Evaluation of Dramatherapy Process with Clients in Addictions Rehabilitation Community

The paper presents partial results of an ongoing research into evaluation of dramatherapy process in a community type addictions treatment and psychorehabilitation. The research is a continuation of an ongoing evaluation process of a dramatherapeutic Evaluation rating created by the research team. The results of using the evaluation rating were described in a previous paper. Dramatherapy sessions were provided weekly over 16 weeks in a group form. They were focused on embodied expression, insight through the means of metaphor and stories and exploring playfulness. Our interest was to observe the dramatherapeutic process and its specifics with clients in addictions rehabilitation and in the specific setting of the community type treatment in a psychiatric hospital. Qualitative data was gained from process recordings, comments of clients during evaluation session, and a focus group of dramatherapists. Quantitative data will be available from the evaluation rating that constitutes a second part of this research.

Providing dramatherapy as a part of treatment at psychiatric hospitals has its tradition also in Czech Republic. The research-therapeutic team of Prof. Valenta is actively involved in different settings in mental health care, such as departments for clients with neurosis, clients with addictions, children’s department of a psychiatric clinic or a prison facility. The effects of dramatherapeutic process are obvious to dramatherapists and participants of the sessions but it is necessary to provide appropriate evaluation tools. It is a difficult task also because the therapeutic change in dramatherapy happens due to metaphor, embodiment or play, described as core processes [4]. Knowledge, insight, or emotional change is a complex inner experience that is difficult to be translated into linear language. Therefore, some dramatherapy approaches do not dissolve the therapeutic effect by verbal reflections at the end of sessions. In dramatherapy, similarly to other kinds of therapy, it is possible to observe emotional, behavioural or cognitive transformations in clients and measure them with existing scales. However, to capture the specific healing factors that dramatherapy provides it is necessary to create evaluation instruments that would reflect the nature of its process. Usually, as a way of evaluation of the process and the dramatherapy outcomes, client assessment tools are applied in the beginning, throughout and at the end of the process. There are many existing assessment tools used in dramatherapeutic praxis and research. They are closely connected with particular dramatherapeutic approaches or theories. A published historical overview of assessment tools used in dramatherapy [9] described that these tools are based on effective factors in dramatherapy, or specific methods used by particular schools. The idea is that they should not measure only general psychological characteristics but also focus on the areas that are specifically dramatic, such as role, enroling, keeping role, switching roles, projection, working with body, with space, overlap between metaphor and consensual reality.

Therefore, our research team developed a measurement tool called Evaluation rating. It is a client assessment instrument based on observations of dramatherapists of clients’ behaviour specific to dramatic activities during dramatherapy sessions. It includes items such as position of client in group, activity of client, spontaneity, concentration of attention, emotional expression, affective reactions, non-verbal expression, interaction in group, imagination, distance, level of dramatheraputic involvement (movement, sound, picture, character, verbalization), entering role and usage of space. The instrument was fully described in previous articles of research team members [2]; [11]. There is an ongoing process of validity evaluation of this rating. It is focused on discovering correlations in assessments in individual items of the evaluation rating conducted by a therapist and co-therapist team providing dramatherapeutic intervention. The first part of data collection was performed in three settings: psychiatric hospital at a department for women with neurosis, at a children’s psychiatric hospital and at a prison facility with male clients [7].

Methodological research of validating the Evaluation rating assessment tool still continues at a psychiatric hospital at a department of a therapeutic community for people recovering from non-alcohol substance addictions. The collected data will provide further evaluation of the rating scale itself but it will serve a quantitative part of the research focused on the evaluation of dramatherapy process. In this article, we present partial qualitative results of the research.

Research goals

Our main research goal is development and evaluation of an evaluation tool for dramatherapy process applicable in various settings. Partial research goals included evaluation of the particular dramatherapeutic process conducted at the community type department of a psychiatry hospital for clients with non-alcohol addictions.

The aim of the research was evaluation of dramatherapy process from the position of clients and dramatherapists. We focused on discovering possible differences and commonalities in the perceptions of the effects of dramatherapeutic involvement perceived by clients and observed by dramatherapists. From the position of dramatherapists, we were interested in the evolvement of the process, group dynamics and addressing the needs of clients based on the observations of the process. We present partial results from the qualitative part of the research.

Research participants and setting

Dramatherapy sessions took place at a psychiatry hospital in Kromeriz, at a department for clients in treatment of non-alcohol substance addictions or non-alcohol substance abuse with alcohol addiction. The department functions on the principles of a therapeutic community. It is a newly created department and dramatherapy has been a part of the weekly programme since the beginning. It is an open department for men and women. The treatment usually lasts four to six months and it follows four stages of therapeutic community. There is a high fluctuation of clients, in the first five months of the existence of the community, only one patient has completed the treatment. The personnel of the department include a psychiatrist, a psychologist, an addictions specialist, nurses and social workers. Dramatherapists are coming to the community once a week as external professionals.

Dramatherapy sessions were provided for a period of four months, once a week for an hour and a half. The team of dramatherapists consisted of four core therapists that were present at most of the sessions and of three substitute therapists. The sessions were organized in a group of all community members together with the possibility of separating into smaller groups. The original proposal was to divide into two groups and lead two separate dramatherapy processes. However, the community was small at the beginning and later on they showed a wish to stay together as one solid group. Over time, the therapists were facing a question of whether to stay in a big group or work in smaller groups with the opportunity to reach more intimate personal topics. Eventually, a way of working evolved, where the beginning warm-up part of the session was done in a big group, including a ritual, energizers and concentrative activities. The main topic of the session was realized and discussed a smaller group. The closing part of the sessions happened again in a full group with a short reflection and a closing ritual. The structure of the sessions followed steps of greeting of the dramatherapist and the group, warm-up, opening of playspace, starting play, main topic, closing, and reflection [10]. Moreover, it included an opening and closing ritual that provided a safe border for beginning and ending of the playspace.

Particular sessions focused on different topics that were chosen by dramatherapists leading them. The choice of media used was done according to the dramatherapists preferences and the topics generally followed self-knowledge, getting to know each other in the group. The methods included the usage of story, metaphor, symbol, imaginative techniques as well as different materials, objects, and body sculptures.

Research results

Our research questions were focused on the dramatherapeutic process in the context of community type psychiatry department in treatment and rehabilitation of non-alcohol substance addictions. We were interested in exploring the specifics of this dramatherapeutic process and its effective factors.

In the qualitative part of our research we discovered interesting phenomena that were specific for this particular dramatherapeutic process. Some of these observed characteristics were influenced by the dramatherapists, some of them by the personalities of the clients and some by the type of treatment, which was a very specific community type department at a psychiatry hospital.

For the dramatherapists, the dramatherapeutic process was characterized by the dilemma of supporting group cohesion versus individual progress. The rules of group work and theory of stages of group development [5] state that the progress of the group can proceed only as fast as its slowest member. However, this appeared to be denied in this particular open group. The reasons might contain the community type treatment with its leaders and also the high flexibility of this client group.

Selection of methods and techniques by the dramatherapists was a process that required a lot of balancing of ideas and approaches in accordance with getting to know the group and their needs. In the beginning, the team took on a strategy of a slow start by introducing the way of working in dramatherapy to the clients through non-verbal embodied games, ice-breakers, activities including turn-taking, and working in pairs. The idea was to introduce dramatherapy to the clients step-by-step in order for them to start feeling comfortable.

However, new clients joined the community every week and some clients left. Such high fluctuations lead the dramatherapists to a decision point of staying on the level of games versus moving on to deeper topics. It seemed that considering the presence of newly arrived members and preparing them for embodied work would mean that the group would never get to exploring topics through dramatherapy. Therefore, the team decided to take a risk of not going through basic activities with some clients. The outcome was positively surprising. The clients were able to join the activities even though they did not go through the preparation stage.

In the beginning of the dramatherapy programme there were a few clients who used laughter as a defence strategy when play or embodied activities seemed ridiculous to them. In the reflections in the end of the sessions, the clients expressed that they did not know “if they are doing it right” or they “did not like acting out.”

Further into the programme, clients who had experience from previous dramatherapy sessions represented a solid part of the group. Their serious participation helped those in need of defence to overcome it quickly. New members of the group looked up to those with experience and trusted their judgment. They were flexible in learning about the ways of working in a dramatherapeutic group. They quickly adopted the style and participated.

Reactions of clients to the dramatherapeutic process as we observed them were: fear of being ridiculed and overcoming it, the need for belonging to the group, high flexibility and community support. As far as typical personality trait of these clients, we observed flexibility, will to be likeable, challenges in owning responsibility and being modest, black and white thinking especially in judging truth and lie or forgiveness, the need to deal with and to discover oneself, the need for expelling energy and search for excitement, and also difficulty to calm down and concentrate.

Observed characteristics specific for the community type treatment were shared decision making, which was strict and based on black and white non-forgiving thinking of many of the group members, and a need to be together as a group. Also, the leading community members showed an interest for the group to look good in front of visitors, which dramatherapists were considered too. The community was able to give each other support and critique in discussions. Over the time, we observed development of the clients’ dramatic expression as they were getting more familiar with the methods of dramatherapy.

Clients perceived dramatherapy sessions as focused on getting to oneself, opportunity to expel energy, to think about something else, relax and prepare for further work. They consider abstinence difficult and dramatherapy sessions brought joy and energy. Further they recognized dramatherapy as playful activities that lead towards deeper inner work. Clients admitted that in the beginning they felt embarrassed or shy but then got used to the type of embodied play and role play.

Components of dramatherapy identified by clients were divided into categories of general mental health support, intrapersonal development, interpersonal development and specifics of dramatherapeutic methods. General mental health support components that dramatherapy provided for the clients in the research group included relaxation, self-expression, good mood, meaning, fun, tension release, happiness, will for life and energy. Components of intrapersonal development were mostly personal characteristics or skills that clients felt to be encouraged in the dramatherapeutic process. They included fantasy, knowledge, modesty, honesty, self-determination, overcoming personal limits, power and abstinence, courage, contact with feelings, self-confidence and self-critique. Components of interpersonal development were created by feeling the trust and power of the group. Clients expressed a higher understanding in the group, communication, and natural friendships. Also, they mentioned that they worked on love and relationships in general. Clients observed also characteristics of the process that are typical for dramatherapeutic methods such as improvisation, open-end story, ritual, symbols, will for product creation and acting. These are parts of dramatherapy core processes that clients observed in the work as specific for the sessions and helpful in the process.

Interpretation of research results

Demonstrated and observed client and group characteristics were considered the most important needs to be explored in the dramatherapeutic process and goals of further dramatherapeutic sessions were based on them. The goals set by the dramatherapists included relaxation, expelling energy, concentration, cooperation in group, and learning about oneself. The main focus of the dramatherapists was on providing safety, positive and supportive atmosphere, and appreciation. The methods and topics selected allowed for exploring self-knowledge, self-reflection, cohesion of the group and encouragement in treatment.

These goals of provided dramatherapy sessions were in accordance with the goals of dramatherapy such as reduction of tension, development of empathy, creativity, fantasy, unblocking communication channels, personality integration, self-esteem and self-confidence, support, responsibility, independence, self-control and forgiveness [8].

Especially effective and specific for dramatherapy are therapeutic principles that promote change. They include pretend “as if” play, “here and now” principle of collapse of time and space as described in psychodrama [3], heightened awareness, ritual, group dynamics and therapeutic relationship [4], [11]. These principles were followed in all of the dramatherapeutic sessions offered. From the evaluation of the clients, it is obvious that these goals were perceived from the offered activities.

As far as reactions of clients during the dramatherapeutic process, the observed defensive laughter represents a common appearance in the beginning of dramatherapeutic interventions. It happens when the fine line of aesthetic distance is disturbed. Dramatherapy works with aesthetic distance [6] as a balance between emotional and rational involvement. It means that participants engaged in play are aware of being actors and at the same time they are fully submerged in the playful activity. They perceive themselves from the perspective of the first person and also from the point of a third person, as if looking at oneself from the outside. This phenomenon helps people to function in social interactions including play [1]. The clients in our group were stepping into play and stepping out of it, they had a hard a time with finding the balance of staying in role and looking at themselves from the outer view. At that point, they were not able to feel safe to submerge into play. The outer perspective took the lead and the fear of being judged stayed present in this first phase. Later on, the clients accommodated to this way of working and did not feel embarrassed. We observed that clients who came to the group later in the process adjusted more easily.

The need to belong to a group seems to be very strong and connected with the high flexibility of clients in this group. Clients who were new to the dramatherapeutic process quickly adopted the style of work. We feel that it is also the community spirit and the stages that community members go through that allows the more experienced ones to motivate and support the new members. However, the specific personality characteristics of clients with addictions include the wish and the skill to shape oneself according to the group requirements as their previous survival strategy.

Discussion

Areas of interest that have emerged from the analyses of the process from process recordings, evaluation session with clients and a focus group with dramatherapists require further analyses and comparison with quantitative data that were collected through the evaluation rating scales. The observations of dramatherapists and clients meet at points of goals and effective factors. However, a deeper analysis is necessary and will be helpful for further dramatherapeutic processes.

Dramatherapy creates space for playfulness and therefore offers a safe ground for relaxation in a non-threating environment. This is important for clients recovering from drug addictions because they are in the process of learning to trust and also to offer a reliable relationship. Play in dramatherapy constitutes a base for encouraging self-esteem. There are no wrong answers in play and everything is possible. Clients in the research group expressed the need to find themselves, to discover who they really are and what they want in life. Play and metaphor in dramatherapy serve as an experimental space for clients to explore new roles or new possibilities in their lives, without any threat of failure.

The beginning part of each session consisted of games that required a lot of energy. They served as powerful energizers, fulfilling the wish of clients to do something active. Their need for excitement can be a part of the change in energy levels they deal with in their new life without drugs. The reason might also be just the need of their young bodies for movement and fun activities, which the community regime does not include so much. The dramatherapists chose activities that supported this need, however, they also observed that it is difficult for the clients to calm down and concentrate. Therefore, energizing activities were followed by concentrative work. These exercises offered learning to pay attention to other members in the group, focus on movement and precision rather than speed.

Specifics of this dramatherapeutic process start with the setting. It is a community type treatment, but it is a part of a psychiatry hospital. That means that there are principles of community in the group, but some factors of everyday life still follow the hospital rules. Another specific was that the dramatherapists represented external staff, so clients considered them visitors in a way. Also, dramatherapists were fluctuating as well as the group of clients was fluctuating. Therefore, each session became a process of its own. It is possible to see a thread throughout the whole series of sessions, but the focus of the dramatherapists was mainly on each session separately as a complex unit with its beginning and its end. The reasons were that the same dramatherapist would not lead the next session most likely and also that the clients in the group would be different again. Those dramatherapiest who were present at most of the sessions were more focused on the process as a whole. On the contrary, those attending only a few of the sessions did not focus on the continuality. They provided their attention to the clients within the limited time allotted that they had within their particular session. They did not feel the need for a closer relationship with the clients and could not take responsibility for opening a topic that would carry over to a next session. However, those clients who attended more dramatherapy sessions gained experiences from them that constituted their own dramatherapeutic process. During each session, they worked on a different part of their personality or a topic. The process was more of a process of each individual client and a process of the group rather than a followed plan of the dramatherapists. The offer of extraordinary activities, that dramatherapy represented in the everyday life of the clients, has gained an established place in the community schedule.

Conclusions

The paper presented partial results of qualitative data analysis from the research focused on evaluation of dramatherapeutic process in a community type treatment for people with non-alcohol addictions. Research results suggested that clients perceive the effective factors of dramatherapy similarly to the dramatherapists that offered the process. The main components of dramatherapy, which lead to change, were identified relaxation, tension release, fun, play, improvisation. Through these means intrapersonal development and interpersonal skills can be encouraged. The qualitative part of research presented will be supplemented with data from quantitative evaluation rating scale. This research is a continuation of a research project focused on evaluation of dramatherapeutic process and development of evaluation tools. Qualitative data serve for better understanding and deeper exploration of perspectives of clients and dramatherapists on the dramatherapeutic process and its healing factors.

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