Tele-psychodrama therapy during the COVID-19 pandemic: Participants' experiences.

Italy was severely hit by the COVID-19 pandemic. In early March 2020, a series of legislative decrees have been issued, establishing the restrictions that all Italian citizens are required to respect, according to which it is strictly forbidden to leave the house if not for reasons of necessity, health, or work. This qualitative study investigated which aspects clients find helpful or hindering in shifting to group tele-psychodrama due to the COVID-19 pandemic, after participation in an in-person psychodrama group. Participants were 15 adults who were members of a pre-existing in-person psychodrama group that shifted to a tele-psychodrama group format facilitated by two psychodrama therapists. The Client Change Interview was used at the end of the tele-psychodrama as a post-treatment assessment. All the interviews were transcribed and then underwent a thematic analysis. The analysis yielded six shared themes: the role of tele-psychodrama sessions during COVID-19 pandemic; perceived effectiveness of tele-psychodrama; main advantages of tele-psychodrama; limitations encountered during the online intervention; the termination of tele-psychodrama; and the relationship with the therapist. The findings provide preliminary evidence for the clinical practice of tele-psychodrama and lays the groundwork for further studies that can contribute to the use of electronic platforms in psychodrama interventions.

Introduction

Pandemics are characterized by a widespread state of uncertainty, confusion and emergency (World Health Organization [WHO], 2005). In response to COVID-19, multiple countries have enforced safety measures adapted to the local context and the epidemiology of the disease in order to limit community spread of the virus (WHO, 2020). As of March 2021, there were 116.1 million COVID-19 cases and over 2.5 million deaths (WHO, 2021) worldwide. Europe has seen a further escalation in the incidence of new cases and the associated mortality rate (WHO, 2021). Given the widespread of COVID-19, its burden on mental health is expected to be higher than past epidemics. In Italy, the first European country that had to face the pandemic severely, high rates of insomnia, depression, anxiety and post-traumatic stress symptoms in general population have been documented. These outcomes on mental health were associated with risks factors (being under quarantine, having a loved one deceased by COVID-19, working activity discontinued or experiencing other stressful events) related to COVID-19 (Rossi et al., 2020).Within this framework, public health measures – including personal protection, physical distancing, and restrictions on movement – have led to substantial changes in the provision of mental health care. Attempts to prevent the spread of the infection through social distancing have led to a rapid rise in the use of tele-psychotherapy (McBeath et al., 2020). COVID-19 has created an extraordinary and unforeseen situation for mental health professionals worldwide who had to deliver psychotherapy via telephone or internet, a practice that was relatively infrequent prior to the COVID-19 outbreak (Humer et al., 2020). Myths about tele-psychotherapy, such as difficulties in developing a therapeutic alliance or making the right diagnosis at a distance, are among the greatest obstacles identified by mental health professionals (Connolly et al., 2020). However, previous studies on the effectiveness of tele-psychotherapy have reported encouraging results with similar outcomes when delivering psychotherapy remotely as compared to face-to-face psychotherapy (Andersson, 2016; Berryhill et al., 2019; Hilty et al., 2013). Clients’ positive attitude toward tele-psychotherapy have also been well-documented (Connolly et al., 2020; Humer et al., 2020). Overall, tele-psychotherapy may thus be one of the new and timely frontiers in the field of psychotherapy research. Although most studies in psychotherapy have focused on treatment outcomes, in the last two decades scholars have shown growing interest in psychotherapy change processes (Orkibi, Azoulay, Regev et al., 2017; Orkibi, Azoulay, Snir et al., 2017). Change process research focuses on identifying, describing, and predicting the effects of the processes that bring about therapeutic change over the course of therapy (Elliott, 2010; Greenberg, 1986). This qualitative study investigated which aspects clients find helpful or hindering in shifting to group tele-psychodrama due to the COVID-19 pandemic, after participation in in-person psychodrama group.

Introduced by Jacob Levi Moreno in the early 1920s, psychodrama is an action method of psychotherapy typically conducted in a group format where guided role-play is used to gain insights and work on personal and interpersonal problems and possible solutions through the elicitation of spontaneity and its resultant creativity (Moreno, 1946). Moreno’s psychodrama theory and practice have been associated with positive psychology, particularly in five core concepts: spontaneity and creativity for adaptation; positive relationships; mutual responsibility; expansion of roles repertoire and character strengths; and act hunger for deep engagement (Orkibi, 2019). More generally, both psychodrama and positive psychology aim to promote flourishing in both the individual and social levels as well as optimal functioning (Peterson & Park, 2003; Orkibi, 2019; Seligman et al., 2005). Fundamental empirical findings of positive psychology resonate in the psychodrama literature, in particular such concepts as well-being, optimism, self-esteem, gratitude and spirituality (Manzaree et al., 2014; Miller, 2007; Tomasulo, 2019). Psychodrama with adults has been used with a range of issues (Orkibi & Feniger-Schaal, 2019) including in the treatment of anxiety, depression, post-traumatic stress (Ron, 2018), the stress related to HIV/AIDS (Karabilgin et al., 2012), addiction (Somov, 2008; Testoni, Cecchini et al., 2018), for managing fear of death and its representations (Testoni, Ronconi et al., 2018; Testoni, Biancalani et al., 2019). Given the mortality associated with the COVID-19 virus, psychodrama may also help to manage the fear that could come from this deadly disease, thus improving personal well-being (Testoni, Cichellero et al., 2019). As mentioned, the lockdowns because of the pandemic provided an opportunity to investigate which aspects clients find helpful or hindering in shifting to tele-psychodrama group, after their participation in in-person psychodrama group. Given the dearth of literature on the effectiveness of tele-psychodrama, the study contributes preliminary data on client perceptions of change after tele-psychodrama interventions in time of global crisis.

Method

Participants and procedure

The participants were members of two ongoing in-person psychodrama therapy groups in Northern Italy directed by two trained psychodramatists. Of the 8 participants involved in the first group, 6 agreed to be interviewed at the end of the online psychodrama. The second group was comprised of 10 participants of whom 9 agreed to be interviewed. A total of 15 participants took part in the study (10 women and 5 men) whose mean age was 40.73 years (SD = 11.07). Overall, they had engaged in psychodrama group therapy on average for 19.87 months (SD = 15.36), as shown in Table 1 . Two respondents had previously participated in a psychodrama group over a period of two years with the same psychodramatist. The participants had engaged in therapy for a range of problems such as anxiety, depression and panic disorders.

Table 1

Description of participants.

	Pseudonyms	Age	Months of participation in this group	Previous participation in other groups
Group 1
	Elisa	37	2	No
	David	26	12	No
	Kevin	27	6	No
	Miriam	28	2	No
	Francesco	30	45	No
	Jasmine	35	45	No
Group 2
	Patrizia	42	7	No
	Fabrizio	38	19	No
	Amelia	55	5	Yes
	Nancy	45	6	No
	Roberto	54	26	No
	Gabriella	42	34	No
	Olivia	58	30	No
	Stefania	57	34	No
	Beatrice	37	25	Yes

The participants had started their in-person psychodrama therapy at different times. However, because of the pandemic, on March 2020 the weekly psychodrama sessions of the two in-person groups moved online and were conducted until May 2020 via Zoom, an online videoconferencing platform. A total of 12 online sessions were conducted, then the participants switched back to in-person psychodrama therapy at end of the lockdown period in Italy at the end of May. Given the sudden restraints due to the COVID-19 pandemic that prevented in-person therapy delivery, clients were invited by the psychodrama therapists to proceed with the sessions online. All willingly joined as this opportunity represented a way for them to continue with psychotherapy and to find support during a difficult time when they were forced to stay at home.

After the tele-psychodrama ended, the psychodrama therapists (who are colleagues of the principal investigator) informed the clients of the opportunity to participate in the study and be interviewed by two researchers. Prior to the interview, the researcher explained objectives of the research, clarified that participation was voluntary and confidential, and that they could withdraw at any time without any consequences. All interviewees signed an informed consent form via email. All the names mentioned below are pseudonyms. This study was approved by the Ethics Committee for Experimentation of the University of xxx (n. BC87D0713FC80E7F9A788 3D210F888DC).

The tele-psychodrama

The general structure of the sessions consisted of the three classical phases in psychodrama: warm-up, action, and sharing (Kellermann, 1987). The warming-up aims to focus the participants in the present of the session and to inspirit their spontaneity and creativity. In this phase brief “check in” often involved each group member recounting important events experienced since the last session (Nolte, 2019). During the action phase two types of activity were conducted: either the protagonist activity during which a participant took the role of protagonist and enacted a significant experience of his or her own, or a group activity in which each participant was given equal time to address a particular relevant issue. Finally, during the sharing phase each of the members of the group could share how they emotionally related to the activity that was carried out during the session.

The main specific psychodrama techniques used were role reversal, doubling, and soliloquy (Cruz et al., 2018). Role reversal refers to the protagonist stepping out of his/her role and enacting the role of a significant person in their life or part of his/her self. Doubling refers to other group member or the therapist voicing aloud in the first person the unspoken voice of the protagonist. Soliloquy refers to the protagonist verbally expressing his/her thoughts and emotions about something.

Based on the psychodrama therapists’ expertise in clinical practice, these psychodrama techniques were adapted to the online modality: role reversal and doubling was done with only the protagonist’s and his alter ego/double’s cameras open in the scene; soliloquy was done with only the protagonist’s camera open in the scene. First, using Google Slides, a virtual theater was used to recreate the actual stage by inserting into the slide background a picture of a real psychodrama theater (i.e., room), where the participants were used to doing their in-person psychodrama sessions. To simulate the movements that the participants would have made during an in-person psychodrama session, the photographs of each of the participants were placed on this theater background and were moved dynamically according to their positions during the tele-psychodramatic activities. The sessions included activities using the camera (with all the participants together or only those who were on the stage at that time), and activities in which movement on the virtual theater was also added to the video call. The role reversal technique was done by only leaving on the cameras of the two people involved. Breakout rooms for pairs were created in which one person told the other a significant event, which was then shared by the other person after returning to the main room in front of the whole group by using the doubling technique. Significant objects or photographs that group members had at home were used to talk about significant events related to them. Other activities were adapted to the online context such as drawings made by the participants which were then displayed on the screen, and shared and commented on by the whole group. A sharing phase took place at the end of the activities to conclude the online group.

Data collection and analysis

Data were collected in June and July, 2020.

The Client Change Interview (CCI) protocol (Elliott, 2010) was used at the end of the study as a post-treatment assessment. The CCI is a semi-structured interview designed to investigate what changes took place and what caused them. The interview focused on the following: reflections and thoughts about the overall experience, what clients found helpful, useful, or important, or, how they have changed over the course of therapy to date, and future suggestions. Each interview was conducted individually via Zoom, lasted approximately 40 min, was audio-recorded and subsequently transcribed verbatim. After the data analysis by the first author the texts were very careful translated into English in order to maintain the linguistic style the participants had used in the original Italian language. The CCI texts were processed through Atlas.ti, a qualitative data analysis software (Muhr, 1991). The qualitative interview data were analyzed by thematic analysis, which followed the six phases outlined by Braun and Clarke (2006): preparatory organization, generation of categories or themes, coding data, testing emerging understanding, searching for alternative explanations, and writing up the report. The textual analysis proceeded in a “bottom-up” manner, wherein categories only became clear as the analysis unfolded. Shared and recurrent themes found in the participants’ interviews were grouped together to form broader distinct categories. The analysis of texts was conducted as follows: the authors of the research first analyzed the texts individually; then, they considered the main different interpretations and decided on the final structure of the report.

Results

From the data analysis, six areas of thematic prevalence emerged: the role of tele-psychodrama sessions during COVID-19 pandemic; perceived effectiveness of tele-psychodrama; main advantages of tele-psychodrama; limitations encountered during the online intervention; the termination of tele-psychodrama; and the relationship with the therapist.

Theme 1: The role of tele-psychodrama sessions during COVID-19 pandemic

In this theme, the participants’ reflections about overall experience of tele-psychodrama are indicated. All the participants described the tele-psychodrama as a useful way to ensure continuity and to preserve a feeling of belonging to the group, especially in emergency situations. Amelia, a 55-year old who had been part of the group for 5 months, said:

You had this feeling of having a continuation, even if it was partial, even if it was online, even if there was no physical contact, it was still a continuity, I felt part of the group, I felt I could say anything and that every time I could work in the session.

Similarly, Olivia, a 58-year-old who had been part of the group for 30 months, explained: “For me it was important to have participated in this online psychodrama because it was a way to maintain the relationship and the contacts, I had established… if it had not been for online psychodrama, the relationships would have ended.” These comments underscore the importance of the online group, which took on the role of a fixed point of reference in a general state of confusion and uncertainty because of the spread of the COVID-19 virus. Elisa, a 37-year-old who had been part of the group for 2 months, mentioned the importance of having maintained the psychodrama schedule in the online modality: “We kept our usual appointment on the same day, it was a nice appointment, mentally it was pleasant.” Similarly, Kevin, a 27-year-old who had been part of the group for 6 months, stated:

What scared me was the thought that I would not have the frequency and continuity of the group, but it did continue and having this set time during the week that broke up the routine helped a lot, even being able to compare with how the others felt, seeing that the psychological problems related to the lockdown were similar for all of us, it helped me avoid feeling so alone since in fact I was isolated because of the quarantine and certainly this was the greatest help.

All the participants contributed to the tele-psychodrama group. This creative experience was described by Gabriella, a 42-year-old who had been part of the group for 34 months, through an image:

We were a team as though each of us were a wonderful color, but that color alone was not so bright or magical, but putting these colors together turned into a rainbow that propagated the light and fused the colors together.

This experience represented the consolidation of pre-existing relationships with the members of the group. Gabriella said:

It was however a confirmation of a path that I had personally decided to engage in and that I have been working on for several years. It gave me the opportunity to see that even in another modality with a different relationship, the profoundness, proximity and affection of the people - that I have for them and that they have for me - is the same, it was the same so it's not that we are influenced by the original environment of psychodrama and by the professionalism of the therapist, but it is precisely a union of souls who see themselves in their deepest and most intimate being and this possibility of seeing each other even on screen certainly consolidated this.

All the participants described the online group as a space in which participants could express their fears and concerns freely. Beatrice, a 37-year-old who had been part of the group for 25 months emphasized the importance of sharing one’s feelings at the present time:

Psychologically it was like a life line to cling to. … the fact of sharing the problems that this emergency has created was very important, I would say a beacon in the fog for both the therapist as a reassuring figure and for the group as figures who legitimate emotions, so you do not feel you are the only one to experience them.

Similarly, Nancy, a 45-year-old who had been part of the group for 6 months said: “It helped me when it seemed to me that I could not gather up enough courage; it was like saying we are all in the same boat”.

Theme 2: Perceived effectiveness of tele-psychodrama

In this theme, the focus is on the perceived effectiveness of tele-psychodrama and how participants have changed over the course of therapy.

One issue that emerged from all interviews was the experience of change after the online intervention, although there were some differences across the participants. Most participants reported somewhat less change and lower perceived effectiveness in tele-psychodrama than in traditional in-person psychodrama. David, a 26-year-old who had been part of the group for 12 months, described his experience with the online sessions: “The online psychodrama supported me, but compared to in-person psychodrama it was certainly less incisive for me”. A similar position was taken by Fabrizio, a 38-year-old who had been part of the group for 19 months, who reported how this experience did not lead to new acquisitions: “Since the beginning of March, it feels like I’ve been stuck… I felt more when we did the in-person sessions”. In some cases, the perceived experience of being stuck was associated with the desire of giving much more space to those in the group who appeared to be in greater difficulty. Roberto, a 54-year-old who had been part of the group for 26 months explained his lesser involvement during the online sessions as follows:

There was another [member of the group] who was living the situation at home badly. In that case, I did not feel the need to put myself in the center when objectively there were people from my point of view who needed it more.

In contrast, some participants described the online group as an opportunity to pursue a change that had already begun in the in-person psychodrama group. Beatrice defined her path as follows:

I feel that psychodrama has given me a great starting point to achieve a change, but I feel like I’m on the road, so I do not feel that I completely changed, but I feel that important components have been added to the dough, but the bread is not ready yet. A culinary image; that is to say, it is not cooked, it is not finished, it has not fully changed, I have not achieved it, however, important components have been added to the dough thanks to online psychodrama.

Amelia’s experience was similar:

I feel changed because I have released a lot of energy so I feel much more energetic, I feel strong, I feel I can assert my thoughts, that I am not a fragile but a strong person. I see it in my attitude toward other people, at work and in all areas of my life. I feel more energetic, I feel more decisive, I feel strong, I feel good. I feel like myself.

Another meaningful example was reported by Gabriella who explained her awareness today of having achieved a change through the enhancement of the positive aspects of herself and of life:

“I would also like to be surer of my positive sides, to see them a little more instead of always focusing on the negative ones that certainly exist, there will always be some, but I would also like to see the positive sides of myself with the same focus as I see the negative ones”.

At the same time, the experience of tele-psychodrama allowed participants to be more aware of the benefits of psychodrama. Beatrice described the role of psychodrama in her life: “It gives me motivation to change, to absorb the blows of life, to re-elaborate things”. Amelia further explained psychodrama helped her “to experience myself, to think, to try, to sort things out, it makes me feel good and so when you feel well, you also feel good with the others”.

In general, both tele-psychodrama and traditional in-person psychodrama were seen by all the participants as useful means to encourage reflections on their life. Miriam, a 28-year-old who had been part of the group for 2 months affirmed:

Every time online I found the same positive elements of psychodrama, because every time you do activities you find food for thought, you think about your past, your present, your future. I think that when you focus even if it’s just for two hours no matter how, it is something that helps you.

Theme 3: Main advantages of tele-psychodrama

This theme reflects the most helpful and useful aspects of tele-psychodrama.

The use of Zoom for remote psychodrama sessions highlights some of the helpful characteristics of this treatment format. Beatrice talked about paying more attention to the image of herself displayed by the video camera and the fact that she had the opportunity to watch herself doing things from a completely different perspective compared to in-person psychodrama. She said: “In the case of online psychodrama you look at yourself… so certainly it was much more intense”. Another similar experience was noted by Fabrizio:

The possibility to see yourself on the video while you speak, while you pose, you may notice some of your expressions that are not exactly like what you imagined, similar to when you hear your recorded voice and you say ‘I'm not the one who is talking’, in the video it’s the same thing.

The main beneficial feature of the online format was universally identified as the opportunity to take part in the session from home, thus avoiding movement and optimizing their time. Patrizia, a 42-year-old who had been part of the group for 7 months, said: “The most convenient thing is obviously that you don't have to move because you are at home”. Similarly, Nancy highlighted how this modality was also beneficial with respect to family or work commitments: “I was fine at home especially in terms of time, in the sense that I can turn off the computer and I can go prepare dinner and there is no travel time in the car, no parking…” Beatrice highlighted the different advantages of tele-psychodrama: “For me, for example, it allowed me to contact distant people very easily, to access other situations I would not have been able to access”. Similarly, Fabrizio stated: “Maybe for those who have problems or disabilities or transportation problems it would be a good solution. For those who are far away and want to be part of a certain group, it would be a good opportunity”.

For some participants with personal difficulties not only in asking for help, but also in contacting professionals to get an appointment, the online modality can be an easier way to ask for psychological support, as Olivia said: “It's a tool that seems easier to access, that seems more affordable even less demanding… but only apparently.”

A similar position was taken by Jasmine, a 35-year-old who had been part of the group for 45 months. She explained that the online modality facilitated the sharing of her emotions: “I don't know why but behind the screen it is easier to open up even if we are close, sometimes in the group I am a little more inhibited and instead I found it much easier to open up”. Some participants hoped that some of the innovative aspects that emerged from the online modality would be maintained even after the COVID-19 emergency. Beatrice said:

I hope there will still be some professionals who will provide people with the opportunity to access to online psychodramas because I saw that they work, they are beautiful and it gives me the opportunity to participate where I could be never be physically present.

Beyond the desire not to limit this experience to the state of emergency, other participants hoped that the online format would not replace in-person psychodrama, as Patrizia stated: “Let's say that if there were still restrictions that force us to socially distance, I would still do it online, but it should not be a permanent solution”.

Theme 4: Limitations encountered during the online intervention

This theme addresses the hindering aspects of tele-psychodrama. Several limitations with respect to in-person psychodrama were identified by the participants. In terms of implementation, some psychodrama techniques were not perceived as very effective online, although there were conflicting views among the participants. Roberto said: “Personally I would have struggled with being the protagonist online because when it's in person it is easier to get involved seriously… but [online] I can get less involved because I can interpose many more filters.” Similarly, Nancy described having some difficulties in recognizing herself inside the online theatre during the psychodrama activities:

The least effective was having made a theater with the characters. I could not identify with the person who was in the theater. Although it was a very nice idea because she really wanted to recreate the same environment, bring our minds back to the place where we had a physical experience, I was unable to return to that place.

By contrast, Stefania described the same activity differently: “Even the fact of doing the theater, it made me want to go inside the theater. I just wanted to go back immediately”. Beatrice considered that the online format was further proof of the effectiveness of traditional psychodrama techniques:

The methodology worked; that is, I felt a role reversal even from a distance, even if not in a group, even though it took place in my room and with the others in their own rooms, it worked. An empty chair worked too. The method worked. Obviously, there is a different emotional impact because privacy is not maintained as well in the home as in psychodrama clinic, so you always have someone there, but the curious thing is that despite everything, it worked.

Another meaningful limitation of tele-psychodrama was the lack of typical features of in-person psychodrama. The absence of the possibility of physical contact was mentioned in almost all the interviews as limiting. Amelia indicated

the most difficult thing is that there is a great lack of contact. The hugging, the gaze, the music, even being able to move since online you are basically sitting, and I feel that at a certain point something becomes too tight.

In tele-psychodrama group, Fabrizio felt that expressions of spontaneity were inhibited: “We were all rigid in front of the camera. Perhaps it lacked a little spontaneity”. The perspective on others was hindered by the screen. Nancy said: “Being there physically is different when you do dramatization because you have a view of everything; that is, you can see a foot moving, you can understand the complete physical language, you do not just have a face”. On the other hand, Nancy stressed that, for her, the need for physicality was not a fundamental component in the effectiveness of psychodrama: “Everyone talks about the lack of physical contact, but I do not miss the physical contact, not a bit′ and continued by arguing that: ′I found myself better working in a group from a distance”.

A crucial limitation was the reduced ability to feel the human warmth of the other participants in the group. This was addressed by Roberto: “All of us are looking at a screen so you do not have the warmth, you do not have the presence”. Similarly, Jasmine said:

One thing that unfortunately cannot be improved is that I missed the physical contact, when you feel weak not having the therapist who takes your hand, who puts her hand on your shoulder, your group that looks at you. In moments that touch you deeply, it is a severe lack, you feel a bit lonely even though you are in the group, but you still feel alone. Human warmth is something that unfortunately cannot be dealt with online.

Because of the social distancing measures, tele-psychodrama was conducted in private environments such as the participants’ homes. The environmental drawbacks mentioned in the interviews were mainly related to the lack of a separate space that preserved their privacy. Most participants reported that the lack of a safe place was often linked to a lesser ability to express themselves freely. Elisa said: “Not having a completely protected and free space means you lose the freedom that exists in the theater”. A similar position was taken by Fabrizio:

I did not feel the same level of participation or the same possibility to express myself because in any case other people could possibly hear me and therefore from that point of view, I noticed that during the months we did online psychodrama I did not experience the same effects and benefits of doing it in the usual environment.

The lack of privacy reported by the participants pertained to family members at home. By contrast, the possibility that the other members of the group would enter into their daily lives was not experienced as a problem. Beatrice said:

It was nice to peek into the homes of the others, and I also felt that the others could peek a little into mine. It was a sweet invasion of privacy. Here it is protected in the group, so it is very nice to see the nooks and crannies of the houses, it is like discovering something more about a person.

In other cases, some participants found an appropriate place to carry out the online sessions effortlessly. Olivia said: “Luckily I live in a big house, I have space, so I also have the opportunity to retreat into a corner to do what I need to do, so I did not feel constrained in this sense”.

One key feature that emerged concerned the setting, as Beatrice noted: “Usually the setting is not managed by the client, but in the online situation you have to choose an appropriate setting”.

Beyond the environmental disadvantages, technological and network connection difficulties played an important role in the implementation of online interventions. Olivia described how a low-quality internet connection affected the establishment of the therapeutic atmosphere:

In psychodrama when you get into the part you enter in a particular atmosphere and if you lose some words or the [internet] connection, this means you lose the thread for a moment. This does not happen in an in-person group setting so you have more difficulty tuning in, that is, entering the remote situation and it is more difficult to maintain it.

The availability of other devices during the online sessions, such as a telephone, created additional sources of distraction. Roberto explained: “You have a lot of distractions. You can use the phone whereas in person, you can't”. The other limitations identified by the participants concerned the time allocated during the online sessions. On the one hand, for some participants they had less time with respect to their personal needs. For example, Amelia said: “It takes more time when you are online, I said several times that at a certain point it was too tight but because it was only a temporary thing and we all wanted to go back to the studio [in-person]”. On the other hand, being in front of the screen for too many hours was extremely exhausting, thus highlighting the need to possibly recalibrate the intervention with respect to the traditional in-person group, as David stated: “In my opinion two hours was too long, but I understand that when there are a lot of us, time passes: we cannot do everything, probably the group was too big”.

Theme 5: The termination of tele-psychodrama

This theme reflects the participants’ thoughts about the termination of the tele-psychodrama and the return to in-person sessions.

The termination of the tele-psychodrama took place when the lockdown had temporarily ended in Italy. All the participants noted that the termination of the tele-psychodrama was smooth, probably because it was not the real end of treatment since the group returned to in-person sessions. Amelia said: “There was no difficulty terminating the online sessions”. For some participants, the return to in-person psychodrama was described as a relief, as Beatrice said:

I was relieved that we could see each again because the last period in particular there was a bit of fatigue from being online. I believe that if we were used to doing psychodrama online, it would not have been so exhausting…. If I decided to do psychodrama with people all over the world, I would not have experienced it as so fatiguing because I would have chosen to do it.

Fabrizio explained: “For me it was positive because I went back to an environment that had its own privacy and I could see the others again even though we needed to take the proper precautions”.

By contrast, for other participants, the end of the online sessions and the return to physical interaction was not as effective because the social distancing measures to prevent the spread of the virus hindered free and spontaneous expression of emotions. Kevin described his difficulties returning to in-person psychodrama: “I have always seen that room as a place where you are free to do anything and the fact that there are restrictions created a little discomfort”. Roberto pointed out that both in-person and tele-psychodrama are currently not completely effective: “Because of the limitations that exist today, both have unfortunately lost their effectiveness in the sense that they have become incomplete”.

Theme 6: The relationship with the therapist

In this theme, the participants’ opinion about the importance of the relationship with the therapist for the success of the online sessions are indicated.

At the beginning of the online groups all the participants expressed various concerns when the therapist suggested continuing the psychodrama remotely. Jasmine recalled: “At first I did not expect the online group to work well, I expected something a bit airy-fairy”. Trust in the therapist’s skills, however, was crucial to facilitating participation in the online group, as Beatrice said: “When the therapist asked me to participate, I threw myself into it because I support her, but I really thought she was out of her mind, what could we do; instead it was a complete surprise”. With respect to the activities carried out, all the participants recognized the therapists' ability to adequately manage the emergency. Gabriella stated: “It was conducted with the same professionalism and it had the same intensity that the psychodrama therapist expresses to us in-person. This was important for the encounters, otherwise they would just have become video calls.”

A summary of the helpful and hindering factors is presented in Table 2 .

Table 2

Helpful and hindering factors in tele-psychodrama therapy.

Helpful factors	Hindering factors
Maintaining continuity of treatment	Absence of physical contact
Universality of feelings shared by others in the group enhanced cohesiveness	Difficulty in expressing and perceiving emotions online
Taking part in the session from home without the hassle of transportation to the clinic	Less ability to feel the human warmth
Having the opportunity to watch oneself doing activities in front of the video camera	Lack of adequate physical space to participate from home comfortably
Mitigation of the sense of social isolation due to social distancing and lockdowns	Lack of sufficient privacy
Trust in therapist’s skills	Technological and network connection problems
	Too many sources of distraction

Discussion

This qualitative study was designed to better understand which features clients find helpful or hindering in tele-psychodrama during COVID-19. From the interviews of 15 participants, the analysis yielded six shared themes: the role of tele-psychodrama sessions during COVID-19 pandemic; perceived effectiveness of tele-psychodrama; main advantages of tele-psychodrama; limitations encountered during the online intervention; the termination of tele-psychodrama; and the relationship with the therapist.

All the interviews highlighted some fundamental psychotherapeutic factors that were preserved in the online group. The feeling of being accepted and belonging to a group underscored the importance of the dimension of group cohesiveness. This is important in psychodrama where the clients express their ideas, feeling and behavior freely, and thus boost a greater sense of integration in the group (Blatner, 2000). In this context, tele-psychodrama affirms its value in strengthening mutual interpersonal relationships. Because of the COVID-19 pandemic, the lockdown, and the need for social distancing, some participants experienced feelings of alienation and believed they alone were suffering. Sharing their concerns and feelings within the group reinforced the group component of the universality of the effects of the pandemic (Blatner, 2000; Yalom & Leszcz, 2005). Tele-psychodrama activities helped participants to better manage the fear of infection and mortality from COVID-19: as indicated in the literature, there is evidence that psychodrama has proven to be very helpful in managing the fear of life-threatening diseases (Testoni, Ronconi et al., 2018; Testoni, Biancalani et al., 2019). As to psychodrama techniques, the online sessions showed the need to adapt classical techniques like doubling, role reversal, soliloquy to the online modality- as in the case of this study, asking participants to turn the camera on and off. Some participants perceived psychodrama techniques less effective online than in-person sessions. One might speculate that this difference may relate to the fact that participants were members of a pre-existing psychodrama group that only after the spread of COVID-19 shifted to a tele-psychodrama group format.

More precisely, the participants disagreed as to the change processes that took place during tele-psychodrama intervention compared to the in-person sessions. Overall, a substantial preference emerged for in-person psychodrama over tele-psychodrama. Some participants indicated that this kind of intervention did not produce either substantial changes or only a small improvement. At the same time, the need to reach a personal change was considered less important than giving space to other members of the group who appeared to be in greater difficulty. These results are consistent with the construct of altruism in group psychotherapy, where people are encouraged to go beyond their tendency to be self-centered, and consider the needs and feelings of others (Blatner, 2000). In addition, through the experience of altruism, many clients may feel they are needed and useful to others (Yalom & Leszcz, 2005). In certain cases, the online intervention led to a positive transformation, which confirms the literature indicating that participants believed that psychodrama contributes to the re-evaluation of one’s past realities, catharsis, rediscovery of new insights and new understandings (Kipper, 1992; Somov, 2008). This is achieved more effectively by a psychology that views people as active change agents, which nurtures their capacity for self-reflection to make their own life worth living (Blatner, 2000).

Following the COVID-19 outbreak, people faced with unexpected life changes that forced them to create new solutions to adequately adapt to the situation. In the interview, Gabriella explained her current position of achieving changes focusing on the enhancement of her strengths rather than paying attention to negative aspects of her life. This ability to adjust well to life’s unexpected changes is very close to the conceptualization of creativity and spontaneity in psychodrama. In fact, creativity is to be considered a universal quality that helps most people to survive and adjust to life situations. Also, spontaneity, which is the catalyzing force through which creativity emerges, is a state of readiness that enables people to respond to new or old situation (Orkibi, 2019). The findings also echo the need for self-compassion, a positive psychology concept that entails being mindful of one’s thoughts, feelings and sensations in the present moment non-judgmentally, being kind to oneself, and realizing the common humanity of others (Neff & Germer, 2018).

In the interviews, the potential of online group therapy was acknowledged and mainly described as a resource that they could draw on in emergencies, or cases of illness or emotional problems. Scholars suggest that tele-psychotherapy might also be advantageous for clients in acute crisis with no access to immediate in-person encounters (Stoll et al., 2020). Online group psychotherapies also have their disadvantages. The first consideration is that the level of functionality and availability of the technology may pose problems to participants in tele-psychodrama groups such as lack of experience with the electronic devices, the internet, and/or network connection difficulties. In addition, there are few ways to prevent members of group from being distracted during the sessions, as many participants indicated. In a private environment such as the home, maintaining privacy is hampered by the presence of others. Moreover, some argued that communicating online remains a limited medium of expression because feelings, emotions, behaviors may not be adequately conveyed. However, some participants found it easier to talk about their fears and feelings in the online group, and manifested a greater openness and less inhibition when discussing emotional concerns. This suggests that tele-psychotherapy may be especially useful for individuals with high social anxiety (Yen et al., 2012). The virtual interaction compared with face-to-face communication may attenuate the oversensitivity to some negative social cues and decrease apprehension and barriers to treatment among these individuals, as indicated by Olivia. Another challenge is that in psychodrama, the action space is generally a designated place where the enactment occurs and the protagonist controls time, space, and reality (Kipper, 1992). This contrasts with online sessions where the action space is simulated. The physical activity involved in in-person psychodrama focuses people's attention on non-verbal language which has a twofold function: conveying messages indirectly to the others as well as serving as a cue to reinforce certain inner states. People learn to recognize their own mode of expression and discern their automatic reactions and can alter their embodied emotional state physically (Blatner, 2000). Because of the lack of embodied physical presence, this could only be partially achieved in online sessions, and hence the participants focused more deeply on facets that could be perceived through a webcam, such as facial expressions, pacing, and tone of voice. This is very recurrent not only in tele-psychodrama, but in all tele-psychotherapy groups (Weinberg, 2020). In online groups, the paradox of the online physical presence of the participants and physical absence in the studio, will demand further explorations of the idea of the online stage and supplementary reality compared to the Moreno’s conception (Nery, 2021).

As in in-person psychodrama, the online sessions included a final phase of sharing as an attempt to raise the learning experience of the group by discussing their own experiences and difficulties (Kipper, 1992). The termination of the online group coincided with the shift back to in-person psychodrama therapy. However, some of the participants described the in-person encounter as characterized by difficulties. This was mainly due to social distancing measures to limit the spread of COVID-19 such as wearing masks, maintaining an interpersonal distance that hindered the normal unfolding of psychodrama. We hypothesize that for some participants these social restrictions in in-person psychodrama (i.e the impossibility to touch one another or see the facial expressions) hindered the spontaneous expression of the self and their emotions.

The last issue pertained to the importance of the therapeutic alliance. Despite the initial skepticism towards online group therapy, the findings confirm reports in the literature with regard to the importance of having faith in therapist’s skills (Blatner, 2000). Scholars have observed that a higher expectation of help before the start of a group is correlated with a positive therapeutic outcome (Yalom & Leszcz, 2005). A positive outcome in online group psychotherapy is more likely when the clients and the therapist agree on the goals and tasks of therapy (Weinberg, 2020). The therapist’s faith in the potential of the method to generate a positive transformation functioned as an important catalyst that facilitated the formation of a therapeutic alliance in online group therapy. These findings corroborate the hypothesis that online psychotherapy is as effective as in-person psychotherapy and can be applied to cases where it is not possible to provide the client with in-person psychotherapy. Scholars reported both for the clients and psychotherapists that feeling more confident, competent, connected and authentic in online sessions led to more positive attitudes toward online psychotherapy (Békés & Aafjes-van Doorn, 2020).

The findings point to the need to develop further online interventions aimed at supporting clients at a distance when in-person therapy is not feasible. These forms of interventions appear to be very promising since they offer the opportunity to continue along a chosen path even in the event of unexpected situations, such as the outbreak of COVID-19, or other events, such as for people living abroad or health professionals working in a remote place. It could be also used for diverse situations where the client is isolated or unable to leave his home.

Conclusion

The pandemic has led to the suspension of in-person therapy. Since some of the participants noted the importance of receiving psychological support during COVID-19 pandemic, this kind of intervention should be made available and be properly designed to cope with this adverse situation. Online group therapy research is still relatively scarce and lacks clear practical guidelines to determine its effectiveness. However, inasmuch as the global emergency shows no sign of abating it is crucial to train mental health professionals to implement new therapeutic solutions and compensate for the lack of physical presence.

Limitations and future directions

This study has several potential limitations, in particular the small number of participants, which precludes generalization. Another limitation is the fact that the participants all belonged to a pre-existing psychodrama group prior to COVID-19 outbreak, although it enabled them to compare their experiences. It is also important to acknowledge that external circumstances forced the transition to tele-psychodrama, thus the findings may be moderated in future by voluntariness of use. Additionally, this study involved two psychodrama groups from the same area of Northern Italy. Clearly, more observations are needed to confirm the effectiveness of tele-psychodrama groups. The qualitative analysis of participants’ interviews helped us to better understand the pros and cons of conducting tele-psychodrama group; however, it also pinpointed some critical issues, especially related to the treatment setting and the difficulties implementing psychodrama techniques which sometimes undermined the online sessions. In light of the ongoing need for therapy even in times of social isolation, future studies should focus on what kind of interventions can be adopted effectively in tele-therapies.

Author contributions

Conceptualization: Gianmarco Biancalani, Ines Testoni; Methodology: Gianmarco Biancalani, Maria Silvia Gugliemin, Lucia Moretto, Ines Testoni; Formal analysis and investigation: Gianmarco Biancalani, Chiara Franco, Shoshi Keisari; Resources: Maria Silvia Gugliemin, Lucia Moretto; Supervision: Gianmarco Biancalani, Ines Testoni; Data curation: Gianmarco Biancalani, Chiara Franco; Project Administration: Gianmarco Biancalani, Ines Testoni; Visualisation: Gianmarco Biancalani, Chiara Franco, Ines Testoni; Writing - original draft preparation: Gianmarco Biancalani, Chiara Franco, Hod Orkibi, Shoshi Keisari; Writing - review and editing: Gianmarco Biancalani, Chiara Franco, Hod Orkibi, Shoshi Keisari.

Funding

The research group did not receive funds for this study.

Ethics statement

This study was approved by the Ethics Committee for Experimentation of the University of Padua (n. BC87D0713FC80E7F9A788 3D210F888DC).

Declaration of Competing Interest

The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.