In Love with a Delusion
Jacob Moreno, the psychiatrist who created psychodrama group therapy, put on the therapeutic stage a patient infatuated with an imaginary lover
In the early 1940s, a psychiatrist heard about a 23-year-old woman, Mary, who needed help. Her two sisters had spent years seeking therapy for Mary, but she resisted receiving any assistance. Nothing was wrong with her, Mary insisted. She fought off any suggestion that her love life had gone way off track. When her sisters told her that her infatuation with a man named John was based on fantasy, not reality, Mary grew infuriated. Mary had only once seen John from afar at a Christmas party, but that slight encounter had been enough to blossom into her obsession. Mary was convinced that she and John had a powerful three-year romantic connection.
In truth, John was a stranger to her. Yet his image haunted Mary. She hunted for him during her waking hours and dreamed of him at night. Sometimes she walked into the houses of strangers looking for him.
The psychiatrist who heard of her case, Jacob Moreno, an immigrant from Austria in his forties, managed the Beacon Hill Sanitarium in Beacon, N.Y. He had spent years developing a new type of psychiatric therapy, psychodrama, that he believed could cure Mary of her obsession. Nothing else was working. Mary had refused treatment elsewhere and had previously run away from other psychiatric hospitals. Moreno and his novel treatment — psychodrama — could be Mary’s last chance. His idea was to solve Mary’s delusion by putting her on a stage, in front of an audience.
Two decades earlier, Moreno, then new to psychiatry, had created psychodrama by braiding experimental theater techniques with the individual psychotherapy rising in popularity in the early years of the twentieth century. He began experimenting with a new approach to therapy in his Theater of Spontaneity, a Vienna venue that featured actors in improvisations based on audience suggestions, much like today’s improv performances. To his surprise, the actors told him their improvised performances gave them insight into their own personal struggles.
Moreno was intrigued, and he tried melding stage art with psychiatric exploration. In his own practice he moved away from traditional, one-on-one psychotherapy and instead played with giving psychiatry patients a stage, co-actors, and even an audience. Working together, all these participants could find meaning in experiences shared on the stage. Under the direction of a skilled therapist, psychodrama prioritized action over analysis by giving patients control over their on-stage reenactments of events from their lives. In scenes, patients could test revisions in their behavior and even switch roles with other figures in their lives. In a teasing comparison with the work of Sigmund Freud and other psychoanalysts, Moreno said, “You analyze their dreams. I try to give them the courage to dream again. I teach the people how to play God.”
Moreno formally established the practice of psychodrama at the Beacon Hill Sanitarium, where he found it successful in treating patients with a variety of conditions, including schizophrenia. Psychodrama became the world’s first form of group psychotherapy. By the mid-1940s it was in use in hospitals and institutions across the United States, becoming a significant part of the burgeoning field of group psychotherapy.
Moreno found Mary’s case fascinating. Could psychodrama relieve her of her delusion? He wanted to help her but believed he could not do so until he had built a therapeutic relationship with her. That would be difficult, because Mary did not consider herself sick or in need of help. Nobody had previously succeeded in convincing Mary that anything was amiss about her obsession for a man she had never met and had barely seen. How could Moreno make a connection with her? “The first step had to be carefully planned, as it would determine the entire course of treatment,” Moreno wrote. He first asked Mary’s sisters to stop hindering her efforts to find John. Instead, they should adopt an attitude of cooperation. Moreno told the sisters to inform Mary that they had tracked down a close friend of John’s who lived in Beacon.
In his sanitarium, Moreno decided to create a space where Mary could live out her delusional longing for this imaginary man, a place where she could fully experience and explore her fantasy. This happened in a room of the sanitarium’s main building that served as a stage for psychodrama sessions. In this psychodrama theater, Moreno began applying a psychiatric technique he called “therapeutic deceit.” It meant to temporarily lie to the patient in the service of her treatment and recovery.
Mary was soon bound for Beacon in the company of her suddenly solicitous sisters. Soon the therapeutic deceit began in earnest. “The claim that John was in Beacon was not entirely a deception,” Moreno observed. Because John was mostly a fantasy, the psychiatrist reasoned, “he could be [in Beacon] as well as anywhere else.” Using psychodrama, Moreno planned to make John appear and take part in Mary’s treatment. “John was a fictitious person to us, but to Mary he was real,” Moreno maintained.
Mary, in the company of her sisters, appeared at the sanitarium, went into Moreno’s office, and asked the psychiatrist where she could find John. Moreno was prepared for this question. He lifted a Western Union telegram from his desk and passed it to her. It read:
“Have to appear before the draft board tomorrow will come within two days. John”
Mary was elated to have a direct communication from John. Moreno now had time to execute the other preliminaries of his plan. He introduced Mary to two of his colleagues in her treatment: William, who told Mary he was John’s friend, and Jane, acting as a friend of John’s mother as well as taking other roles. Soon Mary asked for John’s street address to write to him. Moreno gave her one that had been readied in advance. Meanwhile, William offered Mary tips on how to appeal to John in a letter, and she told him what she hoped to hear back from her lover. The correspondence between Mary and John flew back and forth.
Because John was not real, Moreno and his collaborators could manipulate the character at will. “The real John was hard to produce, but the fictitious John was completely under our control,” Moreno noted. The lover was a figure in a play, and the medical team was writing and directing the production. Moreno continually delayed John’s appearance in Beacon.
In an early letter, John wrote to Mary, “William can tell you much about my people; I want you to like them.” In putting these words into John’s mouth, Moreno intended to ease Mary into the sanitarium’s psychodrama theater, where as a spectator she could watch the performance of a scene that featured William and Jane enacting Mary’s initial meeting with John. It offered three different versions of that event.
One version had Mary first encountering John at a holiday party and observing him from across the room; they didn’t speak. The next version had Mary talking with John in a drugstore. The last version gave another scenario in which she silently watched him in profile, from behind. In all three scenes, William’s performance disappointed her. Mary called out corrections. She criticized William’s posture and his voice. He didn’t look gentlemanly enough. “There was a strong flow of feeling between [John] and me,” she objected.
At this point, Moreno invited Mary to mount the stage and take the role of John, to step into the shoes of her lover. She did so without hesitation, and her performance of John’s voice, words, and gait impressed Moreno. “It made us think of Hamlet if Shakespeare would have met the actual prince and had asked him to take the role of the ghost of his father,” Moreno remembered. The more Mary tried to bring John to life, the clearer it became that she had never seen his full face and had viewed him from no closer than seven or eight feet away.
But that impression of John, no matter how brief, had obsessed her for three years. On the stage, she portrayed him in a variety of scenes: driving a red auto, sending Mary instructions for her to prepare for a date, and doing other things — all of which William tried to imitate for his own stage characterizations of John. Mary was growing increasingly impatient to be in John’s actual presence, so Moreno allowed the psychodrama session to end with a scene in which John finally arrived in Beacon. “It is good psychodrama,” Moreno declared, “not to end a session with a ‘letdown’ for the patient, but with a high point.”
Though trained as a physician at the University of Vienna, Jacob Moreno was attracted to theater work as a young man. In Vienna, he met an actress, Barbara, who was suffering in a difficult marriage. Inspired by his work with the Theater of Spontaneity, Moreno asked her to enact scenes from her marital relationship on stage before an audience. The audience found these scenes more moving than the improvisational work they had previously seen at the theater. The drama seemed real. Watching conflicts and breakthroughs as they happened in real lives felt more consequential than in invented scenarios.
Moreno immigrated to the United States in 1925, settling in New York. His interest in theater continued. He founded the Impromptu Theater at Carnegie Hall in 1929 and later worked at the Guild Theater. His psychiatric practice expanded, as well, and he began his work at the Beacon Hill Sanitarium in 1936.
Moreno believed that psychodrama provided unique advantages over traditional psychiatric therapies, particularly psychoanalysis, which then dominated much of psychiatry. First, Moreno saw psychodrama’s emphasis on action and enactment as superior to talk-based therapies. He maintained that acting spontaneously and creatively was essential to mental health. And he thought psychodrama harnessed the power of a group to bring about healing. He recognized that psychodrama could effectively heal flawed relationships — the key to many patients’ conflicts. Moreno loved when psychodrama scenes involved “role reversals” in which patients took the role of another person in their lives, thus building empathy and understanding of others, sometimes leading to a shift in perspective and behavior.
While psychodrama gained recognition and won adoption by many other therapists, it faced criticism from psychiatrists who questioned its lack of traditional scientific validation. Could Moreno really get results from it?
Mary’s psychodrama treatment had begun atypically. Usually, an analysis followed each session so patients could reach a better understanding of their problem and start planning future sessions. Mary, however, would resist or even flee the hospital if any formal analysis led her to think she was receiving treatment. To her, the goal of her time in the sanitarium was to get together with John. Moreno permitted Mary’s deviance from the normal path in consideration of her delusion.
In her second psychodrama session, Mary surprised everyone by voluntarily walking onto the stage and declaring what she wanted to happen in the dramatization. She had just received a letter from John saying he expected to meet her father. That wasn’t possible because Mary’s father had been dead for years, but she had a scene in mind to play out the meeting. She asked a physician in the audience to take the part of her father and William to play John. Just before the psychodrama began, Mary revealed her excited suspicion that John might be somewhere, hidden, in the audience.
After that scene, the psychodrama continued. Mary instigated more scenes involving people important to her, leading Moreno to reach a curious observation. To him, it was clear that John was merely the most recent of a series of imaginary figures that had obsessed Mary back to her earliest childhood. He concluded that she held stronger emotional attachments to these fantasy people than she maintained with the real people currently in her life. Was it possible to successfully treat a patient with such a powerful devotion to illusion?
So far, Mary’s psychodrama sessions were mostly populated by characters from her imagination. She had created them. Her illness, her delusions, had grown out of her inability to find connections in the real world. So far, Moreno was interested in letting her fantasies fully flower. Only after her obsessions came to life on the stage could Mary make gains in “discovering her own salvation,” as Moreno put it. She still needed to anchor herself in the real world.
An event that gave Mary anxiety signaled the next stage of her psychodrama treatment: she received a letter from John saying he had been drafted into the military and had to again put off seeing her in person. As Moreno hoped, this news jolted her into action. She had heard on the radio that many men called away for military service were having proxy weddings with their fiancées, conducted remotely. Mary immediately suggested to John that they should have such a ceremony. In his next letter, John agreed to the idea and nominated William to stand in his place. Moreno gave his blessings.
The wedding was a joyous and lovely ceremony held on the hospital’s psychodrama stage before an audience of patients and staff, who sang the words of the traditional wedding march. “Mary was a beautiful and tearful bride. She kissed William, promising him eternal loyalty. “Thus Mary and John became man and wife,” remembered Moreno, who had of course encouraged the whole event. He hoped the fulfillment of Mary’s dreams would begin a waning of her delusions of John, and indeed she grew less anxious to see face to face in the days that followed. She was learning, Moreno hoped, that the imaginary characters she encountered on the stage — John, his mother, and his father — were no easier to live with than the real people in her life.
Mary’s psychodrama sessions continued without her realizing she was in therapy. Nevertheless, Moreno’s direction was changing her. She was discovering what it was like to live in a world in which John and the other imaginary characters on her psychic stage vividly filled her mind — at the expense of her sisters and mother and other genuine people in her life, who grew more distant in Mary’s consciousness. When she ran into William, the man who played John on the psychodrama stage, in some other context, such as in the sanitarium’s dining hall, she became angry if he failed to behave like John. “She had no attachment to William as a person, but only in the role of John,” Moreno observed.
Jacob Moreno didn’t work alone in his development and advocacy of psychodrama. His wife, Zerka Toeman Moreno, perhaps exceeded Jacob as a practitioner and teacher of the technique.
Zerka was born in the Netherlands in 1917 and initially set her career sights on working in fashion, costume, and set design. She detoured to the study of psychology when her sister began suffering from a mental disorder. At the start of World War II in Europe, she immigrated to the United States. Her sister followed.
In 1941, Zerka brought her sister in for treatment at Moreno’s Beacon Hill Sanitarium. She and the psychiatrist clicked. Zerka took on the roles of Jacob’s student, research assistant, and wife, and she went on to immerse herself in the psychodrama movement — even though she had never heard of the treatment before meeting her husband. Zerka soon began working as Jacob’s first professional auxiliary ego — a psychodrama participant who played the on-stage parts of various people in patients’ lives. She gained insights into psychodrama techniques from her firsthand experience on the therapeutic stage.
In time, Zerka learned to direct psychodrama sessions, and she grew highly skilled at it. She developed a distinct style that led patients to deeply explore critical past events in their lives. Moreno, in contrast, tended to focus on their current relationships. After Moreno’s death in 1974, Zerka managed the Moreno Institute, an organization that taught and advocated for psychodrama.
Psychodrama is no longer commonly used in mental health treatment. It remains in use for psychotherapy and as a tool for personal development. Therapeutic discussion groups — involving no roles, scenes, or stages — have replaced it as the dominant approach to group therapy. Psychodrama now stands at the fringes of psychiatric practice.
Mary could not always control the subtleties of how William portrayed John on the psychodrama stage. Slowly, as Moreno guided William, John blurred and transformed. Parts of the lover that originated in Mary’s mind slipped away. “He was really William, but she did not realize it,” wrote Moreno, and this was the psychiatrist’s design. No longer solely the realization of Mary’s fantasy, John and William merged into someone new — a character who could assist in Mary’s recovery.
Thus began a new phase of Mary’s psychodrama treatment that Moreno called the period of replacement. John the delusion was losing his power over her, and although (in her own mind) she was a married woman, Mary grew infatuated with his emerging new character as William. “She asked him repeatedly whether he was married and if not, whether he would contemplate marriage,” Moreno wrote. “She invited him for walks and picture shows.” Although the psychiatrist understood that Mary’s new crush was superficial, he welcomed the transference of her interest from a made-up person to a real one, from an imaginary figure to an “auxiliary ego,” or supporting player in the psychodrama.
Now was the time to make John disappear. Moreno had a plot to kill him.
Moreno set up a psychodrama session for Mary in which she learned that John had been killed in action while serving in the military. Moreno may have underestimated the devastation this news would wreak upon his patient: “Mary went into hysterics, insisted on mourning for John and was unapproachable for weeks.” Moreno used the break to alter the characters of John’s mother and father. They became William’s parents. He also gave Jane a new “auxiliary ego” part to portray Mary herself, an enlightened Mary who sometimes heard John’s voice on stage but recognized it as the utterances of a ghost.
When her grieving for John eased, Mary watched Jane’s portrayal from the audience. She saw a version of herself that could distinguish fantasy from reality. Moreno was trying to replace her hallucinatory world with the actual world. He wanted to ease her away from John and toward a real person, William. On stage her interactions were with genuine people. The characters from her imagination diminished in importance. Unknowingly, she was edging toward better mental health.
Now, with Mary’s fantasies weakened, Moreno sought to shift her therapy into yet another phase. The psychodrama scenes that followed would be “the climax of her treatment,” the psychiatrist believed. Having previously encouraged Mary’s bond with John, Moreno now directly attacked it. In one new psychodrama scene Moreno directed to depict a version of events soon after Mary’s arrival at the sanitarium, John refused to meet her because, he insisted, he hardly knew her. He disclosed that he needed his arm twisted to even correspond with her. “In the midst of this act Mary jumped up and tried to hit me,” Moreno declared. He escaped harm only because Mary’s sisters held her back. Mary soon apologized, and Moreno staged additional psychodrama sessions that hammered away at the foundations of Mary’s beliefs about John.
At last, Moreno believed that Mary was ready for the big leap in her treatment that he had planned for her final psychodrama session. He had brought to the sanitarium a young man who had been courting Mary before she began suffering her delusions about John. This man still had a crush on her. Moreno now hoped to engineer a shift of her affections from William to her old acquaintance. The new man understood the complexities of Mary’s treatment and could connect with her whether she was dwelling in fantasy or reality. The scheme worked: Mary was attracted to her old friend. She was growing able to live in the real world, even as she displayed “two dramatis personae,” one with a weakness for fantasy, and another grounded in what was real.
In the end, Moreno concluded that Mary had originally created John as a product of her “realization paranoia,” her desire to situate herself godlike at the center of her story and control everything. She had wanted to make a venue for her own story, as she conceived it, with the entire world as her stage. Unfortunately for Mary, John had not cooperated with his creator as Mary hoped. He wouldn’t do much of what she had wished. “Mary had all the pangs of birth without delivery,” Moreno noted. “It was like a pregnancy without end.” She needed help to escape from the vicious cycle of her fantasies. Psychodrama and its auxiliary egos provided the exit.
Moreno had achieved his goal for Mary: to allow her to return to her family and live without debilitating interference from her delusions. He reported that she did so, and that she soon found a romantic partner who could adjust to her dual existence in the realms of fantasy and reality. It’s not known whether Moreno followed up to learn whether Mary could maintain that delicate, and perhaps impossible, balance.
