THE USE OF PSYCHODRAMA IN THE TREATMENT OF SPEECH DEFECTS
Edwin M. Lemert and Charles Van Riper
Western Michigan College
Much of the work of treating speech
defectives has been done by persons using the methods of clinical psychology,
with strong pragmatic leanings so far as the selection of particular therapy
is concerned. This is not to say that the group of scientists of whom this
is true lacks theoretical premises but rather that their preoccupation with
the workability of treatment techniques has relegated to a position of secondary
importance the task of concept formation and concept integration. A good
deal of the thinking and writing done in conjunction with practical clinical
work is phrased in traditionaI psychological terms of habit-formation and
rewards-punishment reactions. Some writers are frankly eclectic in their
viewpoint.1
Before undertaking a discussion of psychodramatic treatment
methods in speech correction it is necessary to know something of the nature
of the speech defects which may be so treated. First of all, it is to be
noted that clients or patients are non-psychotic; for the most part they
are suffering from a neurosis2 or they simply have a set of bad articulation habits. In those
cases where symptoms are sufficiently aggravated to justify the diagnosis
of neurosis two etiologies may be present. In the one case the speech disorders
are symptomatic of emotional conflicts alone. In the other case a neurological
basis for the pathology exists upon which is superimposed a complex of emotional
conflicts which have amplified the pristine neurological tendencies. In
an adult case it is often difficult to ascertain with any accuracy the relative
importance of the biological and sociopsychological factors interacting
in the overt symptoms. The primacy of neurological factors in a certain
proportion of cases has been established by observational studies of children
which show, for example, in the case of stuttering, that simple repetitive
speech blocks of short duration or brief prolongations appear at relatively
early ages, at a time when awareness of self and other consciousness are
but vaguely developed.3
Usually the small child will talk right through these
primary blocks, especially if this aspect of his family role is accepted
by other members of the group or if they disguise their anxieties or hostilities
towards the child's behavior. The socio-psychological elaboration of these
primary symptoms into serious disorders of communication, with concomitant
emotional and behavioral deviations, tends to coincide with the assumption
of roles and the development of self-consciousness in the play group and
school or with the attainment of a degree of social insight that permits
a response to the finer nuances of parental attitudes. Withdrawal from traumatic
social contacts, with a further interruption of social communication and
inadequate compensations, are the frequent result.
Authorities differ on the curability of stuttering. Some
contend it can be entirely eliminated; others are of the opinion that "cures"
represent a superficial change at the level of overt behavior and without
any basic reorganization of attitudes or role-conceptions. A high percentage
of relapses with symptoms more serious than the original disorder is characteristic
of such "cures.'' A more modest and reliable approach is directed towards
the removal of that portion of the stuttering which is the product
of introjected rejections of the stutterer by the various groups in which
he has played an unsuccessful role. Once this surplus has been stripped
away the client comes to accept in an unemotional way the minimal neurologicals
or the irreducible residual of symptoms having an exclusively psychogenic
origin.
It is possible to conceive all psychotherapy, whether
it is self therapy, inter-individual therapy, or group therapy, as the variation
of a process of alternate role-playing in which self-acceptance without
approval or disapproval, by real or imagined others, leads to insight and
emotional balance. Psychodrama as a form of group therapy differs from other
types of therapy in that it presents a much more complex "others"
instrument through which self-objectification and self-acceptance can be
achieved. It differs also in the element of spontaneity. Its conceptual
kinship in this latter respect, to free association methods, finger painting
and certain forms of occupational therapy is not hard to discern.
Psychodramatic therapy based upon role reversals is often
used in speech correction. For example, a boy treated at our clinic had
acquired a grotesque habit of opening and closing his mouth as if he were
gasping, just before speaking. He was given an assignment to go down to
a ten-cent store daily for a week and for a period of ten minutes watch
the gold fish, with instructions to produce his symptoms every time the
fish opened and shut their mouths. The only concession to ego protection
was permission to hold his hands at either side of his mouth. In another
case a boy had bad blocks growing out of severe penalties inflicted by his
father; he was instructed to lie down upon a couch and orally reenact a
number of episodes from his childhood, alternating between his own role
and that of his father. The clinician in this instance left the room and
retired to his office where the dialogue could be beard by means of a loud
speaker.
Much of our inter-individual therapy contains implicit
and explicit psychodramatic principles. Since many clients are children
special adaptations of treatment are necessary in order to overcome the
difficulty arising out of their inability to verbalize conflicts. In the
effort to obtain enough speech to permit an analysis of symptoms in these
instances some way of invoking it spontaneously had to be found. The use
of fist puppets, a father, mother, child and bogie man who interacted with
each other and with the child, was most efficient in producing speech and
demonstrating conflicts. The father, for instance, would ask the stutterer
to tell bogie man to stop hurting him and the stutterer would refuse and
egg on the bogie man, telling him to cut off the father's legs. Occasionally
in treatment the child is encouraged to manipulate the puppets and talk
for them, and this was found to be very cathartic. The puppet mother in
the hands of the case will punish the child and then get sick and have to
take bad medicine.
With adults, of course, the possibilities in inter-individual
therapy are much greater. One common device is to have the clinician and
client exchange roles and reenact actual or typical interviews. Not only
does this increase self-objectification but it also provides an excellent
opportunity for the catharsis of aggressions which have accumulated in the
counselling relationship.
One of the more effective techniques which was evolved
in the area of psycho therapy is the use of phonograph recordings of dramatized
conflict situations. These are employed in various ways. Sometimes a case
is asked to verbalize or (if his speech is too broken) write out his reactions.
Often he is required to compose a similar scene from his own autobiography
and present it before a group in dramatic form, taking all the parts, or
directing it as a play. Many times the phonograph record is interrupted
and the speech defectives asked to carry on from there. This is especially
valuable in securing identification or catharsis or leads to the solution
of their conflicts. The motivation and freedom so necessary to the success
of this form of therapy seem to lie in this act of interruption. The advantages
of the recording are its mechanical objectivity, its complete dissociation
from the clinician and its repeated stimulus value. One recording of a stutterer's
social and vocational rejections created nausea in a stutterer even at the
fourth hearing. Frequently the more powerful and vivid reactions in cases
are delayed for many hours.
Even more extensively used and that which has been of
unquestionable worth in our speech correction work are real life situations
within the community. The psychodramatic character of this method derives
from the fact that clients are aware that they are engaging in participation
which would not grow out of their usual social contacts and which has only
a remote bearing upon their status. Furthermore in some situations the community
members contacted have been coached beforehand as to the general nature
of the reactions desired of them. On the other hand a good many citizens
have played their parts in the "psychodrama" without realizing
it. One device is for one patient to take another into a place of business,
as a bakery, and call for the manager. Then by previous arrangement with
the clinician he introduces the second case and abruptly leaves him to invent
some sort of plausible conversation and behavior. One girl in a candy shop
has been employed to good advantage because she always responded to stuttering
by an explosion of laughter.
One case treatment comes so near to the type of psychodrama
described in an article by Moreno4 that it is
reproduced in full below:
W. R. was a college sophomore with a very high pitched voice, the type termed an eunuchoid voice. His history showed a normal childhood with complete acceptance by other boy playmates; he was something of a "roughneck kid" according to his father but he had a beautiful voice. His voice was that of a beautiful boy soprano and his family, pastor and music teacher exploited it to the limit, often to the boy's disgust. He had to be forced to go to choir practice. At thirteen and a half, when the first signs of pubertal voice change appeared, his music teacher and parents did everything possible to prevent the change, forcing him to do much singing of cantatas, in glee clubs and choirs where he had to maintain high pitches. The boy's soprano voice continued in his speech as well. The result was that he harbored a great deal of resentment against his father and the music teacher. At the same time he developed a great admiration for his older brother. Eventually he gave up singing altogether. Meantime he was penalized severely by boys when he changed high schools in the tenth grade and later when he was in college. An effort at athletics was dropped because of especially traumatic rejections and he turned to literary interests and shunned social contacts. He persistently refused to recite in college classes. Although he was somewhat effeminate in appearance and was thought of as a sissy, apart from his voice his secondary sex characteristics were normal. He had many girl friends but no male associates.
Through the use of phonation with false vocal cords and throat clearing while his head was hanging downward off the end of a cot to prevent the characteristic elevation of thyroid cartilage to a position directly under the hyoid it was possible to procure a very deep baritone vowel of good quality. In front of a group next day he was asked to lay his head back and repeat the procedure. He began to speak on the same pitch as the vowel. The voice was so deep that it shocked not only the group but the case as well (and the clinician); it was so foreign to the case's previous personality as to make the scene indecently absurd. He cried and left the room and was still visibly shaken a day later. He planned to terminate further treatment because he "couldn't stand the shock." He was then instructed to practice the new voice on prolonged vowels and nonsense material until he could assume it at will, but he refused to use it anywhere save in the clinic.
The clinician composed a one act play in which there were three male and two female parts: a harsh father with a low pitched voice, an heroic older son with normal male pitch, a musical son of 14 years with the old habitual pitch, one hostile girl friend and one sympathetic one. The theme consisted of a harsh father who, in concert with a rejecting, taunting girl, drove the younger musical child from the home, and school playground, to the point where he jumped into the river and was drowned in spite of the efforts of the heroic older boy to save him. The quality of the play was poor but the theme was more disguised than the bare outline suggests. To the case it was just practice material in five parts and pitches. At first he practised it alone, then made a recording of it. However, he refused to do it in front of a group or to hear the record until a year or two later at which time he wept. But after this play had been rehearsed over and over again alone for about a month he performed it alone for the clinician, doing the parts of the older boy and the younger one with great emotion. To carry on the illusion that the play had no specific meaning he was given other plays to act out which had no special significance. A girl worked with him reading the female parts. The result was that the case finally began to exercise the new low pitch in nucleus situations in his rooming house, then in a drama class and then in all situations. The effeminacy disappeared and he went out for athletics without marked success or evident disappointment. Two years later at the time of the last case entry, voice and personality remained strong and masculine.
Certain impressions are left with the
writers as the result of their review of speech therapy from the standpoint
of its relation to psychodrama. It appears in dealing with persons who are
not psychotic that there may be danger in some cases that spontaneous expression
in group situations may weaken or destroy a delicate equilibrium of psychological
forces within the individual. This was forcefully brought out one night
when a group of speech cases was giving spontaneous acts at the home of
the clinician. One girl whose mother was mentally ill and who feared a like
disorder gave such a horrifying imitation of an insane person that she was
suddenly made poignantly aware of potentialities within her personality
which hitherto fore she had only vaguely suspected. Thereafter her speech
became worse she broke off all contact with the clinic.
The writers were further impressed with the results obtained
by reversing traditional psychiatric treatment. In nearly all cases deliberate
exaggeration of speech defect symptoms was the prelude to improvement. When
stutterers first enter the clinic no attempt is made to force them to repress
or eliminate the blocks. Instead they must intensify them. While this as
well as other psychodramatic methods give rich emotional release, its most
beneficial effect; is to point out the ultimate goal of treatment. By deliberately
varying and manipulating his symptoms the individual gradually brings them
under greater and greater control until they are emptied of the bulk of
their pathological emotion and can be accepted in life situations.
1See Charles Van Riper, Speech Correction, 1939. (Chapter XIII)
2The writers see no categorical distinction between neurosis and psychosis as held by some psychiatrists; they are of the same generic order of phenomena.
3C.S. Bluemel, "Primary and Secondary Stuttering," Proceedings of the American Speech Correction Association. 1932. Pp. 91-102.
4J. L. Moreno, "Inter-Personal Therapy and the Psychopathology of Inter-Personal Relations", Sociometry, Volume 1, No. 1, 1937.
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