Drama Therapy for Children Adolescents with Psychosocial Problems: Comparison
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Drama therapy is applied to children and adolescents with psychosocial problems. Drama therapy is an experiential form of treatment which methodologically uses drama and theatre processes to achieve psychological growth. Positive effects were found on overall psychosocial problems, internalizing and externalizing problems, social functioning, coping and regulation processes, social identity, and cognitive development. An adaptive approach was mentioned as the therapeutic attitude. The means established contribute to a dramatic reality, which triggers the mechanisms of change. These are processes that arise during treatment and which facilitate therapeutic change. 

  • drama therapy
  • children
  • adolescents
  • youth
  • review
  • psychosocial problems
  • mechanisms of change

1. Introduction

Psychosocial problems consist of a combination of emotional, behavioral, and social problems [1,2][1][2]. One out of five children and one out of seven adolescents suffer from psychosocial problems, including mental disorders [3,4,5,6][3][4][5][6]. The mean global coverage of prevalence for mental disorders in children aged 5–17 years was 6.7% in 2016, subdivided into conduct disorder (5.0%), attention deficit/hyperactivity disorder (5.5%), autism spectrum disorders (16.1%), eating disorders (4.4%), depression (6.2%), and anxiety (3.2%) [7]. As an expression of dysfunction related to psychosocial problems, a distinction can be made between internalizing and externalizing problems. Internalizing problems concern emotional problems that focus inward, such as depression, (social) fears, withdrawn behavior, and psychosomatic complaints. Externalizing problems concern behaviors that are more outwardly directed, such as hyperactivity, aggressive behavior, and attention problems [8,9][8][9]. Children and adolescents who suffer from psychosocial problems are more likely to be a victim or a bullying perpetrator [10[10][11][12],11,12], experience lower academic performance [13[13][14],14], and have an increased risk of suicide [3,13,15,16][3][13][15][16]. Failure to identify and treat psychosocial problems in time increases the risk of problems in the future [17], for example, of physical disorders [18]. These problems have economic consequences which create additional costs for the society [19,20][19][20]. Many psychosocial problems in children and adolescents are not recognized and treated in time [21]. Addressing these problems at early age is necessary to prevent them from getting worse [22].
The most common treatment for children and adolescents with psychosocial problems are cognitive behavior therapy focusing on cognitive behavior, psycho-education, emotion regulation, communication, interpersonal skills, or parent training [23,24,25,26,27][23][24][25][26][27]. Some studies suggest that cognitive-behavioral therapy is less appropriate for young children and for children and adolescents who have difficulty expressing themselves verbally [28,29,30,31,32,33][28][29][30][31][32][33]. Activating strategies, such as role-playing, are emphasized as effective elements in treatment for these children and adolescents. In particular, role play is seen as important for modeling behavior, to expose fears, and as an opportunity to develop coping skills [27]. Activating strategies, and role play, in particular, are important elements in drama therapy to treat psychosocial problems in children and adolescents [31,34,35][31][34][35].
Drama therapy is an experiential form of psychotherapy which methodologically consists of drama and theatre processes, fictional reality created by a wide range of verbal and non-verbal dramatic techniques aimed to achieve psychological growth and change within a therapeutic relationship [36,37,38][36][37][38]. Drama therapy is one of the creative arts therapies (together with psychodrama, art therapy, dance and movement therapy, music therapy, and bibliotherapy). In drama therapy, drama and theater processes are influenced by and based on different psychological perspectives such as psychodynamic, cognitive behavioral therapy, attachment theory, and developmental psychology, client-centered therapy, or narrative theory [30,39,40,41,42,43][30][39][40][41][42][43]. Drama therapy is considered suitable for children because of the underlying play. Dramatic play is seen as one of the core processes in drama therapy [39,44,45,46,47][39][44][45][46][47]. Dramatic play gives children the opportunity to express (non-)verbally, gain control of their thoughts and feelings, and understand others. A variety of means, i.e., forms and techniques, are used in drama therapy, such as role-play, storytelling, puppet play, and theater games. These are aimed at creating a playspace where children can play in a fictional world. Although playing takes place in a dramatic (“as if”) reality, behavior, thoughts and feelings can be real at the same time. Hence, there is both a distance and a connection between play and daily life [39,46,47,48][39][46][47][48].
Attunement within the therapeutic relationships is important. The drama therapist adaptively matches the drama therapeutic means (e.g., drama role, themes) to the needs, expression, and wishes of the client [49,50,51][49][50][51].
In clinical practice, drama therapy is successfully applied by drama therapists using a variety of drama therapeutic approaches and theories based on good practice, theoretical insights, and intuition [30,49,52][30][49][52]. In a qualitative study, drama therapists reported several effects of drama therapy in children and adolescents, such as improvement of social skills, regulation of emotions, better child and adult relationship, increased assertiveness and self-expression, and more resilient responses to bereavement, separation, and loss [53]. These outcomes are important effects that may promote self-esteem that buffers the negative effect of stressful life events in adolescence [54]. Drama therapy experts assume that drama therapy is used to promote understanding of one’s own and others’ behavior in terms of mental states (mentalization) [55[55][56][57],56,57], executive functions [58[58][59],59], working memory [60[60][61],61], and resilience [39,62,63][39][62][63]. Most studies on the effects of drama therapy in children and adolescents are based on expert opinions reflecting on their clinical work. An overview of effects based on empirical studies using cohort studies and (randomized) controlled trials is still lacking.
Besides the effects of drama therapy on children and adolescents, little is known about what and how drama therapy leads to a positive change in psychosocial problems of children and adolescents [27,34,64][27][34][64]. There is a growing interest in insights into the effectiveness of drama therapy works and which processes contribute to changes of the client’s wellbeing. These processes are called mechanisms of change, referring to processes that arise during the treatment that facilitates the therapeutic change [65,66][65][66]. A few mechanisms of change are described in drama therapy. For example, drama therapists and adult clients describe the importance of a positive therapeutic relationship, working within a safe distance, being actively involved in the therapy, and having physical experiences that facilitate the development of new awareness and language skills through which clients can communicate to themselves and others [67].

2. Outcomes

2.1 Overall Psychosocial Problems

Four studies focused on overall psychosocial problems [76,79,83][68][69][70]. This category consists of outcomes on overall psychosocial problems, problem behavior related to autism, and effect as an underlying concept for emotional functioning. The studies involved six children in the age of 10–12 years [76][68] and 199 adolescents in the age of 12–18 [79,83,84][69][70][71]. Two studies had a RCT design [83[70][71],84], and the other two studies had a pre- and post-test design [76,79][68][69]. One study examined effects on psychosocial problems reported by the adolescents and their teachers [83][70]. The study showed differences between psychosocial problems reported by the adolescent versus the teacher: a decrease in overall psychosocial problems was found reported by adolescents, while no effect was found reported by teachers [77][72]. A positive effect reported by adolescents was also seen in another study examining effects on psychosocial problems [84][71]. One study examined autism problem behavior, both reported by the parents as well as by the students themselves. No effect was found on the autism problem behavior after the intervention [76][68]. There was one study examining the effects of intervention on negative and positive affect. An increase in positive affect was found, but no effect was found for negative affect [79][69].

2.2. Internalizing Problems

Six studies focused on the effects of drama therapy interventions on internalizing problems [75,76,79,81,82,83][68][69][70][73][74][75]. The category internalizing problems consisted of outcomes regarding anxiety, depression, (di)stress and posttraumatic stress, timidity, obsessive compulsive disorder, interpersonal sensitivity, and somatization. The studies involved 164 children in the age of 9–18 years. Two of the studies had a RCT design [81[70][74],83], one study had a CCT design [75][73], and three studies had a pre- and post-test design [76,79,82][68][69][75]. One study examining the effect of drama therapy interventions on internalizing problem behavior rated by the parents and students did not show an effect on this outcome [76][68]. Two studies examined the effect on anxiety [79,82][69][75]. The results of one study showed a decrease in anxiety [79][69], and the results of the other study did not show any effect on anxiety. Two studies examined effects on specific anxieties, i.e., social anxiety [75][73] and phobic anxiety [82][75]. Only a decrease was seen for social anxiety. Two studies examined the effects on depression. Results of both studies showed a positive effect on this outcome [79,82][69][75]. Two studies examined the effects on stress, i.e., distress [83][70], and symptoms of posttraumatic stress [79][69]. The results of both studies showed a decrease in distress rated by the students, and in one study, there was also a decrease in symptoms of posttraumatic stress, while the results rated by the teachers did not show an effect on distress. Other studies examining the effect on psychopathology symptoms showed a decrease in symptoms of psychotic thinking [82][75] and in severe timidity [81][74], while there was no effect on somatization, paranoid ideation, interpersonal sensitivity, and obsessive compulsive disorder [82][75].

2.3. Externalizing Problems

Three studies focused on the effect of the drama therapy interventions on externalizing problems [76,78,82][68][75][76]. This category consisted of outcomes on overall externalizing problem behavior, impulsivity, hyperactivity, (in)attention, assertiveness, hostility, violent recidivism risk, and the number of registered incidents. The studies involved six children in the age of 10–12 years [76][68], five adolescents in the age of 12–18 [82][75], and 91 adolescents in the age of 16–19 years [78][76]. One study had a CCT design [78][76], and the other studies had a pre- and post-test design [76,82][68][75]. One study examined externalizing behavior, hyperactivity, and inattention, both self-rated as well as rated by their parents. No effect was found for externalizing behavior rated by the students. However, parents’ ratings showed a decrease in externalizing problems behavior. In addition, both student and parents reported a decrease in hyperactivity and inattention [76][68]. Another study examining inattention and impulsivity showed a decrease in symptoms on both inattention and impulsivity [78][76]. One study examined results on hostility [82][75], and one study examined assertiveness and violent recidivism risk behavior [78][76]. The results of these studies showed a decrease in hostility and violent recidivism risk behavior and an increase in assertiveness, but there was no increase in the number of registered incidents [78][76].

2.4. Social Functioning

Three studies [76,82,83][68][70][75] focused on the effect of drama therapy intervention on social functioning. This category consisted of outcomes related to social skills, more specially the perception of the students and teachers regarding the extent to which psychosocial problems interfered with home life, friendship, leisure activities, the outcome on self-esteem in social behavior and the satisfaction with social support. The studies involved 134 children in the age of 11–18 years. One of the studies had a RCT design [83][70], and the other studies had a pre- and post-test design [76,82][68][75]. One study examined effects on overall social skills rated by the children and by their parents. The results showed a positive effect on overall social skills rated by the parents, while the results rated by the children did not show any effects of intervention on overall social skills. Results regarding more specific socials skills, such as communication, cooperation, responsibility, empathy and self-control, rated by the children and by their parents, did not show any effects. However, the amount of engagement rated by the parents showed an increase after the intervention [76][68]. One study examined the effects on satisfaction with social support and social desirability behavior; no differences were found after the interventions [82][75]. Another study examined to what extent the psychosocial problems interfere with friendship, with home life, and with leisure activities from the perception of students and their teachers. A positive effect was observed when the scores of the students were analyzed, while no effects were found for the scores of the teachers [83][70].

2.5. Coping and Regulation Processes

Three studies focused on the effects of the drama therapy interventions on coping and regulation processes [76,78,82][68][75][76]. This category consisted of coping skills, cognitive distortions, self-control and regulation processes. The studies involved 102 children in the age of 10–19 years. Two of the studies had a pre- and post-test design [76,82][68][75], and one study had a CCT design [78][76]. Two studies examined the effects on self-control. The results of one study showed a positive effect on self-control rated by the adolescents and their by mentors [78][76]. However, results of the other study did not show any effects on self-control rated by students and by their parents [76][68]. One study examined dealing with anger, assertiveness, distrust, and coping skills (problem solving, palliative coping, social support, reassuring thought, stress, and poor coping) rated by the juvenile and rated by the mentors. These results showed a positive effect on dealing with anger, assertiveness, and on coping skills (problem solving, palliative coping, social support, reassuring thought, stress, and poor coping). The same study examined the effect on cognitive distortions (aggression, justification, physical aggression, oppositional behavior, sub assertive behavior, and negative attitude) and found a decrease in cognitive distortion, but did not find an effect on negative attitude [78][76]. In addition, an increase in motivation for treatment was found. One study examined the effects on the attribution style in good and bad situations, but no effect was found [82][75].

2.6. Social Identity

Three studies focused on the effects of drama therapy interventions on social identity [80,82,83][70][75][77]. This consisted of attitude change and self-esteem. The studies involved 12 children in the age of 7–8 years [80][77] and 128 adolescents in the age of 12–18 [82,83][70][75]. Two of the studies had a RCT design [80[70][77],83], and one had a pre- and post-test design [82][75]. One study examined the effect on attitude change. The results showed a positive effect on the way the children evaluate themselves and other children. Furthermore, the results showed a positive effect on the amount of potency the children saw for themselves, other children and adults. There was no effect on attitude change regarding activity, sharing, imagination, and feelings [80][77]. In the study examining the effect on self-esteem, no effect was found [82,83][70][75].

2.7. Cognitive Development

Four studies focused on the effects of drama therapy intervention on cognitive development [78,80,81,83][70][74][76][77]. This category consisted of a subset of cognitive functions and abilities: language skills, academic performance, attention deficit and cognitive structure. The studies involved 12 children in the age of 7–8 [80][77] and 229 adolescents in the age of 9–19 years [78,81,83][70][74][76]. Three of the studies had a RCT design [80[70][74][77],81,83], and the other study had a CCT design [78][76]. Two studies examined the effect on academic performance in mathematics and one study on reading and spelling. The results in one study showed a positive effect on mathematics [83][70], and the results of the other study did not show effects on mathematics, reading or spelling [81][74]. Two studies examined the effect on language development in terms of oral expression [80[70][77],83], and results showed an increase in oral expression. One study examined the effect on attention deficit as a neuropsychological outcome. The results showed a decrease in attention deficit [78][76]. One study examined the effect on the perception of the extent to which the impairment interfered with classroom learning. The results rated by the students and by the teachers did not show an effect on the perception of the extent to which the impairment interfered with classroom learning [83][70].

3. Outcome Drama Therapy Characteristics

3.1. Drama Therapeutic Means

The drama therapy means are the forms and techniques of drama therapy that were applied during the drama therapy sessions. Two studies mentioned dramatic reality [76][68] as a means where children and adolescents create a fictional reality based on their imagination [76][68] or based on personal stories [84][71] and dramatic reality as a projective technique where the children and adolescents project inner feelings on dramatic representations [84][71]. Three studies applied projection as a means in different forms such as dramatic projection [75][73], projective techniques [79][69], symbolic play as a projective technique [82][75] where the children and adolescents project unconscious inner feelings at a safe distance [76,82][68][75] and verbalize how they felt [79][69]. Role playing was also mentioned as a projective technique in one study [76][68]. This is where the children had the opportunity to empathize with the role and project their ideas about how their feelings. Storytelling [76][68], symbolic play [83][70] and pairs techniques [83][70] were also mentioned as a reflective technique where the adolescents reflect on their points of view and feelings [83][70]. Storytelling was also mentioned in three other studies. One study used storytelling as a technique to create a symbolic and safe distance from reality [82][75]. Another study mentioned storytelling as a means that was used to share strong emotions and subsequent relief [83][70]. One study used storytelling focusing on group play and social interaction. In this study, movement, voice, role play, and pantomime were used focusing on group play and social interaction [75][73]. Four studies [79,80,83,84][69][70][71][77] used acting out personal stories as a means to transform these stories into alternative scenarios developed by group members [83][70] or to express feelings [80,84][71][77]. Three studies mentioned improvisation [79,80,82][69][75][77] as a means where the children and adolescents adopt new roles, and explore spontaneity [79][69], express and play out feelings [80][77], and can play a variety of roles attuned to their needs and requests [82][75]. One study used role-playing games to practice perspective-taking exercises [78][76]. One study mentioned theatrical exercises as a means to transform the experience of adversity [84][71]. Playing a role was mentioned by one study as a means to express the inner characteristics of the role in a way that can be understood by others [80][77].

3.2. Drama Therapeutic Attitude

Three studies reported the therapeutic attitude [76,79,82][68][69][75]. All of them described an adaptive approach where the drama therapists created opportunities to cooperate, build cohesion, share feelings and where the children and adolescents are accepted as being of unconditional worth. One of the studies mentioned specifically that the adaptive approach was based on the view of Carls Rogers [82][75].

3.3. Supposed Mechanisms of Change

WResearchers categorized the mechanisms of change into two categories: specific drama therapeutic mechanisms of change and general mechanisms of change. Nine categories were identified reflecting specific mechanisms of change which contribute to the effectiveness of the drama therapy intervention. The first category was related to the process where expression is stimulated in drama therapy. The second category concerned the process of sharing. The third category was the process that allows participants to gain experiences in the drama therapy. The fourth category concerned processes in the drama therapy where participants become aware. The fifth category was the process of reflection. The sixth category was the process of embodying. The seventh category was the process in which participants witness others in the drama therapy. The ninth category is the process in which participants are stimulated to be creative in the drama therapy [76,82][68][75] and are stimulated to use their imagination [76,79][68][69] 

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