Elmo Painter

Therapist, Healer, Life Artist

The Liberated Heart: Stress-related Illnesses and the Benefits of Emotional Expression & Catharsis through Psychodrama

by Elmo Painter

Both in a cultural and a physiological way, the heart represents the emotions. When we’re given advice to pay attention to our emotions, we hear people say, “Listen to your heart”, or “What does your heart tell you?” We give our heart to those we love. Our hearts ache with grief when we experience loss. The heart pounds with panic when we fear an impending loss. Physiologically, the heart plays an important role in the emotional process. The limbic system sets off the Sympathetic Nervous System, which in turn constricts and sets the circulatory system, governed by the heart, into high gear. The heart works doubly hard when we’re in an emotional state. There is no wonder it has been named the representative of emotional life.

Relationships can be stressful. Humans, and all mammals, are social creatures. We have evolved to emotionally depend on each other for survival (Panksepp, 2005), and stress can be at it’s highest when we are involved in relationship turbulence. We will explore the physiological functions behind the emotion of stress, and the effects of these functions when they are prolonged. Using the therapeutic medium of psychodrama, we will see how stress release and stress management can be obtained through exercises of perspective. The type of emotional catharsis that is the most effective and long lasting is the kind that induces a permanent shift of consciousness and behavior.

What role does our cognitive perspective of a particular situation have in relation to stress as an emotion and stress-related diseases? If we change our perspective and facilitate emotional release using psychodrama, can we prevent the dangerous effects of long-term emotional stress?  This subject is interesting because we can explore possible cures, and preventative measures, that we hold within ourselves. Our bodies are intelligent enough to have a system to induce stress for survival, and simultaneously, our staggeringly complex minds have the ability to hush the trepidations of our anatomy.

What is stress?

Stress is difficult to define, as are most emotions. It manifests differently for everyone and depends on the given situation at hand. As an emotional state, Jaak Panksepp would break it down depending on the circumstance of the stress. If someone is worried about a person or situation, the basic emotions would be seeking and fear together (Panksepp, 2005). We’ve all had the experience of being worried about someone, or the way someone feels about us. Sometimes it takes the form of jealousy, or a fear that we have offended someone. Either way, there is a fear of loss. This level of worry is a form of stress, albeit a sneaky one. Worry can seem small, normal, and harmless, and it is in a short-term situation. When the state of worry keeps happening it becomes a fixed stress state, sometimes so subtly that we don’t even notice. It can then snowball into a long-term stress state, which has dour consequences.

An extreme form of stress is one of Panksepp’s raw emotions all on its own: Panic. In relationships, panic, as it is explained in two possible stages, panic in a state of separation and then grief if reunion fails, has to do with fear of losing a relationship that is important to us. This is especially so in parent-child relationships. (Panksepp, 2005). We have social needs because we are social animals.  Evolution has selected attachment, care, and love for other creatures because of the dire need for mammals to stay together. We don’t have the ability to lay hundreds or even dozens of eggs and leave them to their own fates. Mammals can only have one or a few offspring at a time, which necessitates a caregiver’s help in order for babies to survive. The need for bonding and intimate care came first with mothers and infants, and then gradually extended into other relationships, such as other family members and unrelated humans, such as friends and romantic partners (De Waal, 1996). Emotions are not necessarily completely cognitive, but our ability to control, manipulate and soothe them does rely on our cognitive perspective and beliefs about the situations that are inspiring the physiological elements of an emotional reaction.

Causal Factors

Robert Sapolsky has identified the major causes of stress: Lack of social support (this goes back to panic and separation), loss of outlet for frustration (panic, or fear & seeking), perception of things worsening (fear), and loss of control and predictability (panic and seeking) (Sapolsky, 2004) (Panksepp, 2005). The importance of social support has been shortly discussed as far as evolution and survival of the species. The consequences of denying or being deprived of this need are grim. Solitary people are twice as likely to get heart disease and also twice as likely to die at a younger age (Sapolsky, 2004). Love is exercise for our very being.  Our interactions with others carry a huge amount of energetic weight. People cry the most about relationships, especially self, family and intimate partners (Bylsma, Vingerhoets, & Rottenberg, 2008). Loss of outlet for frustration might have to do with loss of a distraction from avoided thoughts or situations. For example, drinking and binge eating are outlets for frustrations, as is yelling at someone lower on a given hierarchy. These are examples of mindless outlets and emotional expressions. We will see later that these methods are not effective strategies for catharsis, but merely delay dealing with the root of the subject or emotion being avoided.

Another cause of stress is the perception or possibility of things getting worse. Dan Savage started the revolutionary “It Gets Better” project in an attempt to alleviate the stress of queer youth by reassuring them that it doesn’t have to get worse, life can blossom in the future even though it’s painful now. It helps to give perspective so that their stress from perceived loss of social support/social ostracization doesn’t lead to another cause of death from overwhelming stress – suicide. The last cause that we will discuss is loss of control and predictability. People fear uncertainty more than death (Sapolsky, 2004). Not having a grasp on the future and feeling unstable and inconsistent can lead to a general insecurity about life and relationships. Without a strong foundation on which to build confidence and trust, one can be left with a very rickety sense of self.

The Purpose of Stress

In Stress: Portrait of a killer, Robert Sapolsky says that in early humans, and in other mammals, the real purpose of stress is for “three minutes of screaming terror on the Savannah.” (Bredar, 2008). The stress response made much more sense in an eat-or-be-eaten life. It exists as a survival mechanism to solve an immediate crisis. Predators experience stress when they pursue their meal. If they don’t get what they need, they’ll starve. The prey is obviously trying to escape a brutal and terrifying death. Both animals are literally running for their lives. (Bredar, 2008).

In this day and age, the majority of humans are not running from a lion on the Savannah. Not only are we not experiencing immediate danger, we have forgotten how to turn off our stress response. Our “crises” come from our own psychological torment. As will be discussed next, our perspectives on life and relationships may actually be harming us, and the process that has evolved to keep us alive may be doing more harm than good (Bredar, 2008).

Darwin suggested that emotional expression served as the first means of communication in early humans (Darwin, 1872). We didn’t have language, but we could use facial expressions, posture, tone and volume of voice, and physical affection. This was/is the pre-linguistic language that parents and infants use to communicate needs and bond (De Waal, 1996). Perhaps the expression of stress is a cry for help, either in an immediate threat situation or a need for social support. Sometimes we need reassurance of our social standing in important groups like family, friends, and communities, as well as other social situations such as jobs and artistic and academic careers.

What stress does in the body

When we are in a state of stress, our bodies treat each of the aforementioned causal factors as a potential threat. The threat or perceived threat activates the hypothalamus in the brain. This sets off the Sympathetic Nervous System (SNS). The activation releases the hormones adrenaline and cortisol. Adrenaline increases heart rate and blood pressure and boosts energy supplies. Cortisol shuts down many of the body’s systems. It also breaks down fat, proteins, glycogen and releases glucose into the bloodstream to provide more energy in case of a need for action (Mayo Clinic, 2010). The systems and functions that are interrupted during a stressful state are: the immune, reproductive, and digestive systems. Blood moves from the gastrointestinal tract to the extremities to prepare to fight or run. The body’s growth and repair functions slow down, the lungs work twice as hard as they normally do to get the most oxygen into the body as possible, and blood clotting happens more quickly in case of injury. The heart pumps faster in order to get more oxygen to the brain, and to move blood to the arms and legs. The arteries constrict to increase the speed of this process, which increases blood pressure (Bredar, 2008). We also excrete more water through sweating and urinating. This can lead to dehydration in extreme cases and increases the need to replace water-soluble vitamins like Vitamin C (Schiff & Wardlaw, 2008).

During a panic attack, respiration quickens. After the attack passes, the person will take at least one slow, deep breath. After the Sympathetic Nervous System does it’s “fight or flight” work, the Parasympathetic Nervous System kicks in to do the opposite – “rest and digest”. The Parasympathetic Nervous System (PNS) is reminiscent of Darwin’s principle of Antithesis (Darwin, 1872). It’s the body’s way of bringing balance, or homeostasis, back to the body. After our stress hormones lead all of these exploits around our body, the body needs a pit team to switch over to the opposite mode. The PNS turns on our temporarily impaired systems, slows the heart rate and blood pressure, and turns on our growth and healing systems to deal with any damage that occurred when were in a wild state of dismay.

Effects of long-term stress


The body’s physiological responses to stress hormones are a far cry from homeostasis. Some of the results of prolonged high blood pressure, constricted arteries, and rapid heartbeat are: cardiovascular disease, heart attack, and Arthrosclerosis (arteries can become damaged from being constricted and shooting adrenaline, which leads to plaque build-up) (Bredar, 2008), (Schiff & Wardlaw, 2008). Having excess stress-induced energy can lead to tooth damage from tooth grinding, insomnia, increase or decrease in appetite, increased likelihood of making poor food choices, and excess abdominal fat, which can lead to cardiovascular disease and diabetes (Schiff & Wardlaw, 2008). Digestive problems that can arise are ulcers (caused by a combination of inhibited digestive and immune functions), stomach problems, nausea, diarrhea, and Irritable Bowl Syndrome (Bredar, 2008).

When our immune and growth/repair systems shut down for long periods of time, it decreases immune resistance to colds, flu, HIV/AIDS, cancer, ulcers, among many other diseases, and takes longer for our bodies to heal from injuries and recover from illnesses (Bredar, 2008).

There are even more dangers of prolonged stress: shrinking brain cells, which lead to memory loss, and pre-mature aging. The hippocampus is so busy creating an emotional stress response, that it’s not making enough other connections. Since this is the area of the brain that controls memory, our abilities in this area are inhibited. In addition, there are protective ends on our chromosomes called telomeres that prevent them from fraying apart. These telomeres dissolve naturally as we age, but when we are under prolonged stress they dissolve faster, leading to frayed chromosomes and early signs of aging (Bredar, 2008).

By this point, the importance of keeping stress under control is probably quite clear. There are many healthy (as well as unhealthy) ways of coping with stress. These include things like exercise, yoga, meditation, social interaction, simple breathing exercises, and just doing whatever makes one happy. The most important of these particular sources of stress regulation are positive and supportive social interaction. But the most important source of all is a positive cognitive perspective of a situation, relationship, and life in general. As Sapolsky expressed in Stress, it is psychological stressors that are keeping our stress mechanisms running in the absence of danger (Bredar, 2008).



Catharsis, as described by Aristotle, is an idea still utilized by psychodrama therapists. Aristotle believed that “through the dramatic representation of a real-life situation, ‘violence within the soul…could be purged’” (Dayton, 2005). Since we have learned that a great deal of stress has to do with the perception of a situation, we will now explore the use of psychodrama to reevaluate and reestablish a perspective on a given situation in order to release the stressful emotions associated with them. Since relationships are such a big causal factor for stress, we will focus on stress as caused by relationships.

In a study about crying, it was cited that most people cry over loss or perceived loss, and the most reported external source of crying is overwhelmingly due to self, partner/spouse or family, as opposed to strangers, friends, authority figures, and “fate” (Bylsma, Vingerhoets, & Rottenberg, 2008). As you’ll recall, Sapolksy listed various forms of loss as a causal factor for stress – loss of control or predictability, loss of social support, loss of frustration outlet, and perception of things getting worse (fear of loss) (Sapolsky, 2004).


Psychodrama as Therapy

Psychodrama uses role dynamics and physical action in order to bring an emotional experience back to the body. The person acting in the role(s) has the opportunity to bring the significance of the story to life, rather than just talking or thinking about it. When a story is embodied, more of the emotional and psychological significance for the person telling the story comes to light. (Dayton, 2005) Like a piece of music, in a given moment we can express our perspective, beliefs, and emotional and personal meaning about a given situation in a brief moment. If we use our whole bodies to express life (since we absolutely use our entire bodies to experience it), we can more accurately remember and process the experience. Psychodrama recognizes that when we need to name and express the right feeling, “…we may need to gently reenter in body as well as mind, the time and space in which that feeling was germinated” (Dayton, 2005).

Role Dynamics theory was constructed by Adam Blatner as a way of describing everyday interactions between humans. Having an awareness of social roles brings an awareness of one’s own beliefs and perspective of their own roles in life. Using these dynamics in psychology is a tool for understanding and changing these beliefs. Role dynamics acknowledges that we are influenced by behaviors and beliefs of others, and social expectations according to our role within those dynamics. When we engage in any hierarchal interactions, we participate in an “overt or covert consensual agreement” to play that role (Blatner, 1991). Everyone plays a number of different roles everyday. These roles and levels on the dominance/submission spectrum change depending on the social interactions we encounter on any given day. They change according to relationships: children, siblings, parents, authority figures, co-workers, teachers, students, creative partners, lovers, flirtatious infatuations and so on. Role Dynamics Theory is attempting to deconstruct the elements of roles that we take on so that people can integrate more aspects of themselves more of the time. It also allows people to use more constructive language when talking about these relationship dynamics. Words and phrases like “imbalance”, “needs more development” and “requires a redefinition” can replace more negative language that takes the power of change away before it’s available to consider, such as “abusive”, “neurotic”, etc. When dynamics are framed with potential for strength and health, it’s much easier to reframe and heal them (Blatner, 1991). Role dynamics recognizes the possibility of thousands of motivations and ways that people act. By acting out the metaphor of putting oneself in another’s shoes, one can change perspective to the other’s motives. Roles dynamics leads to an integration of many selves as acceptable, rather than needing to stick with a stereotyped or given role that is not serving the person. It allows them to “dis-identify with limiting definitions of roles they may be playing” so that we can then “reflect, re-evaluate, redefine, renegotiate roles in life.” (Blatner, 1991). We can decide which of our roles serves us and which ones need some restructuring within the context of our relationships. If we’re aware of role dynamics in general, we have more freedom to be spontaneous, and improvisational with our personalities and relationships, and the freedom to choose not to be subordinate.

Orkibi defines acting as: “to denote one’s intentional and proclaimed enactment of a role, a character, an emotion, or an image in the presence of another or others” (Orkibi, 2010). Acting magnifies the choice of acknowledging and playing a role. He proposes the reflective vs. non-reflective mode that occurs in the state of acting: “Our experience of being is sequentially changed once we become aware of the presence of someone else…who is observing us…another point of view…you can never occupy” (Orkibi, 2010). The others’ view objectifies the actor. We recognize that the other person is projecting onto us their values and judgments. In order to cope with these perceived judgments, we enter a state of self-reflection. We then re-evaluate the perceived judgment that the other has invoked in us. The actor is being witnessed, and in reaction to being witnessed, they go back and forth from reflective to non-reflective. The non-reflective state is when the actor is fully immersed in the moment, too involved within it to reflect. Both states are difficult to maintain in the presence of another, so the actor flip-flops between them. This brings a “balanced distance”. In this state, the performer is both the actor and the observer. (Orkibi, 2010). As anyone who creates art knows, there is a rawness to it. There comes a point in the creative process that an inherent honesty is almost forcefully expressed. Teetering between performer and observer, the person is given the opportunity to revolutionize their perspective and gain invaluable insight to the situation or relationship dynamic at hand. “The function of a metaphor is to facilitate a deeper comprehension of an idea by comparing it to another familiar object or process. In this sense, life is compared to a dramatic performance. “(Blatner, 1991) another purpose of the metaphor can be the dramatic distance that is needed in psychodrama. (Orkibi, 2010).

To show these theories in action, take the example of Tammy, an adolescent girl in group therapy. All of the participants in the group are ages 14-15. Tammy’s parents were in the middle of breaking up, and she was very angry with her father. Under instruction from the therapist, a boy in the group played her father. She had the opportunity to say what she wanted to say to her father, and then switched roles. She took the seat where the “father” was sitting and the boy played her. The boy paraphrased what she had said and she got the opportunity to listen and respond as her father. Then they switched roles again and she was able to say back to her father what her real needs were. She expressed a great deal of relief and laughed. She was in a state of “emotional and rational dramatic presence” (Orkibi, 2010).

Catharsis of Abreaction vs. Catharsis of Integration

Abreaction – such as drinking, binge eating, or mindlessly expressing anger, frustration, or any other emotion at someone – can feel temporarily cathartic. (Dayton, 2005). But the feelings being expressed or the venting actions of food and substance abuse are most likely not coming out from the root of the problem, and these problems and difficult emotions will most likely come back again. When people are stressed, they tend to take it out on someone or something lower in hierarchy than they are – whether it’s their subordinates at work, their kids, their friends, or their pets. As Sapolsky says, “He’s one of those guys who doesn’t get ulcers, he gives them” (Sapolsky, 2004). As much as anyone outside of this person can judge them for their actions, only their internal psychology of the situation will effect their stress level. If they feel justified in their actions, they may have succeeded at taking out their stress. I’d like to think that there are more people out there with a solid sense of empathy, and that these people will experience guilt as a result of their actions. Guilt can also come along with binge eating or substance abuse. After the action is completed and some of the stress is (temporarily) alleviated, we say, “I can’t believe I did that again.” And the stress cycle continues.

Catharsis of integration “occurs as those expressed emotions become witnessed in their concrete form and linked with their early beginnings” (Dayton, 2005). In other words, the emotional story becomes embodied. This level of catharsis involves a shift in thinking, feeling and behavior. Rather than mindlessly expressing any old anger, psychodrama invites the person to express it in a way that it can be felt, witnessed, embodied, and understood mindfully by the self and the observer(s). The ways that the emotion has affected the self and relationships are recognized and discussed. These understanding produce permanent change in perspective, beliefs, and behavior – breaking the cycle of stress caused by the situation for good.


We can open our hearts to a better understanding of ourselves and others, and in doing so we allow full integration of our aspects of self and our perspectives of the motivations of others. If we can gain awareness and change our role within a relationship, or acknowledge the part we have been playing, we can make a decision to reassign ourselves a different role, one that is more integrated of the various aspects of self. Forgiveness is a huge conduit for catharsis. If our role has been the victim, then we identify as a victim, which weakens our foundation of our sense of self. If we can play the opposite role, and deconstruct each, we can integrate the characters and let go of the pain from the original situation.

In a state of stress, there is an action that needs to be completed in order to relieve that stress. So much energy needs an exit strategy, and the PNS needs a cue to kick in. It has even been proven that social interaction and laughter can release hormones that increase the healing of telomeres (Bredar, 2008). We need each other. We need to heal the broken bonds of our relationships. If there is a genuinely unhealthy power balance within a given relationship, then physical distance is a good idea. Forgiveness doesn’t mean one needs to be best friends with someone who continues to cross boundaries. It’s purely for the self to let go, to release the pain of the past, or the worries of the future.

Sources Cited:

Blatner, A. (1991). Role Dynamics: A comprehensive theory of psychology. Journal Of Group Psychotherapy, Psychodrama & Sociometry, 44(1), 33.

Bredar, J. (Producer) (2008). Stress: Portrait of a killer [DVD].

Bylsma, L. M., Vingerhoets, A. M., & Rottenberg, J. (2008). When Is Crying Cathartic? An International Study. Journal Of Social & Clinical Psychology, 27(10), 1165-1187.

Darwin, C. R. (1872). The expression of the emotions in man and animals. London: John Murray. 1st Edition.

Dayton, T. (2005). The living stage, a step-by-step guide to psychodrama, sociometry and experiential group therapy. Deerfeild Beach, Florida: Hci.

De Waal, F. (1996). Good natured: The origins of right and wrong in humans and other animals. Cambridge, Massachusetts: Harvard University Press.

Mayo Clinic staff. (2010, September 11). Stress: Constant stress puts your health at risk. Retrieved from http://www.mayoclinic.com/health/stress/SR00001

Orkibi, H. (2010). The experience of acting: A synthesis of concepts and a clinical vignette. Journal Of Applied Arts & Health, 1(2), 193-203. doi:10.1386/jaah.1.2.193_1

Panksepp, J. (2005). On the embodied neural nature of core emotional affects. Journal of Consciousness Studies, 12(8-10), 158-84.

Sapolsky, R. M. (2004). Why zebras don’t get ulcers. New York, NY: Henry Holt and Company, LLC. 3rd Edition

Schiff, W., & Wardlaw, G. M. (2008). Nutrition for healthy living. New York, NY: McGraw-Hill College.

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