3.1 Symptom-Based Diagnosis and Process-Based Diagnosis

Most psychotherapists in Germany refer to the ICD-10 (2004)—the “International Statistical Classification of Diseases and Related Health Problems”—when diagnosing and classifying mental illnesses. The ICD divides psychological disorders primarily according to the type and severity of the symptoms of the disorders. The diagnostic terminology of the ICD is useful to define what is understood as a disorder, for scientific communication, and to clarify costs for treatment for health insurance providers.

Symptoms are the outcome of disturbances or blocks in the patient’s creative processes of mentalizing and conflict processing. Under sufficiently favorable conditions, a human being’s self-regulating processes “constantly take place in the form of assimilation and accommodation. […] It is a matter of giving up inadequate process structures in favor of new, less painful process structures. […] Under less favorable developmental conditions, individual process levels can develop patterns that serve as emergency or partial solutions for overcoming challenges but are dysfunctional to other process levels and/or are not adaptive for further developments. In this way, the structures of the understanding of self (i.e., reflective consciousness), for example, less symbolize the organismic experience or the felt needs and more the interpretation and understanding of the social environment (‘introjects’) […]. Actualizing such dysfunctional (partial) solutions can thus lead to the development of symptoms” (Kriz, 2012, p. 319).

Mentalization-oriented metacognitive psychodrama therapy works on the dysfunctional self-regulatory processes that produce the symptoms and not on the symptoms directly. The therapist understands that “mental disorders, even the most severe disorders, […] are not mere deficits and dysfunctionalities; in a certain sense, they are also active, even if […] they are processes with defensive and/or compensatory functions. Therefore, they can also be considered functional dynamic constructs” (Mentzos, 2011, p. 283).

In practical psychotherapeutic work, psychodrama therapists implement the idea of the spontaneous-creative human as a process. In their work, they focus on the blocked processes that lead to the development of symptoms. In psychodrama therapy, these processes turn out in:

  1. 1.

    the space of creative inner conflict processing

  2. 2.

    the space of creative psychodramatic play,

  3. 3.

    the space of creative attunement and agreement between the psychodrama therapist and the protagonist in the psychodramatic play, and

  4. 4.

    the space of creative real relationship between the patient and his therapist and other group members.

3.2 The Disturbances in Mentalization and the Resulting Conflicts

The severity of a mental disorder is determined by the severity of blockades in the inner process of self-development. These appear as disturbances in the mentalization process. Mentalizing is the half-conscious, half-unconscious, creative inner mental process that helps people understand themselves and others in a given context. It also helps people process their conflicts, search for appropriate or new conflict solutions, and plan their actions. Nowadays, many psychotherapists offer two qualitatively different diagnoses, one based on symptoms according to the ICD-10, and an additional structural diagnosis, indicating the extent of blockades in the inner processes of self-development. The extent of these blockades determines the degree of structural disturbance (see Sect. 4.4). The structural diagnosis directs the therapist’s attention not to the patient’s symptoms but to the ‘specific mental functions or dysfunctions’ which produce the symptoms (Rudolf, 2006, p. 3).

I differentiate between five different severities of blockades in self-development in a current situation. These are expressed in different degrees of disturbances in mentalization. They are based on the different levels of integration in Operationalized Psychodynamic Diagnosis (OPD-2).

Central idea

The therapist records the degree of disturbance in mentalization through a diagnosis of the patient’s quality of conflict (see Table 3.1 in Sect. 3.3). The quality of conflict indicates the level of mentalization at which the patient’s conflict processing is blocked or deficient. It determines which psychodramatic approaches are to be used.

  1. 1.

    Actual conflicts without a neurotic solution pattern: The patient’s mentalization process is blocked due to an acute relationship conflict or event. It can be triggered by current stressful situations or transition phases, such as a marital conflict, the death of a caregiver, or a workplace conflict. The patient perceives the conflict appropriately but cannot cope with it and/or does not appreciate himself enough for what he does in coping with the conflict (see Sect. 8.3). The patient is structurally well-integrated. The therapist obtains a diagnostic overview of the patient’s conflicts through the symbol work on the table stage (see Sect. 8.3). She addresses an acute relational conflict with a psychodramatic conversation (see Sect. 2.8) and/or with the first four steps of the psychodramatic dialogue with role reversal (see Sect. 8.4.2). In doing so, she resolves the blocks in mentalizing the acute conflict. The therapist works out with the patient the actual extent and consequences of the conflict. She records the patient’s existing coping methods and appreciates them adequately, thereby therapeutically activating the patient’s healthy adult conflict resolution skills.

  2. 2.

    Relationship conflicts with a neurotic solution pattern: The patient’s mentalization process is blocked in all relationships by an old neurotic solution pattern. The old neurotic solution pattern prevents the patient from resolving this conflict appropriately. He cannot adequately differentiate or assert himself in relationships. He does not strike a fair balance between the ‘give and take’ in relationships (see Sect. 8.4.2). However, the patient is well-integrated structurally. The therapist centers the therapeutic work on the relationship conflict that triggered the patient’s suffering. She helps the patient cope with the conflict using the seven steps of psychodramatic dialogue with role reversal (see Sect. 8.4.2), which resolves the block in mentalization that has existed since childhood.

  3. 3.

    A slight deficit in mentalization occurs in patients who protect the inner blockades in their process of self-development with a rigid defense pattern. Such a deficit in mentalization can be found, for example, in people with personality disorders, post-traumatic disorders, or addiction disorders. The patient is then structurally moderately integrated. The therapist uses the psychodramatic techniques of neurotic solution patterns. But additionally, she also makes the patient’s dominant rigid defense pattern the subject of therapeutic communication. She defines it and represents it with an empty chair as an ego state on the stage (see Sect. 4.8). The patient develops awareness of his rigid defensive pattern (see Sect. 4.8) through this explicit metacognitive therapy.

  4. 4.

    A severe deficit in mentalization leads to serious intrapsychic conflicts in relation to one’s self in all relationships. The patient is only slightly integrated structurally. His metacognitive processes of self-development are fragmented and do not work in tandem with each other (see Sect. 4.10). The therapist, therefore, sets up the entire system of the patient’s metacognitive dysfunctional ego states by symbolizing them with chairs (see Sect. 4.7) and promotes cooperation between them through psychodramatic dialogues with role reversal. It liberates the patient’s healthy adult thinking from his fixations.

  5. 5.

    The disintegration of the process of self-development occurs during the decompensation into a nearly psychotic condition or psychosis. The patient is structurally disintegrated. The patient’s ego works only on coping with the symptoms and not on the conflicts that cause the symptoms (see Sect. 9.2). Therefore, any therapeutic intervention focused on the triggering conflicts would increase the disintegration of the patient. Therefore, as a doppelganger, the therapist firstly mentalizes, on behalf of the patient, his thoughts, feelings, and wants that are in his symptom’s control (see Sects. 8.6 and 9.3). For people with psychotic disorders, for example, the tools of mentalizing work as mechanisms of dream work caused by the disintegration of the inner process of self-development. Therefore, the therapist must enter the delusion using the doppelganger dialogue (see Sects. 8.6 and 9.6.2) and the auxiliary world technique (see Sect. 9.6.5) in order to convert the mechanisms of dream work back into tools of mentalization thereby interrupting delusional thinking. In doing so, the patient learns to once again differentiate between reality and fantasy.

3.3 Diagnosis and Planning in Counseling

Many social pedagogues, teachers, and pastors work as counselors in schools, church institutions, family and educational counseling centers, pastoral care, or coaching. They have received further training, for example, in psychodrama or systemic counseling. Some universities offer training in counseling, for example, the Institute of Mental Health at Semmelweiss University in Budapest. In Germany, Psychodrama Institutes offer a two-year training with the title “Psychodrama Practitioner”. It comprises a total of 464 h of lectures and seminars.

The tasks and goals of counseling are varied. Counselors are employed to work in areas of crisis intervention, child or marriage counseling, or addiction counseling. They support the client in the event of a chronic illness and offer them special assistance (see Table 3.1, right vertical column). Counseling usually lasts only for a short period of one to ten sessions. However, it may increase to twenty sessions and more in exceptional circumstances. Counselors can also practice psychotherapy when focused on resolving one specific conflict. However, they refer their clients to psychotherapists in case of severe mental health difficulties.

Table 3.1 Qualities of conflict and the corresponding psychodrama intervention techniques
Full size table

Central idea

This is because 10–20 sessions are certainly not enough to achieve what psychotherapists achieve in 50–100 sessions. On the other hand, counselors work in places where people’s problems arise, for example, in schools, and try to solve them immediately before they become chronic.

Counselors are often under a lot of pressure to perform. But sometimes, patients prefer counseling over psychotherapy because of the following reasons:

  1. 1.

    In many countries, people have to pay for psychotherapy themselves. But it is not always affordable. Counseling, however, may be free or cheaper.

  2. 2.

    Usually, the number of psychotherapists in the country is relatively small.

  3. 3.

    Or the psychotherapists have a waiting period of one year.

  4. 4.

    Psychiatrists often limit themselves to giving a diagnosis and prescribing psychotropic drugs. Therefore, their patients need additional help to understand themselves and their conflicts.

Nevertheless, some psychotherapists insist that counselors need to be familiar with the diagnosis of mental disorders. I think that is inappropriate because the diagnostic approach used in ICD 10, referred to by many psychotherapists, is somewhat confusing for counselors and doesn’t guide their psychodramatic actions. The symptom-oriented diagnostic system does not provide enough guidance for appropriate therapeutic action. Counselors are not “small therapists”. They should develop their own professional identity and ways of working. It includes planning the goal and scope of counseling with the client in the first session. One can do this through the following steps:

  1. 1.

    The counselor focuses on addressing the core of the client’s disorder. She captures the essence of the disorder by diagnosing the quality of her client’s conflict (see Table 3.1).

  2. 2.

    The counselor uses psychodramatic intervention techniques that match her client’s conflict qualities (see columns 2 and 3 in Table 3.1).

  3. 3.

    The counselor discusses the expected number of consultation hours and the overall duration of the counseling process with the client in the initial session. Experience has shown that having greater clarity in this agreement positively influences the success of the counseling process.

  4. 4.

    The counselor uses as many sessions as are required for the specific conflict quality of her client (see column 4 in Table 3.1).

  5. 5.

    The counselor limits her interventions to the client’s current conflicts and their current state of self-regulation.

  6. 6.

    In the case of clients with personality disorder, trauma disorder, or addiction disorder, she always sets up only one chair to represent the dominant defense of the client, in addition to the chair representing healthy adult thinking (see Sect. 4.7). The client should ‘only’ learn to question the dominant dysfunctional metacognitive process in his conflict processing, for example, his defense through grandiosity. This then changes his behavior in all his relationship conflicts. The chairwork with one ego state requires at least 10–20 sessions. The chairwork with several ego states (see conflict quality 6 in the table) is suited for a psychotherapy process of 50–100 sessions.

The psychodramatic intervention techniques mentioned in column 3 of Table 3.1 build on one another from top to bottom. The more disturbed the client’s mentalization (column 1 in Table 3.1), the greater the number of intervention techniques (see column 3) used by the consultant in succession. An example: A 39-year-old client seeks counseling to address her big fears. She is panicking because she doesn’t know if she wants to marry her boyfriend or not. It appears to be an “acute conflict without a neurotic solution pattern”. However, the client is generally a bit inhibited. She is afraid of having to take care of her dominant father-in-law at some point after marriage. In the first session, the counselor works with the table stage. In the second session, however, she also uses psychodramatic conversation (see Sect. 2.8). She asks the client to portray a memory of an argument with her boyfriend. In the following sessions, the counselor applies step 3 of the psychodramatic dialogue with role reversal. In doing this, the client tells her ‘partner’ what she feels, thinks, and wants in her role and responds to herself by reversing into her partner’s role. In the debriefing (step 4 of the psychodramatic dialogue, see Sect. 8.4.2), the client considers what was new for her in this play or what became clearer. It turns out that the 39-year-old client is blocked by a neurotic pattern in the argument with her ‘partner’. Therefore, steps 6 and 7 are also necessary for the psychodramatic dialogue (see Sect. 8.4.2): The counselor assumes the role of the client as a doppelganger, and the client plays the role of her partner. In step 6, the counselor speaks to the ‘partner’ on behalf of the client about what she thinks and feels in her role. In step 7, she negotiates appropriate conditions for marriage with the ‘partner’ on behalf of the client. For example, she tells the ‘partner’ that she does not want to look after her father-in-law in old age. In the role of her partner, the client herself checks the extent to which the partner would accept this condition.

Counselors with little professional training should limit their engagement to clients with conflict processing qualities 1, 2, 3, and 7, as mentioned in Table 3.1. Counselors who have completed professional training to become psychodrama practitioners can also apply the intervention techniques mentioned for conflict levels 4 and 5. A counselor can use psychodramatic self-supervision to diagnose a client’s quality of conflict (see Sect. 2.9). If the counselor understands the client with the help of steps 1–12 of psychodramatic self-supervision and becomes curious about the following conversation, it is indicative of ‘relationship conflict with or without a neurotic solution pattern’. In contrast, clients with intrapsychic conflicts in relation to one’s self often operate from a rigid defense system. Their actions also lead to disturbances in the relationship with the counselor. The counselor can diagnose an ‘intrapsychic conflict provoking interpersonal conflicts’ (see Table 3.1) as follows (see Sect. 2.9): (1) She validates her feeling of disturbance in the relationship with the client. (2) She checks which dysfunctional ego state of the client triggers her negative affect. (3) She symbolizes the client’s dominant dysfunctional ego state with an empty chair and places it on the stage (see Fig. 4.1 and Sect. 4.2). (4) If this dissolves her negative affect, it is an important indication that the client has an intrapsychic conflict in all relationships. The client is probably only moderately or poorly structurally integrated (OPD, 2006).

Building a relationship with clients often by itself forms the basis for their growth and stabilization in therapy. In an acute crisis, the counselor should always schedule a second consultation with the client after the first meeting. It stabilizes the success of the first meeting. After referring the client to a psychotherapist, the counselor meets with the client for further counseling sessions until the client tells her that the first interview with the psychotherapist really did take place. This is because clients often do not reach the psychotherapist they have been referred to. The counselor should engage in psychodramatic self-supervision at least once during a counseling process requiring more than two sessions (see Sect. 2.9). Self-supervision improves their ability to care for the client appropriately and provide them with helpful counsel (Marlok et al. 2016).