Keywords

1 Trauma-Informed Practice

It seems that the term trauma-informed is thrown around by programs without much care or recognition of what it means to be trauma-informed. For some, being trauma-informed seems to mean that they had their staff attend a single training workshop on trauma, while other agencies identify themselves as trauma-informed only after taking careful consideration in developing their policies, procedures, designing their physical space, training staff, and operationalizing a philosophy that holds trauma-informed principles at its core. So, what exactly does trauma-informed mean? The Substance Abuse and Mental Health Services Administration (SAMHSA) published the following trauma-informed principles (2014a) (see Fig. 7.1):

Fig. 7.1
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SAMHSA’S trauma-informed principles

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The National Center for Trauma-Informed Care (NCTIC), established by SAMHSA in 2005, indicates that every aspect of an organization should be trauma-informed and:

assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization (National Center for Trauma Informed Care, 2012, as cited in Wilson, Pence, & Conradi, 2013).

According to SAMSHA’s NCTIC, “trauma-informed” is a philosophy that can be applied to health care, organizations, systems, treatment, prisons, education, and other settings, which is based on six core principles and critically examines the provision of services to avoid re-traumatization and support healing for trauma survivors.

2 History of Trauma-Informed Practice

Our understanding of trauma and PTSD has increased significantly in the past 40 years. PTSD was not recognized by the American Psychiatric Association until 1980 when it was added to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This recognition was the result of multiple larger social forces including the return of soldiers from the Vietnam War and the women’s movement (Herman, 1992; Ringel & Brandell, 2011; van der Kolk, 2014). Since then, trauma-informed practice in social work and other professions has continued to evolve to where it is today. Trauma-informed practice has become the norm rather than a specialty in the field today.

Some major events in the emergence of trauma-informed care included the 1994 Dare to Vision conference hosted by the Substance Abuse and Mental Health Services Administration (SAMHSA) during which the prevalence of trauma was highlighted in addition to acknowledging the re-traumatization experienced by patients during their treatment experiences (Wilson, Pence, & Conradi, 2013). In the late 1990s, the Adverse Childhood Experiences study (ACE) revolutionized the field by highlighting the relationship between childhood trauma, adversity, and family dysfunction as they relate to negative adult health and mental health outcomes (Felitti et al., 1998). By the late 1990s and early 2000s, multiple professionals were writing about the importance of trauma-informed care and trauma-informed organizations (Bloom, 1997; Covington, 2002; Harris & Fallot, 2001; Rivard, Bloom, & Abramovitz, 2003).

While the term trauma-informed in social work is relatively new, social work practice has been informed and focused on trauma, neglect, and adversity from the inception of the field. Social workers historically worked with neglected and oppressed communities, survivors of trauma and family violence, medical trauma, prostitution, human trafficking survivors, poverty, and protecting children, the elderly, and disabled from abuses. The trauma-informed philosophy serves as a bridge between clinical social work, social group work, and macrosocial work practice. Trauma plays a significant role in many social justice concerns, societal or community problems, family conflicts, and individual psychosocial ailments.

3 Trauma-Informed Practice Versus Trauma-Focused Practice

The difference between trauma-informed treatment and trauma-focused treatment is the difference between process and content. Trauma-informed describes a focus on the process of providing services, while trauma-focused treatment describes treatment in which the content of services is trauma-focused. Trauma-focused therapy orients itself on the treatment of PTSD and trauma-related conditions.

Initially, treatments for trauma and PTSD were almost exclusively focused on military veterans, while other trauma survivors seemed to be neglected (van der Kolk, 2014). As a result of this, others have advocated for new trauma-related diagnoses including Complex Traumatic Stress Disorder (Courtois, 2004; Courtois & Ford, 2009; Herman, 1992) and Developmental Trauma Disorder (van der Kolk, 2005, 2014) to describe the specific impact of childhood trauma, attachment ruptures, and family separation caused by immigration or forced displacements.

The current state of trauma-focused social work in clinical settings includes a variety of different approaches. These approaches can be loosely categorized into the following categories: psychodynamic-based, relational, cognitive behavioral, mindfulness-based, body-based, and the creative arts therapies. Psychodynamic-based trauma approaches are oriented around the emotional conflicts and reenactments caused by the traumatic event and early childhood experiences (Horowitz, 1997; Krupnick, 2002). Similarly, relational therapies such as attachment-based approaches focus on the here-and-now therapeutic relationship as a corrective and healing experience for past trauma (Banks, 2006). Cognitive behavioral approaches make up one of the largest categories of trauma-focused treatment approaches which include cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), dialectical behavioral therapy (DBT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure (PE). These approaches focus on changing maladaptive thoughts and behaviors related to the trauma and desensitizing the connection between trauma and present-day triggers (Dass-Brailsford, 2007). It is important to note that EMDR therapy, while often considered a cognitive-based approach, also is a mindfulness-based and body-based approach. Mindfulness-based approaches have also become popular for trauma treatment which are based on Eastern philosophy and the practice of mindfulness-based meditation (Briere & Scott, 2006; Kabat Zinn, 1990, 2003, 2005; Siegel, 2010). Body-based approaches, such as somatic experiencing and sensory-motor therapy, as well as the creative arts therapies, such as art therapy , music therapy , drama therapy, dance therapy, poetry therapy, and psychodrama, have become increasingly utilized in trauma treatment in recent times (Dayton, 2015; Foa, Keane, Friedman, & Cohen, 2008; Gene-Cos, Fisher, Ogden, & Cantrell, 2016; Giacomucci, 2018; Giacomucci & Marquit, 2020; Hudgins & Toscani, 2013; Johnson & Sajnani, 2014; Levine, 2010; Schouten et al., 2015; van de Kamp et al., 2019; van der Kolk, 2014). In addition to the aforementioned methods, many providers or programs utilize an eclectic approach which integrates multiple of the modalities above (SAMHSA, 2014b).

This is by no means a comprehensive list of trauma-focused interventions used by social workers, but most of the popular psychotherapy modalities for trauma and PTSD are included here. It is important to note that the treatment of PTSD and trauma is a specialty which requires specialized knowledge and training for social workers to competently work with traumatized populations. Many have written about the potential for re-traumatization, reenactment, and causing more harm in trauma therapy if not done properly (Giacomucci, 2018; Hudgins & Toscani, 2013; Levine, 2015; Ogden, Minton, & Pain, 2006; SAMHSA, 2014b, van der Kolk, 2014). There is a very real potential for treatment providers and programs to provide trauma-focused services in a way that is not trauma-informed. Unfortunately, this happens often when providers begin offering services specifically for trauma survivors without formal training or fueled by significant countertransferential issues. In a similar way, many trauma-informed programs do not adequately nor directly address the impacts of trauma. A trauma-informed program suggests that staff and administration are educated on the impacts of trauma but does not guarantee their ability to directly treat PTSD or other trauma-related issues. To mitigate these risks, we turn to the role of social work education.

4 Culture, Oppression, and Social Justice

In the discussion of trauma-informed practice, it is essential to highlight the importance of culture, history, gender, oppression, diversity, and social justice. A practitioner who fails to consider the impact of these socio-cultural forces within the group is not fully trauma-informed. Every participant and group leader brings with them their own cultural values, beliefs, assumptions, experiences, biases, and prejudices (Corey, Corey, & Corey, 2018). It is important to develop self-awareness of how one’s culture and aspects of identity may impact their group facilitation or participation. Moreno suggests that cultural values are conveyed through role relationships which are contained within interpersonal relationships (Nolte, 2014). The matrix of relationships within any group setting lends itself to the constant transmission of cultural values between group participants (and the facilitator). Furthermore, when a protagonist offers a psychodrama scene, the interactions between psychodrama roles are also saturated with cultural meaning. Participants belonging to diverse cultures could witness the same scene and have very different feelings, assumptions, or conclusions based on their own system of cultural beliefs, values, and norms. This means that the psychodrama director must be aware of the multiplicity of cultural understandings that exist within one scene or one role relationship and avoid interventions that neglect the protagonist’s subjective cultural experience in favor of the director’s cultural assumptions, values, or norms (Nieto, 2010). Without considering these cultural contexts, a facilitator risks reenacting trauma or neglect through misattunement to the protagonist’s (or other group members’) aspects of identity that have been socially marginalized or privileged. This also includes the responsibility for the facilitator to be attuned to how their own identities (marginalized or privileged) may impact the experience for participants.

5 Trauma and Social Work Education

The past two decades have seen a call to action for social work programs, as well as other helping professionals, to integrate trauma-informed training into their academic programs (Courtois, 2002; Courtois & Gold, 2009; McKenzie-Mohr, 2004; O’Halloran & O’Halloran, 2001; Strand, Abramovitz, Layne, Robinson, & Way, 2014). The growing body of literature highlighting the significance of trauma prevention and trauma treatment has led to this call to action. Social workers are frequently working directly with populations exposed to trauma (Strand et al., 2014). Over the past two decades, research has indicated a strong correlation between trauma and a multitude of mental health, behavioral health, and medical problems (Bloom, 2013; Courtois & Ford, 2016; Dong et al., 2004; Felitti et al., 1998; Putnam, 2006; van der Kolk, 2014). Joseph and Murphy (2014) have even declared trauma to be a “unifying concept for social workers.”

In 2012, a Task Force on Advanced Social Work Practice in Trauma published a set of guidelines on integrating trauma content into social work education (CSWE, 2012). The social work education field has responded as a growing number of MSW programs have begun integrating trauma courses into their curriculum (Abrams & Shapiro, 2014; Bussey, 2008; Strand et al., 2014). Gitterman & Knight (2016) also advocate for the inclusion of education on resilience and post-traumatic growth in social work education. Preliminary research has demonstrated that students indicate an increase in self-efficacy around trauma work after taking an MSW trauma course (Wilson & Nochajski, 2016). To date, the overwhelming majority of social work trauma courses has focused on individual trauma work or the impacts of collective/societal trauma—in contrast, social work education has given very little focus to training social workers to provide group psychotherapy with traumatized groups (Giacomucci, 2019).

6 Trauma-Focused Group Work

Trauma is often experienced at the hands of other humans and in the context of relationships, groups, or communities—making group work a potentially healing and corrective emotional experience for trauma survivors. Group psychotherapy is frequently used with trauma survivors as it provides an efficient alternative to individual therapy and the opportunity for interpersonal support between group members (Klein & Schermer, 2000). In the group psychotherapy field, various studies have highlighted the efficacy of various group therapy approaches for trauma and PTSD with various populations (Avinger & Jones, 2007; Davies, Burlingame, & Layne, 2006; Sloan, Bovine, & Schnurr, 2012).

Social work with groups experts has highlighted the value of group work for trauma survivors through the conceptual framework of mutual aid (Knight, 2006). The benefits of group work for trauma survivors include sharing experience, being with others with similar experiences, decreased isolation, increased self-esteem and self-efficacy, challenging distorted views, enhancing capacity for trust, reducing stigma, and practicing emotional regulation (Gitterman & Knight, 2016; Knight, 2006). Mendelsohn, Zachary, and Harney (2007) write that “group [membership] counteracts the isolating effects of [adversity] and enables survivors to connect with sources of resilience within themselves and others” (p. 227). Conceptually, social group work, mutual aid, and trauma-informed principles exist in congruence. Rosenwald and Baird (2019) write that “mutual aid is characterized by trauma-informed principles of peer support, collaboration and mutuality, and empowerment, voice and choice.” (p. 8). Social workers often work with traumatized communities in which group work skills and knowledge also become applicable. Most social justice oriented community work centers around a collective trauma, neglect, or injustice. Community organizers and social activists are routinely working with traumatized communities with a focus on the content of collective trauma; nevertheless, they rarely have any training or education on the impacts of trauma or trauma-informed practices. The implementation of a trauma-informed approach in community work is essential to prevent re-traumatization of community members. Further information on this subject will be presented in Chaps. 18 and 19.

7 Trauma-Focused Psychodrama

Although Moreno rarely used the term trauma, most of his work was with trauma survivors, including youth at a reform school, people of color, immigrants, refugees, prostituted women, inmates, and severely mentally ill patients at his sanitarium in New York. During Moreno’s lifetime, dozens of Veterans’ Administration Hospitals in the USA integrated psychodrama into their clinical programs (Moreno, 2019). Some even built dedicated psychodrama stages on their campuses. One of the most prestigious and competitive psychodrama internship programs in the world was housed at St. Elizabeths VA Hospital which provided services to US military veterans (Buchanan & Swink, 2017). Moreno died in 1974, six years before PTSD was recognized as by the American Psychiatric Association in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. Nevertheless, Moreno’s methods were widely used in the treatment of trauma-related issues.

Classical psychodrama has been, and continues to be, extensively employed with trauma survivors including in various VA hospitals, addiction treatment centers, psychiatric hospitals, mental health settings, youth programs, immigrant/refugee groups, correctional facilities, and community spaces. The person-centered and strengths-based Morenean philosophy is particularly congruent with most trauma approaches as it recognizes the inherent worth of each person and allows the client to control the pace of the session. Role theory’s non-pathologizing and user-friendly conceptualizations provide trauma survivors with new ways of conceptualizing their experiences of self and others (Giacomucci, 2018). The experiential and highly relational nature of sociometry, psychodrama, and group psychotherapy offers rich opportunities for corrective emotional experiences and moments of healing. Psychodrama’s body-oriented and action-based methodology allows for participants to express themselves through avenues beyond cognition and words while renegotiating their somatic and affective experiences (Kellermann, 2000). Zerka Moreno highlights how the warming-up process moves from the periphery to the center, and as such, the director should not begin psychodrama work with the most traumatic events of the protagonist before warming-up properly (1965/2006). The basic psychodrama interventions of doubling, mirroring, and role reversal are uniquely beneficial for trauma survivors who often struggle with articulating their feelings or sensations, labeling an experience, integrating new perspectives, and connecting with an accurate sense of self or others (Dayton, 2005). Psychodramatic role training is an avenue of simulating real-life experiences and rehearsing new possibilities, especially related to handling future situations related to trauma or present-day triggers.

The rise of trauma-informed care, neurobiology research on trauma, and the increased attention to the pervasiveness of trauma in society brought with it challenges to the practice of classical psychodrama with trauma survivors. The application of psychodrama to traumatized populations requires precise knowledge and slight modification of techniques to avoid re-traumatization (von Ameln & Becker-Ebel, 2020). A growing body of the literature and clinical practice oriented to trauma-specific services prompted the development of the Therapeutic Spiral Model by Kate Hudgins and Francesca Toscani, and the Relational Trauma Repair Model by Tian Dayton (Giacomucci & Marquit, 2020).

7.1 Safety, Play, and Spontaneity

Psychodrama has some inherent advantages to working with trauma survivors, one of which is its experiential nature and emphasis on spontaneity and play. Moreno describes spontaneity as the curative agent in psychodrama—the capacity for an adequate response to a new situation or a new response to an old situation (Moreno, 1946). In many ways, psychodrama is about developing competency and mastery in life through practicing or rehearsing intrapsychic and interpersonal situations on the stage. Moreno theorized that anxiety and spontaneity are inversely related—“anxiety sets in because there is spontaneity missing, not because ‘there is anxiety’, and spontaneity dwindles because anxiety rises” (1953, p. 337). In recent psychodrama research, spontaneity has demonstrated positive correlations with intrinsic motivation, self-efficacy, self-esteem (Davelaar, Araujo, & Kipper, 2008), creativity (Kipper, Green, & Prorak, 2010), well-being (Kipper & Shemer, 2006; Testoni et al., 2016), and social desirability (Kipper & Hundal, 2005). Research has also shown spontaneity to have an inverse relationship with obsessive–compulsive tendencies, stress, anxiety (Christoforou & Kipper, 2006), depression (Testoni et al., 2016), impulsivity (Kipper, Green, & Prorak, 2010), and panic disorder symptoms (Tarashoeva, Marinova, & Kojuharov, 2017). I hypothesize a similar inverse correlation between spontaneity and PTSD. The results of these studies suggest the important role that spontaneity plays in mental health and well-being.

Post-traumatic stress disorder is a stress disorder characterized by states of hyperactivity (hyperarousal, hypervigilance, irritability, anxiety, etc.), and hypoactivity (avoidance, dissociation, loss of interest, etc.). Post-traumatic stress, dissociation, and the tendency toward reenactment decrease a trauma survivors’ ability to respond with spontaneity or playfulness. Spontaneity, play, and safety are intricately connected and perhaps interdependent on each other. In order to help a trauma survivor access their spontaneity again, safety must first be established. Safety is found within the window of tolerance (Siegel, 2010). According to Goldstein, the use of playful interventions in group therapy helps promote safety within the group (2018). Gross (2018) offers the following insight into the relationship between play and trauma:

In many ways, play is the opposite experience of trauma. While play brings about feelings of joy, trauma brings about feelings of hopelessness and despair. While play serves to unite us, trauma serves to isolate us. While play motivates us to actively engage in the moment, trauma motivates us to fight and flee from it. And while play allows us to control our environment, trauma occurs when our environment controls us… play has the potential to serve as an antidote and powerful corrective emotional experience to trauma when integrated into treatment (p. 369).

Play, similar to fight or flight responses, activates the sympathetic system which provides a neurobiological intersection between play and trauma (Kestly, 2018). Playfulness and joie de vivre (zest for life) are necessary to restoring resilience according to Trevarthan and Panksepp (2016). Additionally, the use of the imagination, closely related to play, is associated with resilience in that imagination is required to envision a future self different from a past self (Marks-Tarlow, 2018). Trauma affects imagination resulting in a tendency for trauma survivors to superimpose the trauma upon the world around (van der Kolk, 2014). Through the surplus reality of psychodrama, a trauma survivor can envision a positive future utilizing their imagination and spontaneity. The psychodramatic process places emphasis on both playfulness, imagination, and spontaneity which make it a useful intervention for working with post-traumatic stress. In Chap. 8, the neurobiological underpinnings of psychodrama’s effectiveness will be explored further, especially as it relates to trauma.

8 Therapeutic Spiral Model

TSM is a clinically modified psychodrama model rooted in clinical psychology , attachment theory, and neurobiology; it underlines the importance of safety , containment, and strengths (Hudgins & Toscani, 2013). TSM comes equipped with a comprehensive clinical map called the Trauma Survivor’s Inner Role Atom (TSIRA ) which provides a framework for working with trauma using the simplicity of role theory (Giacomucci, 2018; Hudgins, 2019). It facilitates the safety needed to establish a therapeutic alliance and group cohesion while keeping clients in their window of tolerance and transforming internalized trauma-based roles into roles of post-traumatic growth (Giacomucci, 2018; Hudgins, 2017). Over the past two decades, TSM has increased in popularity in the psychodrama world and contributed to the movement toward trauma-focused and strengths-based approaches in psychodrama (Giacomucci & Marquit, 2020).

While classical psychodrama most often explores interpersonal roles and relationships, TSM is an entirely intrapsychic model. It developed from the realization that before one could interface with others in the world in a healthy way, they needed to do their own personal work and reorganize their internal role atom (Hudgins & Toscani, 2013). The trauma survivor’s inner role atom provides a template of 18 inner roles that contribute to stability, integration, and growth. The simplest way to describe the TSIRA is using a visual of a spiral with three strands—prescriptive roles , trauma-based roles, and transformative roles (Giacomucci, 2017). The first strand represents prescriptive roles which focus on developing the ability for non-judgmental observation, containment, and strengths. The term prescriptive is used to reflect that these roles are directives from a professional and are necessary for the change to occur, just like a prescription from a medical doctor. The second spiral symbolizes the internalization of the trauma. And the transformation that emerges between the interaction of prescriptive and trauma-based roles is represented by the final strand of the spiral. The TSIRA provides a template with intervention steps that target the development of specific psychological functions necessary for healthy functioning after trauma (Hudgins, 2017, 2019).

8.1 Prescriptive Roles and Safety Structures

The clinical map includes eight prescriptive roles with the functions of observation, containment, and restoration/strength (see Table 7.1).

Table 7.1 Prescriptive roles and functions
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In addition to the prescriptive roles , the TSM model includes six experiential safety structures to establish connection, containment, and safety in any group (Giacomucci et al., 2018). Some of these safety structures pull from classical sociometry (including spectrograms , step-in sociometry, and hands-on-shoulders sociometry), one safety structure is an art project, and two of the safety structures are inherently new to TSM and concretize prescriptive roles. These will be covered in further detail in Chap. 11.

The TSM model also offers two new types of psychodrama doubles—the containing double and the body double , which are often combined into one role in clinical settings. While classical psychodrama doubling has evolved to often be employed as one sentence of doubling, the body double and containing double are roles assigned to group members which stay with the protagonist at all times throughout the entire group. This method of giving the double a stable and centralized role in a psychodrama, as opposed to only employing doubling statements, more closely resembles Zerka Moreno’s teaching on doubling (Moreno, 1965/2006). The body double mirrors body movements/postures while making grounding statements to prevent dissociation and enhance somatic processing (Burden & Ciotola, 2001; Carnabucci & Ciotola, 2013). The body double reconnects the trauma survivor with awareness of their own body, thus strengthening vertical neural integration and providing grounding (Lawrence, 2011).

The containing double offers statements anchoring the protagonist in the present moment by expanding or containing feelings or thinking, depending on what is clinically appropriate. The containing double adapts based on the needs of each protagonist. For a protagonist with overwhelming feelings, the containing double would contain the feelings while helping to label internal experience; but for a protagonist prone to intellectualizing or overthinking, the containing double would contain the thinking while helping him access his feelings and physical sensations. One might say that it serves as the corpus callosum, connecting the left and right hemispheres of the brain and providing a balance between cognition and emotion (Hug, 2013).

8.2 The Triangle of Trauma Roles

The second phase of TSM ’s clinical map is only used once the protagonist and the group have adequately accessed their prescriptive roles. The trauma triangle is an evolution of Karpman’s (1968) interpersonal drama triangle of victim , perpetrator, and rescuer. In one’s experience of trauma, however, there was no rescuer; otherwise, the trauma would not have occurred. So, TSM teaches that a trauma survivor unconsciously internalizes the roles of victim, perpetrator, and abandoning authority (Hudgins & Toscani 2013; Toscani & Hudgins, 1995). These three trauma-based roles are the TSM operational definition of PTSD symptomology in action (Giacomucci, 2018).

These three internal roles—victim , perpetrator, and abandoning authority —create a triangulation of role reciprocity . TSM theory conceptualizes the trauma as living within the survivor in terms of these roles, which can be thought of as the introjections of the spoken and unspoken messages from the perpetrator and abandoning authority at the time of the trauma. Although the actual trauma is over, it lives within the survivor and is reexperienced through the surplus reality of flashbacks, night terrors, negative cognitions and feeling states, avoidance, dissociation, and insecure attachments (American Psychiatric Association, 2013).

The interaction of the prescriptive roles with the trauma-based roles is exactly what creates the intrapsychic change according to TSM theory. TSM defines its prescriptive roles as the operational definition of spontaneity in action (Hudgins, 2017) which, when interacting with the trauma-based roles, allows the protagonist to respond in a new, adequate way instead of resorting to the repetitive trauma triangle patterns (Giacomucci & Stone, 2019). The alchemy of prescriptive roles interacting with trauma-based roles is precisely what creates transformative roles —the final stage of the TSIRA clinical map.

8.3 Transformative Roles of Post-traumatic Growth

Post-traumatic growth, which will be covered in depth in Sect. 9.2.2, refers to phenomenon of positive transformation that is often experienced after a traumatic life event (Calhoun & Tedeschi, 2014). The TSIRA ’s transformative roles are the operational definition of post-traumatic growth in action and embodied in the simplicity of role theory . The TSIRA ’s transformative roles include eight labeled roles organized on the three poles of transformative functions—autonomy, integration, and correction. These functions can be conceptualized of as the opposite sides of the trauma triangle roles constituting role transformations from abandonment to integration, victimhood to autonomy, and perpetration to correction (Giacomucci, 2018) (see Fig. 7.2).

Fig. 7.2
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TSM Trauma Triangle Role Transformations. This figure depicts the TSM transformative triangle (heart-shaped) as an evolution of the TSM trauma triangle with the alignment of trauma-based roles and the corresponding TSM Transformative roles and functions

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One of the most important transformative roles on the TSIRA clinical map is the appropriate authority , which is necessary to help remove one’s self from cycling around the internal trauma triangle (Hudgins & Toscani 2013). The appropriate authority is an internal role that intervenes in the repetition of continued abandonment, victimization, and perpetration of the self. TSM’s other role of integration, the ultimate authority, is the integration of all eight of the transformative roles having been internalized, enacted in the protagonist’s intrapsychic world, then their interpersonal world, and finally out in the world. This role is, in a spiritual sense, awakening to the fact that one is a co-creator and co-responsible for mankind (Moreno, 2012).

The sleeping-awakening child is another role unique to TSM. Many trauma survivors indicate that they feel as though they have lost their innocence, spontaneity , creativity, or inherent goodness. The sleeping-awakening child role reframes these beliefs and offers a new construct; this is the role that holds all of the innocence, goodness, uniqueness, creativity, and spontaneity. It was never lost or taken, it simply went to sleep at the time of the trauma and waits for the protagonist to make their life safe enough to be awoken (Hudgins, 2017). It is a truly beautiful moment in a TSM psychodrama to experience an auxiliary play the role of the sleeping child as the protagonist awakens this part of self, and in doing so, taps into a source of inner goodness.

The transformative roles of corrective connection, which are good-enough parents, good-enough significant other, and good-enough spirituality, are significant in their ability to provide protagonists with corrective emotional experiences that have the power to repair the negative influence of prior experiences (Alexander & French, 1946; Cozolino, 2014). TSM psychodrama allows participants to embody the roles of transformation and post-traumatic growth in the safety of a psychodrama, effectively role training them to hold the roles in other arenas of their lives.

While the TSIRA provides a template for transforming trauma, these templated roles are sure to materialize differently in each psychodrama, and especially from culture to culture. TSM has been taught and practiced in over 40 countries with its clinical map consistently providing a framework for inner change (Hudgins, 2017). Some have come to believe that TSM is the most clinically sophisticated psychodrama model available and that its application extends beyond just utilization with trauma survivors (Hudgins & Toscani, 2013).

9 Relational Trauma Repair Model

The Relational Trauma Repair (RTR) model, developed by Tian Dayton, sometimes referred to as NeuroPsychodrama, is another clinically modified approach for using psychodrama and other action methods for work with trauma. RTR is also grounded in the interpersonal neurobiology research and attachment literature offering a variety of sociometric group processes ranging from experiential psychoeducation, action-based sociometry tools, and psychodramatic enactments (Dayton, 2015; Giacomucci & Marquit, 2020). A major strength of RTR is that it can be adapted for clinical use in shorter groups and offers a potent alternative to full psychodrama sessions while employing psychodrama interventions. A common RTR group includes a series of an action-based sociometry exercises followed by a small, but precise, psychodrama vignette. While a TSM or classical psychodrama would often include multiple roles and scenes, an RTR psychodrama most often only has two or three roles but still has the option of growing into a larger psychodrama.

The RTR model has two levels. Level 1 is present moment focused and helps to identify group themes, provide psychoeducation, cultivate interpersonal connection in the group, and warm-up participants for deeper work. RTR level 1 addresses trauma survivors’ disconnection from self and others through group processes that encourage inner reflection and social communication which effectively treats both PTSD symptoms and the underlying trauma. Level 2 is more oriented on the past and involves experiential regression work through the surplus reality psychodrama in addition to role training for the future. RTR’s first level is primarily psychoeducational and sociometric processes, while the second level involves both sociometry and psychodrama (Dayton, 2014).

9.1 Level 1: Sociometrics

The first level was designed to engage, educate, and enhance group cohesion and safety. It was originally developed by Tian Dayton for use in treatment with addictions, trauma, and grief-related issues but has been incorporated into a wide variety of group treatment settings in addition to one-to-one sessions. The facilitation of processes from RTR level 1 requires less psychodrama training than level 2 as it emphasizes educational exercises, sociometry processes, and psychodramatic journaling or letter writing. This phase of treatment includes sociometry processes such as the spectrogram, locograms, and floor checks, as well as writing exercises involving timelines, journaling, and psychodramatic letter writing. RTR’s trauma timeline is a notable contribution to the field which helps contextualize, clarify, and provide coherence to trauma survivors’ often fragmented narratives of the past (Dayton, 2014) (see Sect. 16.3 for more information). Advanced level one practice also includes some simple empty chair work using the letter writing to keep the process contained.

One of RTR’s biggest contributions to the field is the floor check structure, which takes the traditional sociometric locogram and expands it into a more dynamic group tool (Dayton, 2014). This process will be covered extensively in Sect. 11.5. RTR developed with an emphasis on experiential processes “that could put healing in the hands of the process itself rather than exclusively in the hands of the therapists” (2015, p. 10). The RTR model uses mutual aid as its lynchpin by positioning group members as therapeutic agents for each other (Giacomucci, 2019, 2020b). These psychosocial processes are congruent with 12-step principles focused on sharing and identification and are widely employed into addictions treatment programs at both inpatient and outpatient levels of care (Dayton, 2014; Giacomucci, 2020a).

9.2 Level 2: Reconstructive Role Plays

The second level of RTR practice focuses on traumatic “role reconstructions” and “frozen moments,” in addition to strengthening positive, resilient roles, which does require more psychodrama training.Dayton (2014) describes it as “surgical role reconstruction” which allows trauma survivors to renegotiate internalized trauma scenes for moments of repair. Various processes described in this phase include social atom exercises, family sculpting, creating moving sculptures of painful or healing moments, and short psychodrama vignettes.

RTR’s therapist handbook (2014, revised edition) outlines various ways of creating a social atom including basing it on a point in the past, the present, or the future. Level two RTR work brings these pen-to-paper exercises to life using sculpting—an experiential process by which a group member uses other group members to stand-in as the roles depicted on the social atom. Sculpting is different from psychodrama in that it often only involves body posturing, short and prescribed movement, and/or short messages from the roles (see Sect. 13.1.9). Sculptures provide living scenes of past or internal experiences—they are simple and effective processes that can be moved into further action by a trained facilitator. The protagonist can talk to themself or others from outside the scene, role reverse with roles the scene, or offer doubling statements for roles. After exploring the scene, it can be recreated in a new way to provide corrective emotional experiences and role training—effectively making up for what was missing, lost, or craved-for in the original experience. In sculpting, the protagonist takes a more active role co-directing the scene and often observing it from a mirror position. Some action sculptures may only involve placing role players on the stage using proximity and posture without words or movement. Sculpting is versatile in that it can be used to concretize internal parts, the family system, the social atom, or other social situations in the past or future.

RTR’s “frozen moment sculptures” describe the process of identifying a frozen moment for the protagonist—an experience in which a trauma occurred, and the protagonist feels stuck. These frozen moments might be instances from the past when one resorted to a freeze response due to the danger at hand or when one felt helpless or simply stuck and unable to take action. In describing the RTR process of sculpting, Dayton writes:

We are helping clients to revisit moments from their past that block them from moving forward and to resolve them through a process of making their split-off emotions conscious and then translating them into words and processing them rather than defending against feeling them (2016, p. 49).

These specific moments are reconstructed using sculpting or role playing with the purpose of empowering the protagonist with an opportunity to alter the situation for closure or transformation. The same process can also be used as an integrative experience whereby positive memories or celebratory moments from time are sculpted (Dayton, 2014).

10 Conclusion

The increased awareness of the impact of trauma upon individuals, groups, and communities challenges professionals to create systems, organizations, groups, and interventions that are trauma-informed and directly address the impact of trauma. The evolution of the fields of social work, group therapy, sociometry, and psychodrama appears to increasingly be integrating new information and approaches related to trauma-informed and trauma-focused practice. The centrality of the role trauma as an underlying fueling factor of many psychological and social ailments demands that it is given attention and addressed in a truly therapeutic procedure.