Teoría Diádica

Introduction

One of the primary difficulties in therapeutic work with emotionally dis-turbed adolescents is their high level of resistance to treatment. The author is referring specifically to adolescents between 13 and 17 years old who have responded to severely dysfunctional family situations by resorting to sub-stance abuse and runaway, criminal, or suicidal behavior. Their maladaptive cries for help often result in short-term psychiatric hospitalization against their will. The adolescents’ anger toward their parents (which is frequently generalized to all authority figures) and sense of helplessness about their situation are compounded by this involuntary placement, and they enter the institutional setting ready to fight all aspects of treatment. Indeed, it has been noted that the adolescent “views the hospital structure as an adversary with which he is locked in combat and which he much defeat” (Rinsley &

Inge, 1961). Because of the time constraints inherent in brief hospitalization, it is imperative that staff psychotherapists find ways to understand and effec-tively respond to the adolescents’ initial resistance so that treatment can begin as soon as possible.

Although there have been other reports on drama therapy with disturbed adolescents (including Dequine & Pearson-Davis, 1983; Shuttleworth, 1981;

Emunah, 1990, 1995), this chapter focuses specifically on drama therapy as it relates to resistance, and on an approach to the process and structure of

*Reprinted and updated from Emunah, R. (1985), Drama therapy and adolescent resistence, The Arts in Psychotherapy, 12(2), 71–79. With permission from Elsevier Science.

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the drama therapy session intended to engage clients in a trusting relation-ship with the therapist and to facilitate constructive interaction with their peers. The strategies elucidated in the chapter are largely based on the author’s (past) experience practicing group drama therapy over a 12-year period at Gladman Memorial Hospital Youth Center (in Oakland, California).

First, issues underlying resistance and rebelliousness during adolescence will be addressed.

Adolescent Resistance and Rebelliousness

Adolescence is a period of profound physical, psychological, and cognitive change, creating uncertainty and instability. Physical growth and sexual maturation necessitate the development of a new concept of body image.

Piaget (1952) noted that the adolescent’s thinking and reasoning capacities have increased qualitatively, allowing abstract and ethical concepts to be manipulated by thoughts alone without the tangible and concrete checks necessary in previous ages. Adolescent thinking can encompass future time with the possibilities of envisioning idealistic goals and acknowledging con-sequences of personal decision-making. Generally, in late adolescence, ex-istential dilemmas and paradoxes, as well as moral choices and values, must be adequately resolved. Adolescent rebelliousness is often an expression of frustration at having to deal with so many physical, cognitive and emotional changes. It is a rebellion against the responsibilities that independence and developing adulthood require. The adolescent is both overwhelmed and ambivalent; he or she wants to acquire the freedom and privileges of the adult and yet still longs to be cared for and protected as a child.

During adolescence, ties to infantile object relations are loosened and modified as the self becomes more clearly differentiated. The adolescent’s perception of family members changes and family conflicts generally escalate.

The adolescent, struggling with independence and self-assertion, resents being told by adults what to do or how to grow up. Feelings of distrust and anger toward authority figures are apparent. There is a turn to the peer group for support. In the gradual process of shifting allegiance from the parent as the primary love object to the peer group and to the self, the ado-lescent goes through a tumultuous period of inner emptiness, sadness, loss, and impoverished ego-functioning. Blos (1962) describes this “narcissistic phase” as a positive stage in the disengagement process.

The rebellious acting-out of the adolescent can be understood as a normal and necessary precursor to a more integrated and better-known self. New and often paradoxical experiences and abilities, as well as previous develop-mental gains, are gradually integrated into a cohesive sense of identity. In

Drama Therapy and Adolescent Resistance • 109 contrast, however, the disturbed adolescent rigidly dissociates aspects of his or her self. Not simply struggling with areas of “identity confusion,” these adolescents experience a pervasive “identity diffusion,” often perpetuated by dysfunctional family dynamics (Erikson, 1968; Haley, 1980; Kernberg, 1975). Their failure to gradually and safely separate from their families often results in severe adjustment difficulties, low self-esteem, disorganized think-ing, maladaptive ways of handling emotions, and destructive acting-out behaviors. Acting-out is especially rigid and deleterious when the adolescent’s sense of personal power and control is blocked. When even the rebelliousness is experienced as fruitless, hopelessness, despair, and self-destructive behavior often result.

Adolescent resistance to treatment often can be confused with age-appropriate and healthy rebelliousness. Resistance to therapeutic interven-tion develops as the person’s organized attempt at opposing the processes of becoming aware and of the emergence of unconscious forces (LaPlanche

& Pontalis, 1973). For adolescents, the treatment process threatens the di-chotomy of good and bad, created as an attempt to simplify conflicts and ambivalences. Adolescent rebelliousness is a developmentally appropriate reaction to both the seeming childishness of latency and the entrenched authority of adults: it is a necessary aspect of the adolescent’s dramatically changing self-identity. The way in which adolescents initially resist the treat-ment process is by acting rebellious. It is an attempt to conceal feelings of frustration, pain, and fear of being hurt, misunderstood, rejected, or betrayed. Disturbed adolescents in institutional treatment groups struggle to maintain a mutual conformity via their shared rebelliousness, which in itself is a resistance to the treatment program.

The therapeutic approach described in this chapter makes use of the dis-tinction and relationship between rebelliousness and resistance. The drama therapist joins with and supports the adolescents’ rebelliousness, thereby engaging their interest and nurturing the sense of group identity while mini-mizing or even bypassing the underlying anxiety and resistance to treat-ment. Normal adolescent rebelliousness, a necessary determinant of healthy self-identity development, is utilized by the therapist to overcome the ado-lescents’ resistance to the therapeutic process.

Resistance to Drama Therapy

There are specific resistances by the disturbed adolescent to the process of drama therapy. First, drama evokes anxieties related to performance. As previously mentioned, the profound physical and psychological changes during adolescence cause uncertainty and self-consciousness. Adolescents are enormously concerned about their appearance and have a strong need

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for approval and affirmation from their peers. While craving attention, they dare not risk disapproval by “standing out.” Disturbed adolescents, whose self-esteem is particularly low, anticipate ridicule and failure.

Second, dramatic play can be criticized as being childish. Adolescents attempt to define their position and identity by opposing adult authority and by defying any activity that might be considered childish. Hence, the instruction by an adult authority figure to engage in a potentially childish activity is a prime target for resistance.

Third, drama connotes acting like someone else. Although many adults might find this liberating, it can be extremely threatening for adolescents who are undergoing a period of instability and flux. “The struggles of ado-lescents for a stable self-identity represent in part and to a degree dependent on the depth of their psychopathology, struggles against the loss of bound-aries, hence some authors conceptualize adolescence as a struggle against disintegration” (Rinsley & Inge, 1961). Given the tenuousness of their identity and the boundary confusion that could arise through role and dra-matic play, it is not surprising that they initially resist the activity. They fear being other than who they are; rather, they long to establish and assert an identity.

The skillful drama therapist takes into account the particular challenges drama therapy represents for the adolescent. Establishing a relationship with the client and engaging him or her in a constructive way is a gradual and delicate process. Both resistance and involvement take various forms during the course of a session or series of sessions, and the drama therapist must be prepared to respond to each sensitively and efficaciously. The stages that have been identified by the author will now be described. Practical examples of techniques that relate to each stage will be included. Although the tech-niques and approach described provide examples and ideas, they are not intended to be viewed as recipes for successful sessions. Adolescent group facilitation and therapy are not easy, and effective therapy is obviously con-tingent on many factors.

Stage One

Resistance is particularly acute at the very beginning of the session. Almost invariably, adolescent clients confront the drama therapist with “We’re not going to do anything.” They may challenge the therapist with provocative and rebellious behavior, thereby testing his or her ability to maintain control.

They are prepared to instigate and engage in a power struggle; they strive to defeat authority and structure and yet are terrified of succeeding. Tradition-ally, therapists respond to this confrontation by exerting their authority and setting limits. Staff in many treatment facilities use both positive and negative

Drama Therapy and Adolescent Resistance • 111 reinforcements such as, “If you participate, you’ll receive points” or “If you don’t cooperate you’ll be placed on ‘restriction.’” Limit-setting and reinforce-ments, however, are often taken as cues for further opposition. Even if coop-eration does ensue, an antagonistic attitude toward the leader often remains.

The author has found a very different approach—one that allows and encourages clients to behave as they actually feel—to be effective in minimiz-ing initial resistance. For example, if the clients are hostile or aggressive, the drama therapist might incorporate these attitudes into the first exercise.

The sense of permission at the beginning of the session quickly eradicates the misconception that drama means acting “other” than oneself, that it involves childish pretend games, or that it necessarily entails performance;

furthermore, it destroys the image of the leader as an authority figure who will “make the group do things.” When the beginning exercises allow group members to express actual feelings, defenses are minimized. Resistance in the therapeutic situation often comes from the client’s fear of being de-prived of his individuality, his special identity, his current state of mind (Maslow, 1968). With this approach to drama therapy, the clients have little to resist because they are allowed to act as themselves; in fact, they may even be encouraged to exaggerate their rebellious behavior.

Dramatic activity is particularly suited to this permissive approach.

Drama provides an arena in which all kinds of behaviors, attitudes, and emotions can be expressed within a controlled, structured setting. Because drama affords natural boundaries within which enacted behaviors and atti-tudes can be observed and contained, a great deal of permission can be safely granted. This permission creates an environment in which clients will eventually feel free to experiment with alternate behaviors (Emunah, 1983).

Upon first contact with the drama therapist at the onset of a session, adolescents frequently display obstinacy; a common example is the client who stubbornly insists: “I’m not getting out of my chair.”

One day, I spontaneously approached a 14-year-old client, Tim, who insisted he wouldn’t budge from his chair. In a playful tone, I said,

“Try as hard as you can to stay in the chair.” Gently, I took hold of Tim’s hands and attempted to pull him to a standing position as he struggled to remain seated. His aggressive and hostile stance trans-formed into a playful one, and through the physical contact, a relation-ship was established between the two of us. Another client, seemingly delighted at witnessing this match, grabbed my place, claiming that he could lift Tim. Soon all the clients were pairing off with each other, alternating roles that represented resistance and surrender. I have since used this originally impromptu gesture as a deliberate “game” in opening the session.

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As the above example illustrates, the client’s resistance is activated rather than suppressed. Energy, which can be channeled constructively and creat-ively, is released. Encouraging resistance is a paradoxical process in that the client is in fact cooperating: she is both doing what she wants and following the therapist’s instructions. This is reminiscent of Milton Erickson’s approach to hypnosis and psychotherapy as well as of the work of family therapists Salvador Minuchin (1974) and Jay Haley (1973, 1980).

“What happens when one ‘accepts’ the resistance of a subject and even encourages it? The subject is thereby caught in a situation where his at-tempt to resist is defined as cooperative behavior. He finds himself follow-ing the hypnotist’s directives no matter what he does, because what he does is defined as cooperation. Once he is cooperative, he can be diverted into new behavior . . .” (Haley, 1973).

Another example of resistance becoming cooperation is to begin with something the clients clearly want to do. The leader’s initial choice of lan-guage is critical; certain words and intonations are automatic cues for oppos-ition. For example, members of an oppositional group will want to leave.

Thus, this author has often begun sessions asking for volunteers to leave the room. As the response is overwhelmingly “cooperative,” the clients must take turns. Each time, the client is directed to leave, return several minutes later, and identify the group’s improvisation. There are innumerable varia-tions to this game: an instruction might be for the group to nonverbally improvise being in a particular place (movie theater, beach, amusement park) or to enact a given attitude (suspicious, sympathetic, bored). The for-mat of the guessing game de-emphasizes performance, thereby diminishing potential self-consciousness. The fact that the focus is on the guessing rather than on the acting tends to increase concentration and imagination. Further-more, the process of selecting a place (or attitude) of one’s choice and then imagining one is, in fact, in that place conveys a sense of permission and freedom that may carry over into the realm of behavior. For adolescents who feel stuck in an intolerable family situation, confined in an institu-tional setting, and imprisoned by their own limited and often destructive coping mechanisms, this outlet is significant.

When the resistance is not aimed at authority (the leader), but is an ex-pression of anxiety related to performance, any improvisation (however ele-mentary) may be premature. The leader might begin instead with sensory awareness exercises. For example, the clients are asked to remain passively in their seats and, with eyes closed, identity various objects through touch or smell. Or, rather than asking the clients to do anything at all, the leader might begin by performing a pantomime him or herself, while the clients (from their seats) try to identify what/where/who he or she is.

Drama Therapy and Adolescent Resistance • 113 When the resistance is emanating from a sense of helplessness and hope-lessness, the drama therapist might begin by giving the client power within the scene. Dramatic play can enable clients to experience a degree of control over the unhappy and insecure life situation. Specific scenes that deal di-rectly with the issue of control over one’s environment or which symbolize internal self-mastery can be enacted.

Sherrie, a hospitalized 17-year-old girl, entered the drama therapy session muttering, “I hate this place.” After a brief pause, she added,

“And don’t make me do anything. I’ve had enough!” I asked her what she despised most about the hospital. She spurted out a series of criti-cisms. I then asked her what kind of place she would rather be in. She responded, “It wouldn’t be anything like this place.” I asked her to describe what it would be like. Before long, Sherrie was inventing her ideal version of an adolescent therapeutic community. I appointed her director of the new facility. She selected her staff from among clients in the group. Other clients (and an actual staff member) played the parts of newly admitted patients entering from their chaotic worlds disoriented, “stoned,” hostile. The “director” and her staff along with the support of teens who had already been in the program for awhile, skillfully handled each individual’s case. Sherrie’s affect changed re-markably as she carried out this engaging scene. She became quite animated. At the end of the session, she was able to talk about her depression and sense of hopelessness. A degree of distance and per-spective, as well as some sense of hope, was apparent.

The previous example took place in a verbal and relatively high-functioning group of disturbed adolescents. The following example involves a much lower-functioning group of adolescents who were temporarily hos-pitalized while between foster and group home placements.

A large variety of fabrics, props, tent apparatuses, and art supplies were placed in the center of the room. The adolescents were directed to construct individual tent-like structures. Each client became in-volved with designing and creating his or her new habitat. Imagina-tive exterior forms (some utilizing actual furniture in the room), interior decorations, colorful doorpost signs adorned the room. Upon completion, each adolescent was photographed inside or beside his or her special, private “home.” The clients felt proud of their creations.

Each had exercised mastery over the environment during a period of their lives filled with feelings of helplessness and abandonment as a result of a long series of relocations.

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With a group of adolescents who feel and act “out of control,” an activity that immediately provides order and structure is needed.

As I entered a rowdy, disruptive group, I quickly observed that one boy, John, was the dominant leader who was instigating the rebel-liousness. I immediately appointed him the role of judge in a court trial scene, which he readily accepted. John now had power and con-trol through his role in the activity. His “influence” was being used to instill order (literally) rather than chaos. He and I were on the “same team,” rather than opposing ones.

Sometimes any verbal instructions increase participants’ anxiety and become cues for opposition. In this case, the leader might begin the session by bypassing the stage of instruction altogether (Emunah, 1994). This author has at times begun sessions by having a phone ring (on audiotape). The clients are surprised and intrigued and cannot resist answering the phone (an actual prop). Quite spontaneously, they begin speaking to the imaginary person at the other end of the line, often revealing to the leader their inner concerns at that moment. There are endless directions that this initial activity can take, including role play of real-life conflictual situations. The phone is a familiar and cherished object to teenagers. It is a vehicle for communication (at a distance); the fact that it is “disconnected” enables calls to be made without repercussion.

Although the approach described in this section stresses “beginning where the client is at,” it is strategic in nature in that the therapist takes an active

Although the approach described in this section stresses “beginning where the client is at,” it is strategic in nature in that the therapist takes an active