Keywords

13.1 Introduction

Making CBT user friendly to adolescents involves the integration of existing cognitive behavioral techniques with innovative approaches. In this chapter, a discussion of teenagers’ hierarchy of needs is addressed along with reviewing negative self-thoughts and common thinking distortions. As teenagers experience grief, obstacles, or worry, thoughts can easily become negative. Frequently, negative self-thoughts (NSTs) can take over and dominate feelings about one’s self worth and life in general. Cognitive Behavioral Experiential Group Therapy (CBEGT) is an effective model for working with teen groups. The model incorporates cognitive behavioral and psychodrama interventions, allowing group members to identify and modify negative thinking, behavior, and interpersonal patterns while increasing engagement in positive and success-based experiences. The environment creates a safe and supportive climate where clients can practice new thinking and behaviors and share their concerns freely with group members (Treadwell et al., 2004).

13.1.1 Research Support

Cognitive Behavioral Therapy (CBT) is an evidence-based therapy which has been used extensively in the treatment of depression, anxiety, and personality disorders. With the increasing popularity of CBT techniques, especially those developed by Beck and his colleagues (Beck et al., 1979), the treatment has been applied to a wide range of disorders from anxiety and depression to schizophrenia in both individual psychotherapy and group therapy settings. Psychodrama, an interactive method of roleplaying past situations in the present, is often used within group therapeutic settings to facilitate insight and problem-solving. Although traditional psychodrama is conceptualized in terms of three main techniques—warm-up, action, and sharing—there is no dearth of techniques that may be applied in those three phases (Treadwell et al., 2004). The versatility of psychodrama stems from the variety of techniques that have been borrowed or adapted from various individual and group psychotherapy modalities (Wilson, 2009; Hamamci, 2002, 2006; Baim, 2007).

13.1.2 Clinical Application

Cognitive Behavioral (Psychodrama) Experiential Group Therapy (CBEGT) is an effective model for working with teen groups. The model incorporates cognitive behavioral and psychodrama interventions, allowing group members to identify and modify negative thinking, behavior, and interpersonal patterns while increasing engagement in positive and success-based experiences (Shay, 2017; Treadwell et al., 2016). The environment creates a safe and supportive climate where clients can practice new thinking and behaviors and share their concerns freely with group members (Treadwell et al., 2004).

Initially, all members are assessed using various instruments to establish the nature and severity of presenting issues and to uncover other relevant information. The first one or two sessions are devoted to establishing group norms, providing psychoeducation about Cognitive Behavior Therapy (CBT) and schemas, as well as describing the session format. These initial didactic sessions are intended to explain the group format as a problem-solving approach for working through various interpersonal, educational, psychological, and health-related conflicts. The sessions include information about the nature of the structured activities so participants have realistic expectations about how the group will run. Each group member signs informed consent and audiovisual recording consent forms as every session is recorded. The audiovisual recordings create an ongoing record of group activities and serve as a source for feedback for the individuals when requested.

Here’s how the model looks with a group of ten teenagers, ranging in age from 13 to 17. In session one, the facilitator introduces the Beck Depression Inventory-II (BDI), Beck Anxiety Inventory (BAI), and Beck Hopelessness Scale (BHS; Beck, 1988; Beck & Steer, 1993; Beck et al., 1996), explaining the importance of completing each scale on a weekly basis. These instruments are administered before the start of each session and are stored in personal folders to serve as an ongoing gauge of participants’ growth in action group therapy (Treadwell et al., 2008). In addition, the GRIT Survey for teenagers is administered, pre and post, to assess group members desire and determination to stick with and carry out a desired goal (Baruch-Feldman, 2017).

In the second or third session, additional data on early maladaptive and dysfunctional schemas and core beliefs are obtained when group members complete Young’s schema questionnaire (Young et al., 2003; Young & Klosko, 1994; Young, 1999). A list and the definitions of dysfunctional schemas and core beliefs are given to participants during the initial session (Treadwell et al., 2008).

Each group session in CBEGT is divided into three sections typically found in psychodramatic interventions: warm-up; action; and sharing (Moreno, 1934). During the warm-up phase, individuals engage with one another utilizing cognitive and behavioral techniques including identifying upsetting situations, automatic negative thoughts and triggered moods; writing balanced thoughts to counter negative automatic thoughts; and recognizing distortions in thinking and imprecise interpretations of difficult episodes. The second portion, action, employs psychodramatic techniques such as role-playing, role reversal, and mirroring, which facilitate the examination of various conflicting situations individuals experience within the group context. This segment enables group members to better understand the nature of negative thoughts triggered by situations and their effects on moods. The last stage, sharing, involves the protagonist (i.e., the client) listening to and working with the auxiliaries (i.e., group members assisting the protagonist) as they share their experiences with the protagonist. At this stage, the facilitator may provide additional guidance to the protagonist regarding ways to begin resolving the actual situation in real life. Normally, the protagonist will be asked to complete a homework assignment that will be reviewed at the next session.

13.1.3 Multi-cultural Considerations

In my experience, multi-cultural issues can be addressed in the model utilizing specific psychodrama techniques, including role interview and surplus reality (e.g., where one imagines or creates significant others to avoid reproaching relationships) present another’s point of view. Additionally, during the warm-up, the protagonist has the opportunity to discuss and expand on what is important in his/her culture, utilizing the genogram, Maze worksheet, and teen automatic thought record. The genogram, (i.e., Family Tree) is useful in capturing a picture of family and cultural relationships, while the Maze Worksheet allows the group member to record their thoughts and emotions to situations as they identify automatic thoughts, also known as “hot thoughts.” These materials assist in educating the group members gain insight into the protagonist’s values and beliefs. The psychodrama takes place within the cultural context that the protagonist defines. For example, when acting out a scene, the protagonist has control over which group members serve as auxiliaries and provides, through role interview and role reversal, insights into the auxiliaries’ reality. The protagonist can continue providing direction to the auxiliaries as the psychodrama unfolds. This ensures that the psychodrama accurately depicts his/her environment and cultural realities.

The following case study presents Angelica1, a teenager struggling to fit in at her new school and neighborhood. In this case study, Angelica emerges as the protagonist, the main client for the session, and other members of the group serve as auxiliaries, members assisting Angelica, and the audience, those listening and watching the session unfold. The main group1 members include Riley, 15, who was recently cut from the soccer team; Kia, 13, whose grandmother just passed away and Angelica, 16, whose parents recently got divorced, causing her to move towns and change schools. Jan, 17, who worries about being able to afford to go away to college; both Lauren, 15, and Dak, 13, have no close friends; Bobby, 16, and Jenny, 14, are failing classes due to problems at home; Tyler, 17, and Marta, 13, both have social anxiety. Tyler is afraid of graduating from high school and moving on to an unfamiliar environment; Marta is new to the school and doesn’t know how to navigate new social relationships.

13.2 One Teen’s Story

A case conceptualization based on Beck’s rubric (2011) is presented below and applied as an ongoing therapeutic tool. After three or four sessions, the therapist explains and teaches the main ideas behind the technique and asks group members to complete the case conceptualization form on an ongoing basis as the group progresses. A member discusses his or her completed form with the group on an assigned day. Case conceptualization may help group members reflect on their various rules, conditional assumptions, beliefs, and means of coping. Please see Fig. 13.1 for Angelica’s conceptualization.

Fig. 13.1
figure 1figure 1

Cognitive Conceptualization Diagram

Full size image

The conceptualization leads to the more specific cognitive triad of negative thoughts explaining how Angelica’s thoughts reflect themes of loss, emptiness, and failure creating a depressive/failure mindset. Typically, this characterization is distorted, making case formulation useful in challenging the teen’s view of self, the world, and the future. Presenting it in the group during warm-up can be helpful for the action phase and provides structure for the group, ensuring all members feel heard. The cognitive triad is best conveyed to group members using this visual representation (see Fig. 13.2).

Fig. 13.2
figure 2

Cognitive Triad

Full size image

Angelica is a 16-year-old girl who recently moved to a new school. She was eager to make friends, she was feeling very down that she had not made any interpersonal connections yet. Angelica joined a therapy group for teens dealing with depression and anxiety and began the work by telling the group a story about an uncomfortable situation that had recently come up.

13.2.1 Warm-Up

During the warm-up and while completing the Maze Worksheet, a type of thought record, Angelica described a situation where she had been invited to a party by a popular girl in her class. Although that she does not over consume alcohol, Angelica became intoxicated at the party and the popular girl offered to take her home. When Angelica arrived home, her mom was awake and her “new friend” said she would stay with Angelica to make sure she was alright. She passed out and when she woke up, her “friend” was gone and so was her leather jacket. The next day at school, her “new friend” ignored her, and Angelica heard the friend telling everyone what a loser Angelica is.

After identifying Angelica’s moods, the facilitator of the group began to lead her through testing her automatic thoughts. Using the downward arrow technique by repeatedly asking her questions to evoke the automatic thoughts, the facilitator helped Angelica to consider which underlying thoughts or beliefs caused her feelings to arise in this situation. Angelica eventually identified her negative self-thought. Her schemas of abandonment and approval seeking and core beliefs that she was unlovable and helpless emerged as she completed the Maze worksheet. A portion of Angelica’s Maze worksheet can be seen in Fig. 13.3.

Fig. 13.3
figure 3figure 3

The Maze

Full size image

The protagonist, Angelica, selected Riley, another group member, to be her double. The role of the double is to communicate thoughts and feelings the protagonist is having but cannot express. Angelica was very distressed and had trouble moving forward to articulate her defeated attitude. The facilitator used the soliloquy technique, encouraging Angelica to walk around the room with her double, freely associating her thoughts and feelings. Ultimately, this led her to calm down and express her feelings of rejection. The monologue permitted her inner feelings and thoughts to emerge and gave the facilitator, the group therapist, direction to set the stage allowing Angelica to move gradually into the action phase. Angelica paced around the room, with her shoulders slumped, thinking/talking aloud, expressing her concerns, discomfort, and hopes. Angelica’s double, Riley, walked with her, articulating the thoughts he imagined Angelica was thinking but not outwardly expressing. Angelica echoed the beliefs that she agreed with and dismissed those that were not on target. The technique enabled her to relax, focus, and prepare for the action stage. Additionally, this method allowed other group members to engage and focus on the upcoming action.

As Angelica walked around the room with her double, she realized how her parents’ tumultuous marriage and recent divorce, along with the move from her house to a small apartment with her mom had affected her. She understood that she was consistently looking for acceptance from others and latched on to anyone who seemed to like her. When the facilitator asked Angelica what she needed to do to address the way she felt, she recognized that she had “no self-confidence and was desperate for social acceptance.”

The facilitator asked Angelica to select a new group member to play one of her long-term friends from her previous home. She chose Kia to play her friend long-term friend, Nicole. The facilitator used the interview in role reversal to help Kia understand and play the role of Nicole. Using this technique, Angelica got into the character and mindset of Nicole, giving Kia information about the role. Once the interview in role reversal completed, Kia was prepared to play the role of Nicole, setting the stage for Angelica and “Nicole” to start a conversation. Angelica told “Nicole” how sad she was about not having anything to offer and felt she would never make new friends. She and “Nicole” reversed roles many times, attempting to get Angelica to recognize her strengths and good qualities but, even with the assistance of Riley, her double, she could not see herself as anything but a flawed person who would never have friends again. The facilitator asked Angelica if it might be helpful to explore a role opposite to her perceived “flawed” roles. Angelica was interested and receptive to the idea. When the facilitator asked her to identify the roles she currently plays, Angelica quickly responded: ugly duckling, nerd, lost girl, peacemaker, and perfect student. She admitted that the “lost girl” is the dominant role she inhabits and that she slips into the perfect student role when she feels like the lost girl is swallowing her up. She also realized that the ugly duckling and nerd roles feed her lost girl and sometimes prevent her from trying to form new friendships. As the peacemaker, she realized that she is always thinking about how others feel, while ignoring herself. She said she is always walking on eggshells no matter who she is with. Thinking about her current roles, Angelica recognized that she needed to develop a confident role to help her see clearly what she has to offer others.

To address the confident role struggle role training involves a person delineating a specific aspect of functioning they wish to improve or develop to foster a new role. Usually begin with a specific situation where the person wishes to acquire, role training involves the dramatic setting up of an enactment of a situation. To further explore Angelica’s roles, chairs were placed in the middle of the room and Angelica played each role: ugly duckling, nerd, lost girl, peacemaker, and perfect student, as she expressed her thoughts and emotions about each role. Her double, Riley, sat with her in each role, expressing thoughts and feelings he imagined she was having but not expressing. Another member of the group, Bobby, was chosen, as an auxiliary, to play the “lost girl” and Jenny and Marta acted as the “ugly duckling” and “nerd,” respectively. Lauren took the auxiliary role of “peacemaker.” After several attempts, Angelica, in her confident role, was unable to shut down these powerful roles. Simultaneously, the facilitator learns information from the roles and understand which role to focus on to bring about change. This takes minimal time in session. Another member of the group, Dak, was chosen to play the confident role. After seeing him model this role, Angelica, with the help of her double, was finally able to shut the negative roles down. The final step in the action phase was to have Angelica, using the empty chair technique, address her “new friend” about what she did to her at the party and, afterward, at her house and at school. This technique fosters interpersonal development by asking Angelica to imagine that person sitting in the empty chair and confronting her “new friend.” She was able, with help from her double, Riley, to confidently express her anger about the situation. Furthermore, she told her “new friend” that she was worth more and deserved healthy relationships. As Angelica moved further into her confident role, her body language shifted from a lump shouldered little girl to a more powerful young woman. Use of the “Empty Chair” gives the protagonist freedom or flexibility to express thoughts without having the fear of retaliation. This information lets the facilitator prepare the person for future face-to-face interactions.

Doubling, modeling, and role training are crucial in learning how to get unstuck from repeated negative behavioral interactions. Many protagonists are anxious when learning a new role; it is therefore important to support them as they practice it in the group session.

Before the final stages of sharing and assigning homework to the protagonist, the double, all auxiliaries, and Angelica were de-roled. This de-roling technique is an important procedure which allows members of the action group to transition from the role they were assigned to and return to their own identity. Thus, from each role assigned to auxiliaries, they share their sense of being in character, and let go of any negative emotions that may have arisen from their participation as an auxiliary. De-roling is key in returning group members back to their original role.

13.2.2 Sharing

Following the action phase, group members shared and discussed what occurred, commenting on how the situation affected them. As a rule, no advice is to be offered by group members, only sharing their thoughts from their perspective. Angelica took a huge risk, exposing her feelings and inner struggles; hearing group members share similar painful feelings and experiences led to feelings of acceptance, support, and understanding. Sharing is essential for both the protagonist and for each of the group members as they process the experience, reflect, and learn from each other. Sharing is a key component in developing and enhancing group cohesion. The sharing phase provides time for group members to discuss the events that took place in the action phase.

13.2.3 Alternative Behavior Plan (Homework)

At the end of the session, the protagonist is assigned homework to it encourages the continue the new role development explored in the session. Role development requires practice for habituation to take place and to move the protagonist to feel safe in the new role. Thus, the facilitator addresses the protagonist’s core beliefs and schemas with a behavioral strategy. Homework is a critical factor in encouraging members to practice learned strategies in their own environment (Beck, 2011).

In Angelica’s case, practicing the new confident role was crucial. Angelica, the group, and the facilitator collaboratively designed situations where she could rehearse this new role in her everyday life and practice for developing healthy relationships. In her case, situations were designed to focus on developing a schedule to reach out to group members to develop healthy relationships. The goal was established to create mutual respect between her and a peer and an opportunity to develop lasting friendships. To promote Angelica in this new endeavor, she was asked to choose two people in the group to spend time with before the next session. Although initially reluctant to ask anyone, she asked Riley, her double, and Jenny, who enthusiastically agreed.

Clients like Angelica find CBT components of the psychodrama helpful in becoming aware of their habitual dysfunctional thought patterns and belief systems that play an important role in mood regulation; the action component allows them to see and feel the dysfunction. The schema-focused techniques present an opportunity for a deeper level of insight and merge well with the psychodramatic framework. The schemas and core beliefs provide a deeper understanding into the etiology of clients’ presenting problems and form the basis for treatment planning.

13.2.4 Drawbacks

Teens with severe social anxiety may initially find CBEGT too demanding and may opt to seek individual therapy prior to joining a group. While their experience may be trying, they will likely benefit from the group interaction and support and will, ultimately, choose to participate as a protagonist.

It is important that the facilitator? be cognizant of participants’ BDI, BAI, and BHS scores to ensure a client is ready to act as the protagonist. Additionally, the director must be prepared to address any spin-off dramas that occur as a result of the protagonist’s psychodrama.

The following exclusions are recommended:

  1. (a)

    Individuals with self-centered personality traits and conduct disorders who display strong resistance to group work. They tend to lack spontaneity and are rigid in their portrayals of significant others; that is, they either insulate or attempt to dominate others in the group;

  2. (b)

    Individuals with narcissistic, obsessive compulsive (severe), and antisocial personality disorders for whom individual therapy is more suitable; and

  3. (c)

    Individuals with cluster A personality disorders and impulse control disorders have difficulty functioning in a group.

13.3 Conclusions

CBT and action techniques can be used effectively within the context of psychodrama. In our experience, teenagers, adults, college students, and clinical populations respond well to this approach and, as a result, are able to develop an awareness of their dysfunctional thought patterns and beliefs that play an important role in mood regulation. Other CBT techniques, not discussed in this chapter, such as coping cards and the advantages/disadvantages matrix, are easily integrated into CBEGT during role play or as homework. Although some resistance from group members can be expected, particularly around the Maze Worksheet being completed on time or disclosed in the group, this diminishes as trust and cohesion grow (Yalom & Leszcz, 2005). As group members recognize the usefulness of the structured CBT and action techniques, intimacy and spontaneity tend to increase, creating and supporting a safe space for sharing.

One of the most important elements of CBEGT is that it is data-based. Group members keep track of their dysfunctional thoughts and depression, anxiety, and hopelessness scores from week to week along with reviewing their GRIT scores from pre-to post testing. They can easily see changes resulting from group therapy that make the therapeutic process worthwhile. The use of CBT techniques aligned with psychodrama provides a balance between an exploration of emotionally laden situations and a more concrete, data-based, problem-solving process. CBEGT adds a new dimension to both the fields of cognitive behavior and group therapy and is built on a proven efficacious model. The integration of these methods may be beneficial for clients who have not responded to more traditional approaches.