Well Action Psychotherapy

In the cultural upheavals following the 1939 world war, a time in which the need for mental health treatments of both traumatised soldiers and civilians became urgent and widespread, a novel and surprisingly effective form of psychotherapy emerged in the USA: Psychodrama psychotherapy. This humanistic approach to mental health finally arrived in the UK in the 1970s as part of the Human Potential Movement, one of the international offshoots from the 1960s Esalen Institute in California.

It was the dream of psychodrama’s creator, Jacob Moreno, to see his life’s work reach an international audience. A firm believer in the potential of psychodrama to transform not just individuals, but society as a whole, Moreno struggled to understand why people could be so disengaged from his innovative and powerful approach to treating mental health difficulties.

It was Marcia Karp and Ken Sprague who brought psychodrama to the UK, opening the The Holwell Psychodrama Centre in North Devon in 1974. This novel method of self-exploration caught the imagination of the hippies and hipsters whose attention had been grabbed in the 1960s by the cocktail of Eastern mysticism, creative therapies, psychedelic drugs and an outpouring of artistic energy.

The Holwell Institute trained several hundred psychodrama psychotherapists, some of whom went on to open their own training schools. Moreno’s dream was expanding, even into the territory of traditionally inexpressive and creatively conservative Britain.

The UK health services were slow to embrace psychodrama psychotherapy, unlike art psychotherapy and drama psychotherapy, which by the 1980s were commonplace in NHS mental health services. Perhaps it was because people failed to understand the essential differences between drama therapy and psychodrama therapy, or perhaps it was because psychodrama graduates had an almost evangelical fervour, promising an unrealistic panacea for all mental ills.

One forum in which psychodrama was accepted in the UK was in Therapeutic Communities, designed to treat seriously mentally unwell (but not psychotic) people without the intervention of psychiatrists and expensive psychoactive drugs.

In particular, Jinnie Jefferies (co-founder of the London Centre for Psychodrama) brought psychodrama psychotherapy into the prison service, working to rehabilitate serious offenders at the UK’s flagship therapeutic prison, HMP Grendon.

Through her 3 decades of work in the prison service Jinnie established psychodrama as a core therapy in the prison service. Through the success of this work, and the success of Therapeutic Communities outside of the prison service, psychodrama has established a small but vital niche for itself in helping sufferers of “Personality Disorders”, also known as “Personality Difficulties”.

This brief blossoming of psychodrama in the UK is now fading. Despite appearing in the NICE treatment guidelines for personality difficulties, the number of psychodramatists employed in the NHS and the Ministry of Justice is very small, just a few dozen across the UK. The total number of trained psychodrama therapists never even reached the 1,000 mark, and that number is now declining. For several years now there has only been one active training school in the UK, and each year there are only 2 or 3 new psychodrama graduates, while a much greater number are retiring.

Why is the profession now in such decline? Some blame Covid for closing many of the schools, but others point out that the schools were closing, or running into financial trouble, before Covid.

I believe that the unique philosophy and culture of psychodrama – the very attributes that made it so fascinating to progressive youngsters in the 70s and 80s – are now its greatest problems. The mystical psychotherapy based on a radical humanistic interpretation of Christianity which presents itself as a spiritual calling rather than a financially rewarding profession, appealed to the transgressive culture of the human potential movement.

But now, with cultural and health-service emphasis on diversity, accessibility and evidence-based therapies, and the emphasis on financial reward for expensive education, a hipster fad from the 1970s which appeals to divine intervention for its efficacy is just not gaining attention any longer. Today’s young hipsters looking to "find themselves" and help others do the same, have moved back to psychedelic drug explorations, such as Ayahuasca, while modern health services are turning to cheaper therapies with a large base of professionals such as CBT therapists who can train without risking financial ruin.

The philosophical and financial load of psychodrama training have not just led to a reduction in interest, but also a problem with diversity. One of the aims of rehabilitation is to bring prisoners round to the understanding that UK society is, or at least aspires to be, an inclusive culture of opportunity, in which anybody may flourish. However, I am painfully aware that the prison psychotherapists in general, and the psychodrama psychotherapists especially, do not reflect the diversity of the prison population as a whole. Young Black and Asian working class men, who make up a disproportionate number of prison inmates, are being lectured daily on the opportunities that society offers by a monoculture of white middle-class middle-aged people from a Judaeo-Christian religious background.

Although I’m one of the rare males in the profession, I still feel a sense of deep embarrassment: psychodrama training has become available to me in my late 50s due to a combination of my elite educational attainment, well-off family background, and career success in a STEM industry which has financed the course fees and subsistence required for 5 years (possibly longer) of full time training. This profession is utterly unreachable by pretty much all of the friends, families and associates of my prison patients, whether they have been hampered by criminal tendencies or not.

Dwindling numbers of psychodrama therapists mean that health service and prison service employers are now struggling to recruit even the small numbers of psychodrama therapists that they need. Once this trend becomes entrenched, these posts will simply be abolished: “Psychodrama was great, but if we can’t recruit then we’ll just have to do the best we can without it” is a common theme. Prison rehabilitation and Personality Difficulty treatment will continue without psychodrama. Less potent in their outcomes perhaps, but the replacement of psychodrama therapy with the less effective drama, music and art therapies will allow these services to continue, albeit in less efficacious form.

Can we save psychodrama? Can the public service niches in which this obscure profession has thrived be preserved? It seems unlikely given that the total financial outlay for psychodrama training – course fees, personal therapy fees and professional supervision fees, together with lost income due to the time demands of placements and training sessions over a 5 year (or longer) training, is between £50,000 and £100,000, and this cannot be funded through the current student loan or career development loan schemes. University graduates with further qualifications (a pre-requisite for entry to a psychodrama training) are already burdened with massive debt. Psychodrama salary expectations on the other hand are only a little more than the expectations for counsellors and CBT therapists, who can train in a single year, and whose trainings can be supported by student loans. So psychodrama is simply not a financially viable option for most people who want to work in the field of mental health.

My thought is that psychodrama training schools need to work closely with the organisations that employ their graduates. The Ministry of Justice, and the NHS, need to be made aware of the problems afflicting the profession, and need to be offered input into the training standards so they match the needs of these employers. Conversely, the MoJ and the NHS need to take an interest in where their future employees are going to come from, and need to work closely with the training schools.

This has been the approach taken for forensic and clinical psychologists for decades. For instance, HMP Grendon has developed a forensic psychologist training pathway that runs hand-in-glove with British Psychology Association accredited training programmes. Trainee psychologists carry a significant part of the prison psychology workload, and in exchange they are paid a trainee stipend and a contribution towards their course fees.

The current UKCP training standards are hard to justify. Many seasoned trainers were themselves trained to much less rigorous standards, which has led many to question whether the length of training has more to do with keeping training schools solvent than with turning out psychotherapists who are fit to practice.

The "one size fits all" approach to training standards may be functional for psychotherapists working in private practice, but it's bizarre for those intending to make a career in public service. The question to the NHS and MoJ has, so far, been "These are our training standards, are they good enough for you?" to which the answer has often been "No" to BACP accredited courses and "Yes" to UKCP accredited courses.

The question that should be being asked is: "What are the training standards you require?" and to tailor courses accordingly. I'm imagining a time in which the British Psychodrama Association starts its own accreditation scheme within the UKCP's scheme: NHS accredited 1:1 psychodramatist, NHS accredited group psychodramatist, MoJ accredited group psychodramatist, etc.

Such a stepped approach to training would enable trainees to apply for "real" jobs more quickly. Perhaps NHS 1:1 psychodrama accreditation could be attained in 3 years at which point the trainee could begin earning within the NHS. After that, the NHS accredited group psychodrama accreditation could be attained in another year, at which point the trainee could apply for a more senior role. Meanwhile, MoJ group psychodrama accreditation would require a year of experience in the prison service, and (being more complex than NHS work) would be transferrable to the NHS, but not vice versa.

Such an approach might seem burdensome to the course providers and accreditors. But it will allow trainees to start earning more quickly, reducing the massive financial barriers to entering the profession and increasing much-needed diversity. It would also give the end-employers the confidence that post applicants can do what they're required to do even if they don't meet the gold standard of "UKCP accreditation" yet, because employers would have had an input to the standards.

Add to these ideas the more standard practices of employers providing trainees with a trainee stipend, or access to a training loan which can be repaid either financially, or through continued service to the employer once trained, and the profession might actually be able to attract enough trainees of enough diversity to ensure the continuation of psychodrama in the UK public services.