Modern psychiatry is enriched with amazing discoveries in neurochemistry, neurophysiology, psychopharmacology and genetics. Modern psychiatrists are also familiar with psycho-genetics*, psychodynamics**, and object relations theory***. These domains can be integrated with clinical psychodrama theory and the psychoanalytic theory of action and decision-making of Leo Rangel.

Modern psychiatry is enriched with amazing discoveries in neurochemistry, neurophysiology, psychopharmacology and genetics. Modern psychiatrists are also familiar with psycho-genetics*, psychodynamics**, and object relations theory***. These domains can be integrated with clinical psychodrama theory and the psychoanalytic theory of action and decision-making of Leo Rangel.

*Psychogenesis: Attempts to understand “psychogenetics” are based on the premise that what happens in the mind in the present is influenced or even determined by events and processes that happened in the past (i.e., psychic determinism). Discontinuities and mental conflict that appear random and unexplainable in an individual’s current actions and behavior can be understood by following a chain of causation in the sequential relationship of psychic events arising from a complex interplay of conscious and unconscious forces with anlage that form during childhood experiences.

**Psychodynamics: The aspect of psychoanalytic theory that explains mental phenomena such as thoughts, feelings, and behavior, as the result of interacting and opposing unconscious motivational forces. The theory focuses on the interplay of such forces and personality developmental progressions, regressions, and fixations. The concept of the psychic apparatus as a tripartite structure of the mind (Ego, Id, and Superego) aids in understanding intrapsychic dynamics.

***Psychoanalytic Object Relations Theory: The term “objects” refers significant others with whom an individual related in childhood the mental representations of significant others, usually one’s mother, father, or primary caregiver.

Object Relations Theorists stress the importance of early family interactions that form mental representations of individuals in relation to others that significantly influence interpersonal relationships later in life.

Many contemporary psychiatrists may not be unfamiliar with clinical psychodrama theory and it’s integration with the psychoanalytic action and decision-making theory of Leo Rangel.

Not all decisions or subsequent actions are drastically influenced by unconscious psychological factors or internal psychological conflicts. When the actor decision-maker’s internal world is unconflicted there is little need for therapists to extensively probe hidden psychological elements. When the decision-maker’s internal world is in conflict however, his or her decisions can become personalized and unconsciously equated in the external world with unresolved internal conflicts. Current life events can be influenced by symbolic distortions of relationships, strong emotions, and unconscious fantasies.

Rangell (1971) believed that understanding the ego function of decision-making would help psychoanalysts deal with the concept of freedom and responsibility. Using Freud’s (1926) concept of signal anxiety as a starting point, Rangel developed a psychological explanation of the process of unconscious decision-making by the ego. As a result of signal anxiety, which alerts a person to intrapsychic danger, defensive operations of the ego are initiated. The aim of these defenses is to keep untamed derivatives of instinctual drives, id impulses, and/or painful affects from emerging into consciousness and/or effecting actions.

According to Rangell, before fully experiencing signal anxiety, the ego permits a small, controlled amount of impulse to discharge—a tiny “test” within the mind, to see whether the ego can allow the impulse full- blown expression. (Rangel, 1971, p439).

In Rangel’s theory such a tiny “test” happens, then one’s conscience responds to the trial balloon and causes the ego to produce anxiety. Like the impulse that initiated it, the level of this anxiety is small—below the level of signal anxiety (Freud, 1926). At this point, the ego must “choose” what to do next: allow the full discharge of the impulse or stop the impulse from being discharged. Rangel (1971), called this process intrapsychic choice conflict:

The delineation of an intrapsychic choice conflict spells out a moment in intrapsychic life in which the human psyche is confronted with the opportunity, and the necessity, to exercise its own directive potentials and to determine its own active course....Taken by itself, psychic determinism is incomplete, unless it is viewed in the context of the role played by the individual himself in controlling and shaping his own destiny (p. 440).

Rangel then describes a “decision-making function of the ego” (p. 431) specifically designed to resolve the intrapsychic choice conflict, which is followed by action. The anxietychoice- decision-action sequence he describes serves as the theoretical model for the psychoanalytic contribution to decision theory. All decision-making, whether it involves engaging in an international conflict or buying a piece of land, involves planning. Rangel (1971) helps us understand the planning process in which the individual unconsciously scans “memories of previous psychic traumata, by which the utility of anticipated decisions are judged. The scope and security of predictions are thus enormously amplified by bringing into play previous experience and the entire sweep of the psychogenetic past” (Rangel, p 439).

In the anxiety-choice-decision-action sequence that Rangel refers to, both emotional and cognitive elements operate mostly on the unconscious level. According to Rangel, uncertainty results from an incomplete or unsatisfactory cognitive search for the anticipated outcome— what would be called in today’s terms the “what if” scenario. When a satisfactory “what if” outcome can’t be determined, indecision results:

Indecision is the unwillingness or inability of the ego to commit itself to a course of action either because of this or even after the cognitive consequences are known; and doubt is the emotional state accompanying either or both of these cognitive conditions (Rangel, 1971, p. 439).

As a child matures into an adult, decision-making obviously begins to involve increasingly sophisticated and conscious thinking—but some of the “problem-solving” preceding it continues to take place largely on an unconscious level. Frozen childhood fears and revival of childish over whelming emotions in the adult individual’s mental life influence decision-making functions. When fixations and regressions from past traumatic experience or conflict are severe enough, the secondary process thinking involved in decision-making is inhibited.

If psychoanalytic theory in search of intellectual insight looks at the psychogenetic past and psychodynamics of the present. Psychodrama seeks creative new ways of approaching action-decisions and personal responsibility in the here and now. As Moreno indicated, ancient wisdom from the past can be applied but in a new way. A psychodrama therapist through applying doubling, role reversal or soliloquy techniques with her patient can bring the “Tiny Test” described by Rangel into life on the psychodrama stage. A series of scenes can be explored to examine the contemplated action, imagined consequences and responsibility for them.

Ginny is a thirty-year-old psychiatric nurse. She is unhappy with her career. At her psychodrama group she confronts her unhappiness. Ginny says, “I really am thinking about being a pediatric surgeon.” The group asks challenging questions. The director invites Ginny to explore the chain of possible events that could be the results of her decision. The first scene finds Ginny announcing her decision to her husband and teenage son. A group member who has heard about Ginny’s husband in the group is chosen by Ginny to play her husband Fred. Another man in the group her teenage son Will. Will says,

“Cool mom. You would make a great surgeon. Remember when my little nephew Luke had to have emergency surgery for his appendix? That little guy was so tiny. But, the surgeon new he could help Luke and he just did it. Mom your good at decisions.”

Next Fred spoke, “Honey, we got to discuss this, you and me. Ginny, we are just getting our finances going good. We even will soon have most of the money for Will’s college.”

In the silence that built, the director had Ginny reverse roles with Fred. Ginny had a long speech prepared for Fred but now she had to stay in role and become the interrogator not the defense lawyer/accountant. Her double echoed what had to be her mixed feelings.

Ginny had vivid memories of her parents’ arguments when her mother wanted to work outside the home. Ginny told the group that she could picture her father’s angry face. His refusal to listen. Her fear that her parents would divorce. Her mother’s depression when she chose to stay a housewife “for the sake of the family.” She also recalled how intensely supportive her mother was about Ginny’s entering nursing school.

At subsequent scenes, Will offered to work after school to help pay for Ginny’s premed studies. Fred stayed skeptical but listened reluctantly when Ginny was able to point out to Fred how she had supported him when he was in grad school. Fred left the house abruptly to “Take a long walk and think.” The director replayed that scene several times as Ginny gained some confidence despite the intense mixture of inner feelings that her double helped her to face. Ginny cried. She did persist.

In the share-back phase the group noted that the more confident Ginny acted the more respect Fred seemed to have for her. Several group members reminded her that they would be there for her at future sessions however things came down.

Clinical psychodrama theory insists---show me, don’t tell me. Don’t talk and ruminate about action---Act! Feel! Make mistakes! Laugh! Cry! In the safety of the psychodrama group---let the chips fall where they may. We the group will help you to be the action you…the feeling you. You can be you---not your parent’s or anyone else’s image of who you should be to get their approval. The “WE” of the group is OK with your tears, your anger and your action. We celebrate your freedom, your dignity and your responsibility as you claim it. We love you for you!

Ginny’s life situation brings to life the interface of intrapsychic theory and the create and creative action theory of psychodrama group treatment.