Evaluation of Dramatherapy at the Addiction Recovery Unit by Alumni I

Introduction

Substance abuse is a serious public health problem and social issue at present. It is a cause of psychiatric and somatic co-morbidity, including infectious diseases, higher mortality rates, social exclusion and crime [11].

The system of medium-term and long-term residential addiction treatment in the Czech Republic is provided by specialized centres in psychiatric hospitals and in therapeutic communities. Over the last 30 years, clinical specialities dealing with expressive therapy have been developing and working at gaining a firm place in the system of helping professions in the Czech Republic. Expressive therapies are increasingly popular with substance-abusing clients. Art therapy in particular has built itself a strong foundation in both the medical and social departments. Many therapeutic communities have also added dramatherapy to their treatment programmes, whether as part of group therapy or as a leisure drama activity (e.g. TC Magdalena, TC Renarkon, TC Salebra, TC Podcestny dum). Although many addiction recovery wards of psychiatric hospitals are transforming toward the therapeutic community approach, other expressive therapies, apart from art therapy, are much less common and established part of the programmes.

Despite the fact that the number of clinical practices in dramatherapy has been on the rise in the Czech Republic, this practice is rarely analysed and verified by research studies [8]. Given the high and, more importantly, constantly growing prevalence of substance abuse clients in the therapeutic process in the Czech Republic and abroad, the research theme of dramatherapy intervention with these clients receives very little professional attention.

The present paper introduces a long-term research project assessing the dramatherapy process at an addiction recovery ward of a psychiatric hospital. The main focus will be on the evaluation of key topics reflecting the specific contribution of dramatherapy to clients treated for addictions from the perspective of alumni (abstainers).

This survey also aimed at extending the data of the extensive interim evaluation, verifying its conclusions, and hence reducing the degree of subjective interpretation.

Theoretical Framework of the Research Project

The principal objective of the entire long-term research project was to assess dramatherapy from the point of view of the participants in the process - the clients and the dramatherapists. The aim of the research is to use qualitative analysis in order to understand the dramatherapy process from the perspective of the main participants in the process and characterize the specifics of the process, noting the relevant context of the psychiatric hospital environment and the general characteristics of the clients in question. These variables largely determine the process itself. The qualitative analysis explores the participants’ subjective image of the process as they interpret their experience and feelings.

The research likewise aims at assessing the potential benefits of dramatherapy, its influence on psychotherapy as part of treatment programmes, and the effective factors of dramatherapy with substance abuse clients. The evaluation is used to identify the key processes that make up the general principles of dramatherapy.

The terminology used in this study, in relation to key processes in dramatherapy intervention, is based on Phil Jones’ theory of core processes [6]. Jones identified eight core processes: dramatic projection, dramatherapy empathy and distancing, role playing and personification, interactive audience and active witnessing, embodiment, playing, life­drama connection and transformation.

For the purposes of this paper we chiefly focus on two core dramatherapy processes, namely life-drama connection and transformation. The aim of the partial research was to verify the potential of dramatherapy intervention over the long run with an emphasis on achieving the potential of transferring experience from dramatherapy intervention to the daily life of alumni-abstainers.

An interim analysis of the three-year process, from the viewpoint of clients in treatment, has strongly verified and evaluated in particular the situation-specific benefits of dramatherapy intervention at present over the course of treatment (e.g. emotional outlet, mood change, group cohesion). Given the context of data collection, it was impossible to ask and answer the crucial question of whether dramatherapy intervention also fulfils core processes such as life-drama connection and transformation. As these core processes can only be reflected in hindsight, partial research focused on the residential treatment alumni was carried out.

During the research we drew on the basic theoretically described potentialities concerning the effectiveness and singularity of art therapies (including dramatherapy) in the psychotherapeutic care system. We drew on the following phenomena: the therapeutic potential of art, inner experience, physical experience, self-awareness through a powerful experience, expression, the phenomenon of play, the space of play and the principle of fiction and metaphor.

As with other complex processes, dramatherapy is not created through gradual development but rather through extraordinary moments, which are characterized by quantitative leaps and indicate discontinuity. These exceptional moments are milestones on a path taken by the individual and the group in the drama space of play, which are often linked to deep personal insight on the part of clients. It is often difficult to put these moments and experiences, accompanied by strong emotions, into words, to consciously register and process them [13].

Dramatherapy deliberately uses the drama medium for therapeutic purposes. It is important to understand the phenomenon of drama and theatre in a wider sense than just a specific type of art.

Theatre helps to understand oneself and the world. Theatre helps one view oneself from a distance, answering the question Who am I?, finding where one stands, and reflecting on one’s own present, past and future. Theatre has the capacity to pack a story into a single time, place and act. The compactness facilitates learning from the story, widening one’s perspective of the world, and finding inspiration in the new solutions [9].

Theatre and art serve humans in their efforts to find and comprehend the meaning of their existence [4].

The need to express oneself through art is as old as the beginning of time. People have always needed to express their emotions and feelings through art. Art helps to heighten the immediate experience, and brings relief through expressing intense emotions. It is the ability of humans to express their thoughts, feelings and ideas. Creative artistic activities are also reflective. They always mirror and comment on human existence [2]. The need for self-expression is one of the elementary human instincts. Creative instinct includes basic needs such as the need to play and the need to decorate (the need to be appreciated for creativity) [14].

Artistic activity is always expressive, evoking impressions and experiences which are real and often more pressing than ordinary reality, although the viewer or listener is aware of their fictional nature.

Goodman [3] ranks ‘expression’ as one of the basic types of symbolization. Symbolization is a tool conveying the contents of experience between people who can understand symbolic expression. Croce [1] describes expression as an independent type of intuitive sensory knowledge, which he distinguishes from logical conceptual knowledge. Similarly, Russell (1910-1911) divides human knowledge into two types: knowledge by acquaintance and knowledge by description. Knowledge by acquaintance requires the perceptual presence of the object to be known. The same applies to expression. Expression also requires the perceptual presence of the known object. In other words, it is impossible to gather meaningful knowledge of an expressive object through its description. Otherwise instead of listening to, for example, Beethoven's 9th Symphony one could simply read a report about it or study a sound wave diagram [15; 16].

Every expression is a certain type of symbolization requiring interpretation. It is important to bear in mind, however, that each interpretation has its own subjectivity, and therapists working with clients need to adopt a critical approach to the overestimation of interpretation as an instrument of understanding.

Art and the need to express oneself are natural phenomena of human society, which are perceived and experienced on the sensory level, always evoking feelings, impressions and emotions. These are the basic and core principles explaining the efficiency and effectiveness of expressive therapies, including dramatherapy in the treatment of clients. Any creative activity involves being in touch with oneself, a reflection on the present, and the intense experiencing of this process. The art form creates a safe space for conveying negative or traumatizing emotions and feelings. Unlike other expressive therapies, dramatherapy, as a means of this expression, uses movement and one’s body to dynamize the creative process of experience, shorten the client's distance, while requiring the construction of safety and the inner commitment and motivation of the client to work on internal transformation.

Drama reality is the key concept in dramatherapy and perhaps its only true characteristic. Compared with verbal therapy, where interventions are primarily held as part of an actual situation by means of the therapeutic relationship, interventions in dramatherapy develop exclusively through the drama reality. Dramatherapy always carries a form of contact with this experience, whether through roles, improvisation, action, contact, meeting, dramatization of stories, game and rituals [12].

Research Goals

While conducting the partial research into the evaluation of dramatherapy by alumni, we asked ourselves the following question: Has participation in dramatherapy influenced the personal lives of the clients? If it has, how do the clients describe and interpret this influence?

The question is based on the prediction of the need to seek the specific potential of the dramatherapy intervention at an addiction recovery unit from the perspective of support for a long-term change in the client’s life. The interim analysis principally suggests a situation and the dynamics specific contribution of dramatherapy to treatment, resting in change of mood, ventilation of negative emotions, group cohesion, diversion, etc. Given the nature of the respondents, clients in treatment, there is no other possibility to generate data on the said potential of the dramatherapy intervention than from respondents- successful alumni. This is why alumni focus groups were held during alumni meetings at the hospital unit. The partial research aims at describing the potential application of conscious transfer of experience from dramatherapy interventions to normal life from the perspective of the abstainer.

Research Participants and Setting

Research participants were selected on the basis of non probability institutional sampling. The participants were selected with respect to the main purpose and objective of the research. The research sample was composed of participants who took an active part in dramatherapy interventions at the addiction recovery unit of the Kromeriz Psychiatric Hospital between February 2014 and June 2017, completed the residential treatment, and have been abstaining.

The empirical research was held at an addiction recovery unit operating on the principles of therapeutic community. It is an open coed ward designed for substance dependence treatment. Structured into four phases of varying length, the treatment is medium-term (four to six months). The ward has 24 beds. The Mandala ward was established on 1 February 2014. Two weeks into the existence of the ward, dramatherapy became part of the patient treatment programme. The 90-minute dramatherapy interventions were held once a week. The drama therapists are external employees of the ward. Additionally, the drama therapists entered the process without prior knowledge of the client's history or diagnosis, relying solely on the client’s involvement during the intervention. Spanning a period of nearly three years, the dramatherapy process was suspended for the summer breaks and over Christmas. These breaks divided the process into time-limited stages, each concluded with an evaluation meeting with the clients. The process in the therapeutic community never comes to an end. The open group does not allow for a clear determination of the end of the process. The end of treatment depends on every personality. The group never terminates for all its members at the same time.

Data for the partial research was collected at alumni meetings, which are held once a month at the addiction recovery unit, between April and September 2017. It was impossible for ethical reasons to contact the successful alumni in any other way than at these meetings. The sample was therefore to a certain extent distorted because the alumni groups were only frequented by a small number of alumni, who were the abstaining part of the alumni community. These respondents may have been more motivated than the alumni who did not participate in the groups. Furthermore, a large share of the alumni also continued with treatment in a therapeutic community or a follow-up care centre, joining alumni groups in relation to the institution they last attended. There were also a high number of clients- alumni, who relapsed and lost touch with the unit.

Ten respondents voluntarily participated in the research, of whom 2 were women and 8 were men, aged 22 to 38. Two alumni abstained for 3 years without relapse and joined a follow-up centre after the treatment, 2 alumni abstained for 1 year without any follow-up treatment, 1 alumnus abstained for a year and has recently returned from a year-long programme in a therapeutic community, 1 alumnus abstained for 1 year with one relapse without follow-up care, and 4 alumni abstained for 3 months or less and have not yet entered any follow-up treatment.

Research Methodology

Due to the subject of the research, the qualitative approach was primarily employed to collect, process and analyse the data. The principal characteristics of this qualitative survey agree with the characteristics provided by [7]. When describing the phenomenon, the analysis method depends on words not on figures, the survey is strongly focused on a small number of cases, the context of the entire case is used to understand part of the experience and the process is inductive.

The research design was based on semi-structured interviews in the form of a focus group. This method facilitated a study of the opinions, feelings, values, and attitudes of the target population and their influence by group phenomena [10]. The focal point of discussion was: the specific contribution of dramatherapy intervention during and after treatment from the perspective of the alumni. The focal point was clearly defined and comprehensible for all the participants.

Due to the selected semi-structured concept of the focus group, model questions concerning the perceptions, motives, feelings, impressions, and judgements of the participants, in the context of personal experience with the dramatherapy intervention during treatment, were determined.

Model questions:

•     What vivid memories of the dramatherapy do I have?

•     What role and function did dramatherapy have for me in the unit’s treatment programme?

•     Am I aware of the benefits of the dramatherapy experience in my daily life?

The data was made anonymous, open-coded, reduced, and subsequently reconstructed based on categories. The relations between categories and concepts were defined [5].

The ethical aspects of the qualitative survey were ensured with the data anonymization and informed consent signed by all the respondents.

Conclusion

The first part of the article: Evaluation of Dramatherapy at the Addiction Recovery Unit by Alumni I introduces the research design and objective of the long-term research project at the addiction recovery unit of Kromerlz Psychiatric Hospital. The article describes the theoretical background of the research, the research methodology and the research participants. The findings and the qualitative analysis of the focus groups will be discussed in the second part of the article: Evaluation of Dramatherapy at the Addiction Recovery Unit by Alumni II. Given the conciseness of data collected within the qualitative analysis and the need to introduce the context of the issue under research, the comprehensive article was split into two parts.

Funding

This paper was methodologically supported by grant funds of Palacky University Olomouc IGA_PdF_2017_005 - Research Strategies, Diagnosis, and Therapeutic Intervention in Special Education.