A historical journey of Psychodrama and Nursing

Little has been written about the links between Dr J.L. Moreno, his psychodramatic methodologies  and the nursing profession. In this article Dr Wendy McIntosh explores nursing and academic literature and identifies strong links between them, many of which have not previously been reported within the context of major influences on nursing. This paper presents parallel journeys, the author’s personal journey with the work of Moreno and the significant influence of Moreno’s concepts and techniques on the profession of nursing since the 1930s.


It is 1990 and I am co-facilitating a 12-week relaxation course for clients in a mental health unit in Perth, Western Australia. Suzanne, my co-facilitator, engages with the clients. As I listen, I feel contained by her words and her inclusiveness of everyone in the room. I want to be part of this group. I have been nursing for 10 years but this is the first time that I have witnessed a colleague working with clients in this way. After the group we talk about the processes that she used. I find out more about her training. I am introduced to psychodrama and to a man called Moreno and I want to know more.

Several months later, my personal life is fragmenting and I ask Suzanne to recommend someone with whom I can talk. She suggests some colleagues with whom she works at the psychodrama institute in Perth. I make an appointment. I am waiting in the reception area, worrying. Have I made the right decision? Should I run? After all, as with other difficult times in my life, this too will pass. I have not previously shared much of myself with other people, my thoughts, my feelings, my wishes and dreams. Will I be able to share with this person whom I have not yet met?

A woman comes towards me. She introduces herself, greets me warmly and invites me to come with her. I walk into her room. It is warm and filled with what I assume to be personal items. I sit down in a comfortable chair. She sits opposite me but at an angle. There is no desk between us. She looks at me. I read open concern on her face. I cannot remember her words. I do remember dissolving into tears and crying heartily. I am not aware of how long I cried. It seemed a long time. She makes one comment, “This is very painful” and I cry more. I am seen and I feel validated. I do not have to
justify my experience. I am held emotionally. My body settles as the woman engages with me. I start to tell my story.

Warming Up to My Relationship with Moreno

These are the two key events that warmed me up to the work of Moreno. They created in me a sense of new possibilities, of working with clients with a sense of myself intact and with interventions that were new, unfamiliar and exciting. I wanted to learn more about Moreno and about psychodrama. I could see how this approach would assist me in my life and also in the work that I did as a mental health nurse. I enrolled in a group leadership course at The Wasley Centre in Perth. I was hooked.

During the training I was introduced to many concepts and action interventions, some of which I had initially met during my nursing training in Scotland. I could not, however, recall having heard the name Moreno before. At the end of the group leadership course my life changed in a number of ways. I moved interstate to Queensland. I started a new relationship, a new job and enrolled in psychodrama training in Brisbane. Several years rolled by. I used my experience of psychodrama and knowledge of Moreno’s concepts in my work with individual mental health clients, and in group facilitation and staff training. At all times I held onto the work of Moreno and was guided by my ongoing training in psychodrama.

I wanted to pursue further academic study and enrolled in a nursing masters degree at university. But I was not sure quite which courses would suit my twin interests of psychodrama and nursing. I talked this over with my principal supervisor and together we realised that little had been written on this topic. With her strong warm up to history, she encouraged me to research Moreno’s influence on nursing from the 1930s to the 1990s (see McIntosh, 1999). I was excited. My journey with Moreno intensified. I was aware of a large life force working within me.

I asked my psychodrama trainers in Brisbane if they could assist. I was introduced to Bridget Hirschfeld who held much of the archival material for the Australian and New Zealand Psychodrama Association (ANZPA). Bridget showed me the archival library. My heart leapt, my warm up to my purpose intensified and I felt privileged that I had access to this world of information about Moreno.

The more I read about Moreno, his life, his work, his purpose, his creativity, his vision for the human race, his excitement and joys, the more I felt a stronger link with this man. Although I had similar visions, I had not before thought of myself as a creative genius or a person who could influence the world. As I read ‘Psychodrama’ Volumes One, Two and Three (1972, 1975a, 1975b) and ‘Who Shall Survive’ (1993), it became clear to me that all human beings can create change for themselves and others. I became increasingly hopeful for the human race and for the profession of nursing.

Moreno and Nursing

Moreno believed that individuals are influenced by the society in which they live and work, and in turn they influence that society. His work embodies a holistic approach, emphasising particularly the relationships that individuals develop intrapersonally, interpersonally and systemically. The interaction between nurses and clients and their families and friends, is a major focus of the nursing profession because nurses relate to individuals who are experiencing a range of emotional, psychological and behavioural states. It is important then that nurses develop the capacity to interact with those individuals in creative and spontaneous ways, ways that enable safe and effective nursing care. Moreno’s methods of psychodrama, sociodrama, group psychotherapy and role training assist. The use of interventions such as role reversal, doubling, mirroring and sculpting afford nurses the opportunity to explore and understand their own responses to the clients and colleagues with whom they work. They can gain a deeper awareness of the client’s perspective and experience. These deeper insights assist nurses to identify a broader range of intervention options, and prevent them becoming frustrated and stuck and ‘giving up’ on their client.

A review of the nursing literature highlights the fact that many of Moreno’s techniques, including mirroring, doubling, role play, role reversal, role training, soliloquy and empty chair, have been used in nursing since the 1930s (Bektas, 2006; Burwell, 1977; Carlson-Sabelli, 1998; Drew, 1993; Hagen & Wright, 1945; Hailes, 1998; McLaughlin, Freed & Tadych, 2006; Samiye, 2007; Siegal & Scipio-Skinner, 1983; Starr, 1977). Of all the techniques developed by Moreno, role play is the one most commonly referred to in nursing texts especially in the field of nurse education. Only a few of those texts, however, mention the origins of the technique and the essence of role play as envisaged by Moreno. Similarly many other Moreno concepts such as interpersonal therapy, interpersonal relations, group therapy, action techniques, action research, action methods and acting out have been used in nursing whilst acknowledgment of their creator has been absent. Furthermore, according to Blatner (1997), Carslon-Sabelli (1998) and Williams (1989), many of those concepts have been misunderstood and misused in nursing and other disciplines, especially the concept of acting out.

Zerka Moreno (1974:10) criticises practitioners who utilise Moreno’s concepts and techniques without acknowledging the origins of their practice. According to her, when origins are disregarded there is a risk that “practitioners undermine a system of thought, a view, a philosophy of the world, a synthesis of methods which hang together and whose break up produces confusion rather than enlightenment …. invite confusion instead of producing cohesion”. Her warning is reinforced by other authors (Blatner,1997; Davis, 1987; Greenberg, 1974), who emphasise the importance of practitioners having knowledge of the philosophical underpinnings of Moreno’s work and his rationale for the use of techniques in psychodrama and group psychotherapy.

Historically Moreno’s influence on nursing can be divided into two main areas, mental health and nursing education. Nurses from these two areas have been more influenced by and more accepting of group psychotherapy and psychodrama than the general nursing field (Burwell, 1977; Consedine, 1984; Drew, 1990). Since sociometry and techniques such as role play have also been used as teaching strategies in general nursing (Goble, 1990; Loweinstein, 2004), the potential impact of Moreno’s work on the profession has been wide-reaching and beneficial. The benefits range from facilitating effective learning and increasing staff cohesiveness and self-awareness (Boylin, 1961;
Consedine, 1984; Drew, 1990; Will & Forsythe, 1993) to deepening empathy for clients, broadening nurses’ understanding of human relations and increasing understanding of health care systems and systemic influences. Moreno’s work also influenced the development of nursing theories which appeared in the literature from the 1950s onwards, although few acknowledged their debt to Moreno. An examination of selected texts identified links between the work of nursing theorists such as Peplau (1952), Orlando (1961) and Rogers (1989) and psychodramatic concepts and techniques. For
example, these authors empathised the need for nurses to recognise the way in which their interactions impact on their clients and therefore to develop greater awareness of their own responses.

Uncovering the Links

From the very beginning, nurses have been afforded the opportunity to experience Moreno’s work either in the mental health setting or through general nursing education. Moreno first introduced psychodrama into mental health treatment in America in the 1930s and nurses were involved as auxilary egos. During the 1940s, as psychodrama concepts and techniques were adopted by an ever increasing number of hospitals, Moreno’s work was widely disseminated among nurses. Student nurses were educated in sociometry and psychodrama at the Institute of Sociometry and in schools of nursing in New York as early as the 1940s. As with all staff employed at Beacon Hill, Moreno’s psychiatric sanatorium near New York, nurses were integral players in the development and maintenance of the therapeutic community there.

Regarding the relationship between nurse and client, there are many parallels between Moreno’s thinking and nursing philosophy. Firstly, in both psychodrama and nursing it is vital that the relationship is therapeutic. Secondly, in nursing and psychodrama it is important that the psychodramatist or nurse works with, rather than for, to or at the client. Thirdly, it is imperative that the psychodramatist and the nurse be aware of their own reactions and responses to the client Finally, it is equally important in both disciplines that the client’s feelings, perceptions and thoughts are regarded as their reality. By following these principles nurses provide themselves with a rich source of information regarding the meaning that patients make of their experience. They are then able to expand on this in-the-moment information. Moreno emphasised the significance of a full reciprocal relationship between therapist and client. He advocated eye-to-eye communication. He promoted bodily contact as a useful way of providing the client with a sense of immediate connection to the world and to another human being, for example a reassuring hand on a client’s shoulder or the firm grasp of the client’s hand. However, he clarified that touch was contra-indicated when used to benefit the therapist rather than the client.

Moreno’s actions of taking the hand of or hugging a client during therapy contradicted what had been the traditional form of psychotherapeutic intervention since the 1930s. However, Moreno (1975b) discussed the use of touch in nursing and attested to the benefits experienced by clients when a nurse made physical contact. According to Moreno (1972) the physical connection made by a nurse with a client assists that person to settle and thus alleviates the suffering experienced by them. In touch, a client can realise that they are not alone and that another person is there with them. Moreno (1975b:17) stated, “…nurses have always known that. Nurses have always known that you have to go to the patient, go to his bedside, take his hand”. Nursing theorists Peplau, Orlando and Rogers (previously cited) encouraged nurses to be conscious of the use of self in their work. They also advocated the value of touch to enhance the nurse-client relationship.

Peplau (1952), Orlando (1961) and Rogers (1989) have been recognised for significantly changing nurse education and practice from the 1950s (Tomey & Allgood, 2002; Willis & McEwan, 2002). An investigation highlights many links between their work and that of Moreno. For example, Peplau invited Moreno to present lectures about interpersonal relations to student nurses and she used psychodrama to assist the students to role reverse with doctors, colleagues and clients. Her classes were popular and other teachers would send their students or attend themselves (Callaway, 2002). Roger’s theory, the Science of Unitary Human Beings (1989), signalled a new paradigm for nursing. She proposed nursing as a science that recognised humans as integral to the universe. She advocated therefore that nurses be mindful of the influence of a multidimensional universe of open systems that affected and influenced the health of individuals. Moreno was credited by Davis (1987) as having developed systems theory in the early 1940s. Rogers’ terminology differs from that used by Moreno, but her ideas about the significance of the universe and the importance of each individual in it bear close resemblance to his ideas, especially the function of the cosmos (time, space and
reality) that must be fully integrated into therapy.

Currently in Nursing

Solution Focused Therapy (SFT) (McAllister, 2010; Wand, 2010) has been gaining increasing prevalence in nursing and mental health fields. It uses the miracle question to assist clients to project themselves into the future (de Shazer, 1985). At the 2005 Australian and New Zealand Psychodrama Association (ANZPA) conference in Brisbane, workshop facilitators Milne-Home and Hill discussed similarities between the miracle question used in SFT and surplus reality. Moreno developed the concept of surplus reality to enable individuals to ‘live’ their unspoken fears, perceptions and expectations, to visit and experience the future and that which can be created by and for them there. Surplus reality is used in psychodrama to assist the protagonist to expand perceptions of needs and fantasies. Nurses find themselves with clients during highly significant moments of life such as birth, death, amputation, chemotherapy, depression and suicidal thinking. In any of these moments they can use surplus reality to assist the client to experience dreams, hopes and fears for the future. In facilitating verbal and physical expressions of the previously unspoken, nurses uniquely provide clients with a place for the untold story to be expressed, heard and validated. This is to truly contribute toward healing.

That presentation by Milne-Home and Hill sparked some internal questions for me about contemporary forms of therapy and their possible connections to Moreno. As I become increasingly familiar with the SFT approach I am struck by the similarity of its concepts and interventions to those that I learnt in psychodrama, albeit under different names. For example, the use of scaling in SFT reminds me of the sociograph in psychodrama. I have not yet been able to locate any acknowledgement of or link to Moreno in the SFT literature.


I have been consciously walking with Moreno since 1990, both personally and professionally. Over this time I have grown to appreciate that the nursing profession has been travelling with Moreno for a much longer period. But what strikes and inspires me is that, although Moreno was a major influence on nursing from the 1930s, few acknowledgements of or references to his work can be found in the nursing literature. I hope that this article opens a door of interest for nursing scholars, clinicians and
researchers to further explore the importance of his work for nurses and nursing. I have learnt much about myself, past, present and future through engaging in Moreno’s unique techniques. In understanding Moreno’s concepts, I have deepened my appreciation of myself and the journeys I have taken in life. At times when I feel most challenged in my professional role, I imagine him standing with me and encouraging me to be present. So I breathe and wonder out loud, and the restrictions on my spontaneity dissipate. I introduce Moreno and his work in every presentation I am invited to do, in every workshop that I facilitate, in the one-to-one work I do with clients and in
professional supervision sessions I conduct with health professionals. I walk with0 Moreno in life. I walk with him in my nursing role. I will continue to encourage nursing colleagues to walk with him in the future.

For interested readers, a full historical picture of Moreno’s influence on the nursing profession can be found in Wendy McIntosh’s unpublished 1999 masters thesis ‘A Critical History of the Influence of Jacob. L. Moreno’s Concepts and Techniques on Nursing 1930s-1990s’. A copy can be obtained from Wendy by going to her website at www.davaar.com.au


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Wendy McIntosh (RN, Grad. Dip. MH, MN, PhD) is a mental health nurse working in private consultancy practice in Brisbane.She has been training in psychodrama since 1990.