Knowledge and attitude of mental health professionals towards psychodrama as a psychotherapeutic tool

Aim: To understand the attitude and knowledge of mental health professionals towards psychodrama. Materials and Methods: Knowledge and attitude towards psychodrama was studied during a basic psychodrama workshop for 30 mental health professionals, which included psychiatrists, residents of psychiatry, psychologists, social workers and mental health nurses. A specially designed 10 item questionnaire was used for a pre and post-test which evaluated on various aspects of psychodrama to know the attitude and knowledge towards this unique therapeutic tool. Participants were asked to rate their experience of the psychodrama session. Written informed consent was taken from all participants. Results and Discussion: Results showed that in all 10 questions there was a marked, positive change in the post test results. The 3 hours basic course made an impact on attitude and knowledge of psychodrama of all participants. The acceptance of the session, by the participants, delivered an average score of 7.8 on a 10 point scale. Conclusion: Mental health professionals must necessarily undergo workshops on psychodrama in order to bring about positive and impactful results in their clinical applications, which would go a long way in effective clinical therapies. Psychodrama with proper training can have a wide range of clinical applications in various psychiatric settings.


Introduction
Jacob Lewy Moreno in 1921 conceived and developed psychodrama. 1 Moreno believed that everyone has a moral responsibility in the healing, growth and evolution of another human being. From what we know from neuroscience, we are all connected and wired at every level of our existence for developing connections. Psychodrama employs guided dramatic action to examine problems or issues raised by an individual. 2 According to him, a role has three componentsthinking, feeling and action-each developing from a relational context. The concept of role is practical and aimed at helping people reflect and change their own beliefs about themselves, allowing them to describe their feelings and behaviors from more than just a few basic drives or mental mechanisms. 2 Psychodrama has three phaseswarm-up, enactment and sharing. The warm-up serves as an atmosphere in which the individual can begin to trust the director, the group and also the method. During the enactment, highlighted through expressions, gestures, stances and many other non-verbal variables, communication with others reinforces internal attitudes and feelings. Group members experience a shift in role boundaries by playing another role.
Sharing is a time for group catharsis and integration. 3 The protagonist presents a concrete problem, enactment of which helps to go into the deeper feelings related to a problem by several ways: enactment, mirroring, empty chair, role reversal, replay, doubling. 4 Psychodrama facilitates skills of introspection by finding ways of developing insight into interpersonal relationships, personal growth, and integration on cognitive, affective, and behavioral levels. 4 Time for warming up to the point of creativity is necessary in order to reach a level of emotional expression.
Psychodrama has been tried as an innovative way to improve the self-awareness of nurses, enhancing the type of reactions that they have to the various situations that they experience.
Individuals experiencing difficulty with relationships, social and emotional functioning, trauma or addiction might find psychodrama a helpful approach. 3 Psychodrama has also been found to be useful in palliative care practitioners, who often face serious communication challenges as a therapeutic intervention for helping an individual sort out emotions such as grief around patient loss. 5 Another disorder where psychodrama was used was in sleep disorders using puppets, which were more common in young children. This method could be adapted effectively by individual practitioners, enabling children to establish a good sleep pattern without the use of medications. 6 During the first phases of adolescent development, young people have little self-efficacy and resistance against substance use. The aim of the study conducted was to demonstrate the effectiveness of psychodrama by roleplaying scenarios on the self-efficacy of students in resisting substance use. Short-term outcomes of the class-based scenario training were observed to be effective in the development of students' self-efficacy to resist the temptations of substance use. 7 The authors wanted to look at the knowledge, attitude and experience of varied mental health professionals about a not so commonly used psychotherapeutic tool.

Aim
To understand the attitude and knowledge of mental health professionals towards psychodrama.

Materials and Methods
Prof. Dr. Jochen Becker Ebel, a German trainer and psychodrama practitioner, conducted a free three hours basic psychodrama workshop for 30 mental health professionals, which included 4 psychiatrists, 5 residents of psychiatry, 13 psychologists, 4 social workers and 4 mental health nursing to improve their awareness and knowledge about the subject on 6 th of February 2018 at Department of Psychiatry, Yenepoya Medical College, Mangalore, India.
A specially designed 10 item questionnaire prepared by the first five authors by consensus was circulated among all the participants. A pre and post test was conducted on various aspects of psychodrama to know the attitude and knowledge towards this unique therapeutic tool. Participants were asked to rate their experience of the psychodrama. Written informed consent was taken from all participants. The questionnaire included the following questions: 1. What do you understand by psychodrama? 2. Who is the founder of psychodrama? 3. What are the phases of psychodrama? 4. List the most common techniques used in psychodrama. 5. What do you understand by the 'protagonist'? 6. What is meant by mirroring? 7. Purpose of psychodrama? 8. What are the goals of warm-up phase? 9. What is soliloquy? 10. What are the applications of psychodrama?
Each correct response was given one mark and half mark for a partially correct answer. It was evaluated by three authors and average of the three scores was taken as the final mark. An extra question was added in the post test to rate the whole experience of the session on a 10-point scale (higher the better) in order to gain a better perspective on the acceptance of this therapy by the mental health professionals.

Results
The age of the participants varied from 25 years-40 years, and the years of previous years of experience in psychiatry ranged from 1-10 years. However results showed that for all 10 questions there was a marked improvement in the post test results. The maximum score possible was 20. The mean average pre-test score was 11.75. The mean average post test score was 18.3. A 63.3 % increase in scores over pre-test suggesting that even after having varied ranges of previous years of experience in psychiatry, knowledge about psychodrama was limited and inadequate thus making the post-test acceptability more welcoming.
The two questions that showed maximum difference in the pre and post test results were. 1. The phases of psychodrama 2. What is Soliloquy These were the areas of poor understanding for the group. These topics were specific to psychodrama. Whereas the two questions that showed the least difference in the pre and post test results were 1. What is mirroring 2. What are the applications of psychodrama The group members had a better understanding of these areas probably as everyone had some psychology background, but needed a thorough informative session to know the topic in detail.
Rating for the experience of the session had a mean average of 7.8 on a 10 point scale.

Discussion
After the 3 hours session it was observed that most of the answers in the post test were more accurate and there was a significant improvement from the results obtained in the pretest. Also the rating for the experience of the session had a mean average of 7.8 on a 10 point scale which shows good acceptability.
Strengths of the study were that it looked at knowledge and attitude of mental health professionals towards an uncommon psychotherapeutic technique in Indian context. A trained professional was the resource person, immediate assessment, and involvement varied mental health professionals.
Limitations were small sample size and assessment done after a basic course without clinical experience.
In Sri Guru Ram Das Institute of Medical Sciences and Research Amritsar, Punjab, India, a study was done to enhance the learning of clinical respiratory physiology by role-playing technique used in psychodrama. It concluded that role-play lectures were an effective, economical, and easily reproducible method to help students understand the core concepts and features involved in different neurological diseases. The most important advantage of role play is that if such experience in a real setting is not possible, then a mock situation can be created, which may not be ideal but will at least be satisfactory for experimental learning. If students can talk about or act what they are learning, then they can relate to it and apply it in their daily lives. The visual impact and active participation helped students to better understand the concepts. 8 Another study assessed the impact of a course on communication skills for third-year undergraduate dental students at a dental institute in India. This study showed that simply attending to patients during a clinical course did not improve professional communication skills. In contrast, the implementation of a course on communication skills did improve the students' dentist-patient interactions. Integrating the teaching and development of a relevant, outcome-based course on communication skills provided clear evidence of communication skills acquisition among these dental students. The course could be introduced in other Indian dental schools. 9 In India, due to lack of manpower and training psychodrama is not adequately used and practiced. Also due to unawareness of techniques of dramatization of one's own conflicts, it becomes slightly cumbersome to explain and to execute the same in therapy. Jochen Becker -Ebel has been training lot of professionals in psychodrama in India. 10 A meta-analysis conducted on the basis of 25 experimentally designed studies showed an overall effect size that points to a large size improvement effect similar to or better than that commonly reported for group psychotherapy in general. The techniques of role reversal and doubling emerged as the most effective interventions. Addressing the individual psychodramatic techniques as a way of demonstrating the merit of the entire therapeutic procedure is a novel approach. It means that each component (technique) of the process plays an important role by itself. The implication for clinical practice is that separate psychodramatic techniques can be adopted and incorporated into various forms of group psychotherapy. Role reversal, doubling, and role-playing enactment, singularly or together, could add to the psychotherapeutic endeavor of many forms of group treatment. 11 There is a wide variety of measurement techniques to measure the effectiveness of psychodrama, mostly used is The Brief Symptom Inventory (BSI), in different languages. In psychotherapeutic practice, most patients have mixed disorders and not just one. That is why it is important to report results and measure the effectiveness of psychodrama psychotherapy, which would allow us to compare studies with each other and also with other psychotherapeutic methods. 12 Psychodrama, as a form of group psychotherapy, has shown the potential for bringing about positive change in participants for almost 80 years. 13 Advantages are that psychodramatic approach can be readily integrated with many other approaches to psychotherapy. It can be used with a variety of clinical populations and foci. These include adults, children, adolescents, the elderly, couples, families, therapy groups, business groups, community groups, mental health, addiction, mental retardation, other disabilities, delinquency, criminal justice, organizational development, trauma, etc. It can serve as a one-session or brief intervention in understanding themselves and also to explore the perspective of others. 14 Also under skilled direction, some emotional difficulties can be resolved and alternate behavior patterns can be learned. 3 Psychodrama role-playing teaches empathy skills par excellence. It is also seen as a powerful and effective mode of communication.
With a number of advantages, few limitations also have been identified. Directing a psychodrama requires a number of interrelated and complex sets of skills and excessive training and also development of personal qualities are required like high intuition and charisma. 11 Since psychodrama places heavy emphasis on trust and safety, counselors generally need to prescreen and prepare group members for the psychodrama process, thus ensuring group members being open to working on sensitive issues. Selecting individuals who would be a good fit in a group together may become a time-consuming process. Confidentiality can also be a concern in psychodrama. Also only those who can enact and use their dramatization skills maybe benefitted from this therapy. 14

Conclusion
Mental health professionals must necessarily indulge into psychodrama workshops in order to bring about positive and impactful results in their clinical applications, which would go a long way in effective clinical therapies. Psychodrama with proper training can have a wide range of clinical applications in various psychiatric setting. Hence conducting awareness programs as well as training programs about psychodrama by trained professionals for its proper utilization as psychotherapy is needed to widen range of therapeutic interventions.