focused therapy offers a more holistic approach to treatment of eating disorders (Wilkes,
2006).
Utilizing psychodrama therapy methods to promote emotional interventions could
facilitate more successful recovery in women diagnosed with eating disorders (Uhler &
Parker, 2002). Psychodrama therapy modalities used in an eating disorder focus generally
3

have little research to draw from as indicated by an exhaustive literature review;


therefore, this study will add to the research literature. Additionally, the study provides
research to add to the theory related to how clinicians provide treatment for this specific
population.
Statement of the Problem
The purpose of this generic qualitative research study is to articulate the
experiences of women who previously engaged in psychodrama therapy as a component
of eating disorder treatment by interviewing women utilizing in-depth, face-to-face
interviews. This research study will add knowledge to the fields of psychodrama therapy
and eating disorder treatment and elicit questions for further research. The research
problem is that there is a gap in the literature and practice documentation resulting in
insufficient knowledge regarding the use of psychodrama therapy treatment particularly
with women diagnosed with eating disorders. This study adds research knowledge to
increase treatment options for the women diagnosed with eating disorders.
Purpose of the Study
The purpose of this generic qualitative research study is to articulate the
experiences of women who engage in psychodrama therapy as a component of their
eating disorder mental health treatment. The adult female participants, obtained through
snowball sampling, were interviewed using open-ended questions. This research study
adds to the gap in the literature of psychodrama therapy and eating disorder treatment.
The study also provides support for the use of psychodrama therapy as a primary
treatment modality rather than an adjunct. The study promotes clinical recommendations
4

for therapists who work with this population of patients by articulating positive use of
this modality with eating disorder patients.
Rationale
In the past twenty-five years, advances have been made in the treatment of eating
disorders, however evidence-based psychological therapies, such as DBT and CBT, are
the treatment of choice for bulimia nervosa and binge-eating disorder in adults (Wilson.
Grilo, & Vitousek, 2007; Yager, 2008). Fewer advances have been made in the treatment
of anorexia nervosa in adults and adolescents, as well as those diagnosed as EDNOS
(Chavez & Insel, 2007; Wilson, Grilo, & Vitousek, 2007). Increased attention to
documented studies of alternative treatment methods is needed to support their use in the
treatment of this population. Efficacy claims of non-evidence based treatment
methodologies are anecdotal and therefore do not receive their due acknowledgement in
the field (Pignotti & Thyer, 2009).
The rationale for this study was to acquire data from women diagnosed with eating
disorders about their experience participating in psychodrama therapy during the course
of their inpatient treatment experience. Psychodrama therapy has limited
empirical research specific to the eating disorder diagnoses as evidenced by an exhaustive
review of the literature. This study adds to the empirical literature, encourages more
specific study in this area, and augments current treatment intervention strategies.
Integrating psychodrama as a primary therapeutic intervention rather than an adjunct or
non-intervention may provide better treatment outcomes for women diagnosed with
eating disorders.
5

Research Questions
1. What are the treatment experiences of women who previously engaged in
psychodrama therapy as a component of eating disorder treatment?
2. Based upon the participants experiences about the use of psychodrama as a
therapeutic intervention for their illness, how can these experiences enhance
clinicians overall treatment of eating disorders?
Significance of the Study
CBT and DBT have become associated as the interventions of choice for eating
disorder treatment (Wilks, 2006). Cognitive behavioral therapy focuses on the intellectual
and educational aspects of treatment. One concern regarding CBT is that CBT does not
make the deeper emotional and neurobiological connection that psychodrama and other
experiential forms of therapy can do such as art therapy, movement and dance therapy,
and music therapy (Beck, 2008; van der Kolk, 2002). Psychodrama is focused on actionoriented modalities and allows the clients to move from intellect to feelings based
therapeutic intervention accessing and reprogramming the brain neurobiology (Dayton,
2005b).
Documented research on psychodrama techniques and methods is available with a
primary focus on trauma and chemical addictions mainly occurring in the mid 1980s
through the early 2000s. Current research is necessary to improve awareness and
acceptance of Morenos theory in the scientific and psychological fields. Long-standing
practice by respected clinicians and wide spread clinical practicum of the psychodramatic
methods is important to aid in psychodramas acceptance in the scientific community
6

(Lewis & Johnson, 2005). Practitioners in the psychodrama field do not often document,
write, and publish on the outcomes of their patients; therefore, leaving the empirical data
lacking in the field (Blatner, 2007). Recommendations for ongoing research in the area of
psychodrama include: to develop studies that focus on issues of technique to specific
populations and to diminish the subjectivity in research (Kipper & Ritchie, 2003).
Because there is little research in the field of eating disorders connected to psychodrama,
there is a need for ongoing research in this area of specific population, which this study
intends to examine.
Definition of Terms.
Action. The second phase of the psychodrama process when the director stages
the enactment for the protagonist to portray their problem or issue (Dayton, 1994).
Alexithymia. Difficulty experiencing, expressing, and describing emotion (Beales
& Dolton, 2000).
ATLAS.ti. A computer software tools used in qualitative research for data
management (Miller, 2000).
Auxiliary. Auxiliary (sometimes referred to as Auxiliary Ego) is a participant
represented in the drama to represent the people in the protagonists life or other aspects
of the protagonists inner world as accurately as possible, using information shared by the
protagonist as well as her own experience of that thinking, feeling, and behavior appear
to be a part of the role (Dayton, 2005b, p. 15).

Axial coding. For the purpose of this research, axial coding will be defined as the
second phase of coding that looks for new ideas or codes which will help the researcher
move towards key concepts and help organize ideas and themes (Neuman, 2006).
Categories. Concepts that allow the categorization and clarification of data (Berg,
2007).
Coding. An analytical approach used in qualitative research to detect major
themes that assist with building theory used in grounded theory (Leedy & Ormrod, 2005).
Constant Comparative Method. For the purposes of this study, constant
comparative method will refer to the analytic approach to data (Patton, 2002). The data
will be analyzed to allow the theories to emerge from the interviews and by comparing
the data obtained from one participant with the data obtained from another participant
(Patton, 2002).
Dimensions. For the purposes of this study, dimensions will refer to distinctions in
analysis (Creswell, 2003).
Director. The person in charge of the psychodrama. He/she directs the action and
decides which psychodramatic technique to use to guide the protagonist in their work
(Dayton, 1994).
Double. An auxiliary ego used to play the part of the protagonists inner self or
inner voice (Dayton, 1994).
Grounded theory. For the purpose of this study, defined as a method used to
systematically analyze qualitative data to develop theory (Patton, 2002).

In-depth interview. Using techniques and questions to create a situation where the
participants in the study will disclose both information and the meanings of their
experiences (Berg, 2007).
Interview guide. The basic set of questions to be used in the interview process of
the study participants (Berg, 2007).
Milling. Can be used as a warm up of having the participants walking around the
room, stopping them and having them share something with each other (Dayton, 1994).
Open coding. For the purpose of this research, open coding will be defined as a
way to examine the data for the first time with the researcher locating themes in
participant reporting and assigning initial codes as a way to synthesize data into
categories (Neuman, 2006).
Phenomena. Key themes in the data that symbolize concepts in grounded theory
(Bowen, 2006).
Processing. When the protagonist has completed the action section of their drama
and the director aids the group in processing shared experiences and/or feelings related to
the drama (Dayton, 1994).
Properties. General or specific qualities that add new information to categories
found within grounded theory (Bowen, 2006).
Protagonist. Protagonist is defined as the person whose story is being enacted or
told, the person who, de facto, represents the central concern, or emerging themes in the
group (Dayton, 2005b, p. 13).

Psychodrama. Psychodrama is defined as the science which explores the truth by


dramatic methods (Moreno, 1987, p. 18).
Qualitative research. The method of collection of data that is naturalistic,
authentic, and nonlinear to find out the experiences of the participants in the study.
(Neuman, 2006).
Role Reversal. A technique used in psychodrama in which the protagonist and an
auxiliary switch roles in order for the protagonist to experience the auxiliary roles
situation (Dayton, 1994).
Snowball sampling. For the purpose of this research, snowball sampling will be
defined as a sampling method the researcher will use that will ask for recommendations
for a sample from word of mouth of colleagues or friends (Berg, 2007).
Soliloquy. The protagonist shares with the group their thoughts and feelings that
may have otherwise been unspoken (Dayton, 1994).
Spectrogram. A warm up exercise used where there is an imaginary graph on the
floor with extremes at each end. The director makes a statement or asks a question and
the participants place themselves on the graph. Sometimes sharing is incorporated with
the placement on the graph (Dayton, 1994).
Theoretical sampling. The availability of ample numbers of research participants
to interview and re-interview in order to verify themes, incongruencies and/or to expand
data in grounded theory (Bowen, 2006).

10

Theoretical saturation. A concept in grounded theory, which illustrates a situation


when a category within qualitative data is accepted while additional data would not yield
additional information (Bowen, 2006).
Warm-up. This is the first phase of the psychodrama where the group prepares for
the drama by loosening up under the assistance of the director (Dayton, 1994).
Assumptions and Limitations
The researcher reported the findings in a non-biased manner and presented the study in
an approved academic format. There was an assumption that the participants would be honest
in the interest of scientific research. Participants of this study were assumed to have a diagnosis
of anorexia nervosa, bulimia nervosa, or eating disorder NOS due to their admission to
treatment at an inpatient eating disorder facility and to their disclosure in the Informational
Research Packet Participant Assessment and Demographic Form (Appendix A). It was
assumed that the participants in the study had attained a sustained period of recovery from their
diagnosed disorder. The criterion of sustained recovery was identified as one year.
A limitation of the study was that the participants were voluntary and had the right to
withdraw from the study at any time, and therefore the research findings were limited to the
number of participants. Other limitations of this study originally outlined included; participants
who were not in recovery would be omitted from the study; the study does not include the
experiences of adolescents or males diagnosed with an eating disorder. Another limitation of
the study is that participants who report as experiencing suicidal and/or homicidal ideations are
excluded from participation due to concerns of safety.

11

Theoretical/Conceptual Framework
Morenos work came out of the existential theory where the practice was to aid
individuals in developing ways to understand and cope with their lives in holistic and
evolutionary ways (Blatner, 2000). Morenos theory is based in the concepts of
spontaneity, creativity, and intuition as part of the life experience (Moreno, 1964).
Existentialists emerged from the post-World War II era pursuing scientific truth through
the experiences of their reality and existence (Capuzzi & Gross, 2003). Existential theory
looks at the experiences of lives in a framework of time, development, and culture from
the individuals own perspective (Capuzzi & Gross, 2003). Existential therapy is present
focused, task or action-oriented, where clients learn from their experience, not from
reason alone (Wylie & Turner, 2011). Psychodrama is one type of experiential
therapeutic approach that is oriented to existential theory. The experiential nature of
psychodrama places it in the existential theoretical arena allowing patients to heal
through action (Beyer & Carnabucci (2002).
In Morenos exploration into how action therapy could aid people, Moreno
watched children play believing that children learned by imitation and internalized
behaviors (Blatner, 2000; Fox, 1987). Moreno believed this process extended into adult
life where patterns were formed and beliefs instilled. Moreno developed an existential,
phenomenological, and process oriented philosophy, one that emphasized creativity
(Jacobs, 2002, p. 71). The existential theory and experiential nature of psychodrama
therapy used in the treatment of eating disorders are closely tied through examining the

12

participants experiences with the process through discovering the participants reality
and framework.
Organization of the Remainder of the Study
The remainder of the study, commencing with Chapter 2, includes a review of the
literature about psychodrama and its documented uses in therapeutic treatments of
substance abuse and trauma. Eating disorders are defined as well as the theories
corresponding to therapeutic treatments for this patient population. Group process is
discussed as it applies to use in psychodrama therapy and eating disorder patients.
Chapter 3 outlines the qualitative methodology of the dissertation and explains in detail
how the study will be conducted using the constant comparative method in thematic
analysis of the narrative interviews of the studys participants. Chapter 4 presents the data
analysis from review of the transcripts of the in-depth interviews. Chapter 5 presents the
findings of the study and proposes opportunities for future research.

13

CHAPTER 2: LITERATURE REVIEW


Introduction to the Literature Review
The purpose of Chapter 2 is to describe the origin and development of the
Morenean theory of psychodrama to orient the reader to the theorys history and process.
Further, this chapter covers the historical and contemporary uses of psychodrama as well
as its uses in various treatment populations. Chapter 2 provides the definitions and
criteria for diagnosing eating disorders as described in the DSM-IV-TR (2000) under the
headings of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder, NOS. Information
about previous and current treatment issues relative to eating disorders are discussed in
this chapter.
Chapter 2 ties together the research that is available for review for psychodrama
treatment with eating disorder patients and the more prevalent research available for
patients diagnosed with substance abuse or trauma. The specific eating disorder section
and defined diagnostic criteria in the DSM-IV-TR were added in the year 2000 as a
recognized mental health disorder (Annus, Smith, Fischer, Hendricks, & Williams, 2007).
Prior to 2000, there were no specific diagnostic criteria for eating disorders. Theories
related to the eating disorder illnesses have been linked to family of origin issues,
socialization issues, and learning influences, aligning them with substance dependence
illnesses in their treatment (Annus et al., 2007). This linkage is this reason to review
substance dependence psychodrama literature and suggests the connection to eating
disorder psychodrama treatment uses.

14

Group processes and group work are the methods of therapeutic intervention
discussed in this chapter because of the prevalence of psychodrama being used primarily
in a group format (Blatner, 2007). The literature also subscribes to group therapy as the
most helpful method working with eating disorder patients (Becker, Grinspoon,
Kilibanski, & Herzog, 1999).
Theoretical Framework
History and Development of Psychodrama
Moreno (1994) believed that psychodrama is the science of action. Moreno
developed an existential, phenomenological, and process oriented philosophy, one that
emphasized creativity (Jacobs, 2002, p. 71). Traditional psychoanalytical methods of
therapy were cognitively focused and tended to be a very long-term process for the client.
Morenos development of the classical psychodrama theory was regarded as both a
therapeutic method and an underlying theory. The theory and method were inseparable
components of a single system and allowed for shorter term treatment opportunities for
the client (Kipper & Matsumoto, 2002). Evolution in the field of psychodrama has taken
place since the 1920s to a modern recognized theory often used in combination with
cognitive approaches to enhance the patients work (Moreno, 1994).
Moreno was a lover of stories (Jacobs, 2002). Morenos exploration into how
action therapy could aid people Moreno watched children play believing that children
learned by imitation and internalized behaviors (Moreno, 1994). During the observations,
Moreno put the ideas into action with the development of an improvisational theater for
children. This activity led to the development of the Theatre of Spontaneity where
15

Moreno continued to experiment with a variety of interactive and improvisational


approaches laying the groundwork for sociometry (Moreno, 1987). Moreno believed that
human beings naturally act and interact coining the term social atom and the study of
sociometry. Moreno believed this process extended into adult life where patterns were
formed and beliefs instilled (Moreno, 1994).
While in medical school in the early 1900s, Moreno continued to observe human
interactions while assisting in the psychiatry department. Moreno spent time organizing
early self-help groups for prostitutes in Vienna who were being exploited and harassed by
the government (Moreno, 1987). Moreno recognized the power of the interaction among
the group members and began to put together the concepts of group therapy and
psychodrama (Moreno, 1987).
Moreno was in conflict with Freuds popular theories of the time and needed the
freedom to experiment with his concepts of spontaneity and theatrical therapy. Moreno
moved to America to pursue his desires (Moreno, 1987). From the 1930s to the 1940s
Moreno expanded on the work, published, and opened Beacon Hill Sanitarium and
Beacon House Publishing (Moreno 1994). This was also the time where psychodrama
was formalized and the Hudson Valley Training Institute for Professionals was started
(Moreno, 1994).
In the years of 1940 1960, Moreno formed the first professional association for
group therapists: the American Society for Group Psychotherapy and Psychodrama
(ASGPP). The Sociometric Institute and Theater of Psychodrama in New York City
opened attracting professionals to educate them on Morenos work (Moreno, 1994).
16

During the years of education and expansion of the work, Moreno reached out to other
professionals in the field of therapy by way of professional conferences for an
interchange of approaches. These conferences included such innovators as Joshua Bierer,
Virginia Satir, and Maxwell Jones (Moreno, 1987).
Transcending from the therapeutic theatre, sociometry, group therapy, and
psychodrama, Morenos work influenced such therapists as Fritz Perls in the 1950s and
Virginia Satir in the 1970s. Perls began the Gestalt Therapy movement where the basis
was in being creative and spontaneously experimental in the clinical work with patients
focusing on the here and now (Perls, 1966). Virginia Satirs work with family systems
and roles came directly out of Morenos work with sociometry (Satir, 1988). Sociometry
began with the identification of relationships among beings and their interaction among
each other (Moreno, 1964).
The Process of Psychodrama
Psychodrama is a holistic and brief therapy as opposed to the long term,
intellectual experience of psychotherapy, but there can be a blending of the two for an
enhanced therapeutic experience (Fisher, 2007). It is also an intensive form of therapy
that is considered more effective than the conventional talk therapy methods (Blatner,
2007). The theory of psychodrama was founded in the form of group therapy that mostly
focuses on the work of a single person within a group context who is identified as the
protagonist (Moreno, 1964). The group members serve as adjunct therapeutic agents or
auxiliaries to the protagonist

17

The process of psychodrama is three-part. There is the warm up, action, and
processing phase to every drama (Kipper & Ritchie, 2003). The warm up is the first part
of the process where the group is warmed up to each other and to the drama that is about
to unfold. Under the active participation of the director, the warm up allows the creativity
and spontaneity to float to the surface of the group in preparation of part two of the
process. The warm up is also used to help identify who the protagonist will be in the
drama. There are several warm up methods that can be used. The method used is the
choice of the director. Spectrograms and milling exercises (see p. 13, Definition of
Terms) are common warm up methods.
The action phase of the drama is where the director stages the enactment for the
protagonist to portray their problem or issue that came to the surface during the warm up
phase. The act of the work done by the protagonist and the auxiliaries is used as a
corrective or emancipatory approach to therapy versus a cognitive recognition approach
(Moreno, 1994). Psychodrama action phase allows the director to assist the protagonist in
creating problematic situations in their life and in their perception of it while on the
stage giving opportunity for the protagonist to modify their responses and create a new
internal formula for healing. There are several types of action methods that are available
to be used by the director and are usually determined by the issues that are being
presented in the moment by the protagonist. A few of the methods used are the double,
role reversal, and soliloquy (see p. 13, Definition of Terms).
The use of the action phase with a patient diagnosed with an eating disorder
allows the patient to have an experience that incorporate more than cognition which is
18

hypothesized to allow for the opportunity for greater healing. Although the auxiliaries do
not play the pivotal role in the drama, auxiliaries gain indirect personal insights from the
portrayal of the roles and may adapt them to their own life issues, truly making
psychodrama a group experience (Kipper & Hundal, 2003).
Moreno (1994) considered every group participant to be an agent of healing
because of the power of the work. During the process of the drama, the entire group of
participants is forced into movement outside of their cognitive selves into a possible
uncomfortable, emotional, and spontaneous place (Moreno, 1994). For the patient with an
eating disorder, this process could enhance their healing experience encouraging
emotional healing connections.
The processing phase, part three of the process, is when the protagonist has
completed the action section of their drama and the director aids the group in processing
shared experiences and/or feelings related to the drama (Dayton, 2005b). During the
processing phase, the auxiliaries have the opportunity to share their own experience of
the drama presented by the protagonist and the impact the drama had on their own issues.
This phase also allows the group to cool down from the intensity of the work and to put
closure to the session (Dayton, 2005b).
Psychodrama, Trauma, and Addiction
In the late 1980s and on-going, more substantiated research exists to validate the
benefits of psychodramatic techniques, especially in a group format with clients of
trauma and addiction (Jacobs, 2002). Moreno was recognized to be years before his time
in the theorys development because of the innovative use of a group format promoting
19

healing (Blatner, 2007). Morenos wife, Zerka Moreno, in a personal interview (March
15, 2009) stated, Read Who Shall Survive and dig the guts out of it and then tell me
that Morenos work was not scientifically based. Freud was not a scientific writer, just
more mainstream. After Morenos death, Mrs. Moreno continued the theorys work and
research and continues to educate, write, and facilitate groups in her husbands honor and
her own professional interests.
Morenos studies were thought to be groundbreaking and creative, but their
epistemology was questionable and their application lacked convenience (Blatner, 2000).
Morenos work was rarely published outside of his own Beacon House publishing
company and distribution of Morenos work outside of his own close circle of followers
was difficult because of the use of Beacon House versus other well-known professional
publishing houses and journals (Blatner, 2000). In addition to the publishing difficulties,
Morenos writing style did not fit with the professional scientific community and was a
mix of terms, hypotheses, anecdotal stories, and philosophical speculation (Blatner,
2000). These issues reinforced the concern with the conservative mainstream
psychoanalytical community regarding Morenos unconventional theory and methods.
Overwhelming trauma can occur in many forms. Our first social atom (taken from
psychodrama) is our family of origin where our initial emotional and psychological
damaging can occur (Dayton, 2007). Growing up in a less than nurturing environment
can set individuals up in childhood for dissociation, emotional numbing, self-soothing
techniques, and trauma defenses (Mellody, Miller, & Miller, 1989). These problems can
emerge as emotional disorders, addictive disorders, food disorders, or other compulsive
20

regulatory methods (Dayton, 2007). Other ways of coping or mastering traumatic


recollections and emotions are with substance abuse, eating, working, distraction, and
other compulsive behaviors connecting the neurobiological and the emotional trauma
reaction (van der Kolk, 2002).
When an individual is exposed to traumatic events or overwhelming experiences,
developmental delays may occur in the individuals ability to function in a healthy
emotional manner encouraging self-soothing acts (Mellody, Miller, & Miller, 1989). The
foundational concept of self-soothing or medicating ones emotions appears to be a
consistent thread among those who have difficulties in emotional regulation and
expression of feelings due to distortions of self, due to relational trauma (Dayton, 2000;
Hudgins, 2002; Mellody & Freundlich, 2003; Normandi & Roark, 1998; van der Kolk,
2002).
Psychodrama methods have been studied in similar areas of emotional regulation
and self-soothing such as substance abuse and trauma. Trauma survivors have been aided
in the use of psychodrama and experiential methods to come to terms with the
overwhelming experiences of their trauma. Van der Kolk (1996) wrote:
Prone to action, and deficient in words, these patients can often express their
internal states more articulately in physical movements or in pictures than in
words. Utilizing drawings and psychodrama may help them develop a language
that is essential for effective communication and for the symbolic transformation
that can occur in psychotherapy (p. 195).
Psychodrama Used With Addictions and Trauma.
Women who have been diagnosed with alcoholism are believed to have begun to
drink in order to change their mood or find a way to self-medicate not with intention of
21

becoming alcoholic (Dayton, 2000). Alcoholics and addicts are traumatized and hurt
individuals who utilize forms of self-medication for emotional regulation that keeps them
stuck in the unresolved emotional pain and shame (Dayton, 2005a). Womens addiction
issues are frequently interrelated with issues of trauma (Stewart, 1996). Common relapse
related triggers for female addicts are issues of unresolved trauma, negative self-image,
difficulties in interpersonal problems, and dysfunctional emotional regulation (Uhler &
Parker, 2002).
Addiction issues are often coexisting with other compulsive coping strategies and
can be exchanged from one compulsion to another such as substances to food, or viceversa (Buck and Sales, 2000). Because of this coexisting relationship, treatment
communities have used similar therapeutic interventions consistent with substances and
eating disorder related issues. Group-oriented settings for substance treatment have set
the stage for group-oriented settings for eating disorder treatment. Born out of 12-Step
based philosophies, cognitively oriented methods, and psycho-educational methods are
the underpinnings of addiction related treatment programs (Yager, 2008). Experiential
therapies such as psychodrama have been utilized, as stated earlier in substance abuse
settings with positive outcomes. According to CODA, Inc., of Portland, Oregon, their
experience of utilizing deep emotional therapies including psychodrama, have been
effective in the treatment of women with addiction issues (Uhler & Parker, 2002).
Psychodrama methods allow for the addict to address the unresolved issues and to move
through the issues to the other side of the emotion (Dayton, 2005b).

22

Historical Treatment Usages of Psychodrama


As mentioned previously, Morenos development of psychodrama came from
interactions with children and observing them as they explored their world. Morenos
work progressed to work with prostitutes and the development of self-help groups.
Moreno used his own publishing house for the dissemination of the work and there was
little other outside empirical publication until the 1960s.
Between the years of 1960 and 2005, most of the published work came from
studies of male and female adult participants in the areas of trauma, anxiety, and
substance abuse. Male and female child abuse survivors, male military combat veterans,
and female opiate abusers were the primary participant populations (Dayton, 2005a;
Theiner, 1969; Thomas, 2005). There were several adolescent studies, mostly where the
participants were diagnosed with psychopathic issues, schizophrenia, or had been
identified as juvenile offenders (Carpenter & Sandberg, 1973; Goldstein 1967; Levenson
& Herman, 1991). Outside of these populations studied, there were a few publications
focused on special populations such as the blind and the elderly. University students,
couples, and the business marketing areas were other identified groups.
Detailing some of the more broad reaching uses of psychodrama research includes
a study where psychodrama methods were used with blind adolescent students
hypothesizing that the psychodrama interventions would be beneficial in aiding the
students ability to increase their learning capacity (Friedman & Pasnak 1973). Results
identified that psychodrama methods used in conjunction with other types of activities
such as clay modeling, free play, and school homework tutoring enhanced the learning
23

experience of the blind students catching up with their sighted peers (Friedman &
Pasnack, 1973).
The couples study by Fow (1998) used the psychodrama technique of role
reversal with a goal of cultivating a shared sense of understanding of the partner in order
to deepen identification with the partner prompting positive behavior change. This study
reported clinical success in the building partner empathy and positive change (Fow,
1998).
Carnabucci (2002) utilized psychodramtic methods in business marketing training
discussing improvements in career and overall company attitudes and productivity. While
yet other research of University students struggles with test anxiety were studied using
psychodrama, systematic desensitization, and no treatment in three groups with a
conclusion that psychodrama methods are as effective a mode of counseling as systematic
desensitization in treating test anxiety (Kipper & Giladi, 1978).
An interesting paper by Remer and Morse (1993) utilizing short duration
psychodrama methods with elderly patients diagnosed with Alzheimers indicated
clinical success to reclaiming memory and increasing spontaneity and mobility in the
participants activity. Other non-traditional approaches such as art and music therapy
proved positive with this population, prompting the introduction of psychodrama as an
intervention alternative.
After reviewing all of the publications related to psychodrama uses from 1940 to
2005, there were positive clinical results in all of the studies ranging from decreased
anxiety, decreased depression, increased therapeutic alliances, reduction in cognitive
24

distortions, increased body comfort, increased esteem, decreased hostility and anger, and
overall general improvement in affect.
Contemporary Psychodrama
For this section, published research from peer-review journal articles (2006 to
2010) was reviewed. The years of 2006 and 2007 provided the most literature but with
little change in populations studied. Adolescents, adult females, and school students were
the primary populations researched with ongoing emphasis on PTSD, anxiety, and
depression related diagnoses (Amatruda, 2006; Gregerson 2007; McVea & Gow, 2006;
Olff, Langeland, Draijer, & Gersons, 2007). A new area of study where psychodrama was
used was with the Latino population where psychodrama was connected with Latino
ethnic psychology interventions and associated with folk healing in that tradition
(Comas-Diaz, 2006)
The papers where students were the participants became more educationally
focused in their hypotheses, for example, using psychodrama in a Race Relations course
to help increase students awareness and interest in attaining diversity (Kranz, Ramierz,
& Lund, 2007). Another educationally focused study used psychodrama methods to
provide High School girls with preventative and proactive methods of role play to
increase their awareness when confronting potential dating violence (Fong, 2007).
The years of 2008 and 2009 provided even more limited writing in the area of
psychodrama. Those peer reviewed articles were again focused on adolescents and adults.
This time though the adult population studied were in the areas of money, or financial
distress, and clinical professionals. Klontz, Bivens, Klontz, Wada, and Kahler (2008)
25

used psychodrama to work with adult males and females with varying mental health
diagnoses who exhibited disordered money behaviors. The clinical success found from
this study indicated decreased psychological distress and increased healthy money
attitudes.
Adolescent studies during this time period focused on students with aggressive or
violent behaviors. A comparison of CBT and psychodrama interventions were performed
with significantly similar clinical success using each of the interventions providing both
long term and short term decreases in aggressive and violent behaviors (Karatas &
Gokcakan, 2009). Again the overall conclusions of the reviewed studies during this time
frame identified psychodrama as a positive method of therapy and intervention.
The years 2007 to 2010 produced a few dissertations in the areas of psychodrama,
but with the integration of other types of modalities used in conjunction with it.
Improvisational theater (Veenstra, 2009), role play (Sirridge, 2010), and body alchemy
(Ridge, 2007) which all are part and parcel of Morenos original psychodrama theory all
concluded that use of the methods provided various improvements in the populations
studied, including, but not limited to, increase in esteem, decrease in anxiety and
depression, and stress reduction. They were also identified as educational training tools.
Psychodrama Therapy with Eating Disorders
There is little that has been published directly related to eating disorders and the
use of psychodrama as a method of treatment; however, there are generalized beliefs of
professionals in the eating disorder field that psychodrama aids in the facilitation of
relational maturity, empathic interaction, and emotional congruence (Hall, 1978). It is
26

believed that individuals affected by eating disorders also have difficulties in the area of
emotional regulation and expression of feelings in their lives affecting the ability to be
spontaneous and in the moment (Cockell et al., 2003).
Traumatic events are experienced and imprinted on our brain (Herman, 1997).
Survival teaches us how to shield or protect ourselves from the trauma. Psychodrama is
used to be a corrective action to trauma. It creates an opportunity to do in the here and
now what we were restricted from doing when it may have been unsafe or too dangerous
to act (Apter, 2003). Psychodrama allows individuals to have problems surface, be
reconstructed and played out in the present moment releasing the long-held feeling on
both the psychic level and the cellular body level (Dayton, 2005a). Women with eating
disorders have held emotions affecting not only cognitive distortions related to food, but
also to their body image (Christian, 1996).
Bernstein and Putnam (1986) have made correlations between a variety of
psychological conditions and somatizations, such as bulimia, with histories of neglect and
abuse. Abuse in the form of family of origin related experiences could contribute to
disordered eating. In a study by Annus, Smith, Fischer, Hendricks, and Williams (2007),
associations of eating disordered symptoms among adult women identify food and bodyrelated teasing from family and friends, negative maternal modeling, and criticism of
eating behavior as risk factors for the development of disordered eating. Additionally,
peer and Western societal focus on thinness reinforce the dieting and binge/purge cycle in
the distorted perception of body acceptance (Annus et al., 2007). Self-esteem and selfworth are associated with eating disorders, as well as the feeling of shame (Buck & Sales,
27

2000). Body dissatisfaction and body image perceptions are also associated with the
distorted feeling of shame (Buck & Sales, 2000).
Diagnostic Classifications and Criteria for Eating Disorders
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR) (APA, 2000), there are two specific eating disorder
diagnoses and one general eating disorder category. Anorexia Nervosa (AN) and Bulimia
Nervosa (BN) are the two specific categories and Eating Disorder Not Otherwise
Specified (EDNOS) is the general category. The DSM-IV-TR diagnostic criteria are
applied to men and women, but the anorexia specific subsection favor women with the
criteria of amenorrhea as a core identifier. Instead of amenorrhea, abnormal or reduced
testosterone functioning may be used as core criteria for males in this subsection
(Greenberg & Schoen, 2008).
AN is characterized by the DSM-IV-TR as a refusal to maintain a minimally
normal body weight, an intense fear of weight gain, and a significant disturbance in the
perceived size or shape of the persons body. In order to be diagnosed with AN,
postmenarchael females must experience amenorrhea (the absence of at least three
menstrual cycles, and must maintain a body weight that is less than 85 percent of the
expected normal body weight. AN has two sub-categories, restricting type and binge
eating/purging type (APA, 2000). According to the DSM-IV-TR, (2000, p.264) binge
eating is described as:
eating, in a discrete period of time (e.g., within any 2-hour period), an amount of
food that is definitely larger than most people would eat during a similar period of
time and under similar circumstances and a sense of lack of control over eating
28

during the episode (e.g., a feeling that one cannot stop eating or control what or
how much one is eating.
Additionally, purging type is described as self-induced vomiting or the misuse of
laxatives, diuretics, or enemas. (APA, 2000, p.264).
BN is characterized by an essential feature identified as binge eating in
conjunction with inappropriate ways to prevent weight gain, in addition to self-evaluation
that is excessively based on body weight and shape (APA, 2000). There is no weight
specific criteria to be diagnosed with BN. Amenorrhea is not required to obtain a
diagnosis with BN as it is with AN. BN also has two sub-categories: restricting type and
binge eating/purging type. The main difference in the sub-types is that individuals in the
former group do not regularly engage in binge eating/purging behavior where those
individuals in the latter group do. The main distinction between AN and BN is current
weight and menstrual status (experiencing a menstrual cycle or not).
The general category of EDNOS is reserved for those individuals that are
presenting with clinically severe symptoms, but fail to meet the specific criteria outlined
in both AN and BN. Most likely AN individuals who have not met the criteria of
amenorrhea or those BN individuals who only meet the criteria of binge eating only are
those who will qualify for EDNOS.
Shared commonalities between the two specific categories that are not part of the
DSM-IV-TRs criteria include; high levels of neuroticism, obsession, and perfectionism,
as well as low levels of self-motivation or directedness (Tozzi et al., 2005). Overt
behaviors that are engaged by individuals diagnosed with eating disorders include
29

engaging in extreme dietary restriction, binge-eating, purging, misuse of laxatives,


misuse of exercise, body checking and measuring, body avoidance, control over eating,
shape, weight, and eating rituals (Fairburn & Bohn, 2005).
Factors that have been identified for the development of eating disorders include
negative parenting, cultural pressure to be thin, peer pressure, relational difficulties,
childhood abuse, genetic predisposition, maturity fears, negative emotionality, esteem
issues, perfectionism, body image distortions, and dieting (Polivy & Herman, 2002). The
most frequently aligned issues with eating disorders have been esteem issues and
perfectionism, with dieting as another causal role (Holston & Cashwell, 2000; Keel,
2006; Bulik, Tozzi, Anderson, Aggen, & Sullivan, 2003; Polivy & Herman, 2002).
Dynamics and Causative Factors for Eating Disorders
Esteem and perfectionism are two of the most frequently cited factors related to
the development of eating disorders (Polivy & Herman, 2002). Perfectionism related to
concern about making mistakes has been identified as a strong predictor of both AN and
BN; whereas, perfectionism pertaining to concerns about actions has also been associated
with the development of eating disorders as well as anxiety disorders (Bulik et al., 2003).
Perfectionism also appears to present before the diagnosis of eating disorders and
continues after eating disorder recovery (Polivy & Herman, 2002). Esteem appears to
play a role in the development of eating disorders and is repeatedly associated with onset
of the disorder (Brewerton, 2004; Michel & Willard, 2002). The debate is whether the
esteem is developed before or after the perfectionism (Keel, 2006). Research suggests
that esteem may only affect eating behaviors under stressful circumstances, but during
30

normal circumstances, that eating behaviors and self-esteem are not as likely to be
present (Sassaroli & Ruggiero, 2005).
Body dissatisfaction and dieting are both assigned as contributing factors to the
development of eating disorders. It is believed that body dissatisfaction drives the dieting
behavior and self-esteem may be an underlying factor (Polivy & Herman, 2002). To
achieve positive esteem, the distorted thought is that if one has a perfect body, self-worth
is achieved (Keel, 2006). Cultural and societal pressures are external factors that can also
be contributing factors to the development of eating disorders. Media messages, perfect
body type, beauty, sexual desirability may activate the need to achieve the perfect body
image (Polivy & Herman, 2002). These pressures again present as esteem related factors
in eating disorder symptoms.
Alexithymia (difficulty experiencing, expressing, and describing emotion), as
mentioned earlier in this paper, has been identified as a common trait in individuals
diagnosed with eating disorders (Beales & Dolton, 2000). The importance of
acknowledging this effect is that deficiency in understanding, experiencing, and
expressing emotion makes it more difficult to get in contact with ones true feelings.
Difficulty with emotions increases the need to develop more complex avoidance coping
skills that in turn increase the eating disorder symptoms (VanBoven & Espelage, 2006).
Emotional dysregulation, traditionally associated with the diagnosis of Borderline
Personality Disorder, is a common feature that is also observed in the patient diagnosed
with an eating disorder (Costin, 1999). These features include: lack of control of
emotions, chaotic interpersonal relationships, poor sense of self, and impulsive behavior
31

(APA, 2000). The connection to patients with eating disorders, who present with similar
symptoms can occur because of the lack of appropriate nutrition, esteem issues, and
alexithymia. This connection is where the treatments using DBT and CBT originated
(Polivy & Herman, 2002).
Research in Other Fields of Study Related to Eating Disorders
The United States military medical community provided research in the field of
eating disorders. Studies conducted by military medicine include findings of higher
incidence of eating disorder diagnoses in the military than in the civilian populations,
more likely in military dependents than active duty personnel (Waasdorp, Caboot,
Robinson, Abraham, & Adelman, 2007). Other military studies include a study
identifying eating disorders being a problem for college students and college athletes
comparing such issue for students of the United States Military Academies (USMA) with
the conclusion indicating comparable risk for USMA to civilian colleges (Beekley,
Byrne, Yavorek, Kidd, Wolff, & Johnson (2009). In another military study, young adult
female military recruits with a body mass index in the upper end of the Marine Corps
weight standard report eating disordered behaviors such as purging, binging, or
restricting in order to make weight and are at higher risk to develop a fully diagnosed
eating disorder that nonmilitary recruits (Garber, Boyer, Pollack, Chang, & Shafer,
2008). Yet other military studies focused on obesity and physician related attitudes in
treatment of obese patients stating that there are still negative stereotypical physician
attitudes in the treatment of obesity (Warner et al., 2008).

32

Although obesity is not a term used in the DSM-IV criteria of eating disorders,
the interrelation to ED NOS can be closely identified. Other non-military related studies
focusing on obesity were derived from such groups as foreign policy makers, public
health, and consumer groups. In a study conducted by the International Security &
Counter Terrorism Reference Center (2008), there was an identified correlation between
significant economic growth in Asian countries and a marked increase in the number of
obese persons prompting the countries to promote weight loss programs. Other studies
focused on the obesity stigma and considerations for public health such as the study by
Puhl and Heuer (2010) discussing stigma and discrimination toward obese persons posing
psychological and physical health issues, identifying that stigmatization and
discrimination interfere with effective public health intervention efforts.
Other types of research in the area of eating disorders were found in the arenas of
internet pro and con eating disorder support groups (Borzekowski, Schenk, Wilson, &
Peebles, 2010; Ignatow, 2009), advertising and marketing affecting young womens
attitudes regarding body dissatisfaction and cosmetic surgery promoting eating
disordered behaviors (Bakir & Palan, 2010; Lin & Yeh, 2009; Petina, Taylor, & Voelker,
2009). Although these studies provided insights into populations affected by societal
variables related to disordered eating behaviors, they do not discuss therapeutic
intervention strategies.
Group Practice in Therapy
Group process is the interaction and energy exchange between members and
leaders (Jacobs, 2002, p. 32). Group interactions occur in patterns and different kinds of
33

groups. For example, therapy groups will have different processes than self-help groups.
What makes group therapy work? Yalom (1995) lists eleven factors that are important for
group success. Three of those important factors are the instillation of hope, universality,
and group cohesiveness. Feeling the hope that is provided by the group facilitator and
other group members is helpful for the patient to continue in the group process
(Constantino, Arnow, Blasey, & Agras, 2005). A positive alliance between the group
facilitator and women with bulimia nervosa provides a positive contribution to treatment
outcome (Constantino et al., 2005).
Universality is the second factor that aids group members in feeling like they are
not unique, alone, or different. It helps the participant feel as if someone else understands
and has empathy for the situation. The third, group cohesiveness provides a safe and
compassionate environment for the members to share openly and honestly with the other
members. These three factors mentioned in Yaloms text are fundamental to the
effectiveness of the group and also primary responsibilities of the group leadership
(1995). Psychodrama group therapy allows for exploration and reconciliation of
relationships, past, present, or future (Apter, 2003).
Group process with people works in stages, such as beginning, middle, and end.
The beginning stage would be the introductory stage where members get to know one
another and begin to develop trust and rapport. The middle stage is when the group
members do most of their therapeutic work within the context of the group process. The
end stage, or closing stage is when the group puts closure to the experience and moves
away from the group experience (Jacobs, 2002). Similarly, psychodrama has defined
34

stages of process and is ritualistic in its approach. This stage of psychodrama not only
provides a sense of process, but also a sense of group safety with this modality. Using a
defined and predictable process with clients with eating disorders is helpful to aid in the
alleviation of their stress levels (Constantino et al., 2005).
Creating a safe environment for group members to become vulnerable and
express feelings is a primary objective of a psychodrama group (Dayton, 2005b). Without
attending to the groups anxiety about participation in the experiential format, there
would be a fundamental breakdown in trust and security (Haley-Banez & Walden, 1999).
Offering this type of group at an inpatient setting, during the treatment process allows the
client to walk the walk prior to leaving treatment while under the supervision of a
clinical professional. After participating in the group, the client can integrate their newly
found skills and tools into the ongoing treatment plan as outlined by their clinical team.
Psychodrama must be used very carefully and with trained facilitators (Klontz,
2004). It must be integrated with part of an overall treatment plan/goal plan. Being in a
supportive environment with adequate emotional grounding is encouraged in the use of
this form of therapy (Klontz, 2004). Psychodrama has been integrated with other forms of
therapy in recent years including cognitive behavioral therapy and rational emotive
behavioral therapy (Treadwell, Kumar, & Wright, 2002; Avrhami, 2003). The approach
of combining action-oriented therapy with the fundamental therapies is to provide a
global course of treatment for groups and individuals.
In working with patients with eating disorders, the use of cognitive behavioral
therapy has been found to be productive (Treadwell, Kumar, & Wright, 2002). Cognitive
35

distortions, learning styles, educational, and cultural backgrounds represent a few of the
challenges that can be addressed with multiple therapy approaches. Spontaneity,
creativity, and being present in the moment are key concepts in the Morenean Theory
(Moreno, 1964). Moreno believed that spontaneity is defined as a lack of control and that
the protagonist needs to be able to act free from emotional pressures and bonds (Moreno,
1964). Moreno (1994) believed that as we mature and have encounters within
relationships and society, we lose our spontaneous ability to identify our own emotions
and creativity in conforming to societal and familial norms. Using psychodrama in
therapy sessions allows the protagonist to create and recreate each time allowing them to
train and retrain their emotional regulation and responses with each drama. This
recreation is recognized as a core part of the theory activating the psychobiological
system providing an expanded experience of healing and sensory integration for the
patients recovery (Dayton, 2005a). Spontaneity in the drama also trains the protagonist
to be present in the moment, also enhancing the retraining process of the protagonist
(Scott, 2000).
Cognitive changes need to have a parallel healing process including a form of
emotional experience that will create a neural brain chemistry change (Fisher, 2007).
These tandem events between cognitive and emotional can occur during psychodrama
work when the emotional imprint in the body can be reconfigured. Van der Kolk (1996)
connects the cognitive and emotional in the study of traumatic memories coexisting
between semantic and sensory imprints where narrative therapies may change the
semantic memory, but not the sensory memory. Psychodrama methods can aid in the
36

sensory changes needed to heal from dissociation in traumatized individuals providing a


link between trauma healing to eating disorder healing concepts (Dayton, 2006; Dayton,
2007; Fisher, 2007).
Group work with eating disordered patients is believed to be the most effective
way to provide treatment for the reasons of universality, support and acceptance,
interpersonal relationship development, confrontation/boundary setting skills, and
friendship (Costin, 1999). By sharing and listening to others with similar eating
disordered related issues, an individual can make connections and enhance their esteem
by realizing they are not alone with the disorder and that they are not crazy (Costin,
1999). Because of the restriction in emotional connectedness, eating disorder groups
allow the patients to practice relational skills and develop emotional connections with
themselves and others (Costin, 1999). Commitment to an ongoing group provides the
patient with the ability to follow through with goals and develop a manner of
accountability to something outside of the eating disorder.
Crucial Theoretical/Conceptual Debates
Moreno chose to develop psychodrama, an action-oriented theory separating from
the popular Freudian psychoanalytical theory of the times, creating great controversy
(Apter, 2003). Moreno did not prescribe to detailed research or documentation of his
work, which has caused the scientific community to consider the theory and interventions
as not empirical (Blatner, 2000). Proponents of quantitative research posit that due to the
anecdotal nature of psychodrama literature, it is not of scientific quality to be considered
a valid treatment modality or theory (Kipper & Ritchie, 2003).
37

Klontz (2004) writes at length about the ethical practice of psychodrama therapy.
Klontz identifies experiential therapy (which includes psychodrama) as related to
psychodrama in regard to the primary vehicles of change that both therapy modalities
have in common. However, there are differences in how they use experiential techniques.
Klontz highlights some of these differences and concluded that in group therapy there is
(a) less control over the content and direction of the therapy session, (b) greater potential
for adverse experiences, (c) greater potential for stress that might result from
confrontation and criticism from other members, and (d) the possibility of a client
growing dependent on the group (2004, p. 173).
Feasey (2001) states in his text that an important factor hindering effectiveness of
experiential techniques is lack of therapist understanding and performance during the
exercises. The goal of psychodrama and other experiential techniques is that it is the
protagonist that determines the content and direction of the work, not the therapist. There
should be no judgment, analysis, or subjective interpretation to shame the client (Moreno,
1994).
Clients with an eating disorder diagnosis are considered to have significant shame
related emotions and distorted thoughts (Costin, 1999). Assurance of appropriate and
professional psychodrama facilitation is essential for those clients as to not perpetuate the
shame cycle (Dayton, 1994).
Psychodrama is not suited to all client populations. Moreno viewed psychodrama
as having a universal appeal and application to all, whereas more modern scholars cite
psychodrama as not being recommended for clients who are seriously disturbed, such as
38

sociopathic populations (Kane, 1992). Some clients diagnosed with anorexia nervosa,
restricting type, could be inappropriate for psychodrama interventions early in their
inpatient treatment due to extremes in cognitive distortions and cognitive processing due
to malnutrition (Christian, 1996).
Bridging the Gap or Resolving Controversies
In a study by Norcross, Koocher, and Garafalo (2006) entitled Discredited
Psychological Treatments and Tests: A Delphi Poll, the authors polled 101 experts in the
field of mental health to rank 59 treatments and 30 assessment techniques on the experts
perceived discreditation of the items. Morenos psychodrama theory was included in the
poll and was judged by the group to be unlikely discredited. In a journal article by CritsChristoph, Wilson, and Hollon (2005), the writers argued that experientially oriented
therapies were a positive adjunct to cognitive behavioral therapy. The writers go on to
state that due to the ability to use psychodrama in a brief course of treatment, it is a
modality that deserves more attention and research (Crits-Christoph et al., 2005).
Review of the Critical Literature
Morenos Impact
Morenos impact on the treatment community of his time included the
development of psychodrama as a theory and a modality of therapeutic intervention.
Although there was controversy at the onset, the use of psychodrama therapy has gained
recognition and acceptance, especially in the field of substance dependence and trauma
healing (Dayton, 2005a).

39

Credibility and research in the field of psychodrama has increased since the
beginning of the work, as have the integration of other experiential forms of expressive
therapies such as art and movement therapies. The use of these therapeutic interventions
in the context of individual, group, and family work has become more acceptable in the
main stream of the psychological community and utilized in private practices and
treatment communities (Hornyak & Baker, 1989). Although there has been increased use
and study in the experiential fields, there has been limited research directly related to
patients with eating disorders prompting this study (Treadwell & Kumar, 2002).
Cognitive Behavioral Therapy and Dialectal Behavioral Therapy
The treatment modalities most commonly associated with patients with eating
disorders are Cognitive Behavioral Therapy (CBT) and Dialectal Behavioral Therapy
(DBT) (Treadwell & Kumar, 2002). The goals of CBT are to affect change in the client
and are thought focused. The therapy has a variety of intervention methods to assist in
these goals. Some of these intervention methods include reinforcement, extinction,
shaping, identification of cognitive distortions, thought stopping and cognitive
restructuring. There are several other methods of interventions, including homework
exercises, reframing, role-playing, and relapse prevention. Again, these intervention
methods are cognitively focused and do not sufficiently engage the patient at a
feelings/emotional level.
Psycho-education is also an important part of CBT. The therapist provides
information to the client about what has been learned in research about similar problems,
as well as assignments of books or articles to support the client's change. Again, there are
40

limited amounts of interventions that focus on feelings and insight into the past. Without
a historical perspective to help in conceptualizing, effective and holistic treatment
planning is limited.
The modalities used in CBT can be used in a combination or variety of ways. The
modalities are time limited, meaning that there is a specific set of sessions and these
sessions can be structured to be short term. The format of the interventions is structured
and goal-oriented with the client participating in homework assignments in-between
sessions. Clients work on a collaborative level with the therapist to solve problems and
reach the goals.
The therapist utilizes specific components in CBT that include: problem list,
diagnosis, working hypothesis, strengths and assets, and treatment plan (Capuzzi, 2003).
The problem list includes areas of the client's life that are experiencing difficulties, such
as financial, relationship, legal, and work issues. There usually is an interwoven theme
among the problems that become apparent after the therapist and the client work together
for a short time. Diagnosing a problem is not always utilized in CBT, since it tends to
refrain from the medical models. If a therapist is working with a third party payer, a
diagnosis may be necessary to receive payment for services rendered (Jongsma, Peterson,
& Bruce, 2006).
The working hypothesis is the map that connects the problems and issues together
into symptoms. These symptoms help the client and the therapist identify the next stage,
strengths and assets that lead to the development of a treatment plan. The treatment plan

41

is the outline that is developed with action steps to help facilitate change in the client
through working with the therapist (Capuzzi, 2003; Jongsma, Peterson, & Bruce, 2006).
Cognitive behavioral therapy has been studied extensively and has proven to be
helpful to many types of client problems. Some of the specific interventions CBT has
proven useful include: anxiety, depression, substance abuse, eating disorders and social
phobias (Capuzzi, 2003). One of the noted limitations of CBT is that experiential
counselors believe there is little focus on feelings and emotional aspects of the client's
issues. There is also no historical perspective taken into account, only focus on the
present and making a change. Some researchers believe that CBT will lead to
"understanding of the problem, but may not help change the feelings associated with the
thoughts" (Capuzzi, 2003, p. 229). Due to the previously noted need to have patients
diagnosed with eating disorders to reach a deeper feelings level in their recovery process,
utilizing only CBT in the treatment modality is believed to be less beneficial.
Dialectical Behavioral Therapy (DBT) is a skills-training technique originally
designed by Linehan in the treatment of the emotional instability of patients diagnosed
with borderline personality disorder (BPD) (Linehan, 1993). DBT is grounded in CBT
and incorporates concepts from Zen Buddhism of being mindful in the here and now in
order to help with emotional regulation (Linehan, 1993). DBT teaches behavior skills to
replace dysfunctional behavior that is practiced as a result of emotional dysregulation
(Linehan, 1993). There are four modules in DBT skills development including
mindfulness skills for cognitive dysregulation, distress tolerance skills for behavioral
dysregulation, interpersonal effectiveness skills to aid in challenging cognitive
42

distortions, and emotional dysregulation skills to teach to observe, identify and validate
ones emotions (Brodsky & Stanley, 2002).
Although there is an emotional component to DBT, the teaching does not include
experiential skills to change behavior after the emotions are observed, identified, and
validated, making DBT effective, but again lacking in the deep emotional release of held
feelings (van der Kolk, 2002). Combining a short course of CBT with a long-term course
of DBT have been used and reported to be effective in the treatment of bulimia, but less
effective for restrictive anorexia diagnosis with only a 50% recovery rate for bulimics
(Wilks, 2006). Further study is indicated to discover what other interventions can be used
with CBT and DBT to further improve the recovery rates for patients diagnosed with
eating disorders. Experiential forms of intervention have given initial indicators of such
enhanced methods such as art and movement therapy (van der Kolk, 2002).
Art Therapy with Eating Disorder Patients
The National Coalition of Creative Arts Therapies Association (2009) identifies
Margaret Naumburg as a pioneer in the art therapy movement. In the 1930s, she allowed
patients to engage in spontaneous expressions of art to become the objects of selfreflection leading them to self-understanding (Blatner, 2004). This led to another art
therapy notable, Edith Kramer in the 1950s to posit that making imagery would
sublimate the feelings and heal the inner world by helping the patient transform personal
experience into expression of the human condition (Blatner, 2004). These pioneers
allowed spontaneity and creativity to flow from the inner emotional world of the patient
much like Moreno theorized psychodramas foundation.
43

For the patient with an eating disorder, the distorted and difficult body-mind-spirit
connection can be bridged from inner reality and outer reality in the use of art therapy.
Shapes, forms, colors, construction, and texture are all parts that can be used to detach or
re-attach to ones body (Levens, 1990). Art therapy can be used either in individual or
group formats with patients with eating disorders and allows the patients to explore and
communicate emerging feelings in a creative and open venue (Johnson & Parkinson,
1999).
Movement Therapy with Eating Disorder Patients
Body and movement expressions have been used as vehicles for healing
throughout history, noted as early as Greek and Roman times and throughout historical
indigenous tribal rituals (Blatner, 2004). According to the American Dance Therapy
Association (2009) Marian Chace introduced dance and movement therapy in the 1960s.
It is believed that dance therapy can mobilize patients who are withdrawn and resistant to
other types of treatment allowing for body connectedness to occur (Blatner, 2004). Body
awareness and connectedness are significant parts of movement therapy making it a
natural fit to help in the treatment of patients with eating disorders, but there is limited
empirical research published in this area.
Body awareness and satisfaction are distinct criterion in the diagnosis of both
anorexia and bulimia leaving the patient with an intense focus on their appearance and
how others perceive them. Body image is psychological in nature and much more
influenced by self-esteem than by actual physical attractiveness as judged by others
(Davison & Birch, 2001). This perception of body image is not inborn; it is learned and
44

reinforced by interactions with family, peers, society, and media (Davison & Birch,
2001). Self-objectification has been shown to produce body image distortion and shame
with the potential to develop disordered eating (Piran & Cormier, 2005). Thought focused
therapeutic interventions with body image include positive self-talk, cognitive
restructuring, and reframing through CBT and DBT. Body image movement-oriented
therapeutic interventions have been introduced and show that integrating movement,
body acceptance, and mind-body connectedness aids in the recovery of the patient
diagnosed with eating disorders (Beck, 2008).
Summary
Morenos development of psychodrama was born out of creativity and
spontaneity, as were the other forms of therapy mentioned here. Integration of various
forms of therapeutic intervention may be the best type of treatment offered the patient
with eating disorders. The limited amount of research in the areas of experiential
therapies specific to the treatment of eating disorders supports the need for this study.
Experiential therapies offer structured activities that allow for creative expression within
a therapeutic setting to help the individual develop a greater connection with the
subconscious mind and emotions. With well-trained guidance, this connection can be
used in the enhancement of eating disorder treatment.
Evaluation of Viable Research Designs
Psychodrama is spontaneous and creative in its application allowing the trained
practitioner to be present in the moment with the patient. Practitioners of psychodrama
tend to be more clinically oriented than research oriented relying on shared anecdotal
45

information when advocating the effectiveness of the method (Kellerman, 1991).


Although Moreno developed specific tests to measure psychodrama such as spontaneity
and creativity tests, role tests, social atoms, and other action-oriented tests, they are
almost nonexistent in the literature of experimental research (Kellerman, 1997). Moreno
rarely engaged in quantitative study of psychodrama defending the idea that the validity
of the work does not need proof beyond face value and the reporting of the patient and
therapist (Kane, 1992). Blatner (1973) admits that theoretical and empirical research is
lacking, especially in form of controlled outcome studies. Since 1973, there has been
more research in the field of psychodrama, but the majority of these studies have been
qualitative in nature.
Research designs discovered in this review in coordination with eating disorders
and psychodrama appear to be mostly qualitative and narrative in nature. Quantitative
designs were used in the studies that explored outcomes associated with CBT and DBT
using the Eating Disorders Index (EDI) to measure change.
Recommendations in the field of psychodrama research have indicated that
therapists need to increase the number of quantitative research studies in the area of
classical psychodrama techniques, design studies that focus on issues such as suitability
of psychodrama to specific populations, diminish subjectivity of measurements in studies,
and use combined research methods (quantitative and qualitative) as the means of
measurement in the evaluation of psychodramatic issues (Kane, 1992). Ongoing research
in the field is necessary to continue to strengthen the acceptance in the scientific
community of psychodrama as a valuable therapeutic intervention.
46

Chapter 2 Summary
The literature reveals the origin and progression of the Moreanean Theory of
psychodrama and the importance of spontaneity when facilitating the therapy. Eating
disorders have been identified as having their origin in emotional regulation difficulties,
family of origin issues, societal issues, and differences in learning style (Annus, Smith,
Fischer, Hendricks, & Williams, 2007). With cognitive behavioral therapy being
identified as the treatment of choice for clients with eating disorders with limited benefit,
psychodrama and other experiential techniques have been identified as adjunct treatments
for this population (Kipper & Hundal, 2003). It appears appropriate to explore the
experiences of women who are diagnosed with eating disorders and are participating in
eating disorder mental health treatment that take part in psychodrama therapy in order to
encourage more research in this area of specialty.

47

CHAPTER 3. METHODOLOGY
Introduction
This chapter discusses the qualitative design of the study, methodology, and
researcher philosophy that was used to investigate the previously identified research
questions. Chapter 3 provides a detailed accounting of the sampling procedures and
participant recruitment process, as well as discusses the data analysis procedures, share
the expected findings, and discuss the ethical issues related to this study.
A Re-Statement of the Study Purpose
The purpose of this generic qualitative in-depth interview research study is to
acquire and articulate the treatment experiences of women who previously engaged in
psychodrama therapy as a component of eating disorder treatment. This study adds to the
field of psychodrama therapy and eating disorder treatment knowledge by enhancing
clinicians treatment approaches to this population, and elicit ongoing research questions.
Research Questions
The research questions for this study are:
1. What are the treatment experiences of women who previously engaged in
psychodrama therapy as a component of eating disorder treatment?
2. Based upon the participants experiences about the use of psychodrama as a
therapeutic intervention for their illness, how can these experiences enhance
clinicians overall treatment of eating disorders?

48

Research Philosophy
The selected methodology of the research is generic qualitative inquiry as first
discussed by Husserl during the mid-1890s (Embree, 1997). Husserls philosophy
opposed the way of scientific laws of mathematics and physics in research and believed
that human perception of being in the world was necessary to research (Sadala & Adorno,
2002). Merriam (1998) wrote about social reality being in constant change and that the
world is being shaped by the experiences and interpretations of humans. The aim of
qualitative research is to gain deeper insight into individuals, events, or phenomenon
(Farber, 2006). This generic qualitative research study listened to the experiences of
women diagnosed with an eating disorder who have participated in psychodrama therapy
as a primary treatment modality. Through this research process, the participants stories
uncovered common themes and provided new opportunities for development of treatment
applications for professionals providing therapy to this population.
Moreno (1964) believed that as people work through the recreation of their
perceived reality of a situation being open to internal and external messages they can
heal. Interpreting the actualization of a situation in the here and now through spontaneity
and creativity are the basis of the theory of psychodrama (Apter, 2003). Interviewing the
participants as to their experience with psychodrama provided additional information
about psychodrama and its use in eating disorder treatment making qualitative in-depth
interview research appropriate for this study.
The ontological assumption of this research study is that the participants provided
insight into the experience of psychodrama therapy that has proven beneficial to the field
49

of eating disorder treatment. In conducting open-ended, in-depth interviews of the


participants the epistemological assumption concluded that there is information obtained
to pursue additional research in this field of study. The axiological assumption predicted
that supported research in the area of psychodrama and eating disorder treatment is
important to the field and to those diagnosed with eating disorders enhancing
professionals treatment approaches with this population. Founded in postmodernism and
grounded theory, basic interpretative method of content analysis of the in-depth interview
data provided the researcher with material to reduce and refine the experience of
psychodrama therapy used with women with eating disorders (Neuman, 2006).
Research Design
In the attempt to understand the participants experience with psychodrama
therapy, in-depth face-to-face interviews were used. The interviews were digitally audio
recorded and examined to discover the participants knowledge of a phenomenon or
experience (Patton, 2002). The interview method allowed the participants to share their
experiences in their own voice and from their own perceptions (Patton, 2002).
In conducting in-depth interviews, techniques of probing, redirecting, clarifying,
and confronting were used to try to obtain information (Berg, 2007). Probing was used to
try to obtain more information from the participant as well as to try to clarify information
already given in the interview (Berg, 2007). Confrontation and redirection were used
when conflicting information was presented during the course of the interview (Berg,
2007). Summarization was used to insure that the information gleaned was understood by
the researcher (Berg, 2007).
50

Sampling Procedures
The population from which the participants were drawn was adult women, age 18
to 65, who previously received treatment for a diagnosed eating disorder, who had a
minimum of one year of recovery and who were not suicidal. The participants received
psychodrama therapy as a therapeutic modality during their course of treatment. The
researcher obtained participants from several resources through the snowball procedures
meaning, as participants found out about the study they informed others whom they may
be acquainted and met the criteria and were interested in participating in the study
(Neuman, 2006). This sampling approach was used because the population consisted of
participants who were diagnosed with eating disorders of Anorexia Nervosa, Bulimia
Nervosa, or Eating Disorder, NOS and who participated in psychodrama therapy during
their treatment (Glicken, 2003). This purposeful, snowball sampling approach was being
used because the population consisted of participants who had specific attributes and
were of a sensitive and difficult to reach population (Berg, 2007). A minimum of 10
participants were sought out for the study. The first ten people who responded and meet
the criteria for the study were selected to participate in the study. The criteria indicated
for the appropriate number of participants for a proposed qualitative research study
utilizing in-depth interviews in a population as described would include sufficiency and
saturation (Seidman, 2006). Obtaining ten participants met sufficiency and saturation in
having acquired an adequate number of observations and themes from the participants
interviews that the examples were repeating instead of extending (Mertens, 2005).

51

Recruitment Strategies
The researcher proposed to obtain participants from several resources detailed in
the next few paragraphs. Once participants were reached, they contacted the researcher
directly through email or telephone with the understanding that it was the participants
choice to pursue the interview or even respond at all.
Participants were recruited from several resources including flyers posted, with
permission, in the local 12-Step meeting locations, an outreach letter mailed to licensed
treatment professionals requesting to inform their clients of voluntary participation in the
study, and a flyer posted on the community information board at a local supermarket.
Participants recruited through licensed treatment professionals were not directly referred
to the researcher from the treatment professional. The participants were given the
researchers contact information to contact the researcher directly. There was no
confidentiality breech on the part of the treatment professional because there was not a
direct participant referral being made.
Data Collection Procedures
Once potential participants responded to the request to be part of the study by way
of email or telephone call, initial contact by the researcher to the participants was made
by way of emailing an informational research packet to the participant to include; a letter
of introduction to the study, a participant assessment and demographic form (Appendix
A), and a copy of the informed consent form.
If the participants met the criteria for inclusion in the study, the participants were be
individually interviewed face-to-face by the researcher. The initial interviews took place
52

in a private room at one of the branches within the Maricopa County, Arizona, Library
District convenient to the participants home. Permission was received by the Maricopa
County Library District to reserve library conference rooms to interview the participants
in the study. The researcher scheduled the interviews at the convenience of the
participant. Through snowball sampling, recruitment of participants spread from the
localized coverage area to other states. A revision was made to the approved IRB
proposal to expand the data collection to other states. The revision was approved by IRB
and the researcher expanded the participant interviews to Colorado, Pennsylvania,
Washington, and Texas.
The participants were interviewed using a field tested interview guide (Appendix
B). Each interview was audio-taped using a Sony ICD-UX200 digital recording devise,
with the participants consent. Audio-taping the interviews allowed the interviewer to pay
close attention to the participant, reducing distractions (Berg, 2007). The digital audio
recordings were transcribed in a Word document format by a paid contracted
transcription company, GMR Transcriptions, into documents that are compatible with the
qualitative data analysis software Atlas.ti.
The transcribed data was analyzed using grounded theory methods of content
analysis procedures looking for relevant and recurrent themes among all of the
participants (Leedy & Ormrod, 2005). Data was identifiable by a randomly selected name
chosen by the participant. Record of demographic information, digital audio data, and
transcriptions of interviews are kept in separate locked cabinets at the researchers home
office (Berg, 2007).
53

Using a standardized open-ended interview format (Sproul, 2002), this writer


conducted in-depth interviews to gain insight into the experience of women with eating
disorders that participated in psychodrama therapy. Because the women were unfamiliar
with the administrator of the questions, the basic demographic data from the participant
assessment and demographic form (Appendix A) was be reviewed in the initial part of the
interview process to attempt to provide a warm up to the session (Berg, 2007). The
researcher was the only interviewer to question each participant in order to positively
affect reliability and validity (Berg, 2007). Additionally, the same questions were posed
to each participant. The interviews were between 60 to 90 minutes in length. Follow up
interviews were conducted for clarification and validation of initial interview transcripts
for five of the ten participants. These interviews lasted for an additional 30 to 60
minutes. Total approximate time for participant involvement was estimated at two to
three hours.
Results of Field Testing Interview Guide
Field Test Request Correspondence was emailed to seven professionals in the
clinical therapy field. The letter invited the professionals to review the proposed
Participant Interview Guide requesting feedback from their perspective and experience.
All of these professionals are experienced in treating patients diagnosed with eating
disorders and six of the seven are certified in experiential forms of therapy. All of the
professionals selected had more than ten years of experience in the field. Six of the
professionals had more than twenty years of experience.

54

Two of the professionals were PhD educated, both of whom had achieved the
highest level of certification in psychodrama therapy and who are also trainers of
psychodrama. Two of the Masters level therapists are also the highest level of
psychodrama certification and are also trainers. One of the professionals is a Registered
Dietician who is also a licensed counselor.
Of the seven professionals surveyed, five replied to the request. Of the five
respondents, two indicated the proposed interview guide was appropriate as written. One
respondent proposed a minor rewording of one of the questions, which was revised. One
professional suggested including a question that addressed discovering clients feelings
about safety during their psychodrama therapy sessions. This suggestion was added in the
revised Interview Guide (Appendix B). One professional provided a significant amount
of suggestions for the Interview Guide encouraging some additional questions in the
revised Interview Guide (Appendix B).
Data Analysis Procedures
Descriptive interpretation of the data that was collected teased out categories and themes
(Creswell, 2003). Part of the data analysis procedures included looking at the number of themes
and categories that came up during the interviews. The researcher also looked for properties and
inconsistencies in the data, prompting reanalyzing the data to trigger second interviews with
participants for clarification purposes (Creswell 2003). The data was reanalyzed until saturation
was completed (Berg, 2007). The recordings were transcribed by a contracted transcription
company utilizing digital transfer from the Sony recorder. The transcription company signed a
confidentiality agreement with the researcher. The data was analyzed by the researcher with the
55

aid of Atlas.ti computer software. Open coding was used to identify categories or themes that
arose in the analysis. Axial coding determined subcategories and overriding themes that arose
within the subcategories of the originally identified open coded categories (Berg, 2007). Themes
were tied to existing theories of Morenean psychodrama as an experience to reframe or
experience feelings in the here and now, and new theories were developed (Berg, 2007).
Limitations of Research Design
Limitations of the research design were the possible bias of the researcher due to
previous experience and feelings of psychodrama therapy. Adopting an objective position
during inquiry aided in performing the project objectively (Glicken, 2003). The researcher in
this study consistently evaluated the ability to set aside previously known values and
knowledge about the experience of psychodrama therapy and experiences; then, through
researcher curiosity identified the reality for the study participants.
Another original limitation to the design was that the sample population was proposed
to be of one particular geographic location in the United States and may not be a true
representative sample of the population of women who are diagnosed with eating disorders.
However, during the recruitment process of the study, due to word-of-mouth snowball
sampling, the geographic location originally proposed expanded to include a variety of states in
the United States. Although this sample is still not representative of all women with eating
disorders, it is a sample that can provide insight into this population for further study with an
expanded, more closely representative sample.
The proposed text-related data collection methods were analyzed using Atlas.ti
software a recognized credible software analysis tool. The internal validity of this study was
56

demonstrated in the rigor and trustworthiness that the researcher maintained with the gathering,
maintenance, and interpretation of the data (Koro-Ljungberg, 2008). Using the data analysis
methodology described with the interview guide outlined in Appendix B, aided in supporting
an alliance with the problem of this proposed study. The study was not intended to provide
proof that psychodrama therapy is an effective form of treatment for women with eating
disorders, but to share the treatment experiences of the therapy in their treatment and to offer
professionals in the field of eating disorder treatment insight into treatment options for their
clients. Further quantitative research could be conducted to determine the effectiveness of the
therapy with this population.
Qualitative Validity and Reliability
The validity and reliability of this study was be established by obtaining a recording of
each participants interview and carefully transcribing it into a manuscript format. These
manuscripts were compared to the original recording to insure accuracy in the transcription
process (Lincoln, 1995). The use of a contracted professional transcription service and the use
of the Atlas.ti software analysis program also contribute to the validity and reliability of the
study.
The participants of the study were consulted during the process of data analysis to
validate this researchers interpretation of the coded categories established in the content. The
participants were contacted by the researcher for any clarification of the transcript, and of the
researchers preliminary analysis of the studys data. The researchers dissertation mentor was
also included to review the first few transcripts to insure credibility. A second interview was
conducted for clarification or validation purposes with five of the ten participants. The second
57

interview was scheduled in-person or by way of telephone interview. A formal, final written
transcript was offered to the participants upon completion of the data analysis. The
participation of the interviewees during this process improved validity in this study (Leedy &
Ormrod, 2005).
Expected Findings
The following assumptions were formulated based on the researchers experience
in the field and associated research with other types of illness. Women who have
experienced trauma and addiction and who have participated in psychodrama therapy,
tend to have positive outcomes and emotional regulation changes as a result of the
intervention (Dayton, 2000). With conventional talk therapy and cognitive therapy those
diagnosed with chemical dependency issues have a greater ability to persuade and
manipulate others more readily than with psychodrama therapy (Ramseur & Wiener,
2003). The spontaneity and creativity of psychodrama minimizes the ability of
manipulation of words due to the degree of action involved in the experience (Moreno,
1987). Having attended to women with eating disorders who have participated in
psychodrama therapy the anecdotal feedback from patients indicates there is a variation
to the experience that the patients feel with psychodrama as opposed to talk therapy. The
expected findings are expanded upon in Chapter 5.
Ethical Issues in the Study
The researcher of this study is a professional therapist in the field of eating
disorders and chemical dependency who actively uses psychodrama therapy as a mode of
treatment in practice. The researcher was vigilant to avoid conflict of interest to enter into
58

the interview and data analysis process. The researcher is a professional therapist in the
original community where the research was conducted. The researcher does not have any
personal acquaintance with colleagues who were contacted regarding this research. IRB
approval was obtained related to all aspects pertinent to this study prior to initiation of the
research. Continued IRB updates were submitted during the course of the data collection
to meet the requirements of ongoing IRB review. All of the text and transcribed materials
are securely stored in a locked file cabinet in the researchers home office for a period of
seven years. After the required seven year storage, the materials will be destroyed and
disposed of.
There were some limitations to this study; the participants could withdrawal from
the study at any time, because their participation was on a voluntary basis (Mertens,
2005). Researcher bias, interviewer dishonesty, sample size being too small, and sample
not being generalizable were also potential limitations to the research, (Creswell, 2003).
These issues did not present themselves during this study. Potential IRB confidentiality
and privacy issues working with a protected population did not prove to be a limitation
because all consent forms were developed and completed accordingly.
The participants were part of a protected population where anonymity,
confidentiality of the identity of the participant, and emotional support was paramount.
Having the records coded with the participant-chosen fictitious name aided in the
protection of the participants identity. The participants were be advised of the risks and
benefits of engaging in the study and were reminded that they were part of the study on a
voluntary basis and had the option to drop out at any time with no repercussion. Due to
59

the participants protected status, the researcher provided participants with a list of
resources, should they require the support of a professional during or after the research
study. Because participants came from various states, the researcher developed support
lists specific to each participants location. Potential distress resulting from the interviews
was discussed with the participants during the informed consent process of the study.
Conclusion
There is limited research devoted to using psychodrama therapy techniques with
women diagnosed with eating disorders. The literature discovered in the review was
primarily psychodrama focuses on its use with substance dependence, trauma, and
depression. Writing discovered about eating disorders was mainly related to body image
disturbance, societal and peer influences, and core issues connected to family of origin.
Cognitive behavioral therapy has been identified as the intervention of choice in most
literature without regard to experiential or action oriented approaches such as
psychodrama. This generic qualitative research study describes the treatment experiences
of women with eating disorders who engaged in psychodrama therapy during their course
of treatment and as a result offer enhanced treatment options to treating clinicians.

60

CHAPTER 4. DATA COLLECTION AND ANALYSIS


Introduction
This generic qualitative research study explored the experiences of adult women
diagnosed with an eating disorder who participated in psychodrama therapy as a
treatment modality. The design employed for the research was generic qualitative
research (Merriam, 1998). In this research study, the researcher analyzed the data with
the constant comparative, descriptive interpretation techniques typically associated with
grounded theory. However, no attempt was made to produce theory; rather the analysis
was used to gain deeper insight into the participants stories uncovering themes and
providing new opportunities for development of treatment applications for professionals
providing therapy to this population.
Central Research Questions
1. What are the treatment experiences of women who previously engaged in
psychodrama therapy as a component of eating disorder treatment?
2. Based upon the participants experiences about the use of psychodrama as a
therapeutic intervention for their illness, how can these experiences enhance clinicians
overall treatment of eating disorders?
Data Analysis Procedures
As detailed in Chapter 3 of this research study, the data analysis began
simultaneously with the data collection. As the study participants were responding to
specific, and open, questioning in the research interviews, the researcher was recording
immediate thoughts by use of personal notes for interpretation of responses during and
61

after participant interviewing. By doing so, the researcher was able to identify emerging
concepts and categories in the data, which would then be explored by this researcher with
the research participants for further clarification and elucidation of the central research
question (Patton, 2002).
Data analysis occurred simultaneously with data collection, as the researcher
identified responses that appeared common among all research participants and concepts
began to emerge from the data sets. Upon completion of the data collection, the
participant narratives were transcribed, read over several times, and continuously coded
using open, axial, and selective coding and the constant comparative method with the
assistance of Atlas ti software. In this way, data analysis continued throughout the entire
process of data collection to the identification of themes from the data. During this phase
of the analysis, the coded data was constantly compared to identify consistencies and
differences. The noted consistencies between the codes revealed categories, which were
then expanded into properties (Patton, 2002). After having arrived at categories and
properties from the data, themes were provisionally identified. The provisional themes,
by use of the constant comparative method, were further compared to the already coded
and categorized data. This process finally yielded the presence of two general themes
common to all research participants experiences of psychodrama therapy.
Participant Profiles
The participants for this study were chosen according to the criteria detailed in
Chapter 3 of this dissertation, and the following is a description of the research

62

participants using the names by which the participants chose to be called for the purposes
of this study: Refer to Table 1 for participant demographics.
Anna is a 60 year old, Caucasian female, who was diagnosed with bulimia
nervosa. Anna is married and lives with her spouse in Arizona. Annas highest level of
education is PhD (ABD). Anna participated in inpatient and outpatient treatment for her
eating disorder.
Cecelia is a 25 year old, Caucasian female, who was diagnosed with anorexia
nervosa. Cecelia is in a relationship and lives with her partner in Arizona. Cecelias
highest level of education is a Bachelors degree. Cecelia participated in inpatient, partial
hospitalization (PHP), outpatient, and 12-Step meetings for her eating disorder.
Kelly is a 40 year old, Caucasian female, who was diagnosed with bulimia
nervosa and eating disorder NOS. Kelly is married and lives with her spouse in Arizona.
Kellys highest level of education is a Masters degree. Kelly participated in inpatient,
outpatient, and 12-Step meetings for her eating disorder.
Baby is a 50 year old, Caucasian female, who was diagnosed with bulimia
nervosa and eating disorder NOS. Baby is married and lives with her spouse in Arizona.
Babys highest level of education is some college. Baby participated in inpatient,
outpatient, and 12-Step meetings in the treatment for her eating disorder.
Lilly is a 38 year old, Caucasian female, who was diagnosed with eating
disorder NOS. Lilly is single and lives alone in Colorado. Lillys highest level of
education is a Bachelors degree working on her Masters degree. Lilly participated in
inpatient, outpatient, and 12-Step meetings for the treatment of her eating disorder.
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Anne is a 50 year old, Caucasian female, who was diagnosed with eating
disorder NOS. Anne is married and lives with her spouse in Colorado. Annes highest
level of education is some college. Anne participated in outpatient therapy and 12-Step
meetings in the treatment of her eating disorder.
Sue Ellen is a 60 year old, Caucasian female, who was diagnosed with eating
disorder NOS. Sue Ellen is married and lives with her spouse in Colorado. Sue Ellens
highest level of education is some college. Sue Ellen participated in outpatient therapy
and 12-Step meetings in the treatment of her eating disorder.
Julie is a 33 year old, Caucasian female, who was diagnosed with eating
disorder NOS. Julie is divorced and lives alone in Pennsylvania. Julies highest level of
education is a Masters degree. Julie participated in outpatient therapy in the treatment of
her eating disorder.
Ann is a 31 year old, Caucasian female, who was diagnosed with anorexia
nervosa. Anne is in a long term relationship and lives with her partner in Washington.
Anns highest level of education is a Bachelors degree. Ann participated in inpatient,
partial hospitalization (PHP), outpatient, and 12-Step meetings in the treatment of her
eating disorder.
Lauren is a 53 year old, Caucasian female, who was diagnosed with eating
disorder NOS. Lauren is divorced and lives alone in Texas. Laurens highest level of
education is a Masters degree. Lauren participated in inpatient and 12-Step meetings in
the treatment of her eating disorder.

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Table 1
Participant Demographics
Name
Anna
Cecelia

Eating
Disorder
Bulimia
Caucasian
Nervosa

Age Race
60
25

Anorexia
Caucasian
Nervosa
Bulimia
Nervosa,
Eating
Disorder
NOS
Bulimia
Nervosa,
Eating
Disorder
NOS
Eating
Disorder
NOS
Eating
Disorder
NOS
Eating
Disorder
NOS
Eating
Disorder
NOS

Kelly

40

Caucasian

Baby

50

Caucasian

Lilly

38

Caucasian

Anne

50

Caucasian

Sue
Ellen

60

Caucasian

Julie

33

Caucasian

Ann

31

Caucasian

Lauren

53

Eating
Caucasian Disorder
NOS

Anorexia
Nervosa

65

Education Treatment
PhD
(ABD)

Inpt, Outpt

Inpt, Outpt,
Bachelors PHP, 12Step
Masters

Inpt, Outpt,
12-Step

Some
College

Inpt, Outpt,
12-Step

Bachelors

Inpt, Outpt,
12-Step

Some
College

Outpt, 12Step

Some
College

Outpt, 12Step

Masters

Outpatient

Inpt, Outpt,
Bachelors 12-Step,
PHP
Masters

Inpt, 12-Step

Findings
The objective of this study was to understand the experiences of adult women
who were diagnosed with an eating disorder and who participated in psychodrama
therapy as part of their treatment experience. This study also was seeking to discover,
based on the participants experiences, how their experiences can enhance the treatment
of eating disorders. The participants were asked several questions during their interviews
based on a field tested interview guide (Appendix B). There were also sub-questions
developed throughout the process as commonalities between what the participants
experienced were identified by the researcher, as well as after revisiting the emerging
concepts in the transcription review and coding process.
The experience shared in the interviews of the participants detailed eight
predominant categories: experiences in the psychodrama, eating disorder specific topics,
protagonist vs auxiliary or audience experiences, comparison of psychodrama to other
therapies encountered, emotions/feelings generated during the experiences, therapist and
treatment recommendations, challenges in recovery, and opportunities in recovery. Each
participant provided thematic categories and properties that emerged in the analysis of the
transcripts. Table 2 highlights the categories, properties, and themes that emerged from
the research.
Following is an in-depth presentation of the findings organized according to the
identified theme, and then presented in greater detail according to the categories from
which the theme emerged. Each section will begin with the identified theme, and it will
then be broken down according to the various categories that contributed to the
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identification of the theme presented. Quotes from the participants interview transcripts
will be interjected throughout this section. Refer to Table 2, Experience of Participants,
for an overview of the category theme findings.

Table 2
Experience of Participants
Categories
Fear of emotional
connection

Fear of body connection

Properties

Emerging Theme

Experience Vulnerability
Showed depth of pain
Exposed layers of emotion
Became introspective
Could not shut down feelings
Could not numb feelings
Had to pay emotional attention
Became honest about feelings
Took a lot of emotional energy
Predominant feelings: fear, pain,
shame, anger

Theme 1: Connection

Being on Display
My appearance is not enough
Being seen
Cannot separate from my body
Pretending not there
Shrink away
Become invisible
Be perfect
Constant comparison
Self-loathing of my body
Cushion between self and others
Being present with my body

Theme 1: Connection

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Table 2 Continued
Fear of connection to
self

Experience of Participants
Categories

Belief I can be fine


Recognize things about self
I am enough
Being able to have a voice

Theme 1: Connection

Properties

Emerging Theme

Better skills to cope


Empowerment
Express self more freely without shame
Getting to know myself at a different
level
Become introspective
I am loveable
Accepting my humanity
Believing I can heal and change
Having a relationship with myself and
food
Isolation/disconnection from myself
Self-loathing
Be nice, be good, be loved
Allow vulnerability
Empowered to make decisions
Fear of connection to
others

Don't have to be alone


Dont have to be unique
No need for comparison to others
Seeing others from a different
perspective
Seeing self-connecting to others safely
New awareness of situations
Development of empathy
Connection with a Higher Power
through others and then to self
68

Theme 1:
Connection

Table 2 Continued
Encouraged participation with others
and life
Vulnerability proven as safe in this
environment
Connect with people on a deeper level
Be with friends and family
Accepted by others
Experience of Participants
Categories
Properties
Need for safety in
therapy
Therapists need to be known
Non-judgmental
Compassionate
Encouraging
Trustworthy
Truthful
Authentic
Eating disorder is not the focus of the
therapy
Holistic awareness of the core
problems
Allowing processing time for the work
Allowing enough time for the work
Being familiar with the therapist and
the group
Being aware of the fears of body,
emotions, vulnerability, and mistrust

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Emerging Theme
Theme 2: Safety

Fear of Connection
The first theme that emerged from the data analysis and became overwhelmingly
clear early in each participant interview was the concept of having fear and of being
connected. Whether that connection was emotional, physical, relational, or personal it
was consistently identified throughout each participants sharing. The eating disorder
behavior aided the participants in covering up their fear of connectedness. It was also
consistent throughout the sharing that the participants found their experience with
psychodrama therapy associated with identifying and finding some healing or resolution
to their fear of being connected.
Emotional Fears
The participants shared their experiences of being involved in psychodrama
therapy as being overwhelming, providing them with a venue to expose their emotions in
the presence of others. The eating disorder behavior of using food to numb emotions was
not available to them during treatment and their experience of the drama, allowing the
participants to feel their feelings. Being disconnected from emotions exacerbated the
other identified themes of fear of connection to body, self, and others. The primary
emotions identified by the participants were the feelings of fear sometimes referred to
as anxiety or feeling overwhelmed, pain sometimes referred to as sadness or grief,
shame, and anger. These feelings were also referred to as the bad feelings that caused
the most distress, so medicating them with food, or attempting to withhold food, was the
behavior. Being detached from their emotions and staying in a cognitive-oriented, or
thinking state, did not allow for emotional connection. By engaging in the psychodrama
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experience allowed the participants to become connected to their feelings and took a lot
of energy. Having to pay attention to the emotional pain was identified by most of the
participants as uncomfortable and too revealing. Julie reported:
The awareness of living in fear then also fuels me I eat to try to calm that fear
and so it becomes that vicious cycle of having that awareness that having the fear
tying so much of my self-worth into that fear then creates me to overeat which
then again just contributes to the fear.
Having the fear of connecting to the emotions fuels the eating disorder behavior. Shutting
down, because it was just too hard to feel the emotions, was soothed by the food or by the
perceived control over the food. Anne reported:
When I eat, thats exactly the thing Im trying to get rid of the pain, the
emotions. Please go away and leave me alone. Ill just eat. So to turn off the
eating for a moment and go to the pain urgh! is hard, frightening, scary,
terrifying that all is its. I dont think theres any other way to heal, but go to the
pain.
Lauren shared:
I credit that one method for helping me get unstuck emotionally and spiritually in
my eating disorder; therefore, it was a breakthrough for me.
Julie shared:
It helps me kind of step out of whatever emotion Im feeling and kind of look at it
from the outside.
Cecelia shared:
It allowed me to work through experiences or work through emotions that I
couldnt get out, whether it was on paper or I just couldnt get out in another
way. And for me, it was it also brought things out as I would go through it
more, go through when I wentthrough my experience, it brought things out that
I didnt realize were there. I dont itwas very cathartic and it pulled things out
that I didnt realize could have been there.

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Another connection that came up repeatedly during the interviews with the
participants about the need to present as nice or perfect which was a cover-up of the
true emotions being felt by the participants. They would attempt to become disconnected
from the feelings by presenting a false feeling of joy or contentment. The participants
shared that this was partly because of the desire to stay disconnected from the true
emotions underneath and partly because of their lack of connection to the self or
esteem. Anna stated:
Taking on most of the blame for the situation, continuing to be very angry at
people long after the event was long over. I think a lot of eating disorder people
are very nice. They try to be very nice, and sometimes thats genuine and
sometimes thats just a cover up a mask.
After participation in the psychodrama experiences, the participants shared that
they were glad that they allowed themselves to pay attention to the process. It allowed
them to examine the emotions, process them, and realize that they could move forward in
healing and recovery by allowing themselves to become vulnerable to the process. The
participants also identified that the emotions were not going to kill them. Anne reported:
I allowed, for the first time, one of the few times, to experience the pain. Ive
always been afraid that the pain would kill me. If I ever let it in or let it out, I
would die and I didnt die, but the pain and the tears of it all, it was so
overwhelming, but it felt so good to get it out finally and so the surprise would
be the depth of the pain. The surprise would be I didnt die in my pain.
At first I was very hesitant to jump in. Extremely hesitant, but once I did so, I
have to say that that moment for me was one of the most dramatic, without it
being a play on the word, but in a sense of being able to release feelings and
emotions and have movement. It feltit was an incredible experience, really.
Rather than talking something through and to actually do it like that was very
intense, and I sobbed and sobbed and sobbed and sobbed during that whole time.
It was very cathartic, you know. It wasnt until I allowed myself to let loose that I
experienced anything that was healing and healing came eventually. I mean, once
I started into it and let myself go, the pain was so tangible. I dont know that in all
72

the counseling Ive done and everything Ive gone through that anything was
quite like that the pain coming up in that manner.
Ann shared:
Just being overwhelmed with all the emotions, and all the feelings that had been
bottled in for so long I would say after a little bit of time, maybe a couple of hours
or the next day I definitely felt better because I was able to cope and to move
forward with it instead of return back to my old behavior.
The most poignant experiences shared related to the fear of emotional connection
and the healing received as a result of participating in psychodrama therapy was that
emotions dont have moral value and that I dont have to live enslaved in the secrecy
and darkness of the shame of the food, which is so shameful. The cognitive therapy that
most of the participants received before accessing experiential methods, such as
psychodrama, was not touching the emotions and allowed me to stay in my head. Kelly
shared, I experienced that on a physiological level of what it was like to have that
anxiety, fear, and then, move through it in a functional way.
Body Related Fears
Another concept of disconnection that became very present in the data analysis
was the fear of being connected to ones body in conjunction with the fear of ones body
being seen/visible. One of the challenges shared in participating in psychodrama was that
if the participant was portraying a primary or auxiliary role, they were on stage and
were being seen. The fear of being compared in body image with others in the groups
was another area of vulnerability. Connecting this with anorexia nervosa, where Anne
shared that if the emotional feelings got hard, I didnt want to be there because Id just
shrink away or it wasnt there. Thats kind of life and what was going on. It brought back
73

that whole shutdown feeling, a kind of emotional feeling that I would go through if
anything got hard. Lilly shared that I spent my life making sure that nobody saw me
and Anne stated to take that step to not be invisible is terrifying. So you have to have the
right person to lead you into that, I think. These concepts were both speaking to not only
the fear of being seen and having their bodies on display, but also the safety that is
necessary in order to positively participate in psychodrama, which will be discussed
further in this chapter as an identified theme.
It became obvious that being aware of body image issues of people who are
standing up in front of other people was very sensitive within this population. The lack of
connection to ones body was also a significant theme that arose. Using the disordered
eating behaviors allowed these participants either to shrink away to not be seen or
build a barrier that no one will want to look at me. Anne stated:
I think because for me an eating disorder is so body-centered and oriented and so
insane, with that whole body image thing and all of that ties into that, to be able to
move in a way that is wasnt about, On, no! Whos looking at me? Oh, my gosh,
if I move over that way Im going to knock a chair over because Im so big. All
of those little lies that go with all of the stuff and to just give in to the moment and
experience myself in a way where I didnt feel fat or judged, was free and healing.
Kelly stated:
Being seen, the shame about being a woman, and owning femininity, owning
sexuality you know, that whole piece, and that piece was helpful with the body
image stuff.
Anne shared:
I think it can be most helpful in eating disorders because of the whole body image
thing. I think those of us who struggle with eating disorders because were so
ashamed of our bodies and so ashamed of anything that bring attention to them, to
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be able to express ourself in that way can give us a hope hopes a good word
that were not stuck there, that this isnt how it has to be.
Having participated in the psychodrama experience, the participants shared that
they could be more present with themselves and with their bodies with reduced feelings
of shame. They also found a sense of my appearance is enough and that I do not need
to look perfect to be ok. These awarenesses allowed them to become more holistically
connected with themselves by working through the body image fears and disconnects.
Fear of Self
With the above mentioned fears of emotional and body connection, the
participants also identified a strong theme of becoming fearful of connecting to
themselves. Lack of esteem, self-worth, and empowerment were all identified in the
interviews. The emotional eating and disconnection from their bodies reinforced their
desire to remain disconnected to the self. Feeling overwhelmed because I am not
enough and the desire to be one down to others was common. The participants also
shared that they had used food to remain disconnected and isolated from others and
from self. The questioning of being loveable and being enough came up again and
again in the interviews. Anne shared:
I think for me there was always such a disconnect. A disconnect to consequences.
A disconnect to how it feels. A disconnect to the emotions really happening. A
disconnect to even sometimes of being in the moment, of being present because
the connection for me is with the food. If Im connected with the food Im not
going to have to worry about what else is hurting, what else is happening, what
else is going on. Who cares? Ive got my food. So, yeah, disconnection is an
unhealthy keyword for eating disorders, in my opinion, totally. Will God bless
me? Im supposed to love myself. I dont know how to do that because I look in
the mirror and see something thats unlovable. I think every day, every moment is
an opportunity to go before God and surrender and to examine the pain and to
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find that freedom and that place, but I think fear. Fear and fear keeps us from
really wanting to look inward, really wanting to feel the pain.
Anna shared:
I think the issues of trust and acceptance. People are just people, including myself
and including those people who have hurt me. And seeing it more as a human
thing than being eating disordered, I think, was such a secret for me for so long
that I assumed that if anybody found out about the eating disorder they wouldnt
like me or they would think less of me, and those were of course all feelings I had
about myself, that I was damaged or flawed or all that. But psychodrama helped
me move past that.
Cecelia shared:
It empowered me because I could put names and faces on things and I could disassociate the eating disorder from Cecelia. It wasnt that Cecelia was the eating
disorder and they were synonymous. Its that they could coexist and I could
actually be Cecelia without the eating disorder and it didnt consume me. Because
it had been such a long time since I really had felt that way. It gave me a new
perspective and outlook. I was empowered.
Kelly shared:
Psychodrama was important in owning my truth, owning my reality, speaking my
voice all that stuff that sometimes can be issues with eating disorders. It
changed the way I experience myself. It helped me move from a place of I cant
to I can, just mastery, I dont have to be a victim, and that the past was the past
and that I survived that.
Baby shared:
I always felt very isolated in all of my therapeutic work, working with counselors
or with clergy or whoever, that they didnt really understand and that I was the
only one on the earth that felt like this, and I think this kind of an experience in
the psychodrama and seeing what they go through and the feelings that they were
presenting, it made me realize how similar we were and that I dont have to feel
shameful or bad or anything because I felt that way or that there was no hope
because I was the only one who felt like this. I think that was some of the biggest
breakthroughs that I might have had during those types of experiences.

76

Julie shared:
I think psychodrama could help to get to what the underlying issues are as
opposed to just looking at the food and overeating and looking at the symptoms of
it. Psychodrama has been beneficial in kind of looking at, for instance, sometimes
its my codependency that creates the overeating and looking at some of the more
root causes of what causes my eating disorder to happen. Its about my
relationship with myself, and Im being paid attention to.
The participants shared that their experiences with psychodrama, although
challenging at times, allowed them to recognize things about themselves and begin to
heal. They could see themselves as loveable and allow for vulnerability. They believe
they can express myself more freely and become empowered to make decisions for
myself with the belief of knowing I am going to be fine. I no longer need to be
isolated and disconnected from myself and I can be accepting of my own humanity.
Fear of Others
Another idea that came out of the theme of connectedness was the fear of being
connected to others. The participants made this reference in the previous sections by their
comments indicating that by allowing themselves to become emotionally vulnerable in
the presence of others was challenging. Also allowing themselves to be physically visible
in their bodies was challenging. However, the experience of participating in psychodrama
also challenged the participants to step outside of themselves to become more aware of
others perspectives. The visual and participatory experience of the psychodrama allowed
for the ability to see myself connecting to others safely and encouraged participation
with others and then with life.
Connecting with others was described by Ann, Anna, and Anne as not feeling
alone and getting to know people at a different level and understanding that it is not
77

all about me and provided me the opportunity to experience a level of intimacy I


wouldnt have expected. Baby shared, I was most affected emotionally or some sort of
like epiphany is when I was observing and I could observe and just kind of feel things.
She continued to share, Its like looking in a mirror. Lauren shared:
I was able to see the power of the eating disorder from different perspectives,
especially as it relates to family and the impact of the eating disorder, the illness
itself, on different family members, and I was really able to see how everybody
had such a completely different role to play in supporting the illness continuing.
Lilly shared:
For the first time, I could see the bigger picture. Extracting it from my own being,
and seeing it on the outside, that made it really clear to me how wrong that was. I
definitely had more compassion for people and felt more connected.
Sue Ellen shared:
It felt good to be supportive of someone elses recovery and seeing them get their
ahas through it. I felt very bonded at that moment with my group. A relationship
with people who understand. It helped me to see that some people cant give me
what I need a learning process, I can recognize others who are acting out
inappropriately sooner.
This realization of connectedness enhanced the other experiences of connecting to
emotions, body, and self, by being able to know it is ok to connect to others and to
develop relationships through safety. There is no need for comparison or isolation due to
the esteem issues related to the eating disorder. The participants shared that through all
of these connectedness themes, the psychodrama experience aided in breaking these
barriers to recovery in ways that they had not experienced with other types of therapy.
This will be further discussed in the summary of this chapter.

78

The Need for Safety in Therapy


The second theme that arose in the analysis of the interview data was the
expressed need for safety with both the therapist(s) involved and the therapeutic process
itself. The participants identified many other types of therapeutic modalities they have
encountered on their journey to recovery from their eating disorder including: cognitive
therapy, DBT, individual, couples and group therapies, 12-Step programs, hypnosis,
EMDR, Gestalt, medication, art, yoga, tai chi, relaxation, equine, somatic, nutritional,
music, and bio-feedback. The most predominant therapeutic modality reported was
cognitive behavioral therapy including DBT in both individual and group formats. All ten
participants stated that the other types of therapy, like psychodrama, were better than the
cognitive therapy and worked much more quickly and made more of a lasting
impression. Anna stated, cognitive doesnt always get you where you need to be. This
experience rang true with all of the participants interviews regarding psychodrama
compared to other types of therapies they have encountered.
Kelly shared:
I did long-term cognitive therapy for my eating disorder for so long, and it didnt
it was not helpful. It did not, ultimately, solve the problem the cognitive piece
didnt I mean, perhaps, it was a step in the journey. I think doing experiential
work, and then, working a 12-Step program, and really looking at my
codependency, or what, ultimately, codependency looking at the codependency
work and the 12 Steps in Codependence Anonymous was really important for me.
But just having an internal shift from the psychodrama.
Also ringing true was the theme that there needed to be safety with the therapist,
group, and process due to the intensity and powerfulness of the experience. A majority
of the participants described the psychodrama experience compared to other forms of
79

therapy as feeling like there was an internal shift and that it got to the core of the
emotions. Most of the participants experienced their psychodrama sessions at an
inpatient or intensive workshop setting and were connected to their facilitators prior to
participating in the sessions. There were a few participants who shared about having
somewhat limited prior contact with the facilitators, but had familiarity with some of the
other group members or the environment prior to participating in the sessions. The
commonality in these two statements is that there was familiarity and safety with the
facilitators, some of the group members, and the environment.
Safety with Therapist
The descriptors identified by the participants for the therapist facilitating the
psychodrama sessions included: compassionate, skilled, trusted, nonjudgmental,
supportive, caring, encouraging, truthful, assertive with gentle presence, creative with
safe boundaries, and authentic. The importance of the safe environment seemed to be
directly connected to the facilitators ability to provide a safe container for the work.
This component promoted internal safety for the participant, allowing them to feel more
open to the experience. Sue Ellen stated, Having that safer environment, being with
people I knew, I think it was a much more positive experience. I think I felt freer to cry,
freer to feel, and then I had the support afterwards, too. Additional comments about the
safety of the environment provided by the therapists included that the therapists should be
aware of the fears being brought to the sessions by the participants including, but not
limited to their emotions, body, vulnerability, and overall mistrust due to their eating
disorder symptoms and barriers. But also important to know is that the eating disorder is
80

not the focus of the psychodrama work but that it should be a holistic awareness of the
core. Summing up that the facilitators be not only skilled in their ability to direct the
psychodrama experience, they also be skilled in their ability to treat those diagnosed with
eating disorders. Lilly sums it up by saying, Its not about the food, its about feeling
safe.
Anna shared:
If the person is not trained well to do it in the first place, then I can see it could
very easily unravel and become a big mess, because youre dealing with such
profound memories and vulnerabilities that if the person isnt trained to go slower
or go faster or whatever they need to do, I think it could really hurt the person
thats working with it.
Julie shared:
But I also think in the process of doing this over a number of years that has also
been an incredible place of growth for me as getting a little bit more comfortable
with that and really seeing the benefits of doing so and finding an environment
with a group where I can go and be really, really safe and really connected to
people on a kind of a deeper level and I dont often have that in outside life with
coworkers and even family and so its just been a great place to have that kind of
safety.
Cecelia shared:
Having to go through these uncomfortable situations, which is kind of scary
situations, just from the standpoint of scary, not safe, scary as in just territory that
you havent gone into yet, and so, its very comforting and it does feel very safe
to have those people around you and help support you through that, from a
healing perspective.
Safety with the Process
Psychodrama has a very distinct process as outlined in Chapter 2, including the
warm-up, enactment, and processing phases. The participants were consistent in
describing that the experience of the psychodrama be a safe one having time to start, to
81

develop, and to come to their natural conclusion and I dont think that can be rushed
said Lauren, during her interview. Lauren continued to say that it was critical for
everybody to have a chance to say first of all to get feedback to the people that were
playing roles, and then to own what was happening to them in that process. There was
overwhelming identification among the interview participants that it was necessary to
have enough time to complete the exercise, especially the processing time afterward.
Another shared the sense of importance regarding safety was that the groups should not
be facilitated by a lone therapist. There was an increased feeling of trust and support
when the groups were facilitated by a team of therapists. Anna shared, its just so
powerful that you need to have somebody who really knows how to move you through it
and also to take care of you afterward.
Another significant and surprising awareness as a result of analyzing the
interview data came when asking the participants about their experiences of being in the
role of the protagonist versus the auxiliary or audience roles. Although the role of the
protagonist is traditionally thought of to be the significant role providing a cathartic
experience (Moreno, 1987; Kim, 2003), a majority of the participants identified the
audience or auxiliary roles as the most significant for them.
Part of this identification was about the sense of safety they felt not being in the
spotlight, not having to perform, not having to be perfect, it was less intense
emotionally. The areas described above were also identified earlier in this chapter as
ways the participants can become disconnected and engage in the symptoms of their
eating disorder. However, participants shared they can be more emotionally available
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due to the distance, relax and observe, have the visual impact, see others and have
internal awareness, and it provided a cushion between myself and the protagonist.
This concept may be key to the facilitation of psychodrama with this population of
patients and may provide an increased awareness in the field serving this group. The use
of the observing ego, containing double, or body double, as identified in Kate Hudgins,
PhD, Therapeutic Spiral Model (2002), may be a more appropriate way to manage the
emotional intensity and safety concerns of this population versus traditional
psychodrama.
Anne shared:
I wish that every person in the world could experience it in some form however
that would look in some way because I really think most all of us have issues
that are deep and dark and painful and to express them in that manner is more
healing and real than anything Ive experienced, really. Its pretty amazing.
Baby shared:
You can either grow you cant stay stagnant. You get better or you get deeper
into it, so you have to choose. Thats the opportunity. You have to choose every
day to not let it get to you. Even if you succumb to whatever your particular issue
is, thats the challenge and the opportunity to try again next hour or day or
whatever. So really the challenge and the opportunity are the same thing.
Cecelia shared:
I think it also was a big tool in helping me with my recovery and being able to,
after I left inpatient and went into partial outpatient and then was really kind of
back in the real world, the psychodrama experience had enabled me and had given
me the tools to recognize the certain voices from my addiction, and my eating
disorder that I dont think I think I would have still have gotten that, but I think
that it does help it equips you a lot faster with it, and I think it does help you
push through some of your stuff a lot faster because you have to face it.

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Lauren shared:
I dont know how many years of therapy it would have taken for me to get that,
that I got in that one day. I would say that the work I did in ther had the most to
do with my belief that it could be different, and then my finally accepting it. So
its I dont know who dreamed it up, but it is absolutely one of the most
profound therapies Ive ever participated in. I think it should be a primary
modality in inpatient treatment where people are in an environment where they
can process their breakthroughs, and then in outpatient treatment programs where
there is substantial time to use psychodrama as a treatment modality. I think it
should be a requirement.
Anne shared:
For me, personally, it is the most powerful than anything that Ive done before or
since. I think anytime theres a chance to act out a role, a situation, a higher
feeling, for me, is far more powerful than to write it down or to tell the story.
Sue Ellen shared:
If someone in recovery from an eating disorder asked me about group therapy
with psychodrama involved, I would say do it. Its interesting, its fun, youll
learn a lot about yourself and what you need from life and God and people. And
things I would want to pass on to any woman with an eating disorder, its worth it.
Even if I dont gain a super thin body, Im gaining sanity and peace of mind and a
way of life that works for me. Whereas life was not working before. It was very
painful and I was causing pain to all those around me, and I dont have to do that
anymore.
Summary of Findings
The primary objective of this research study was to understand the experience of
adult women diagnosed with an eating disorder who participated in psychodrama therapy
as part of their treatment experience. The use of in-depth interviewing and the constant
comparative method of open coding proved beneficial in mining out data useful to
achieve the studys objective. This researcher was able to uncover commonalities in
experience among the research participants with saturation relative to the study sample
size. The commonalities of the adult women diagnosed with an eating disorder who
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participated in this study uncovered (a) fear of feeling connected; whether that connection
was emotional, physical, relational, or personal, (b) and a need for safety. The
participants were consistent in sharing that participating in psychodrama therapy as a
treatment modality for their eating disorder was beneficial and made a difference in their
recovery. They shared that the start of the process was hard and uncomfortable at first,
but in the end was a positive result. The modality helped them to escalate their recovery
at a quicker rate and was more impactful than other therapies, most predominantly
cognitive behavioral types of therapy (Fisher, 2007; Pascual-Leone & Greenberg, 2007).
The integrated approach of using CBT with psychodrama in a safe environment helped
the participant identify and change their cognitive distortions, particularly related to
intimacy or relational issues (Hamamci, 2002; Treadwell, Kumar, & Wright, 2002). The
participants shared that the experience helped them to make holistic connections,
emotional, physical, and relational, that had previously been difficult to access due to
their own lack of esteem, trust, and acceptance.
A secondary objective of this research, based on the experiences shared in this
study, was to enhance the clinicians overall treatment of eating disorders. The
participants shared the overwhelming need for safety and trust with their facilitator(s),
environment, and group indicating the importance of the clinicians to be highly skilled
not only in the facilitation of psychodrama methods, but also the eating disorder
diagnosis and symptoms (Kipper & Ritchie, 2003; Klontz, 2004; Moreno, 1964, 1987).
Awareness of the importance of body image issues and sense of respect for appropriate
emotional distance were identified as key aspects of facilitating psychodrama with this
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group. The use of containing and observing roles provided more safety to this population
and may provide clinicians with an awareness of using a less traditional protagonist
intensive role, and a more trauma based awareness Therapeutic Spiral Model (TSM) in
the treatment provision to this population (Hudgins, 1998).
In presenting this data, it is important to recognize that the small sample size puts
limits on the generalizability of the findings. The participants encompassed all three areas
of diagnostic criteria for eating disorders, but were predominantly ED NOS diagnoses.
All participants were Caucasians, impairing any attempt to generalize the findings from
this research relative to any other ethnic or racial group. Geographic location of the
participants was varied aiding in an attempt to generalize findings geographically in the
United States.
All of the themes that emerged from the research were arrived from a point of
saturation among the participants, and this merits attention in spite of the small sample
size. The ability to uncover so many commonalities of experience among the participant
interviews, given all three diagnostic criteria for eating disorders were represented, adds
value to the findings of this research.
Chapter 5 will provide a summary and discussion of the results of this research
study. The chapter will also include a discussion of the limitations of this study and
recommendations for future research in the area of interest related to eating disorder
treatment utilizing psychodrama methods.

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CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS


Introduction
Chapter 5 will provide the results and conclusions of this dissertation research
study. The chapter will also discuss limitations of this study and make recommendations
for further research in this area of relevance. This concluding chapter of the dissertation
manuscript will bring the project discussion to a close and provide information to support
ongoing research in the field.
Summary of the Results
This generic qualitative research study was guided by the research questions: (a)
What are the treatment experiences of women who previously engaged in psychodrama
therapy as a component of eating disorder treatment; and (b) Based upon the participants
experiences about the use of psychodrama as a therapeutic intervention for their illness,
how can these experiences enhance clinicians overall treatment of eating disorders?
Although the literature review explored studies focusing on the use of psychodrama
therapy facilitated in the treatments of substance abuse and trauma, (Avrahami, 2003;
Beyer & Carnabucci, 2002; Dayton, 2000; Dayton, 2005a; Dayton, 2007; Hagedorn &
Hirshhorn, 2009; Hall, 1978; Hudgins, 2002; Mactas, 1998; Uhlr & Parker, 2002), the
current research was sparse when attempting to examine the experiences of this specific
population of women, ages 18-65, diagnosed with anorexia nervosa, bulimia nervosa, or
eating disorder NOS (Baratka, 1994; Dayton, 2005b; Dayton, 2007; Hornyak & Baker,
1989; Hudgins, 1989; Hudgins, 2002; Ridge, 2007; Scott, 2000; Veenstra, 2009;
Widlake, 1997). The researcher sought to explore the experiences of this population, thus
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enabling them to share their experiences in participating in psychodrama therapy as a


treatment modality for the recovery of their disease.
As eating disorder diagnoses have become more recognizable to the public in
recent years, it is important to embark on research to assist in providing treating
professionals with additional resources to enhance therapeutic interventions to support
this population. The literature review provided studies supporting the use of cognitive
behavioral based therapies as the treatment modality of choice for the eating disorder
population (Binford, et al., 2005; Brewerton, 2004; Cassin, von Ranson, Heng, Brar, &
Wojtowicz, 2008; Karatas & Gokcakan, 2009; Levens, 1990; Linehan, 1993; Wilks,
2006). However, there have been some studies providing insight into the benefit of
integrating experiential or creative therapies in the treatment of eating disorders, such as
art, yoga, movement, and other experiential therapies (American Dance Therapy
Association, 2009; Ammon, 2003; Baratka, 1994; Beck, 2008; Blatner, 2002; Dayton,
1994) but limited studies directly associated with women ages 18-65 where psychodrama
has been a significant modality in the treatment of the disorder.
Utilizing a grounded theory approach allowed the researcher a systematic
procedure for data collection and analysis. No attempt was made to produce a theory,
rather a grounded theory approach allowed the researcher to personify and surmise what
was seen within the data, as well as to comprehend the raw data. This comprehension
allowed the researcher to identify common experiences verbally expressed by the
participants. The researcher used semi-structured, field tested, qualitative interviews with
the participants. It was the researchers goal to explore and understand the experiences of
88

adult women, ages 18-65, diagnosed with an eating disorder who participated in
psychodrama therapy as part of their treatment experience. Ten women, ages 18-65, were
interviewed. The interviews were audiotaped and notes were taken by the researcher. The
interviews were then transcribed by a contracted professional transcription company.
The systematic approach of grounded theory allowed for the use of open coding.
As data was gathered through the interviews, coding in the form of open, axial, and
selective, was utilized by the researcher. The researcher, to aide in coding, used a
computer software package called Atlas.ti. The use of Atlas.ti allowed the researcher to
link categories that emerged from the data. In addition to Atlas.ti, a constant comparative
method was also used. A constant comparative method is used to compare emerging data,
that has been systematically gathered from the research, for their both their similarities
and differences (Berg, 2007; Mertens, 2005). Through repeated reading of the interviews,
the researcher was able to link emerging themes. While conducting the interviews and
exploring the responses further questions arose from the data. Subsequent questions were
asked of the participants allowing for theoretical sampling. Second interviews were
conducted, which provided theoretical saturation with no further categories emerging.
The coding model allowed the researcher to discover core themes in the participants
reported experiences.
The findings of this study revealed that adult women, ages 18-65, diagnosed with
an eating disorder who participated in psychodrama therapy as part of their treatment
experience shared consistent commonalities in the areas of (a) fear of feeling connected;
whether that connection was emotional, physical, relational, or personal, (b) and a need
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for safety in the therapeutic process. All of the participants reported that participating in
psychodrama therapy enhanced and escalated their recovery process identifying the
modality as being more impactful than other therapeutic interventions they previously
tried. These participants reported that the experience aided in making holistic
connections; emotional, physical, and relational in turn identifying an increase in their
own esteem, trust, and acceptance.
Regarding suggestions for the treatment of eating disorders, the participants
overwhelmingly stated the need for safety and trust with their therapist(s), environment,
and group members. The participants identified the need to have a therapeutic alliance
developed with the facilitator. They also shared the benefit of having the opportunity to
be familiarized with their group members before engaging in vulnerable parts of the
process. The majority of the participants also indicated that the roles of the auxiliary or
audience member in the psychodrama afforded them the most impact in their ability to
recognize awareness about themselves and recovery changes. This last statement is the
most interesting finding in the study to be discussed further in this chapter.
Discussion of the Results
The participants of this research study shared their experiences of participating in
psychodrama therapy as part of their healing experience in the treatment of their eating
disorder. The participants were consistent in sharing that the behaviors associated with
their eating diagnosis, whether it be anorexia nervosa, bulimia nervosa, or eating disorder
not otherwise specified, were utilized to disconnect. With this particular sample
population, the food or control of food was used to numb, soothe, create a barrier, or
90

establish a false sense of self in the presence of others. The researcher identified this
theme in the analysis of the data as the fear of connection. The fear of connection was
then broken down into four sub-groups including; emotional, body, self, and others. The
participants identified the challenges of agreeing to, or participating in, psychodrama in
relationship to this fear of connection as initially overwhelming due to the anticipation
of having the experience of connection. Moreno (1994) identified psychodrama as a
tool to force a client into movement outside of their cognitive selves into a possible
uncomfortable and spontaneous place.
The emergence of emotional disorders addictive disorder, food disorders, or other
compulsive disorders was identified and discussed in research as methods of selfsoothing with connections to emotional dysregulation, and neurobiological reaction
(Beales & Dolton, 2000; Cockell,Geller, & Linden, 2003; Dayton, 2007; Hudgins, 2002;
Linehan, 1993; Mellody & Freundlich, 2003; Normandi & Roark 1998; Uhler & Parker,
2002). The fear of body connection, or extreme body distortion has been identified as a
core concept related to eating disorder issues with a deep disconnection being medicated
or regulated by food (Annus, Smith, Fischer, Hendricks, & Williams, 2007; Buck &
Sales, 2000; Christian, 1996; Polivy & Herman, 2002).
The participants shared the experience of the importance of being open-minded to
the psychodrama session and to stay present whether the participants were in the position
of the protagonist, auxiliary, or audience. The experience of participating in the
psychodrama allowed them to access their body and emotions in a way that was nonthreatening. This therapeutically monitored vulnerability allowed for an impactful and
91

intense experience without fear of judgment or loss of control. The participants


identified the sense of an internal shift allowing them to feel a connection not only to
others in their group experience, but in their relationship with themselves. This shift also
allowed them to not feel alone any more in their disease and become more engaged in
their recovery process. The identification of internal shift in this research study is
congruent with the work of van der Kolk (1996) where parallel healing processes occur in
creating neural brain chemistry changes promoting recovery. The process of allowing
them to become more vulnerable in the presence of others without shame also
encouraged internal growth and the ability to engage in a more spiritual connection. The
power of the group experience, whether as a protagonist, auxiliary, or audience member
allows for indirect insights to be able to adapt changes into personal life issues (Kipper &
Hudnal, 2003).
Another common theme in the analysis of the data was the importance of safety
with the facilitator, the group, and the process of psychodrama. The participants realized
that they were able to confront overwhelming fears of becoming connected when
supported through the psychodrama experience by trusted and skilled facilitators. This
resulted in opportunities for growth and recovery for the participants.
The literature identifies the significance of safety and adhering to the practice of
the psychodrama process in order to promote safety and healing (Dayton, 2005b; Jacobs,
2002; Klontz, 2004; Moreno, 1994). The group process and the therapeutic alliance
developed among the participants and their leader is a dynamic factor important for group
success and recovery (Yalom, 1995; Constantino, Anrow, Blasey, & Agras, 2005).
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Constantino et al., (2005) connect positive alliance among group and facilitator a positive
contribution especially identified in their study with women diagnosed with bulimia
nervosa. Attending to the groups need for a safe container to perform the work is a
primary objective of a psychodrama group (Dayton, 2005b; Haley-Banez & Walden,
1999). This permits the clients to practice in a safe place the actions and activities created
in spontaneity with psychodrama to then be implemented in their day-to-day life.
An interesting area of identification by the participants about the psychodrama
process was that the majority of them stated they gained more insight to their recovery by
participating as an auxiliary or audience role than that of the protagonist. The protagonist
role is traditionally identified in the literature as the role where the most catharsis is felt
by the client (Moreno, 1964, 1987, 1994; Dayton, 2005b; Kim, 2003). The women in this
study identified that when they were in the role of the protagonist, they felt more on
display and more self-conscious and would tend to become more associated with their
defense mechanisms used in their eating disorder disease and disconnect either
emotionally or consciously. Although in the study by Kim (2003) identified that the
protagonist role helps the client more directly come to catharsis, and that the audience
members and not as directly involved and receive less gain in the session; the participants
in this study were not identified as having eating disorder specific diagnoses. Perhaps this
is a significant contributing factor to the identification with the auxiliary or audience
roles with this identified population. The main themes related to this disconnection were
due to the self-esteem related issue of not performing well enough in the role or the
body image issue of being on display. The identified distance in the roles of auxiliary
93

or audience member allowed the participants to connect more intimately to the


experience of the drama, in turn allowing them to internalize and concretize the
connection. This is an area of research to pursue in the future.
The participants shared how the combined use of cognitive behavioral therapies
and experiential therapies were beneficial to providing them with a holistic menu of tools
to help them engage and grow in their treatment process. The combined use of
psychodrama with movement, journaling, equine, or art was identified as enhancements
to their awareness of their disease and its impact on their lives and recovery.
An interesting area of identification by the participants about the psychodrama
process was that the majority of participants stated they gained more insight to their
recovery by participating as an auxiliary or audience role than that of the protagonist. The
protagonist role is traditionally identified in the literature as the role where the most
catharsis is felt by the client (Moreno, 1964, 1987, 1994; Dayton, 2005b; Kim, 2003).
The women in this study identified that when they were in the role of the protagonist,
they felt more on display and more self-conscious and would tend to become more
associated with their defense mechanisms used in their eating disorder disease and
disconnect either emotionally or consciously. Although in the study by Kim (2003)
identified that the protagonist role helps the client more directly come to catharsis, and
that the audience members and not as directly involved and receive less gain in the
session; the participants in this study were not identified as having eating disorder
specific diagnoses. Perhaps this is a significant contributing factor to the identification
with the auxiliary or audience roles with this identified population.
94

The main themes related to this disconnection were due to the self-esteem related
issue of not performing well enough in the role or the body image issue of being on
display. The identified distance in the roles of auxiliary or audience member allowed the
participants to connect more intimately to the experience of the drama, in turn allowing
them to internalize and concretize the connection. This is an area of research to pursue in
the future.
In review of the studys design and implementation, there are some identified
limitations and flaws. The limitations include that the participants are all in recovery from
their eating disorder and may have a bias on the positive aspects of psychodrama therapy
based on their recovery. Another limitation is that all of the participants shared a positive
experience with the psychodrama therapy intervention, so no negative interpretations are
included in this study. The study limited the participation to women diagnosed with
eating disorder, and not men. The body of literature on research related to eating
disorders is limited, and is predominantly related to womens experiences.
Discussion of the Conclusions
The relationship of the findings of this study with the literature presented
previously is supportive of the experience of the women who participated in
psychodrama therapy as part of their treatment for a diagnosed eating disorder as a
positive impact on their recovery. Psychodrama research in other areas of behavioral
issues, mental health and substance abuse treatment has presented with positive results
(Amatruda, 2006; Avrahami, 2003; Blatner, 1973, 2000; Carnabucci, 2002; Carpenter &
Sandberg 1973; Dayton, 1994, 2000, 2005a, 2005b, 2006, 2007; Fong, 2007; Hagedorn
95

& Hirshhorn, 2009; Hudgins, 2002; Karatas & Gokckan, 2009; Kipper & Giladi, 1978;
Kipper & Mastsumoto, 2002; Klontz, Bivens, Klontz, Wada, & Kahler, 2008; Krantz,
Ramierz, & Lund, 2007; Mactas, 1998; Moreno, 1964, 1987, 1994; Remer, Morse,
Popma, & Jones, 1993; Theiner, 1969; Uhler & Parker, 2002). After extensive review of
the literature related to the use of psychodrama therapy with eating disorder patients,
there was little current research associated with this population prompting this research
study (Baratka, 1994; Beck, 2008; Beyer & Carnabucci, 2002; Dayton, 2005a, 2005b,
2007; Hornyak & Baker, 1989; Hudgins, 1989, 2002; Ridge, 2007; Scott, 2000; Widlake,
1997).
A significant and interesting finding in this study is the conflicting identification
of the role of the protagonist versus the roles of the auxiliary and audience as being less
impactful for the majority of the participants. The majority of the literature implies that
the role of the protagonist provides the most impact for internal connection and catharsis
for the patient (Moreno, 1964; Dayton, 2005b; Kim, 2003). The studies disclosing these
findings were not specific to diagnosed eating disordered patients. In this researchers
study, of the 10 participants, the majority (80%) of the participants who identified the
auxiliary or audience roles as more beneficial were all of same diagnostics bulimia
nervosa or eating disorder NOS. The other 20 % who identified the protagonist role as
being the most impactful were diagnosed with anorexia nervosa. The question arises is
the difference in identified intensity of the protagonist role versus the other roles is
correlated to the diagnoses? Do the fear of connection themes identified in the analysis of

96

this study need to be discerned more specifically between the various eating disorder
related diagnoses?
The literature associated with eating disorder diagnoses associate difficulty with
accessing and conceptualizing the self, extremes in body image distortion, emotional
dysregulation, alexithymia, and esteem issues (Annus, Smith, Fischer, Hendricks, &
Williams, 2007; Beales & Dolton, 2000; Binford et al., 2005; Blodgett, Gondoli,
Corning, McEnery, & Grundy, 2007; Bulik et al., 2003; Christian, 1996; Cockell, Geller,
& Linden, 2003; Constantino, Arnow, Blasey, & Stewart, 2005; Hudgins, 1989; Keel,
2006; Lin & Yeh, 2009; Piran & Cormier, 2005; Polivy & Herman, 2002; Wilks, 2006;
Zonnevylle-Bender, van Goozen, Cohen-Kettenis, van Elburg, & van Engeland, 2002).
The issues identified in the literature are congruent with the experiences shared by the
participants in this study. A future study focusing on if there are identified differences
between the three diagnoses and the facilitation of psychodrama with recognition that a
protagonist role may be more beneficial for the anorexia patient versus the bulimic or ED
NOS patient. The other interest resulting from the experiences of the participants of this
study are the differences in body image awareness or distortion and being visible or
seen being more prominent in the bulimia and ED NOS diagnosis versus the anorexia
diagnosis. The Therapeutic Spiral Model (TMS) developed by Dr. Kate Hudgins (2002)
for the use with trauma recovery identifies specific roles of the containing double and the
body double to aid in providing safety and distance in the psychodrama process. These
roles and the TSM itself could be foundational in the psychodrama treatment of eating
disorder related issues based on the findings in this research.
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Limitations
As mentioned briefly in this chapter, there are some identified limitations and
flaws. The limitations include that the participants are all in recovery from their eating
disorder and may have a bias on the positive aspects of psychodrama therapy based on
their recovery. This researcher challenges the idea that if the criteria for participation in
this research study did not exclude participants who were not in recovery from their
eating disorder, the outcome concerning the positive application of psychodrama therapy
as a treatment modality could be different. All of the participants in this study shared a
positive experience with the psychodrama therapy intervention, so no negative
interpretations are included in this study.
The study limited the participation to women diagnosed with eating disorder, and
not men. To date, the researcher could not find any studies specific to men diagnosed
with eating disorders who participated in psychodrama therapy as a treatment modality to
consider the possibility of gender similarities or differences. There may also be
implications to the facilitation of psychodrama to a male population versus a female
population. As mentioned earlier in the study, there appears to be a curiosity to the
impact of the role of protagonist among the three identified eating disorder diagnoses.
Due to the time and financial constraints of this particular research study, this area was
not explored more in-depth.
Recommendations for Future Research or Interventions
Although the research findings were drawn from a United States, geographically
diverse sample size, the study is limited by its small sample size. Therefore, it cannot be
98

expected that this study is generalizable to the whole population of women diagnosed
with an eating disorder who participated in psychodrama therapy as part of their
treatment experience. This researcher recommends that future research include an
expansion of this research study to include a larger sample size of participants throughout
the geographical United States, and expand this research internationally.
The study was limited to adult women diagnosed with AN, BN, and ED NOS
limiting the findings to gender specific issues. This researcher recommends that future
research include gender specific studies of males diagnosed with AN, BN, and ED NOS
with the same participant criteria be conducted. Furthermore, future research should
consider contrast and comparison of gender related issues regarding eating disorders
leading to improved treatment for these disorders.
As identified as an area of interest in the findings of this study, the roles of
protagonist, auxiliary, and audience in psychodrama application with this population
appeared to produce concepts for further research. Do the eating disorder diagnoses of
AN, BD, and ED NOS warrant a more specific approach to the application of
psychodrama therapy in order to gain more positive outcomes for the participants?
Conclusion
The primary goal of this study was to share the experience of women, ages 18-65,
diagnosed with AN, BN, or ED NOS, who participated in psychodrama therapy as part of
their treatment for their diagnosed eating disorder. The secondary goal of this study was
to increase the knowledge base about using psychodrama in the treatment of eating
disorders and to enhance clinicians overall treatment of eating disorders.
99

This study has provided insight into the positive experiences of psychodrama as a
significant therapeutic tool in the treatment of eating disorders when used in an
environment of safety. The study also provides insight into the areas of eating disorder
treatment where focus can be placed on challenging the patients fears of connectedness.
The study also reveals differences in how those diagnosed with an eating disorder may
feel in the role of a protagonist versus the roles of auxiliary or audience member. This
significant finding can be considered by facilitators of psychodrama to safely direct those
diagnosed with an eating disorder in future sessions with a more positive outcome for the
client.

100

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APPENDIX A
INFORMATIONAL RESEARCH PACKET
PARTICIPANT ASSESSMENT AND DEMOGRAPHIC FORM
Thank you for considering participating in this proposed research study. In order
to determine if you qualify for participation, please answer the following questions
honestly and email or mail back to the researcher. (Please circle your answer)
PARTICIPANT ASSESSMENT
Are you a female?

Yes

No

Are you currently age 18 to 65?

Yes

No

Have you received treatment for a diagnosed eating disorder?

Yes

No

Which eating disorder diagnosis pertains to you?(Circle all that apply)


Anorexia Nervosa
Bulimia Nervosa
Eating Disorder NOS
As part of your treatment program, did you participate in
psychodrama therapy as a treatment modality?

Yes

No

Do you have at least one year of recovery from your


eating disorder?

Yes

No

Thank you for answering the questions to help determine if you qualify to participate in
the study. I will be in touch via email or telephone to follow up with you, and if
appropriate, schedule the research interview.
The best telephone number contact is: __________________________________
The best email address contact is: _____________________________________
Participant Name: __________________________________________________

120

APPENDIX A continued
PARTICIPANT DEMOGRAPHICS
In what state are you residing?

________________

If you reside outside of the United States, what country do you reside? _______________
How old are you?

________

Are you: married, single, divorced, widowed, or partnered? ____________________


Do you have any children?

Y/N

How many children do you have? ________

What is your ethnicity? ______________


What is your highest level of education? High School, GED, Some College, Associate
Degree, Bachelors Degree, Masters Degree, PhD, Other __________________
(please circle one or fill in other)
What form(s) of treatment(s) have you had for your eating disorder? Outpatient, Partial
Hospitalization, Inpatient, 12-Step
(please circle all that apply)
Do you currently work with a therapist/counselor?

Yes

No

If so, who? ___________________________________________________


Are you currently active in a 12-Step recovery program?

121

Yes

No

APPENDIX B
PARTICIPANT INTERVIEW GUIDE REVISED
1. You experienced at least one session of psychodrama therapy during your treatment for
a diagnosed eating disorder, how many sessions of psychodrama therapy can you recall.
(Research Question 1)
2. What were the positive aspects of psychodrama therapy for you?(Research Question 1)
3. What aspects of psychodrama provoked strong feelings or reactions from you?
(Research Question 1)
4. What do you recall about a specific role you played in a psychodrama
experience?(Research Question 1)
5. What was your most memorable (or a-ha) moment associated with your psychodrama
experience? (Research Question 1)
6. What did your psychodrama experience do to help you in discovering something new
or different about you and/or your behaviors? (Research Question 1)
7. How would you compare your psychodrama experience to other types of therapy you
may have experienced while working on recovery from your eating disorder? (Research
Question 2)
8. How has psychodrama therapy helped you with understanding and healing from your
eating disorder? (Research Question 2)
9. What other types of therapy have you tried in healing from your eating disorder?
(Research Question 2)
10. How did you experience the style of the psychodrama therapist with whom you
worked? (Research Question 2)
11. How did you experience the therapeutic presence or attitude of your therapist during
your participation in the psychodrama experience? (Reearch Question 2)
12. What were your feelings about safety during and/or after your psychodrama
session(s)? (Research Questions 1 and 2)
13. What recommendations do have for psychodrama therapists who are working with
the eating disorder patient population? (Research Question 2)
122