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International Journal of
Environmental Research
and Public Health
Review
Psychodrama Group Therapy for Social Issues: A Systematic
Review of Controlled Clinical Trials
M. Angeles López-González 1, Pedro Morales-Landazábal 2and Gabriela Topa 3,*
Citation: López-González, M.A.;
Morales-Landazábal, P.; Topa, G.
Psychodrama Group Therapy for
Social Issues: A Systematic Review of
Controlled Clinical Trials. Int. J.
Environ. Res. Public Health 2021,18,
4442. https://doi.org/10.3390/
ijerph18094442
Academic Editor: Paul Tchounwou
Received: 4 February 2021
Accepted: 15 April 2021
Published: 22 April 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
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Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1
Department of Psychology/Faculty of Health Sciences, Universidad Rey Juan Carlos, Avenida de Atenas s/n,
Alcorcón, 28040 Madrid, Spain; angeles.lopezg@urjc.es
2Independent Scholar, 28016 Madrid, Spain; pemolasii@yahoo.es
3Department of Social and Organizational Psychology, National University of Distance Education,
28040 Madrid, Spain
*Correspondence: gtopa@psi.uned.es
Abstract:
The aim of this study was to carry out a systematic review of controlled clinical trials in
order to identify both specific populations and social issues which may benefit from the effective
use of psychodrama psychotherapy. A search was conducted in the WoS, SCOPUS, PsychINFO,
Medline, Academic Search Ultimate, ProQuest, and PubPsych databases, complemented by a manual
search on relevant websites and in the reference lists of the selected studies. Randomized controlled
trials (RCTs) and quasi-RCTs of group-based psychodrama psychotherapy were included. The
Effective Public Health Practice Project (EPHPP) tool was adopted to assess the methodological
quality of the included studies. The search identified 14 RCTs and one quasi-RCT evaluating the
effects of group-based psychodrama psychotherapy. The total number of participants in the studies
was 642 people. Seven studies were conducted in Turkey, two in the USA, two in Finland, one
in Canada, one in Brazil, one in Italy, and one in Iran. The heterogeneity of the issues analyzed
indicates that psychodrama improves the symptoms associated with a wide range of problems.
Despite psychodrama’s long history, most clinical trials in this field have been published this century,
which suggests not only that this psychotherapeutic practice remains relevant today but also that
it continues to attract substantial interest among the scientific community. Nevertheless, further
research efforts are required to understand its potential benefits for psychosocial well-being.
Keywords: psychodrama group therapy; systematic review; randomized controlled trials
1. Introduction
The mental health and psychological care programs run at hospitals all over the
world have been improved and updated over recent years. It has been observed that
classic psychotherapeutic interventions designed to foster health often trigger significant
psychological changes that, although sustained during the first few months, later disappear
gradually over time [
1
]. Consequently, and in accordance with the principles of the
biopsychosocial approach, experts are currently aiming to provide ongoing, comprehensive
care to patients in keeping with more efficient, holistic models [
2
]. This type of care is also
vital to responding to emerging social issues, particularly among vulnerable populations.
In these cases, a number of treatments based on group therapy have been established, one
of which is psychodrama [3–8].
Psychodrama, first created by Jacob Levy Moreno in 1921, is a type of psychotherapy
initially conceived as “deep group psychotherapy”, which was inspired by improvisation
theater. The key aspect of psychodrama is the dramatization by patients of a series of events
as if they were happening in the present. During psychodrama interventions, emphasis
is placed not only on what patients say but also on what they do (the action) during the
dramatization. The aim is for patients to gain greater insight into their situation in order
to enable them to cope better with their thoughts and feelings and increase their personal
Int. J. Environ. Res. Public Health 2021,18, 4442. https://doi.org/10.3390/ijerph18094442 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021,18, 4442 2 of 22
resources and strengths [
9
]. This psychotherapeutic technique offers a broad range of
possibilities when applied to mental healthcare programs, and reports have been published
of effective interventions with clinical patients suffering from different psychological
disorders, e.g., [
10
,
11
] and people with subclinical symptoms, e.g., [
12
,
13
] and as part
of personal development plans aimed at, for example, improving social skills, boosting
self-esteem or changing attitudes, e.g., [
14
,
15
]. Another set of interesting studies are
those carried out at a community level focusing on interdisciplinary prevention programs
implemented in schools, e.g., [16,17].
Psychodrama employs five principal elements [
18
,
19
]: (a) protagonist, someone from
the group who acts out, in different scenes, roles linked to possible difficulties and/or
personal potentialities; unlike in real theater, the actor is also the author of their own work;
(b) auxiliary egos, qualified helpers who play the role of co-therapists; they direct the
protagonist while at the same time acting as external observers of the scene being played
out; their purpose is to play complementary roles; (c) director, who acts as both therapist
and analyst; the director is responsible for guiding the session and for monitoring the
progress of the psychotherapeutic process; they are therefore responsible for choosing
the most suitable therapeutic strategy and using different psychodrama techniques as
required; (d) audience, made up of the other members of the group; the audience may help
by serving as a “sounding box”, amplifying or reinforcing the protagonist’s sensations and
acknowledging and understanding their experience, thereby helping everyone recognize
their own conflicts; and (e) stage, a specific space in which the scene takes place and is
acted out; the stage enables the protagonist to represent their inner world and to play out
all their dreams and fantasies, thereby becoming the “space of the possible”.
According to Moreno’s classic psychodrama, each session comprises three phases
[9,19]
:
warming up, action, and sharing. (a) Warming up is the preparation stage in which initial
contact is established between the director and the members of the group; during this stage,
the aim is to foster group interaction and engage in exercises designed to gradually increase
spontaneity, reduce inhibitions to sharing one’s own experiences and increase participants’
engagement in the session. (b) The action phase (enactment) is the moment in which the
dramatic action (the core aspect of psychodrama) takes place; the protagonist goes onto
the stage and acts out their symbolic or real scene; then, a series of other scenes are acted
out which simulate real-life situations and reflect past events, present challenges or future
possibilities; in other words, everything that is worrying the protagonist is represented
on stage; important events in their past are explored, giving them the opportunity not
only to recount and experience them but also to act on them and reintegrate them in a new
way, thus searching for a resolution to the conflict posed; the aim is to break away from
preconceptions, to deconstruct and then reconstruct the patient’s internal elements in a
process known as catharsis or rational and emotional mobilization. Finally, (c) sharing, is
the phase in which the group shares the experiences and emotions triggered by the session,
with no rational interpretations or questions being allowed; as a result, the patient (and
sometimes various members of the group) may find a way to emotionally or cognitively
integrate their world.
The first academic studies on psychodrama were carried out by its original developer,
Moreno [
20
–
22
]. Although these initial papers were followed by many others, traditionally,
the practitioners of psychodrama have generally tended to publish either descriptive
studies based on specific cases or theoretical discussions [
23
,
24
]. Over recent decades,
several reviews have attempted to sum up the findings of research in this field [
24
–
31
].
Thus, the review by Kellermann [
32
] focused on the results published between 1952
and 1985, analyzing 23 studies including both controlled trials in which psychodrama
was not necessarily the only treatment given and trials aimed at validating only one
particular psychodrama technique. Kellermann concluded that psychodrama is an effective
therapeutic alternative for fostering behavioral changes in adjustment, antisocial and
related disorders.
Int. J. Environ. Res. Public Health 2021,18, 4442 3 of 22
Sometime later, the meta-analysis by Kipper and Ritchie [
25
] reviewed trials published
between 1965 and 1999. The efficacy of certain psychodrama techniques was confirmed
both at an individual level and when all were assessed as a whole. The analyses revealed
an effect size of 0.95 (slightly higher than that established in the scientific literature for
group therapy), and moreover, the techniques of role reversal and doubling emerged as
the most effective. More than focusing on the whole session (which would be the classic
approach), the authors aimed to highlight the importance of psychodrama techniques,
pointing out that each of them plays a key role in the process as a whole.
The contributions made by Weiser are also important. In 2006, this author [
27
] an-
alyzed the results of a meta-analysis carried out by Grawe some years earlier (1994),
confirming that psychodrama is effective for treating neurosis and schizophrenia. Never-
theless, the review concluded by stating that the main therapeutic benefits of psychodrama
were on patients’ interpersonal relationships and that the effect on their symptoms was
weaker. One year later, the same author published another review [
29
] which encompassed
over 50 studies on (a) specific techniques that can be applied during psychodrama inter-
ventions; (b) results from a variety of clinical trials involving different drama therapies;
and (c) the efficacy of the psychotherapeutic process.
Another work that aimed to highlight the value of psychodrama techniques was
the systematic review conducted by Cruz et al. [
30
]. As well as identifying the different
techniques used in Moreno’s psychodrama, the aim of this review was to determine
which enjoyed the highest level of consensus among the scientific community. A total of
11 principal techniques were identified, namely soliloquy, double, mirror, role reversal,
resistance interpolation, sculpture, social atom, intermediate objects, games, sociometry,
and role training.
Finally, in 2019, Orkibi and Feniger-Schaal [
24
] carried out another systematic review
covering research using diverse methodologies (qualitative, case studies, controlled trials,
single-group designs, etc.) published during the first decade of the 21st century. The
review did not focus exclusively on psychodrama, but rather included all methods which
use drama as a therapeutic tool, including drama therapy. The authors highlighted the
fact that while research into psychodrama interventions has increased over the years, the
methodological quality of some of the studies carried out should be improved. Thus, due
to greater pressure to ensure evidence-based interventions and decrease susceptibility to
subjective interpretation, over recent decades, an increasingly number of studies have
begun to document psychotherapeutic interventions based on psychodrama [24,33].
There are several problems associated with controlled research, such as the definition
of areas of therapeutic efficacy, the specific details of the treatment provided, and the vali-
dation of the approach [
34
], which is why it is so important to operationalize the expected
changes by measuring specific results and implementing solid research designs [
34
]. As a
result of these difficulties, the reviews published in this field all suffer from some kind of
conceptual, temporal, or methodological limitation [
24
]. For example, the aforementioned
meta-analysis by Kipper and Ritchie [
25
] only includes works published up until the turn of
the century, and its main aim was to assess the efficacy of different psychodrama techniques
and other reviews, such as the one by Castelo et al. [
28
], adopt a regional approach. Fi-
nally, there are also other reviews in which psychodrama forms part of a multi-component
intervention alongside other treatments, making it impossible to assess its efficacy in an
independent manner [29,35–38].
The results in relation to efficacy areas are unclear, particularly given that the def-
inition of psychodrama differs from one study to another. In some cases, for example,
controlled research includes publications focusing on dramatherapy, using the two terms
synonymously. The differences between drama therapy and psychodrama are clear since
although they share some fundamental aspects, psychodrama works with real represen-
tations acted out on the stage, whereas drama therapy is based on metaphor through art
and uses personal scenes that are both fictitious and symbolic. Moreover, in dramatherapy,
patients usually participate in the narrative in a more indirect manner and with greater
Int. J. Environ. Res. Public Health 2021,18, 4442 4 of 22
distance [39]. On other occasions, it is assumed that the results of research into one single
psychodrama technique, such as role-playing [
34
] or role-taking [
40
], reflect the entire psy-
chotherapeutic process involved in psychodrama when in reality, they are only instruments
to be used in specific situations by the psychodrama therapist.
To evaluate the changes achieved by the psychodrama therapeutic model, we must
examine studies that use the classic group format (psychodrama group therapy), with
no complementary individual interventions, in which it is possible to clearly identify
the warming up, action, and sharing phases established by Moreno himself (classic psy-
chodrama, see [
32
]). Furthermore, to analyze whether psychodrama is a true agent for
change, the outcome measures should be capable of assessing specific changes in patients,
and studies should be methodologically rigorous, comparing at least one experimental
group (treated only with psychodrama) with a control group. Thus, the general aim of this
present systematic review is to identify, within the framework of previous publications,
evidence of psychotherapeutic interventions based on “classic psychodrama” that adhere to
a rigorous research design (controlled clinical trials). The specific aims are: (a) to determine
the scientific production and quality of the selected studies; (b) to identify the problems
treated; and (c) to analyze the methodological characteristics of the research carried out.
2. Materials and Methods
Following the method used in previous studies, e.g., [
41
–
43
], this review implemented
a series of control mechanisms designed to reduce any bias that may exist a priori, as
suggested by the PRISMA—preferred reporting items for systematic reviews and meta-
analyses—method, e.g., [
44
,
45
]. The study was registered in the International Prospective
Register of Systematic Reviews (PROSPERO) in 2021, and the detailed prespecified protocol
is available on request. We, therefore, developed a protocol that enabled us to apply criteria
in a uniform manner to all publications, including search terms, established time limit,
search timing, and inclusion of the database selection.
2.1. Procedure
The documents included were journal articles and doctoral theses, following the
guidelines established for evidence-based reviews by Martín, Garcés, and Seoane [
46
], who
propose that gray literature be included in order to avoid publication bias.
During the search, we followed the recommendations made by Sánchez-Meca, Marín-
Martínez, and López-López [
47
], who suggest a combination of formal and informal search
strategies: (a) formal searches were conducted in the computerized thematic databases
PsycINFO, PubPsych, and Medline, as well as in the multidisciplinary databases Scopus,
Academic Search Ultimate, Core Collection of Web of Science, and Proquest Research
Library; and (b) informal searches were conducted for relevant works extracted from the
analysis of the bibliographic references of journal articles.
The selected works adhered to the following search terms: (TITLE-ABS-KEY (psy-
chodrama) AND TITLE-ABS-KEY (control* OR random* OR trial OR “comparison
group” OR groups OR effective* OR “therapeutic efficacy”) AND NOT TITLE-ABS-
KEY (“drama$therapy” OR “case study” OR “single case” OR “case report” OR “review”
OR “scene-based psychodramatic family therapy” OR “theatre-based interventions” OR
“drama$programme” OR “Improvisation Theater” OR “Improvisation theatre” OR “theatre
activity” OR “drama group therapy”).
Additional works were identified in the references of all the publications returned by
the search, including relevant meta-analyses and systematic reviews. Publications featured
in the Journal of Psychodrama Sociometry and Group Psychotherapy were reviewed
manually since this journal is published by the American Society of Group Psychotherapy
and Psychodrama. Moreover, the bibliographic entries featured on the website http:
//pdbib.org/ (accessed on 20 April 2020), compiled by James M. Sacks and Michael Wieser,
were also reviewed, and contact was made with key authors to locate some original works
Int. J. Environ. Res. Public Health 2021,18, 4442 5 of 22
we were unable to find and to ask them for information on any unpublished studies
of interest.
The respective documentary searches were carried out by MALG in April 2020. The
bibliographic references of the different works were analyzed and the studies included in
the prior reviews at the same time as we continued with the more formal search procedure.
No language restrictions were established, and all publications dated up until December
2019 were included.
Two authors (MALG and PML) reviewed the results returned by the search and
extracted those references that complied with the pre-established inclusion criteria. Inter-
rater reliability between the two reviewers was measured using the Kappa statistic (
k = 0.81
;
95% CI: 0.75–0.87). Any doubts were resolved by consulting a third member of the team
(GT). All potentially relevant studies were retrieved so that their full texts could be read.
2.2. Inclusion and Exclusion Criteria
Only those controlled trials in which an experimental group exposed to a treatment
based exclusively on group psychodrama psychotherapy was compared to another group
that acted as either an active (other treatment) or passive (waiting list and/or placebo)
control group were considered. We followed Munn, Stern, Aromataris, Lockwood, and
Jordan [
48
], who recommend that, in systematic reviews on efficacy, the classic PICOS [
48
]
(participants, interventions, comparisons, outcomes, and study designs) format be used.
Inclusion criteria were as follows: (a) participants, no limits were established as regards age
(i.e., minors, adults, people over 65 years of age), sex or number of participants, and nor
were any restrictions imposed regarding suffering (or not) from a pathology of any kind
or having been (or not) admitted to some kind of mental health center; (b) intervention,
only empirical works researching the efficacy of a treatment based on the classic group
psychodrama psychotherapy format were included; (c) comparisons, only experimental
and quasi-experimental clinical trials comparing different groups were included; this
included both two-group (experimental and control) and multi-group designs with a
control group (active or passive); studies without a control group and case studies were
excluded; (d) outcomes, only those studies which included pre and post-test measures,
carried out using validated assessment instruments with evidence of reliability were
included (the dropout rate during psychotherapy should be noted and stated, although
this was not one of the selection criteria established for inclusion in the review); and (e)
study design: randomized controlled trials (RCTs) and quasi-randomized controlled trials
were deemed eligible.
Exclusion criteria included methodological aspects and factors relating to the inter-
vention itself. Thus, reviews, theoretical works, case studies, single-group trials, and those
in which group psychodrama formed part of a multi-treatment package [
49
–
53
] were not
deemed eligible for inclusion; and qualitative works [
54
] which did not report statistical
data or those whose data were obtained using non-validated instruments were also ex-
cluded. Furthermore, previously structured interventions, e.g., [
55
,
56
], were excluded. By
this, we mean any procedure in which the intervention was “rendered in a structured
format which was repeated for each subject rather than the highly spontaneous manner
which characterizes Moreno’s original method” (Kipper and Giladi [
55
], p. 501), along
with those which failed to specify the three classic phases (i.e., warming up, action, and
sharing), e.g., [
57
,
58
], and those that complemented group psychodrama psychotherapy
with individual psychotherapy, e.g., [57].
2.3. Coding the Publications
During the first phase, each reference was analyzed individually to eliminate false pos-
itives and irrelevant records. A customized database was generated, creating a spreadsheet
accessible in the cloud.
A quality assessment tool for quantitative studies (Effective Public Health Practice
Project, EPHPP [
59
,
60
]) was used to further explore the works’ suitability. Quality assess-
Int. J. Environ. Res. Public Health 2021,18, 4442 6 of 22
ment of the studies was conducted by two members of the research group. Discrepancies
were resolved by consensus, resulting in the following fields being included in the database
compiled by MALG and PML: (a) authorship of the document; (b) year of publication; (c)
title of the publication; (d) selection bias (i.e., information related to the representativeness
of the sample); (e) study design (i.e., information about the randomization of the subjects
to the experimental conditions); (f) confounders (i.e., controlling for strange variables); (g)
blinding (single or double bind); (h) data collection method; (i) withdrawals and drop-outs
(percentage of participants completing the study during the final data collection period
in all groups: enrollment, allocation, follow-up, and analysis); (j) intervention integrity
(e.g., the percentage of participants who completed the intervention and its consistency,
measured in terms of whether or not the intervention was provided to all participants
in the same way and the level of therapist competence); and (k) analyses (e.g., unit of
allocation, unit of analysis, statistical methods appropriate for the study design, analysis
performed by intervention allocation status (i.e., intention to treat) rather than the actual
intervention received).
3. Results
3.1. Scientific Production and Quality of the Publications
The graph at the top of Figure 1shows the results of the document search, comparing
the records pertaining to the selected search terms with those obtained by including only
the term “psychodrama”. As shown in the graph, 26.45% of all items on psychodrama
(4840 items) published up until December 2019 included the selected terms. At the bottom
of Figure 1is a flow diagram charting the process followed for retrieving the relevant works.
The process begins by specifying the number of references extracted from each database
searched. The diagram also specifies the number of documents obtained throughout the
two phases of the process. Firstly, the results for the initial phase (reading of the titles and
abstracts) are given, indicating how many duplicates and non-relevant references (due
to either type of document or topic) were removed. Secondly, the diagram specifies the
number of references recovered during the final phase (i.e., the reading of the full texts).
The decision to include or exclude references depended on the type of study they were
(empirical works) and their design (controlled trials). Following the manual analysis, a total
of 15 controlled trials were selected, representing 0.49% of all non-duplicated references
returned by the search. As regards experimental conditions, 12 studies assessed the effects
of psychodrama psychotherapy in comparison with a passive control group (i.e., waiting
list), and the remaining three did so in comparison with an active control group (i.e., other
treatment). As for study design, 14 were randomized controlled trials, and one was a
quasi-randomized controlled trial.
Table 1presents the bibliometric data pertaining to the retrieved references, indicating
the year of publication for each document, the authors’ full names, affiliation and country,
type of document, and, in the case of articles, the name of the journal and its quality
index. As shown in Table 1, 44 different signatures were identified corresponding to
37 different authors, with the most prolific being Zeynep Karata¸s (4), Turkan Dogan
(2), Zafer Gökçakan (2), Kari Kähönen (2), and Katariina Salmela-Aro (2). Moreover,
66.66% of the references were co-authored, with the collaboration index being 2.73. As
for international scope, the publications were written by authors from 11 independent
research teams with affiliations in Turkey (7), the USA (2), Finland (2), Canada (1), Brazil
(1), Italy (1), and Israel (1). Collaborative works were ascribed to a single country in all
cases, meaning that no international collaboration was detected.
Finally, as regards the quality of the publications, Table 2shows the database compiled
on the basis of the EPHPP criteria [
59
]. In terms of the final score, nine of the studies
obtained a general global rating of “strong”, and seven obtained the category “moder-
ate” [61–64].
Int. J. Environ. Res. Public Health 2021,18, 4442 7 of 22
Int. J. Environ. Res. Public Health 2021, 18, x 7 of 25
295
Figure1.Flowofinformationthroughthedifferentphasesofthesystematicreview.Note:TI(ti‐
296
tle),AB(abstract),KW(keywords),RCT(randomizedcontrolledtrial),q‐RCT(quasi‐randomized
297
controlledtrial).
298
Table1presentsthebibliometricdatapertainingtotheretrievedreferences,indicat‐
299
ingtheyearofpublicationforeachdocument,theauthors’fullnames,affiliationand
300
country,typeofdocument,and,inthecaseofarticles,thenameofthejournalandits
301
qualityindex.AsshowninTable1,44differentsignatureswereidentifiedcorresponding
302
to37differentauthors,withthemostprolificbeingZeynepKarataş(4),TurkanDogan(2),
303
ZaferGökçakan(2),KariKähönen(2),andKatariinaSalmela‐Aro(2).Moreover,66.66%
304
ofthereferenceswereco‐authored,withthecollaborationindexbeing2.73.Asforinter‐
305
nationalscope,thepublicationswerewrittenbyauthorsfrom11independentresearch
306
Figure 1.
Flow of information through the different phases of the systematic review. Note: TI
(title), AB (abstract), KW (keywords), RCT (randomized controlled trial), q-RCT (quasi-randomized
controlled trial).
Int. J. Environ. Res. Public Health 2021,18, 4442 8 of 22
Table 1. Bibliometric data pertaining to the retrieved references.
Year Authors Affiliation Country Doc. Type Journal Quality Indicators
1999 Carbonell, Dina M. Bridgewater State
University USA Article International Journal
of Group
Psychotherapy
SJR (99) = Q2: 0.429.
Parteleno-Barehmi, Ceil Wheelock College,
Boston
2003 Singal, Sally McGill University Canada Thesis
2009a Karata¸s, Zeynep Mehmet Akif Ersoy
University Turkey Article Educational Sciences:
Theory & Practice SJR (09) = Q4: 0.111.
Gökçakan, Zafer Mersin University
2009b Karata¸s, Zeynep Mehmet Akif Ersoy
University Turkey Article Turkish Journal of
Psychiatry
Gökçakan, Zafer Mersin University
2009 Smokowski, Paul R. U. of North Carolina at
Chapel Hill USA Article
Small Group Research
SJR (09) = Q2: 0.763.
JCR (09) = 0.683
Bacallao, Martica U. of North Carolina at
Greensboro
2010 Dogan, Turkan University of Baskent Turkey Article
Arts in Psychotherapy
SJR (10) = Q3: 0.256.
JCR (10) = 0.609
2010
Gatta, Michela University of Padua
Italy Article
Arts in Psychotherapy
SJR (10) = Q3: 0.256.
JCR (10) = 0.609
Lara, Dal Zotto University of Padua
Lara, Del Col ULSS 16 Padua
Andrea, Spoto University of Padua
Paolo, Testa Costantino ULSS 16 Padua
Giovanni, Ceranto ULSS 16 Padua
Rosaria, Sorgato ULSS 16 Padua
Carolina, Bonafede ULSS 16 Padua
Pier Antoni, Battistella ULSS 16 Padua
2010
Sproesser, Erika
University of Campinas Brazil Article Parkinsonism and
Related Disorders
SJR (09) = Q1: 1.05.
JCR (09) = 2.406
Viana, Maura A.
Quagliato,
Elizabet M.A.B.
de Souza, Elisabete A. P.
2011 Karata¸s, Zeynep Mehmet Akif Ersoy
University Turkey Article Educational Sciences:
Theory & Practice
SJR (11) = Q3: 0.200.
2012
Kähönen, Kari University of Jyväskyla
Finland Article
Personality and Social
Psychology
SJR (12) = Q1: 5.689.
JCR (12) = 4.877
Naatanen, Petri University of Jyväskyla
Tolvanen, Asko University Central
Hospital
Salmela-Aro, Katariina University of Helsinki
2014 Karata¸s, Zeynep Mehmet Akif Ersoy
University Turkey Article E˘gitim ve Bilim
SJR (14) = Q3: 0.276.
2016
Dehnavi, Saeed
Islamic Azad University
Iran Article
International Journal
of Medical Research &
Health Sciences
Bajelan, Mahin
Pardeh, Setareh Javaher
Khodaviren, Hamideh
Dehnavi, Zahra
2016
Kähönen, Kari University of Jyväskyla
Finland Article Psykologia
Muotka, Joona University of Jyväskyla
Näätänen, Petri University of Jyväskyla
Salmela-Aro, Katariina University of Helsinki
2016
Özba¸s, Azize Atli Hacettepe University
Turkey Article Palliative and
Supportive Care
SJR (16) = Q2: 0.500.
JCR (16) = 1.199
Tel, Havva Cumhuriyet University
Azoulay, Bracha University of Haifa
Snir, Sharon Tel Hai College
Regev, Dafna University of Haifa
2018 Dogan, Turkan Hacettepe University Turkey Article PsyCh Journal SJR (18) = Q3: 0.401.
JCR (18) = 0.717
Note: SJR (Scimago Journal and Country Rank), JCR (Journal Citation Reports).
Int. J. Environ. Res. Public Health 2021,18, 4442 9 of 22
Table 2. Quality assessment tool for quantitative studies (Wess et al., 2012).
Authors Year G1 SD G2 Ca G3 G4 G5 Wa Wb G6 Ia Ib Aa Ab Ac GG
Carbonelly and
Parteleno-Barehmi 1999 ++ RCT +++ No +++ ++ +++ Yes 82% +++ 93% Yes Middle School Yes Yes +++
Singal 2003 +++ RCT +++ No +++ ++ +++ Yes 100% +++ 100% Yes High School Yes Yes +++
Karata¸s and Gökçakan
2009a
++ RCT +++ No +++ ++ +++ Yes
97.2%
+++
96.0%
CT High School Yes Yes +++
Karata¸s and Gökçakan
2009b
+++ RCT +++ No +++ + +++ Yes
95.8%
+++
91.6%
Yes High School Yes Yes ++
Smokowski and
Bacallao 2009 +++ RCT +++ No +++ ++ +++ Yes CT ++ CT Yes Latino communities Yes Yes +++
Dogan, 2010 +RCT +++ CT +++ ++ +++ Yes 65% ++ 69% CT University Yes Yes ++
Gatta et al. 2010 +q-
RCT +++ No +++ + +++ Yes 100% +++ 100% Yes Public Health Services Yes Yes ++
Sproesser et al. 2010 ++ RCT +++ CT +++ ++ +++ Yes 100% +++ 100% CT University Hospital Yes No +++
Karata¸s 2011 +RCT +++ No +++ ++ +++ Yes 100% +++ 100% CT High School Yes Yes ++
Kähönen et al. 2012 ++ RCT +++ CT + ++ +++ Yes 82% +++ 79% CT Healthcare Service Yes Yes ++
Karata¸s 2014 ++ RCT +++ No +++ ++ +++ Yes 100% +++ 100% Yes University Yes Yes +++
Dehnavi et al. 2016 ++ RCT +++ CT +++ ++ +++ Yes CT + CT CT
Addiction Treatment Clinic
Yes No ++
Kähönen et. al. 2016 ++ RCT +++ CT + ++ +++ Yes 100% +++ 100% CT Occupational Health Care Yes Yes ++
Özbas and Tel 2016 ++ RCT +++ No +++ + +++ Yes 90% +++
78.9%
Yes University Hospital Yes Yes ++
Dogan 2018 +++ RCT +++ CT + ++ +++ Yes 100% +++ 100% Yes University Yes Yes +++
Note: +++: strong, ++: moderate, +: weak. RCT: randomized controlled trial; q-RCT: quasi-randomized controlled trial. CT: cannot tell. Selection bias: G1 (global rating selection bias). Design: SD (study
design) and G2 (global rating study design). Confounders: Ca (Were there important differences between groups prior to the intervention?) and G3 (global rating confounders). Blinding: G4 (global rating
blinding). Data collection methods: G5 (global rating data collection methods). Withdrawals and drop-outs: Wa (Were withdrawals and drop-outs reported in terms of numbers and/or reasons per group?),
Wb (Indicate the percentage of participants completing the study (if the percentage differs by groups, record the lowest)), and G6 (global rating withdrawals and drop-outs). Intervention integrity: Ia (What
percentage of participants received the allocated intervention or exposure of interest), Ib (Was the consistency of the intervention measured? Consistency here is understood here as therapist adherence (not
compromised by being a group intervention) and therapist competence, assessed in terms of informed expertise, with “yes” indicating the maximum level), Analyses: Aa (Indicate the unit of allocation:
community, organization/institution, practice/office, individual), Ab (Are the statistical methods appropriate for the study design?), and Ac (Is the analysis performed by intervention allocation status (i.e.,
intention to treat) rather than the actual intervention received?). GG: global rating for this paper.
Int. J. Environ. Res. Public Health 2021,18, 4442 10 of 22
3.2. Problems Treated
Table 3presents the results of psychodrama interventions applied to different groups
of problems, with varied samples. The themes are categorized in accordance with the
type of participant: those with clinical and subclinical symptoms and community samples.
Firstly, in the four controlled trials carried out with clinical patients, the problems dealt
with were psychic suffering and behavioral disorders (mood disorders, suicide attempts,
psychotic episodes, eating disorders, and social isolation) [
63
], oppositional defiant dis-
order [
65
], opioid dependence [
61
], and Parkinson’s disease [
66
]. Psychodrama proved
effective for improving the symptoms of the oppositional defiant disorder; specifically,
participants displayed a greater impulsive response latency and a lower frequency of
oppositional behaviors [
65
]. In the other controlled trials carried out with clinical patients,
the dependent variable was not related to the symptoms of their disorder but rather to
their biopsychosocial adjustment. Thus, improvements were observed in psychological
distress [63], quality of life [66], and perceived health [61].
Seven of the randomized controlled trials were carried out with patients with subclini-
cal symptoms. In these studies, the intervention aimed to treat different social issues linked
to lack of control over aggressive impulses [
62
,
67
–
69
], traumatic experiences [
70
], and
chronic work-related stress or burnout [
71
,
72
]. For example, Smokowski and Bacallao [
69
]
carried out an intervention aimed at preventing youth violence in a family context with
Latin American migrants. Parents reported an improvement in their children’s defiant,
oppositional behavior, as well as a decrease in parent-child conflict. Following the inter-
vention, participants were better able to express their feelings and had a better knowledge
of themselves. They also reported more optimistic attitudes [
72
] and greater use of creative
solutions [
71
]. The effects of psychodrama therapy on burnout were explored by the team
led by Kähönen in two articles using two modulating variables: sense of coherence [
73
]
and eudaimonic psychological well-being [
71
]. In both studies, Kähönen et al. recruited
public sector workers (e.g., police officers and public prosecutors) with severe symptoms
of burnout. Eight treatment groups were created (four psychodrama groups and four
analytic groups) along with a control group; the intervention lasted nearly nine months. In
the article on sense of coherence, the psychodrama groups were found to improve more
quickly during the intervention, although recovery in the analytic groups lasted longer.
The changes observed in the study on psychological well-being also affected the control
group. However, as in the other study by the same team, these changes were found to
occur more quickly in the psychodrama groups but were more stable during follow-up in
the analytic groups.
Finally, four clinical trials were carried out with community samples. The aim was
to help participants develop professional competencies [
72
,
74
] or personal strengths that
would have a positive impact on their mental health [
64
,
75
]. Thus, Özbas and Tel [
72
]
implemented a program of psychodrama treatment designed to improve the quality of
professional care provided by oncology nurses. The aim of the program was to increase per-
ceived levels of psychological and work-related empowerment and decrease burnout levels
among nursing staff. The results reported by Dogan [
74
] were positive, with psychodrama
being found to instill professional competencies such as empathy and self-awareness in
students enrolled in a psychological counseling and guidance course. In a previous study,
this same author [
64
] analyzed the consequences of an intervention on romantic attachment
among adults. The aim was to explore the benefits of psychodrama for fostering secure
and healthy attachment behaviors. The results revealed significant improvements in one of
the dimensions evaluated: anxiety, measured after the treatment, although no differences
were observed between the experimental and control groups. Finally, Karatas [
75
] explored
the importance of studying hopelessness as a variable that may influence the development
of certain psychological problems (e.g., depression, ideas of suicide, etc.) if sustained
over time. The author confirmed the significant positive effect of group psychodrama on
subjective well-being and hopelessness.
Int. J. Environ. Res. Public Health 2021,18, 4442 11 of 22
Table 3. Samples, variables, measures, and outcomes of psychodrama interventions applied to different groups.
Study Sample Variables Measures Outcomes
Carbonell y
Parteleno-Barehmi, 1999 [70]Subclinical
Depression, verbal aggression,
delinquent behavior, thought
problems, somatic complaints,
social (withdrawn) problems,
attention-seeking behaviors,
and phobic-anxious behavior
YSR
PD/CG post: Withdrawn: F = 10.47 *; anxious/depressed: F = 5.97 *; somatic: F = 1.04;
social problems: F = 4.02; thought problems: F = 2.88; Attention problems: F = 0.14;
delinquent behavior: F = 1.96; aggressive: F = 3.72.
Pre/Post
Singal, 2003 [65] Clinical
Impulsivity, empathy,
self-esteem, oppositional
behaviors
MFFT
BEES
SEI
CRS-R
JI
PD/CG post: Latency response: F = 7.69 *; error: F = 0.46; empathy: F = 1.78; self-esteem:
F = 0.56;
CRS-R, parents’ reports: oppositional subscale: F = 6.07 *, cognitive problems/inattention
subscale: F = 0.04, hyperactivity subscale: F = 0.57, and ADHD index subscale: F = 1.47.
CRS-R, teachers’ reports: oppositional subscale: F = 11.83 *, cognitive problems/inattention
subscale: F = 0.21, hyperactivity subscale: F = 1.13, and ADHD index subscale: F = 0.54.
Pre/Post
Karata¸s y Gökçakan, 2009a
[67]Subclinical
Physical aggression, verbal
aggression, anger, hostility,
indirect aggression, total
aggression
Aggression
Scale
CBT/CG. Total aggression: F = 117.092 *; physical aggression: F = 37.74 *; anger:
F = 50.04 *; hostility: F = 27.23 *; indirect aggression: F = 24.04 *.
PD/CG post: Total aggression: F = 65.10 *; anger: F = 20.17 *; hostility: F = 18.59 *; indirect
aggression: F = 40.99 *.
CBT/PD post: Total aggression: F =15.22 *; physical aggression: F = 28.02 *; anger:
F = 10.67 *
Non-significant differences; post-test/follow-up in both experimental groups.
Pre/Post/3-month
follow-up
Karata¸s y Gökçakan, 2009b
[68]Subclinical
Physical aggression, verbal
aggression, anger, hostility,
indirect aggression, total
aggression
Aggression
Scale
Total aggression: F = 65.11 ***; physical aggression: F = 3.38; verbal aggression: F = 1.85;
anger: F = 20.17 ***; hostility: F = 18.59 ***; indirect aggression: F = 40.99 ***
Non-significant differences; post-test/follow-up in P group
Pre/Post/3-month
follow-up
Smokowski y Bacallao, 2009
[69]Subclinical
Parent-adolescent conflict,
oppositional defiant problems,
anxious-depressed problems
CBCL
CBQ-20
Oppositional defiant behavior: F = 5.50 ***; Anxious-depressed behavior: F = 3.80 **;
Parent-adolescent conflict: F = 4.10 ***; Total problems: F = 3.30 *
Pre/12-month
follow-up
Dogan, 2010 [64]
Community
Anxiety, avoidance ECR-R
PD pre/post: Anxiety: z=
−
2.36 *; Avoidance: z=
−
1.51. CG pre/post: Anxiety: z=
−
1.60;
Avoidance: z=−0.80. Pre/post
Gatta et al., 2010 [63] Clinical Psychic suffering and
behavioral disorders SCL-90-R
PD pre/post: SOM: z=
−
2.02 *; O-C:
z=−0.53
; IntSens: z=
−
0.41; DEP:
z=−1.16
; ANX: z
=−1.63 *; HOS: z=−1.08; PHOB: z=−0.63; PAR: z=−1.35; PSY: z=−2.03 *; GSI:
z=−1.99 *.
GC pre/post: SOM: z=−1.35; O-C: z=−0.27; IntSens: z=−0.54; DEP: z=−0.67; ANX:
z=−0,67; HOS: z=−0.55; PHOB: z=−0.36; PAR: z=−0.73; PSY: z= 0.00; GSI: z=−0.52.
Pre/post
Sproesser et al., 2010 [66] Clinical
Depression, anxiety and
Parkinsonism symptoms,
systemic symptoms, emotional
functioning, and social
functioning
BDI
STAI
PDQL
Depression. PD, pre (M = 23, StD = 12), post (M = 9, StD = 9); CG, (M = 11, StD = 6), post
(M = 12, StD = 6) **
Anxiety. PD, pre (M = 49, StD = 11), post (M = 34, StD = 11); CG, pre (M = 43, StD = 12),
post (M = 46, StD = 14) **
Quality of life. PD, pre (M = 95, StD = 16), post (M = 77, StD = 22); CG, pre (M = 94,
StD = 31), post (M = 97, StD = 27) *.
Pre/post
Karata¸s, 2011 [62] Subclinical Aggression, problem solving CRBDS
PD/CG post: Aggression: U = 17.00 *; Problem solving: U = 2.50 *. PD/IG post:
Aggression: U = 28.00 *;
Problem solving: U = 0.00 *.
Pre/post/ 2.5-month
follow-up
Int. J. Environ. Res. Public Health 2021,18, 4442 12 of 22
Table 3. Cont.
Study Sample Variables Measures Outcomes
Kähönen et al. 2012 [73] Subclinical Sense of coherence OLQ-13
PD/CG: F = 4.03 *; between second and third measurements: F = 7.78 *; PD/analytic
groups: F = 3.00 *; analytic/CG, non-significant differences; six-month follow-up:
analytic/PD: F = 4.36 *.
Pre/middle/post/
6-month follow-up
Karata¸s, 2014 [75]
Community
Bienestar subjetivo;
desesperanza
SWS
BHS
PD/GC post: Subjective well-being: U = 0.00*; Hopelessness: U = 10.00 *. PD/PG post;
Subjective well-being: U = 0.00 *; Hopelessness: U = 2.50 *.
Follow-up. Effect was not long-term in subject well-being (z=−2.83) *; effect was a long
term in hopelessness (z=−0.93).
Pre/post/seg.
2.5-month follow-up
Dehnavi et al., 2016 [61] Clinical Quality of life SF-36 PD/CG: Quality of life: F = 93.84 ***. Pre/post
Kähönen et al. 2016 [71] Subclinical Burnout, psychological
well-being
BBI
SPWB
PD/CG post: autonomy: F = 3.17 **; personal growth: F = 3.03 **. PD/analytic group post:
mean change: F = 3.92 ***; Purpose in life: F = −3.36 **. PD/analytic group, follow-up
mean change: F = −3.10 **. Pre/post
Özbas y Tel, 2016 [72]Subclinical Psychological empowerment,
work empowerment, burnout
PES
CWEQ–II
MBI
Empowerment, pre/post/follow-up: F = 24.00 ***,
structural empowerment, pre/post/follow-up: F = 3.86 *; emotional exhaustion,
pre/post/follow-up: F = 38.55 ***, desensitization, pre/post/follow-up: F = 12.80 ***,
personal achievement, pre/post/follow-up: F = 10.34 ***; empowerment, PD/CG:
F = 38.00 ***; structural empowerment, PD/CG: F = 3.50; emotional exhaustion, PD/CG:
F = 40.33 ***; desensitization, PD/CG: F = 24.08 ***; personal achievement, PD/CG:
F = −9.68 ***.
Pre/post/ 3-month
follow-up
Dogan, 2018 [74]
Community
Empathic tendency scores ETS PD pre/post: ETS: z=−3.18 ***; PD/CG post: ETS: U = 28.50 ** Pre/post
Note. M: media. StD: standard deviation; PD: psychodrama; CG: control group; CBT: cognitive behavioral therapy; IG: interaction group; PG: placebo group; Aggression Scale: 34 items; physical aggression,
verbal aggression, anger, hostility, indirect aggression, and total aggression (Can, 2002); BBI: Bergen Burnout Inventory (Matthiesen and Dyregrov, 1992), 9 items, exhaustion at work, cynicism toward the
meaning of work, sense of inadequacy at work; BDI: Beck Depression Inventory (Beck, Ward, Mendelson, Mock, and Erbaugh, 1961). 21 items, depression; BEES: Emotional Empathy Scale (Mehrabian, 1996),
30 items; individual’s vicarious emotional response to the perceived emotional experiences of others; BHS: Beck Hopelessness Scale (Beck, Weissma, Lesteq, and Tralel, 1974), 20 items, hopelessness; CBQ-20:
Conflict Behavior Questionnaire–20 (Robin and Foster, 1989), 20 items, parent-adolescent conflict; CBCL: Child Behavior Checklist (Achenbach and Rescorla, 2001). Oppositional defiant problems scale, 5 items.
Total problems scale, 60 items (externalizing, internalizing, social, thought, attention problems subscales, etc.); anxious-depressed problems scale, 13 items; CRBDS: Conflict Resolution Behavior Determination
Scale (Koruklu, 1998). 24 items, aggression, problem solving; CRS-R: Conners’ Rating Scales—Revised (Conners, 1997), attention-deficit/hyperactivity disorder (ADHD), conduct disorders, cognitive/inattention
problems, family problems, emotional problems, anger control problems, and anxiety problems; CWEQ–II: Conditions for Work Effectiveness Questionnaire–II ((Laschinger et al., 2001), 12 items, perceived
access to opportunity, support, information and resources; ECR-R: Experiences in Close Relationships-Revised Form (Fraley, Waller, and Brennan, 2000), 36 items, anxiety and avoidance; ETS: Empathic
Tendency Scale (Dökmen, 1988), 20 items, emotional component of empathy and one’s potential for it in everyday life; JI: The Jesness Inventory (Jesness, 1996), 80 items; social maladjustment, value orientation,
immaturity, autism, alienation, manifest aggression, withdrawal, social anxiety, repression, denial, and asocial index; MBI: Maslach’s Burnout Inventory (Maslach and Jackson,1981), 22 items, emotional burnout,
desensitization, personal achievement; MFFT: Matching Familiar Figures Tests (Kagan, 1965), 12 items; reflective-impulsive dimension; Scores are based on the mean response latency (MFFT Latency) and on the
mean number of errors produced (MFFT-Error); OLQ-13: Orientation to Life Questionnaire (Antonovsky, 1987)-13 items, assesses three dimensions: comprehensibility, manageability, and meaningfulness; PDQL:
Questionnaire Parkinson’s Disease and Quality of Life (Boer AGE, Wijker, Speelmen, and Haes, 1996), 37 items, on aspects: parkinsonism symptoms, systemics symptoms, emotional functioning, and social
functioning; PES: Psychological Empowerment Scale (Spreitzer, 1995), 12 items, meaning, competence, autonomy, and impact; SCL-90-R: Symptom Check List-90-Revised (Derogatis, 1994), 90 items, assesses the
different dimensions of the symptoms relating to the different diagnostic categories: somatization (SOM), obsession-compulsion (O-C), interpersonal sensitivity (IntSens), depression (DEP), anxiety (ANX),
hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR), psychoticism (PSY), GSI Global Severity Index); SEI: Self-Esteem Inventory (Coopersmith, 1989), self-attitudes in four areas (social self-Peers,
home-parents, school-academic, and general-self); SF-36: 36-Item Short Form (Ware, 1992), 36 items, physical function, physical role functioning, body pain, social role functioning, emotional role functioning,
general health perceptions, vitality, and mental health; SPWB: Scales of Psychological Well-Being (Ryff, Lee, Essex, and Schumutte, 1994). 84 items, self-acceptance, positive relationships, autonomy, domain of
the environment, purpose in life, and personal growth; STAI: State-Trait Anxiety Inventory (Spielberger; Gonuch, Leushene, Egg, and Jacobs, 1983), 40 items, state anxiety and trait anxiety; SWS: Subjective
Well-Being Scale (Tuzgöl-Dost, 2005), 46 items, well-being subjective; YSR: Youth Self-Report Form (Achenbach, 1991): 112 items; depression, verbal aggression, delinquent behavior, thought problems, somatic
complaints, social (withdrawn) problems, attention-seeking behavior, and phobic-anxious behavior; * p< 0.05, ** p< 0.01, *** p< 0.001.
Int. J. Environ. Res. Public Health 2021,18, 4442 13 of 22
3.3. Methodological Characteristics of the Research Carried Out
This section summarizes the results obtained in relation to the assessment instru-
ments, variables and their measurement, the substantive variables of the samples and the
characteristics of the interventions.
Assessment instruments, variables, and measures. Table 3outlines the assessment
instruments used and the variables measured in each study. It also specifies the follow-up
measures established in each case. All trials included at least two measures, pre and post;
moreover, the works by Karata¸s and Gökçakan [
62
,
67
,
68
], Özba¸s and Tel [
72
], Smokowski
and Bacallao [
69
], and Kähönen et al. [
71
,
73
] also included long-term follow-up measures.
Substantive variables of the samples. Table 4shows the results for the sociodemo-
graphic variables age and sex. In over half of the studies selected, participants were under
20 years of age [62,63,65,67–70], although interventions were also carried out with people
aged between 20 and 40 [
64
,
72
,
74
] and even with those aged 50 and over [
61
,
71
,
73
]. In all
cases, psychodrama was applied to both men and women. As regards sample size, the
mean figure was 40.12 individuals per trial. The study by Gatta et al. [
63
] was the smallest
in terms of sample size, with just 12 participants, and the largest were those conducted
by Kähönen et al. [
71
,
73
], with over 90 people, and Smokowski and Bacallao [
67
], with
81 families.
Table 4.
Substantive variables of the sample (age and sex), structure of the sessions (number and duration, interval between
sessions, and length of the intervention) and type of treatment.
Study
Sample
SD
Session Structure Treatment
Sex Age
w m NSD TNS IBS LOI EG (n) CG (n)
Carbonell y
Parteleno-Barehmi, 1999
[70]
26 0 11–13 N.A. N.A. N.A. N.A. 20 PD (12) WL (14)
Singal, 2003 [65] 18 6 12–17 60–12001 12 7 12 PD (13) WL (11)
Karata¸s y Gökçakan,
2009a [67]13 23 13–14 90–12001 14 7 14 PD
CBT
(12)
(12) CG (12)
Karata¸s y Gökçakan,
2009b [68]12 11 13–14 90–12001 14 7 14 PD (11) CG (12)
Smokowski y Bacallao,
2009 [69]54 27 14 18001 8 7 8 PD (56) SG (25)
Dogan, 2010 [64] 15 5 23–29 12001 12 7 12 PD (11) CG (09)
Gatta et al., 2010 [63] 4 8 15–18 7501 12 7 12 PPD (06) CG (06)
Sproesser et al., 2010 [66] 7 9 49–53 9001 12 15 24 PD (08) WL (08)
Karata¸s, 2011 [62] 18 18 14–17 90–12001 10 7 10 PD (12) CG
IG
(12)
(12)
Kähönen et. al., 2012 [73] 70 24 31–59 9004 64 15 32 PD
AG
(30)
(32) CG (32)
Karata¸s, 2014 [75] 45 N.A. 90–12001 12 7 12 PD (15) CG
PG
(15)
(15)
Dehnavi et al., 2016 [61] 0 30 20–52 12001 12 N.A. 6 PD (15) CG (15)
Kähönen et. al., 2016 [71] 70 24 33–59 9004 64 15 32 PD
AG
(30)
(32) CG (32)
Özbas y Tel, 2016 [72]82 0 18–37 12001 10 7 10 PD (38) CG (44)
Dogan, 2018 [74] 22 1 23–39 18001 12 7 12 PD (14) CG (09)
Note: SD: session duration (min.); NSD: number of sessions per day; TNS: total number of sessions; IBS: interval between sessions, in days;
LOI: length of the intervention, in weeks; EG: experimental group; CG: control group; N.A.: not available; PD: psychodrama; WL: waiting
list; CBT: cognitive behavioral therapy; SG: support group; AG: analytic group; PG: placebo group; IG: interaction group.
Int. J. Environ. Res. Public Health 2021,18, 4442 14 of 22
Characteristics of the interventions. Table 4explains how the sessions were structured
(number and duration of the sessions, interval between sessions, and length of the interven-
tion) and the type of treatment applied to each group. The mean number of sessions was
19.69, the mean duration of each session was between 106
0
and 118
0
, and the interval be-
tween sessions was seven days. Nevertheless, in the two studies by
Kähönen et al. [71,73]
,
the interventions were completely different, since four sessions were scheduled each treat-
ment day, with treatment days being separated by an interval of two weeks, up to a total
of 32 weeks, which was the overall duration of the intervention. As regards the type of
treatment, psychodrama group therapy was implemented in all cases. Two types of treat-
ment were provided to the active control groups: the group analytic method in the studies
conducted by Kähönen et al. [
71
,
73
] and cognitive behavioral therapy in the trial led by
Karata¸s and Gökçakan [
67
]. The group analytic method is based on free-floating discussion,
similar to the “free association” of classic psychoanalysis. Passive control groups were
subjected to similar conditions without treatment, described as follows by the different
authors: waiting list, control groups, placebo, and support groups.
4. Discussion
The general aim of this systematic review was to identify evidence of psychotherapeu-
tic interventions based on classic psychodrama applied within the framework of controlled
clinical trials and published up until December 2019.
The first specific aim was to determine the scientific production and quality of the
controlled trials designed to evaluate the efficacy or effectiveness of psychodrama. To this
end, the review combined systematic analysis of a broad range of bibliographic sources
with the manual review of references found in the documents returned by the search. The
validity of a review depends, to a certain extent, on the documentary sources selected, and
according to cost-effectiveness analyses carried out in previous studies, e.g., [
76
], these
sources must be selected in accordance with document coverage, topic, geographical area,
and language. Thus, for example, in order to avoid publication bias, one of the most
important products of the ProQuest database was included, namely ProQuest Dissertations
and Theses, which constitutes one of the largest collections of doctoral thesis in the world.
Similarly, the contribution made by an open access resource, PubPsych, is also worth men-
tioning. PubPsych offers access to databases from all over Europe, thereby counteracting
one of the most common biases in systematic reviews, the English-speaking bias, which is
the result of the greater number of documents written in English [76].
Having chosen the documentary sources, the next step was to decide on the search
terms. Here, it is worth highlighting the importance of including a set of terms broad
enough to facilitate suitable information collection, despite the possibility of registering
false positives. Thus, after removing duplicates, 2960 references were returned which
complied with the pre-established search equation. Documents deemed ineligible included
studies with no control group, trials which used only one specific psychodrama technique,
exclusively qualitative studies and controlled trials in which psychodrama was imple-
mented in conjunction with another type of treatment. Furthermore, we also detected
a large number of non-relevant studies (31.62% of the initial references returned by the
search) related to other topics such as sociodrama, drama therapy, play drama and different
artistic or creative methods, etc. Although they use similar techniques, these methods do
not correspond fully to what scientific literature understands to be classic psychodrama,
which was the object of our study. The high number of non-relevant references returned
may be due to an incorrect categorization of metadata by documentalists or to an erroneous
choice of key words by authors, who failed to take into account the scientific evolution of
the term “psychodrama”.
Focusing on the results obtained in relation to scientific production, only 143 ref-
erences (4.69%) were empirical studies carried out with a control group. Thus, in the
specific field on which this review focused, we found that only a few clinical trials have
attempted to provide evidence of how psychodrama may affect the treatment of mental
Int. J. Environ. Res. Public Health 2021,18, 4442 15 of 22
problems. Up until the 21st century, publications on psychodrama tended to be descriptive
or quantitative studies lacking in methodological rigor [
33
,
34
]. Nevertheless, over the
last two decades, the number of trials carried out with control groups has increased, as
shown by the fact that 14 of the 15 studies which fulfilled the inclusion criteria fell into this
category. The 15 works selected were written by 11 different research teams, and 66.66%
were co-authored, a result which reflects a consolidated tendency toward collaboration.
Although no publications stemming from international collaboration were identified, the
majority involved collaboration between two different centers, most frequently between a
psychotherapeutic intervention clinic and a Higher Education institution.
Although the number of works included in the final review was low, seven were
found to have a quality analysis rating of “strong”, and the remaining eight were classified
as “moderate” [
61
–
64
] in accordance with the EPHPP criteria [
59
]. In general, the measures
for each of the dimensions evaluated (selection bias, study design, confounders, blinding,
data collection method, withdrawals and drop-outs, intervention integrity, and analyses)
reveal that all 15 studies had a high level of methodological rigor. In relation to blinding,
the controlled trials selected did not usually specify whether the evaluator was aware
of the experimental condition; however, it should be remembered that the double-blind
requirement in Psychology is difficult to guarantee when the psychotherapist (who is aware
of the nature of the treatment being provided) and the evaluator are the same person. This
lack of information was also reflected in other dimensions, such as selection bias or the
identification of key differences between groups prior to the intervention. In contrast, in all
cases, information was provided on the percentage of participants completing the study.
Intervention results cannot be generalized in the event of participant losses of over 20% [
77
]
(in such cases, patients are considered to be non-adherent). In 93.33% of the publications
reviewed, however, a lost follow-up rate of less than 20% was reported, meaning that
the participants can be considered adherent. The methodological rigor of the controlled
trials was consistent with the quality of the journals in which they were published since
73.33% were indexed in either Scimago Journal and Country Rank (SJR) or Journal Citation
Reports (JCR).
The second aim of this systematic review was to determine what types of problems
were treated using group psychodrama therapy. Firstly, we analyzed the studies involving
clinical patients with clinical symptoms. Thus, in adolescents diagnosed with opposi-
tional defiant disorder (impulsivity and oppositional conduct), a significant change was
observed in the behavioral variables of the group treated with psychodrama, although no
improvement was noted in variables measuring empathy and self-esteem, which would
require more time than the 12 weeks for which the treatment lasted [
65
]. We also observed
an improvement in operationalized impulsivity due to a greater response latency and
fewer errors produced. This improved response latency was due not to greater fear of
failure or the inability to come up with alternative solutions but rather to greater reflection.
Adolescents learned to consider the consequences of their actions and to respond more
responsibly. The reflective style seemed to reduce the aggressiveness and oppositional
conduct, which formed part of their impulsivity and lack of planning [
65
]. Moreover,
the authors claimed that psychodrama helped patients get to know themselves better;
following treatment, subjects were better able to connect to their emotions and feelings in a
safe therapeutic setting; moreover, they tested different roles and learned a new repertoire
of responses and behaviors [
78
,
79
]. The process of gaining greater emotional control was
also a key factor in the results reported by Sproesser et al. [
66
] when treating patients
with Parkinson’s disease. In this case, psychodrama helped participants reorganize their
daily routine, establish social ties and reduce anxious-depressive symptoms, all of which
had a positive effect on their psychological well-being (as a measure of quality of life).
This perspective was also shared by Dehnavi et al. [
66
], who highlighted the fact that
psychodrama brought about changes in cognitive insight, consciousness level [...] depth
and scope of individual experiences, understanding [of] self-strengths and weaknesses
which are key to improving quality of life. The therapeutic techniques selected and the
Int. J. Environ. Res. Public Health 2021,18, 4442 16 of 22
work of the therapist are essential in this sense since they aid patients in coping with their
psychological distress, creating a space for self-reflection, which helps them feel more
understood [
80
]. Patients not only feel that others understand them better but also discover
that they are not alone and that their peers are struggling to cope with the same problems,
thereby creating what Foulkes calls a “mirror reaction” [81].
Secondly, we analyzed those trials in which psychodrama was applied to people
suffering from a certain degree of psychological distress, but without reaching the level
required for their problem to be considered psychopathology. In these cases, psychodrama
was used to help them control their aggressive impulses and defiant conduct (e.g., impul-
sivity, defiant behavior, parent-adolescent conflicts, etc.) or to reduce the distress caused by
the presence of chronic stressors. In studies focusing on aggressiveness, many therapists
have used intervention programs in both clinical practice [
82
] and controlled research
trials [
4
,
12
,
32
,
83
]. The results of the clinical trial conducted by Karata¸s and Gökçakan [
68
]
revealed a decrease in participating adolescents’ overall aggressiveness scores. Specifically,
measures for anger, hostility, and indirect aggression were observed to decrease, although
physical and verbal aggression scores remained the same. According to the authors, one
possible reason for this absence of change in physical and verbal aggression may have
been that some of the young people in the group continued to receive disciplinary pun-
ishment at school, something which may have contributed to the maintenance of their
aggressive reactions. Moreover, verbal aggression is a type of behavioral manifestation that
is a common phenomenon in participants’ daily lives. Symptoms associated with chronic
stress constitute another focus of interest in psychodrama interventions. In the study
conducted by Carbonell and Parteleno-Barehmi [
70
] with girls coping with traumatic-stress
exposure, the two areas in which significant changes were observed as a result of the treat-
ment were anxiety/depression and social withdrawal (isolation). These are particularly
sensitive areas in the success of therapies for trauma and chronic stress. In this sense,
psychodrama may potentially play a key role in the treatment of post-traumatic stress. The
study also highlights the importance of group therapy for helping participants to develop
better coping strategies and to gain a greater sense of competence [
70
]. Psychodrama
has also been used to treat one of the most common types of chronic stress found in the
workplace: burnout. Burnout is usually defined as a syndrome characterized by three
dimensions [
84
]: emotional exhaustion, depersonalization, and lack of personal accomplish-
ment. Over recent years, this question has awakened great interest among psychodrama
specialists studying the care or helping professions [
71
–
73
,
85
,
86
].
Kähönen et al. [71,73]
assessed burnout through two modulating variables: sense of coherence and psychological
well-being, both of which mitigate burnout and are particularly effective for preventing
emotional exhaustion, always under the hypothesis of an inverse relationship existing
between the two constructs. The authors highlight the importance of providing this kind
of group therapy since it is a cost-effective intervention in the context of medical care; thus,
treatment with psychodrama may have a major impact on workers’ mental health.
Thirdly, we analyzed cases in which psychodrama had been used with community
samples to explore how certain variables may influence mental health or professional
competencies. The study by Dogan [
64
] analyzed the effect of group psychodrama on
romantic attachment styles among adults. The results failed to reveal any changes in the
variables studied (avoidance and anxiety), probably because a longer treatment time is
required to improve maladaptive attachment styles. Nevertheless, following the interven-
tion, participants reported improvements in empathy and their ability to react reliably and
also said they were more aware of their strengths and weaknesses. Another particularly
important variable in the healthcare field is hopelessness, a construct that promotes a
distorted view of reality and is believed to predict suicide [
87
]. In her study, Karata¸s [
75
]
focused directly on subjective well-being and hopelessness, finding effective evidence of an
improvement in both variables directly after the intervention, although, in the follow-up
test, only the effect of the treatment on hopelessness was found to have persisted. Although
further studies are required to corroborate these results, this is a very promising avenue
Int. J. Environ. Res. Public Health 2021,18, 4442 17 of 22
of research due to its implications for mental health, since psychodrama has a beneficial
effect on certain positive variables such as social adjustment, quality of life, self-awareness,
subjective well-being, and psychological well-being. Dehnavie et al. [
61
] reported that the
psychodrama intervention increased personal exchanges and served as indirect training
for social skills; it also resulted in a greater depth of individual experiences and a better
understanding of self-strengths and weaknesses, thereby fostering emotional and cognitive
integrity [9].
The authors of primary studies report benefits for both patients with clinical and sub-
clinical symptoms and participants from community samples. These findings are consistent
with the results of previous meta-analyses, which found significant improvements in all
types of participants, although those with subclinical symptoms were found to benefit
more from psychodrama, obtaining a slightly larger effect size [
25
,
31
]. The capacity of
psychodrama to adapt and be applied to any environment or population type has been
widely documented in the literature [32,88].
Finally, the third aim was to explore the methodological characteristics of the research
studies carried out. The studies included in the systematic review used a wide variety of
measures. Psychodrama was found to influence dependent variables such as symptoms,
subjective well-being, quality of life, and manifest behavior, among others, measured using
self-reports. This type of assessment instrument may generate bias in the measurements
due to a lack of motivation by participants, possible simulation, social desirability, lack
of introspection skills and memory distortion, etc. see [
89
], and these biases may, in turn,
affect the reliability of the conclusions drawn. Nevertheless, six of the publications followed
mixed designs, meaning that the information obtained through qualitative interviews was
used to complement and explain the quantitative results. In relation to the follow-up tests
administered after the therapy, in the case of psychosocial interventions, and particularly
psychodrama, it is best to take measures after an interval of (at least) two weeks to provide
participants time to process the experience [
72
]. Nevertheless, in eight of the 15 studies
included in the review, assessments were only carried out immediately after the end of the
intervention. In this sense, follow-up evaluations should always be carried out in order to
corroborate the long-term efficacy of psychodrama. In relation to the type of participants
undergoing treatment, most were young people under the age of 20. As regards sample size,
the groups were generally small [
63
,
66
] which, while rendering them more manageable in
terms of the psychotherapeutic intervention itself, nevertheless prevents the results from
being generalized.
One of the methodological inclusion criteria for this review was that studies dis-
tinguish between the three classic phases of psychodrama conceptualized by Moreno:
warming up, action and sharing. The first phase is designed to generate trust and get the
group into the right mood for the different temporal, spatial, and relational movements [
63
]
that occur during the action. During the second phase, the problem itself is addressed and
alternatives sought. It is during this phase that the different psychodrama techniques are
applied, and participants experience catharsis. Finally, during the sharing phase, partici-
pants identify with what has occurred and share feelings and experiences. Thus, both the
group and the protagonist benefit from the exchange. Nevertheless, in the studies analyzed,
the content of each phase was influenced, to a large extent, by the different people and
elements involved in the psychodrama sessions, including the group itself, the problem
being treated and the decisions made by the session leader. In this sense, it is important to
highlight the fact that, in order for a group intervention to be effective and safe, therapists
must be properly qualified and trained.
Upon analyzing the structure of the sessions and the duration of the interventions, it
becomes clear that it is difficult to establish a rigorous, stable, structured pattern for apply-
ing psychodrama therapy. Interventions generally encompassed 12 sessions (although they
varied between eight and 64) and lasted for around four months. Most individual sessions
lasted 1–2 h. Despite the positive changes observed following the treatment, in most cases,
the authors highlight the need for longer interventions in order to render the effects more
Int. J. Environ. Res. Public Health 2021,18, 4442 18 of 22
stable [
61
,
64
,
75
]. This idea is consistent with the idiosyncrasy of psychodrama itself since
it takes time to generate the required catharsis and then assimilate and integrate it. In this
sense, although Kipper and Ritchie [
25
] argue that the number of sessions does not affect
the efficacy of the techniques, it remains to be seen whether it affects the efficacy of the
intervention as a whole.
This systematic review has some limitations, the main one being the low number
of randomized controlled trials that have been published in this field. It is important to
encourage and conduct research designed to evaluate the effectiveness of the intervention,
comparing the results with those obtained in other groups not receiving treatment. This
would help validate the method and enable the benefits of psychodrama to be felt in a
multitude of different scenarios. Nevertheless, not only is it important to design method-
ologically robust controlled trials, but it is also necessary for the resulting reports to include
sufficient information to enable the studies to be replicated. The EPHPP (Effective Public
Health Practice Project) [
59
,
60
] has proven to be a vital tool in this sense, enabling the qual-
ity of primary studies to be assessed and the gaps and weak points of each publication to be
identified. For example, 40% of the documents analyzed here failed to state whether or not
there were important differences between the group at the start of the intervention; 66.66%
failed to specify whether or not the sample was representative; and 47.7% of the trials failed
to determine the competence level of the psychodrama therapist. Therapist competence is
key to determining the reliability of the implementation, and PD practitioners should have
the credentials required to lead the sessions effectively, although it is also true that, to date,
all training programs have been run by non-academic professional private associations and
institutions [
24
]. Returning to the idea of the importance of replicability, RCT reports should
follow clear guidelines for improving research transparency. The CONSORT (Consolidated
Standards of Reporting Trials) group has drafted an extension to its original declaration
(the CONSORT extension for NPT trials) that focuses on specific methodological issues
linked to RCTS involving non-pharmacological treatments, such as psychotherapeutic
interventions [
90
]. One of the recommendations made is that reports include a flow chart
(specifying the number of people participating in each trail phase: enrollment, allocation,
follow-up, and analysis) and checklists as tools for ensuring compliance with the required
standards of quality and scientific rigor. Following these guidelines would improve the
comprehensibility (and therefore replicability) of the RCTs published.
Further research is also required in the field of work-related health and in biohealth
contexts, with an effort being made to structure the intervention as much as possible (in a
systematic and replicable manner) within, of course, the boundaries of the idiosyncrasy of
psychodrama itself, which is based on improvisation and adaptation to each individual
situation and patient.
Future research may wish to increase the number of randomized controlled trials in
order to ensure that psychodrama can be applied within public health service, thereby
benefiting a greater number of people. To this end, an effort should be made to ensure that
the treatment is applied in as systematic a manner as possible. We also recommend that
future studies work with samples that are representative of the population and that they
increase the number of psychodrama sessions, carry out follow-up assessments in all cases
and use, alongside self-reports, other evaluation instruments that complement the results
obtained and help explain and understand them. Alongside result-centered research (which
seeks to ascertain whether or not therapy leads to change), it is also important to conduct
process-centered research, focusing on elements such as the identification, determination,
and relationship between common and specific factors (e.g., participant expectations,
therapeutic alliance, the group process itself, significant events research, insight, self-
awareness, links between clients’ in-session dramatic engagement, and concretization, etc.).
According to recent findings [
39
,
91
–
93
], these factors all contribute to the mechanisms of
change at work during therapy sessions.
To conclude, we can state that psychodrama offers a holistic view of human psychol-
ogy, works with corporal memory, and the sensations experienced by the physical body
Int. J. Environ. Res. Public Health 2021,18, 4442 19 of 22
offer a possible restructuring of the conflicting parts of each individual and, in short, may
help patients in a wide variety of different situations. Psychodrama has been found to be
beneficial for most of the variables analyzed and is an effective means of reducing certain
symptoms and fostering certain strengths and positive attitudes. We hope that this review
will help boost research in this field, increasing its scientific validity and rendering the use
of this therapy more widespread, thereby improving people’s quality of life.
Author Contributions:
Conceptualization, M.A.L.-G., P.M.-L., and G.T.; methodology, M.A.L.-G.,
and P.M.-L.; software, M.A.L.-G., and P.M.-L.; formal analysis, M.A.L.-G., and P.M.-L.; investigation,
M.A.L.-G., and P.M.-L.; resources, M.A.L.-G., and P.M.-L.; data curation, M.A.L.-G., and P.M.-L.;
writing—original draft preparation, M.A.L.-G., and P.M.-L.; writing—review and editing M.A.L.-G.,
P.M.-L., and G.T.; visualization, M.A.L.-G., P.M.-L., and G.T.; supervision, M.A.L.-G., P.M.-L., and
G.T. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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