A Pilot Remote Drama Therapy Program Using the Co-active Therapeutic Theater Model in People with Serious Mental Illness.

The impact of drama therapy on mental health recovery remains poorly understood. We examined the effects of a pilot remote drama therapy program for community members living with serious mental illness. The entire intervention was delivered remotely. Participants with serious mental illness completed a 12-week drama therapy program which included an online performance open to the public. Four quantitative scales were administered pre- and post-program. A focus group was conducted 1 week after the performance. Six participants completed the program and crafted a public performance themed around hope. No significant differences were identified in the quantitative measures. Five themes were identified in the post-performance focus group. Drama therapy presents an opportunity for individuals with serious mental illness to process and share their journeys with their diagnoses and re-create a healthy sense of self with increased community awareness.

Introduction

Serious mental illness (SMI) describes psychiatric conditions that cause significant functional impairment. Schizophrenia spectrum disorders, severe bipolar disorder, and severe major depressive disorder fall under this umbrella. Recent data estimates that 5.2% (13.1 million people) of adults in the U.S. live with SMI (SAMHSA, 2020). Current treatment plans for SMI incorporate pharmacotherapy with psychosocial interventions including cognitive-behavioral therapy and vocational rehabilitation (Elliott, 2016). However, suboptimal integrated care results in increased hospitalizations related to more severe physical illnesses and poor treatment compliance (Cramer & Rosenheck, 1998; Wetzler et al., 2020). Care coordination is critical for improving clinical outcomes in this population and mental health professionals are increasingly turning toward other treatment modalities to improve symptoms and social functioning.

Creative arts therapy is a promising type of psychosocial intervention for SMI. The utilization of creative arts therapy to treat SMI is growing in popularity but consists of highly variable studies using heterogeneous methods to deliver creative modalities including art, music, dance, and drama therapy (Chiang et al., 2019; Ruddy & Milnes, 2003). Notably, the therapeutic goals of drama therapy appear well-suited to promote recovery from SMI which is associated with significant societal stigma and poor quality of life (Corrigan & Watson, 2002; Dong et al., 2019; IsHak et al., 2015; Michalak et al., 2005). Drama therapy offers a creative approach to facilitate cathartic expression and personal growth. Through the use of theater processes such as improvisation, embodiment, and performance, participants can explore ways to create intimate and transformative spaces and tap into innate qualities that they can outwardly express (Emunah, 2019). Drama therapy implemented for high-risk college students, notably those who experienced a major stressor in their lives, participating in a counseling group resulted in increased self-awareness related to the ability to manifest inner feelings which were previously difficult to express aloud (Chang et al., 2019). Individuals with schizophrenia who participated in drama therapy demonstrated improvement in domains including dramatic development and fluency of speech when compared with those who received standard inpatient care (Nitsun et al., 1974). Different modes of verbal and nonverbal expression presented through drama therapy has the potential to overcome communication challenges among people with SMI, particularly those who have speech deficits due to blunted affect and poverty of speech (Cohen et al., 2014). Moreover, the action-oriented process of drama therapy aims to integrate emotional and physical sensations and promote storytelling.

One salient form of drama therapy is therapeutic theater, which uses the process of intentional performance to promote transformation. The Co-active Therapeutic Theater (CoATT) model is one type of therapeutic theater that was developed as a specific intervention utilizing concepts within drama therapy to enhance clinical recovery through a personal commitment leading to public performance. By manualizing therapeutic theater, CoATT improves replication and operational use in different settings. Emphasis is placed on the process of active recovery which acknowledges deliberate goals and re-authors narratives about oneself beyond treatment through the use of metaphor and story rather than autobiographical depiction (Wood & Mowers, 2019). The co-active framework embraces the role of drama therapists and community mental health practitioners to collaborate with participants in their journeys toward recovery. As such, this approach allows participants to portray and confront different aspects of themselves in the context of the drama therapy group. CoATT has been used for various populations in recovery including from eating disorders, substance use disorders, aphasia. A study in 2020 demonstrated perceived enhancements in communication skills and self-confidence built through connections developed between individuals with expressive aphasia (Wood et al., 2020a). These results suggest that CoATT can be used for individuals with communication disorders and reproduced by other community mental health recovery programs that follow the model’s framework.

The COVID-19 pandemic has changed the trajectory of health care delivery and is anticipated to disproportionately burden people with SMI. Increased isolation and reduced access to treatment and community resources may exacerbate symptoms and increase distress (Kozloff et al., 2020). Virtual care appointments attended through telepsychiatry and online psychosocial interventions have become mainstream. However, the effectiveness of psychosocial interventions including programs for creative arts therapy delivered remotely continues to be explored (Arnold et al., 2020; Knott & Block, 2020; Levy et al., 2018; Oddo et al., 2021). An in-person pilot drama therapy program was previously conducted to evaluate the impact of therapeutic theater for people with a dual diagnosis of SMI and substance use disorder (Cheung et al., 2021). Participants reported advocating for changes in the mental health field, a sense of community among participants with lived experience, and recognizing the importance of external support as positive outcomes of the program. Although meaningful research is beginning to emerge regarding virtual drama therapy and its broad applications and challenges (Feniger-Schaal et al., 2022; Pendzik, 2020; Wood et al., 2020b), little is known specifically about remote drama therapy for people with SMI.

Aims of the Study

To contribute meaningful knowledge and evidence to the area of drama therapy for SMI, we developed a remote group-based drama therapy program. This intervention was enabled through a partnership between the UMass Community Intervention Program (CIP) at UMass Chan Medical School in Worcester, MA and the drama therapy program in the Expressive Therapies Division at Lesley University in Cambridge, MA. The study coordinators comprised of psychiatrists, medical students, and research assistants, part of CIP and the drama therapy coordinator at Lesley University. The goal of this pilot study was to evaluate the impact of a drama therapy program for people with SMI. The intervention was delivered remotely to promote safety during the pandemic and increase accessibility for participation. Using the CoATT model, drama therapists worked with participants to craft a themed online performance open to the public with engagement from the audience as they reflected on the cast members’ dramatic expression of recovery. Study evaluation was conducted by the research team who was not directly involved in facilitating the virtual drama therapy program and development of the virtual performance with the participants.

Methods

Participants

Participants were recruited through referral by their healthcare providers or from the community using advertising flyers distributed to mental health centers, private practice clinics, local hospitals, clubhouses, peer support centers, and group homes in the Central Massachusetts area. Eligible participants included: (a) adults between 18 and 65 years of age; (b) DSM-V diagnostic criteria of a serious mental illness such as schizophrenia spectrum disorder, major depression, or bipolar disorder; (c) stable psychiatric diagnosis based on clinical judgment; (d) English-speaking; and (e) ability and willingness to participate in the theater performance activities. Participants were excluded if: (a) their medical conditions were unstable or prevented their full participation in theater performance activities; (b) they were at imminent risk of suicide or injury to themself or others or had a significant suicide attempt within the last 6 months; or (c) were incarcerated.

Virtual Drama Therapy Program

The 12-week program was led by two registered drama therapists, recruited by the drama therapy coordinator, and consisted of 10 weekly 1.5-h exploratory and rehearsal sessions, a public performance, and a focus group. The entire program was conducted over UMass Chan Medical School’s secure, HIPAA-compliant Zoom video platform.

CoATT was used as the basis for the program to manualize the drama therapy protocol (Wood & Mowers, 2019). Following this model, the exploratory and rehearsal sessions were divided into seven distinct sections or “movements” with each movement following the same structure of activities (Table 1). The roles of the drama therapists were to provide a framework for and lead the therapeutic theater exercises of each session and guide the participants toward the creation of a public production delivered online. In parallel, participants engaged in drama therapy tasks to develop their performance skills and express their ideas that shaped their growth in the program and final work. Movement One: Recruitment (week 0) served to identify participants for the program. Participants shared an active recovery process, characterized by their intention to engage in recovery and construct and share a new personal narrative, that was meaningful to them as well as tools and resources they sought to use while participating in the CoATT. Movement Two: Discovery (week 1) was organized around establishing a group contract and theme of recovery with the intent to explore, construct, and communicate a themed production with the community in the public performance. Movement Three: Generation (weeks 2 and 3) engaged the group in a specific series of theatrical improvisation games and drama therapy exercises using metaphor, role, and journal writing to explore the selected topic in depth. The homework activity of this movement was of particular importance, as the written words of the participants were used to create the dialogue and finalize the theme for the play. Co-active supervision between the drama therapists leading the sessions focused on a reflection of the roles, emotions, relationships, and metaphors that emerged in the participants’ work and interpersonal dynamics. Movement Four: Performance intensive (week 4) centered around empowerment through acting skills training and the creation of a skeletal script written by the drama therapists composed of the participants’ work. The intensive was delivered over extended sessions: 3 h, compared with the typical 1.5 h, over the course of 2 days. The final activity of the intensive was to read through the script as a cast and discuss how they can take ownership over the narrative of the play through additional textual edits or acting choices. Movement Five: The rehearsal process (weeks 5–10) co-actively tasked the drama therapists and participants to produce and rehearse the play. The primary focus of the drama therapists was on directing the play while the participants prioritized ownership of the recovery theme and its presentation as a final product. Any changes to the structure of the play were agreed on by the cast. Rehearsing allowed the cast to actively engage in the creation of the therapeutic theater while simultaneously working on their recovery and imagining the production with the presence of the audience in mind. Movement Six: Public performance (week 11) was open and advertised to the general public to allow the cast to reconnect to the world outside of treatment. Attendance at the exploratory and rehearsal sessions was taken during weeks 1–10.

Table 1

Co-active Therapeutic Theater (CoATT) drama therapy protocol

Measures

During the recruitment session (week 0), the Theatre Impact Scale (TIS), Brief Psychiatric Rating Scale (BPRS), Quality of Life Enjoyment and Satisfaction Scale-Short Form (Q-LES-Q-SF), and Perceived Stress Scale (PSS) were administered to measure the impact of the virtual drama therapy program. The four quantitative scales were provided by study coordinators who were not involved in the drama therapy program. The TIS is a 20-item self-report scale with a 4-point Likert design to evaluate dimensions including self-esteem and confidence, performing in front of others, creativity, social connecting, and seeing one’s life as full of stories (Moran & Alon, 2011). The BPRS includes 18 symptom items rated on a scale from 1–7 to measure psychiatric symptoms such as depression, anxiety, hallucinations, and unusual behavior (Overall & Gorham, 1962). The Q-LES-Q-SF consists of 16 items rated on a scale of 1–5 to assess quality of life and life satisfaction in a variety of categories such as physical health, mood, and work (Stevanovic, 2011). The Perceived Stress Scale is a 10-item scale on a scale of 0–4 used to measure ones perceived level of stress (Cohen et al., 1983). One week after the public performance (week 12), all rating scales were administered again to the participants.

Performance Day

The 1-h performance over Zoom was advertised to the local community and crafted to allow each of the cast members to share their stories related to the overarching theme of the play determined by the participants. Flyers about the online performance were distributed to the same sites chosen for recruitment. The performance was held on a weekend evening and the link to the performance was shared to those who signed up for the event. Following the performance, the cast engaged audience members in the prescribed co-active element, in which the cast facilitated an experiential to engage the audience in reflecting on the theme of the production as it related to their own lives. Reflections on the experience were shared through the Zoom chat and their comments were read out loud by research staff moderators.

Focus Group

A semi-structured focus group lasting 45 min was organized 1-week post-performance (week 12) to assess the participants’ experience with the program. The focus group was audio recorded and moderated by the drama therapists and two study coordinators. A script was used to probe topics including drama therapy, inter- and intra- personal relationships, and stigma.

Analysis

Study assessment was carried out by the research team. Paired sample t-tests were used to examine differences in quantitative outcome measures before and after the program. Quantitative data analysis was conducted using SPSS (version 27, IBM, Armonk, NY). For the focus group analysis, the transcript was prepared verbatim and independently reviewed by two investigators (VA, MS) who were not involved in the focus group or transcription process. Thematic analysis was used to generate initial codes, which were then organized into provisional themes based on conceptual similarities. The investigators met to agree on the final themes, which were deliberated and revised to fully develop relevant data captured in the coding process (Boyatzis, 1998; Herzog et al., 2019). Selected quotes illustrate the themes and reflect major viewpoints shared by the participants. Data extracts were coded using Dedoose software (Dedoose, Manhattan Beach, CA).

Ethical Approval

The study was approved by the Institutional Review Board of UMass Chan Medical School. Written informed consent was obtained from the participants with the understanding that the program is voluntary and that they will perform in the final performance.

Results

Eight individuals with SMI (51.5 ± 9.4 years old, mean ± SD) were recruited. Six completed the remote drama therapy program, defined as participants who attended at least 8 of the 10 exploratory and rehearsal sessions and performed in the public performance. 50% of participants were male. Of the six individuals that completed the program, four (66.7%) identified as white, one (16.7%) identified as Black or African American, and one (16.7%) identified as Asian. 50% of individuals were clinically diagnosed with schizophrenia and the other 50% with schizoaffective disorder. The participants worked together to create the virtual production “Lost & Found: A Message of Hope” with the central theme of hope to share with the community.

Quantitative Scales

A modest, non-significant reduction in the BPRS total score was observed (37.2 ± 8.7 vs 32.3 ± 10.7, p = 0.061; mean ± SD, pre- versus post-program). The TIS item that exhibited the greatest change value indicating improvement was “I am at ease when performing in front of others” (TIS5, + 3). No differences in the PSS total score (16.2 ± 6.3 vs 12.7 ± 4.2 p = 0.133; mean ± SD, pre- versus post-program) and percentage maximum total score on the Q-LES-Q-SF (76.2% ± 12.5 vs 76.2% ± 10.1, p = 1.0; mean ± SD, pre- versus post-program) were observed.

Focus Group Discussion

Five themes were identified in the focus group describing experiences with and group-perceived outcomes of the program: (1) Utilizing creativity for recovery; (2) Encouraging individual advocacy; (3) Facilitating self-confidence; (4) Value of social connections; and (5) Acceptance of self and awareness of individual potential.

Utilizing Creativity for Recovery

Participants emphasized the novelty of drama therapy as a unique and exciting means toward recovery. One participant commented: “the whole process like let me and let us be really creative together…it was different from other kinds of therapies where you’re usually talking about yourself or you’re talking and trying to talk through about your problems”. Another participant described the program as “Fun. I mean I look forward to it every day.” Participants discussed the value of using their intrinsic creativity to identify the theme of the play (hope), prepare the script, and shape the structure of the play around this theme.

Encouraging Individual Advocacy

Participants highlighted drama therapy as a safe platform to speak their minds and share their personal stories. The ability to verbalize their thoughts, be vulnerable, and transform their ideas into a group production was a significant undertaking for recovery. One participant stated, “I learn[ed] how to tell my experience, come up with a role, and be able to act it out on video”. Another participant commented, “it was really fun to take part in editing the script once it was written and just to like have it reflect all of our, all of our journeys in a fictional way, but also still speak some truth about the message that we wanted to get across.” Participants demonstrated the importance of self-expression and empathic observation from the audience and the world around them as ways to improve their mental health.

Facilitating Self-confidence

Participants discussed feeling empowered and capable as they went through the drama therapy program. One participant commented, “I never thought I’d do this kind of participation, but it seems that everything went well and I'm so proud of it.” Following the publicized performance, participants felt “a sense of accomplishment” and embraced camaraderie with the cast. One participant stated: “I’m able to express myself in a productive way that made me feel good inside, it made me feel that I had another accomplishment that I have made with everybody.” The virtual drama therapy was viewed as a method to encourage confidence in the participants’ individual capabilities and gain acknowledgement from the public in the skills they acquired and their ability to craft the production.

Value of Social Connections

Participants described the importance of building meaningful social relationships and feeling valued and included. One participant commented: “I just felt good because [the program] reminded me of [my therapist] … and then all of a sudden, she was gone, and she didn’t even say goodbye…I found a way to kind of write that into the play.” Participants identified individuals that supported their journey toward healing before and during the drama therapy program. “Being there…to help them out of their time of need” was emphasized as an essential part of the recovery process.

Acceptance of Self and Awareness of Individual Potential

Participants described the opportunity for self-reflection and personal growth throughout drama therapy program. One participant chose to play the role of a comic relief character to express themself freely and comfortably. Another participant felt motivated to “really evaluate what was…we all came up together like we all got to share what was really important to us like our values and what was important to us all for recovery.” The drama therapy program provided therapeutic benefit and served as a medium for positive change for the participants.

Remote Delivery

The group shared their reflections on the practicality of the program during the focus group. Participants were interested in participating “over Zoom” again. One participant noted “I’m busy with work and I don’t know if I could get to the meeting place consistently every week”. Others reported “transportation problems” and “the way the roads are” as motivators to continue future programs remotely. Digital delivery of the sessions was seen as an advantage to access the program and final performance.

Audience Reception

Immediately following the performance, audience members were encouraged to engage in the co-active audience element and provide their thoughts on the play using the chat function on Zoom to prompt co-active participation between the cast and audience. Comments were read aloud by the cast to engage in the feedback. Cast and audience members reflected on key elements of drama therapy including communication, spontaneity, playfulness, and collaboration. One audience member stated, “The authenticity of everyone came through so powerfully”. Other participants in the audience shared their own messages of hope for the cast including “we are all connected to each other”, “progress not perfection!”, and “embrace the challenge!”.

Discussion

The remote drama therapy program was accepted and well-tolerated by the participants. During the exploratory and rehearsal sessions, participants engaged in a variety of manualized exercises promoting creative expression. The therapeutic space allowed participants to come together and build trust while focusing on their strengths and vulnerabilities. By participating in the program in a physical setting they found comfortable and convenient, participants faced fewer boundaries to engage in the action-oriented, goal-directed tasks presented by the drama therapists and improve their skills in communication and personal development. Opportunities to reflect on growth and observe changes in oneself and within the dynamic of the group were brought about through the incorporation of action-oriented tasks cumulating in a public performance around a theme selected by the participants (Wood & Mowers, 2019). The performance encouraged participants to enact a shared story of hope and allowed audience members to better understand the participants’ experiences living with SMI.

Stigma among community members and health care professionals can be influenced by the mode of information delivery (Corrigan & Watson, 2002). Drama therapy has been shown to reduce self-stigma of participants with mental illness and public stigma of audience members (Orkibi et al., 2014). As a recovery-oriented intervention, drama therapy has the potential to combat poor clinical and functional outcomes among this population (Dubreucq et al., 2021). Through co-active participation between cast members and the audience, participants conveyed their complex experiences with SMI through metaphorical interpretations and received live feedback for their performance. This type of interaction allows for active reflection on the community side to better recognize and engage with the impact of the performance.

Responses from the focus group demonstrated that participants enjoyed the drama therapy process and group-based activities. Notably, building relationships and gaining self-perspective were perceived as important benefits of participating in the program. Previous work using CoATT with individuals with aphasia found similar qualitative themes (Wood et al., 2020a). The connections fostered between the participants with SMI supported a sense of solidarity and drive to create a themed story of hope through a safe medium of expression. A recent study investigating the therapeutic effects of drama therapy for women who were victims of intimate partner violence also demonstrated the healing nature of intentional performance and forming bonds through verbal and nonverbal communication (Mondolfi Miguel & Pino-Juste, 2021). Therapeutic theater therefore provides a platform for individuals to work together and enact stories with significant personal meaning. Moreover, the CoATT model offers a unique avenue towards this goal, given it is a manualized process, allowing for the potential of replicated studies.

The drama therapy program served to unite participants during times of unprecedented isolation. Social networks were built through shared interests and a desire for community despite ongoing barriers to in-person relationships. Participants expressed preference for the virtual format and were able to successfully write the script and rehearse and showcase the production. Interventions delivered remotely reduce financial and transportation barriers which are often experienced by people with SMI (Spivak et al., 2019; Tristiana et al., 2018). Challenges named by individuals with SMI participating in research include chronic physical health conditions, difficulties with transportation, and perceived invasiveness of privacy (Kanuch et al., 2016; Woodall et al., 2010). The ability to physically attend sessions within an intervention appears to be a consistent obstacle which is alleviated by the convenience of telehealth. Optimizing access to such therapies is in line with transformative mental health care which emphasizes maximizing an individual’s ability to function in and be part of their community (Hogan, 2003).

Limitations

This pilot remote drama therapy study has several limitations. The small sample size reduced our ability to assess the impact of the intervention as demonstrated through the lack of significant changes noted in the quantitative measures. The modest, nonsignificant improvement in the BPRS total score was also observed in a recent pilot study on drama therapy for participants who were dual diagnosed with SMI and substance use disorder (Cheung et al., 2021). Further research requires an expansion of the study cohort to detect pre- and post-program differences. This study also lacked a control group to examine the effectiveness of the intervention compared with standard of care treatment. There was a 25% attrition rate with one participant who dropped out citing personal discomfort surrounding the topics discussed during the program. Individuals may join the program with different expectations for their own active recovery which motivate or discourage their continued participation. The CoATT model requires a commitment from those ready to engage in the recovery process which may pose a challenge for people with SMI in ongoing treatment but not active recovery. While web-based delivery of interventions increases convenience and has become commonplace during the ongoing pandemic, technical difficulties remain evident and technological malfunctions as well as poor technological literacy can reduce enthusiasm for participation. Importantly, accessibility and availability of drama therapists remains a significant barrier to implementing drama therapy programs. A model incorporating theater-based interventions into health care delivery will undoubtedly be required to provide such programs to individuals with SMI who face considerable internal and external challenges related to their health and the stigma surrounding their conditions.

Conclusions

Our study demonstrates a partnership between two professional fields: drama therapy and psychiatry. This interdisciplinary relationship allows for a mutually beneficial discourse promoting the further development of drama therapy and the incorporation of its principles into the practice of mental health care delivery. While the prevalence of creative arts therapies, particularly related to art and music therapy, within psychiatric settings is established, to date collaboration between drama therapy and psychiatry has been minimal. Manualized drama therapy processes allow for the creation of more creative interventions which can lead to wider coverage of these services through managed health care. Moreover, the use of theatrical processes in drama therapy proposes that collaboration can overlap with theater practice itself to provide a setting for discourse on mental health. Our findings suggest that remote drama therapy confers personal value to group members as participants in active recovery and advocates for mental health awareness and a need for larger-scale studies to evaluate clinically relevant benefits of drama therapy for people with SMI.