Role play

Find out about role play here

Role plays are another way of hearing feedback about performance as a therapist. They have been used widely in developing therapist skills and awareness for this model of psychotherapy and as an adjunct to supervision of clinical experience. However, trainees are often worried that they will not be able to cope with “difficult” situations that occur outside the immediate training context. So, from an early stage PIT trainers drew on the work of Kagan (1980) to develop a way of addressing these therapist fears.

Kagan and therapeutic nightmares

  • Kagan (1980) Influencing human interactions- eighteen years with IPR In: AK Hess (Ed) Psychotherapy supervision : Theory, research and practice. New York: John Wiley

Norman Kagan was a pioneer in teaching psychotherapy by paying attention to, and developing, core therapeutic skills, using role play and systematic use of recordings.

He commented that therapists have the same basic human dilemmas as everyone else. Kagan described these as four basic fears:

  1. A fear of being hurt by others
  2. A fear of hurting or striking out against others
  3. A fear of being engulfed or taken over by others (seduced and losing control, loss of identity)
  4. A fear of incorporating or seducing others (seducing and losing control, loss of identity.

He describes ways in which individuals behave “diplomatically” to avoid the consequences of isolation and loss of identity.

By “diplomatically” he means both parties play along with a superficial interaction to avoid the risks of being involved in a real meeting.

“A diplomat is a gentleman who can tell a lie in such a way to another gentleman (who is also a diplomat) that the second gentleman is compelled to let on that he really believes the first gentleman, although he knows that the first gentleman is a liar, who knows that the second gentleman does not believe him. Both let on each believes the other while both know that both are liars”

By poking gentle fun at the mannnered ways we can adopt to avoid threat, he opened up a different way of learning psychotherapy

This is another way of describing the basic approach avoidance dilemma described by Hobson (and other psychotherapy theorists, for example Lester Luborsky [CCRT] and Tony Ryle [CAT])

He describes “feigning clinical naïvete” as a way of avoiding shame associated with these strategies both with the client and in supervision:

“ I knew she [the client] was very unhappy underneath but put on a smile, but- and I know this is stupid- I was afraid she might cry if I told her I knew she was “hurting” and then I would feel that I had made her cry.”

Sometimes a trainee would completely tune out of the emotional subtext and avoid the experience by shifting focus or asking a lot of questions.

It was in dealing with this anxiety and even narcissistic injury of trainee therapists that he developed structured safe supervision spaces and the use of role plays.

They developed small group supervision with peers with the group rotating roles as “inquirer / facilitator” a subject, a timekeeper and the others would give feedback.

He also used a way of desensitising therapists to their worst fears by using recordings of therapeutic nightmares of being attacked or being engulfed by the other. Kagan’s ideas have been incorporated extensively into training in PIT.

Feigning clinical naivete

Kagan suggests that therapists typically “feign clinical naiveté” with a supervisor to avoid possible humiliation about their basic fears. He described these as fear of being engulfed or engulfing (seducing) the other; or being attacked / attacking the other. These are seen as the basic fears in any interpersonal interaction, but they are amplified in the close observation characteristic in learning psychotherapy. We used role-plays to set up a series of escalating difficulties to desensitise the trainees to their fears and to help them to discuss the difficulties they experienced in an open way. We developed four stages of increasing complexity and challenge for the trainee therapists.

Developing role play

In the PIT adaptation of Kagan’s methods, a standard format is used for all the role-plays .

F. Margison “learning to listen: teaching and supervising basic psychotherapeutic skills

In: J Holmes (Ed.) Textbook of Psychotherapy in Psychiatric Practice London: Churchill Livingstone pp 165-186

A group, typically of about four therapists in training and a facilitator meet regularly. Two chairs are kept for the members currently playing therapist and client. The “client” is asked to prepare a couple of sentences summarising the basic information about age, gender, and main problems. Sometimes the role-play will be based on an initial session but role players are also surprisingly adept at starting as though several sessions into an ongoing therapy. Either the client or the therapist (or occasionally both) are given cue cards which have a brief instruction explaining what should be done. Typically this is a brief statement about what is the “agenda”, such as assuming that the client has to be told that the therapist is going to be away for three weeks holiday. The teacher stops the role-play after two or three minutes in the early examples, or somewhat longer in the later, more complex examples. After the role-play a standard sequence is followed with the two role players expressing their feelings about the interaction before opening up the discussion to the whole group. It is crucial in this teaching method to establish an atmosphere that is conducive to learning. Other group members are encouraged to describe what they saw, heard or felt. Also they are asked to comment about how they might have felt as the client or responded as the therapist. Criticism of the “therapist” is specifically discouraged.

A safe space for doing role plays

Commonly trainees have had bad previous experiences of role-plays where they have felt humiliated or exposed. So, it is important for the teacher to establish an atmosphere that allows exploration in depth for the role players within a safe framework. In a group that has been working together for only a few weeks it is usually possible for the members to be quite open about their anxieties as therapists. A reliable structure of the teaching session prevents inappropriate drift towards the training group becoming a quasi-therapeutic group.

Role play examples here

Level I role plays: impact of therapist behaviour

The training begins with low key examples of how sensitive the therapeutic situation is to therapist behaviour. So, for example, a trainee may be given a prompt card, which instructs the therapist to be “over-reassuring”, “lean too close to the patient”, “avoid eye contact” or similar undesirable behaviours. The therapist can use these early examples to become sensitive to nuances in the interpersonal situation and also become less anxious about the role-play itself. This is preparation for the next phase when the sessions focus on how to make practical arrangements about breaks, reviews of progress, session times. These particular role-plays have a dual purpose: The experience allows the therapist to be able to structure a therapy with confidence whilst developing sensitivity to the undercurrents of the therapy.

Level II role plays: Agreeing a structure

A common therapeutic error amongst beginners is their tendency to equate listening with passivity and as a result they may give insufficient structure. Whilst learning these basic techniques of structure and contracts they also become more sensitive to the emotional undercurrents involved in negotiating apparently practical issues. For example, any issue related to timing or frequency may be linked with separation issues or feeling neglected.

Issues regarding review of progress are often tinged with feelings of being criticised or, in extreme cases humiliation and narcissistic wounds. This second phase of the role-play training prepares the therapist for the inevitable multiple levels involved in any therapeutic conversation.

Role plays III: Misunderstandings and the alliance

The third group of role-plays focuses on how easily the therapeutic alliance can be damaged and persecutory dynamics established. For example, one role-play simply asks both participants not to take anything the other says at face value. As this is enacted the trainee becomes aware of the risk of invalidating the other’s experience. This helps the trainee to understand the processes described by Meares and Hobson (1977) as a “persecutory spiral”. By enacting the patient role as well it is possible for the trainee to realise just how sensitive the person in that position will be to minor discrepancies, ambiguities or inconsistencies in the therapist. These examples also give practice in how to repair ruptures in the therapeutic alliance.

Many beginning therapists in service contexts have had no experience of their own personal therapy, which is a prerequisite for most trainees wishing to practice primarily in psychotherapy. Whilst role-plays are clearly not capable of providing an equivalent experience, they can increase the trainee therapist’s sensitivity to interpersonal nuances which otherwise are learned only through therapeutic failures with actual clients.

Role plays level IV: “Therapeutic nightmares”

In the fourth stage of the role-play training, a series of role-plays deliberately simulates what Kagan described as “therapeutic nightmares” such as being told of intense suicidal or violent impulses, sexual feelings towards the therapist and antagonistic and hurtful comments about the therapist. Kagan had developed a number of “stimulus vignettes” on videotape, which the trainee could watch and reflect on their emotional response.

Our method draws on that technique, but uses a role-play situation to enact the challenging experience. The therapists have to think on their feet and respond in “real time”, but in a safe environment with no risk to clients. Most trainees find these sessions a demanding but positive experience.

Find out more about role play

Working with risk

Managing risk often involves checking in some detail about how close the client is to acting on suicidal thoughts. We developed role plays to help develop the skills to manage risk and also work in a therapeutic way.

These role plays have been informed by the research on PIT and self harm

Working with somatic presentations

Bob Hobson was a pioneer in seeing bodily symptoms and distress as aspects of the same feeling language. The role plays for developing these skills for upper and lower bowel symptoms, epilepsy-like symptoms, chronic pain are based on the extensive research on PIT with somatic presentations.

Is role play effective?

We evaluated the effectiveness of this role play training in acquiring therapy skills (Palmieri et al, 2007) and the research suggested that role play training was effective in learning new skills.

After the formalised sequence of role-play situations it is possible to extend this model of training into actual clinical work. For example, in a supervision group a trainee can role play his or her client, or can ask another group member to role-play the client whilst the trainee stays in the therapist role. The advantage of this method is that it allows the therapist to become familiar with “what if?” scenarios in dealing with particularly challenging material.

Role plays in maintaining skills

These methods can be supplemented by the use of peer teaching groups first described by Kagan (1980) when the members rotate roles between the roles of commentator/timekeeper, facilitator, “patient” and “therapist”. These techniques are a particularly powerful way of getting across the idea of different therapeutic perspectives. When teaching resources are scarce it is possible to have several groups of more experienced trainees running simultaneously with teachers moving between the groups to add an additional perspective. We have used these sessions regularly with therapists at different levels of experience and it is possible to develop new role-plays relevant to any specific topic such as working with somatic distress or managing self-destructive behaviour depending on the experience and clinical setting of the participants.

Role plays to develop supervision skills

With established therapists who want to progress to the role of supervisor we have used the same structure to role play the difficulties that arise in a supervisory setting where members role play supervisor and therapist and reflect on experiences with different styles of supervision.