gms | German Medical Science

Since 2017, the research committee of the North American Drama Therapy Association (NADTA) has endeavored to review the breadth of published empirical drama therapy research. This project was motivated by the committee’s stated intention to promote drama therapy as a model with an evidence base. The rise and development of evidence-based models of therapeutic intervention has yielded a climate wherein empirically-based research substantiation serves to increase recognition of certain approaches. In attempting to include drama therapy as a contributing part of this trend, the following presentation features an initial step toward raising awareness for both drama therapists and non-drama therapists as to the efficacy of the method.

Outlining the empirically-based evidence for drama therapy as an intervention not only promotes the field, but the livelihoods of practitioners who comprise the profession. A recent qualitative investigation of North American drama therapists found that professional practice in drama therapy is characterized by low occupational visibility, comparatively reduced pay, and a lack of institutional support [28]. Moreover, the researchers noted that drama therapists are currently struggling for professional recognition across the United States and Canada, lobbying for licensure, access to federal funding, and greater employment opportunities [28]. In an effort to grow the profession of North American drama therapy, we envision this project as a supportive step toward occupational promotion. By gathering and aggregating empirical research on drama therapy, we intend for this article to serve as a resource for clinicians, health policies and health sciences.

Before identifying the empirical research that was collected and analyzed for this general review, we will first define the method and practice of drama therapy. Specifically, as researchers affiliated with the NADTA, and drama therapists based in the United States and Canada, we are conceptualizing and writing from a North American perspective. While our search for empirical research included sources outside of North American journals, we find it important and contextualizing to identify our worldview. Therefore, our presentation and discussion of drama therapy is informed by a North American sociocultural lens as well as our proximity to regional theorists and researchers within the field.

Notably, drama therapy can be considered an umbrella term as it is comprised of a number of approaches, intervention models, and theoretical orientations [43]. In synthesizing a core definition of drama therapy, the NADTA [69] outlines the drama therapy scope of practice as utilizing principles and techniques derived from drama and theatre to achieve therapeutic outcomes. This is accomplished via the use of dramatic devices, including role play, improvisation, storytelling, and invoking an imaginal reality to practice adaptive functioning. In North America, drama therapists provide mental health services across a variety of clinical settings and are masters or doctoral-level clinicians often registered with the NADTA. Registered drama therapists work with clinical and general populations and are beholden to the NADTA scope of practice, code of ethics, and guidelines for cultural responsibility when providing services.

The NADTA research committee is comprised of registered drama therapists with an interest in supporting the profession via promoting research in the field through consultation, direct practice, and engagement with the literature. The research chair on the NADTA board of directors is a recently established position and was first filled in December 2015. The inaugural composition of research committee members has worked toward solidifying the purpose and direction of the committee.

Through consensus, it was decided that the committee would focus on collecting and compiling the empirical research in the field as an intentional advocacy effort to promote this type of research among drama therapists and demonstrate the efficacy of drama therapy to non-drama therapists. As stated earlier, the committee’s position is that establishing an empirical base for drama therapy will support further dissemination of the practice and greater recognition of its efficacy among allied mental health professions.

As a first step toward developing this empirical base, the committee began to investigate drama therapy resources from the past three years (2015–2018), seeking to answer the guiding question: what empirical drama therapy research currently exists? The limited timeframe of the initial investigation was set given limited person-power to facilitate a broader project. Additionally, the rationale was that it is good research practice to engage with recent literature, and we assumed, in accordance with a typical scaffolding of empirical research strains, that what we found would incorporate knowledge from previous investigations. In other words, once these articles were collected and processed, we would have a base from which to work backwards in locating contributing foundational drama therapy empirical literature.

This general review includes the NADTA collection of articles from the first step in this process as well as research that we have since identified. Thus, our search was comprehensive and not limited to a specific time frame. In the following sections we will discuss, in depth, the process through which this general review of literature unfolded, including methodology, procedures, and findings.

As a general review, the purpose of the present study is to provide an overview of existing literature. As mentioned, the research question is broad in scope, and the understanding is that there could be follow-up and deeper, more specific questions or paths of inquiry that build off of the present review.

Though our search was intentionally broad, it was still necessary to define boundaries in the review process. In order to focus our search, we first established inclusion criteria. At a base level, the research must distinctly and uniquely consider drama therapy. That is, drama therapy must be the main focus of the research inquiry. Further, drama therapy was defined according to the NADTA scope of practice [69] described above. In regards to our driving criterion of empirical, we collectively agreed to situate our definition within a commonplace understanding of the term. We adhered to the working principle that drama therapy empirical research focuses on the derivation of knowledge about drama therapy and related processes/techniques from direct or indirect observation or experience. This definition includes arts-based, qualitative, and quantitative methodologies. Moreover, the research must be published in a peer-reviewed journal.

Exclusion criteria were generated in an effort to further refine inclusion standards. Examples of excluded documents include unpublished graduate student research, books and book chapters, book reviews, editorials, theoretical pieces, abstracts from conferences with no article follow up, and meta-analyses and/or reviews of the literature. As this was a drama therapy-centered investigation, research focused on psychodrama, multiple creative arts therapies and/or expressive arts therapy was not included. Although we located a number of articles that invoked theatrical practice or principles in their research on psychosocial outcomes, we left these out as the intervention work was not explicitly classified as drama therapy (e.g. research looking at the relationship between stress levels and participation in theatre classes would be excluded).

As our research progressed, we noted that a number of the publications we reviewed contained case studies, case examples, case vignettes, or case illustrations and we needed additional inclusion and exclusion criteria to sort these articles consistently. There has been much debate and discussion among qualitative and social science researchers about varying and inconsistent application and definitions of the case study as a research strategy [38], [97]. Similar to other social science areas (e.g. education research), a lot of early writings and research in drama therapy utilized the case study as a research strategy. Rather than attempt to resolve the debate as to the definition or appropriate applications of a case study approach/methodology to determine inclusion criteria, we returned to our reasons for pursuing this investigation in the first place: to identify research that would be helpful in demonstrating the efficacy of drama therapy. This would include work that other researchers might build upon, cite, or use in future meta-analyses. Again, rather than engaging the debate as to the level of “rigor” or “robustness” of the case study designs, as our purpose was to identify rather than evaluate research, we developed the following criteria for including or excluding case studies: the case study must have a stated method of gathering and analyzing data (e.g. grounded theory, interpretive phenomenological analysis, open coding) and/or the case study must clearly have multiple sources of data (e.g. participant self-reports and clinical observations). This requirement is consistent with the expectations of leading scholars in case study research [90], [98]. While ideally rigorous studies would include both a research design as well as multiple sources of data [38], [62], [90], [98], we allowed for the inclusion of multiple sources of data without a named research design, as there have been many developments in case study design and qualitative methodologies in recent decades [91]. Additionally, we observed a trend that research methodologies were typically not identified in the work we reviewed from the mid-1990’s and earlier and we did not want to summarily dismiss early drama therapy research findings.

Exclusion criteria for case studies included descriptions of happenings that do not feature a systematic approach to the gathering of data, analysis, dissemination of information (e.g. descriptions of classroom content or program/intervention descriptions) or clinical commentary where there may be empirical work but details are not provided. Case illustrations were also excluded if they were primarily used to illustrate theory, were focused on the application of research or assessment tools, or did not provide enough information to allow for future comparisons to other cases (e.g. missing client histories, no mentioned presenting problem or research questions, no details on outcomes, etc.).

As previously mentioned, the initial project featured a review of available empirical literature from 2015–2018. This initial search included both peer-reviewed research as well as available graduate student research. We started our search by viewing the contents of known journals that regularly publish drama therapy research: The Arts in Psychotherapy (North America), Drama Therapy Review (North America), and Dramatherapy (United Kingdom). Other potentially relevant journals such as Applied Arts and Health were reviewed, however yielded no applicable results. Then, we used the search terms “drama therapy” and “dramatherapy” thus accounting for regional variation, “drama therapy” in North America versus “dramatherapy” in the United Kingdom, to search the following databases and search engines: Web of Science, ProQuest, Spectrum, and Google Scholar. Committee members reviewed the retrieved documents to determine whether they fit within our definition of empirical literature. When it was not clear, a second committee member would review the document and together the committee would determine qualification. These articles were then sorted resulting in a preliminary list of categories and sub-categories, which were established through consensus and discussion. The first draft of this document of references and categories was made available on the NADTA website and members of the community were invited to submit additional publications or research projects for inclusion. The list has been updated semi-regularly since June 2018.

For the present investigation, we expanded our search to include work prior to 2015. We also increased the rigor of our inclusion criteria and only included peer-reviewed research. Our new search followed this revamped criteria and sought to build from and re-configure the preliminary framework of categories and sub-categories already in place.

For this new project, key terms “drama therapy” and “dramatherapy” were used with the databases: PsychInfo, ScienceDirect, Social Sciences Citation Index (1900–present), and Arts & Humanities Citation Index (1975–present). After reviewing all articles returned through various searches across the indicated databases, 134 articles were identified as meeting face criteria for inclusion. We then combined this list of articles with our list of references from the first project. Duplicates were removed, and all articles, including those on the initial list, were reviewed to ensure consistency with the more stringent inclusion standards.

After an article was estimated to have met face criteria, a committee member uploaded it to a file storage database where it was to be further considered for inclusion. Subsequently, a second team member reviewed the article and a determination on appropriateness of fit was made by agreement. When there was disagreement about a particular article, a third committee member weighed in to provide a tiebreak, establishing consensus via a majority. All articles that were determined to have met criteria were compiled into a working list of empirical drama therapy research articles.

In the process of reviewing these articles, it sometimes came to light that the article being reviewed cited a previous empirical drama therapy study that was not located in our initial search. When this was noted, the cited article was retrieved, reviewed, and included in our list if appropriate. This resulted in three additional articles added to the final list.

The finalized list of articles was then sorted and organized into major categories and sub-categories. When not all articles were included in a categorization scheme, the categories were re-organized so that a new categorization structure supported all qualifying articles. In addition, the articles were organized such that the primary foci of the article was represented by a sub-category. As such, the sorting process did not result in each article falling into a single category or sub-category. Rather, the committee resolved that it was acceptable for articles to be included in more than one category/sub-category when the article featured multiple relevant variables, such as an overlap with population and setting (e.g. children/adolescents population as well as schools setting), or when the article focused on multiple distinct intervention devices (e.g. video as well as masks). Once each article was appropriately situated within applicable categories, a finalized categorical scheme and category titles were determined through discussion and consensus.

The search described above yielded a total of 89 unique articles that met inclusion and exclusion criteria. These articles fit into three broad categories: drama therapy intervention and assessment; special populations and special contexts; and the profession of drama therapy.

The category drama therapy intervention and assessment contained a total of 36 unique articles. The articles were divided into sub-categories indicating the primary approach, intervention, or purpose of the drama therapy work on which the identified research focused. The 16 sub-categories of this section were titled: assessment; cognitive and behavioral interventions; embodiment-projection-role; face-painting; masks; mindfulness; narradrama and narrative approaches; playback theatre; puppetry; role theory and role; theatre of the oppressed; schema focused drama therapy; Sesame approach; story-making and story-telling; and therapeutic theatre.

The assessment sub-category contained five articles (see Table 1 [Tab. 1]). This included a study of the diagnostic role-playing test (DRPT) [42], and an examination of role play to differentiate those with a diagnosis of schizophrenia from those without said diagnosis [44]. Two studies focused on the 6-Part Story Method (6PSM) as an assessment tool [18], [19], including findings demonstrating possible indicators of borderline personality disorder from the 6PSM. There was also one study of a group process instrument looking at dramaturgical roles in group psychotherapy with children [33].

The cognitive and behavioural interventions sub-category contained two articles (see Table 2 [Tab. 2]). Findings suggest that drama therapy, when combined with principles of cognitive-behavioral techniques such as behavioral activation and cognitive restructuring, is effective in resolving selective mutism [72] and reducing self-reported anger-aggression in male offenders [10].

The embodiment-projection-role sub-category contained one article (see Table 2 [Tab. 2]). The study showed that, while sometimes challenging for participants, engaging with the embodiment, projection, and role (EPR) model of drama therapy can be a therapeutic experience and can impact self-esteem and perceptions of gender roles for those who have witnessed domestic abuse [40].

The face-painting sub-category contained two articles (see Table 2 [Tab. 2]). One group study illustrated that the use of face-painting allowed previously unexpressed roles to emerge and be named [57]. A second group study demonstrated that face-painting can provide a means through which victims of trauma can work through components of the psychological impact of the trauma [56].

The masks and video sub-categories each contained one and the same article (see Table 2 [Tab. 2]). The study in question illustrated that, as a group intervention, both mask work and video work bring about some impact on self-esteem and creates enjoyable experiences for participants [29].

The mindfulness sub-category contained one article (see Table 2 [Tab. 2]), which examined the outcome of a group for adolescents that integrated mindfulness and dramatherapy. Quantitative findings were insignificant in terms of recognizing symptom change, although qualitative data demonstrated that group members improved self-confidence and deepened their understanding of mindfulness [61].

The narradrama and narrative approaches sub-category contained five articles (see Table 3 [Tab. 3]). Findings suggest that narrative approaches can help participants explore and build their self-image, self-identity, and self-acceptance [48], [71], [84], [85] and when practiced in a group, can bring about meaningful communication [70] and connections among participants [48].

The playback theatre sub-category contained four articles (see Table 4 [Tab. 4]). These studies demonstrated that playback theatre provides participants an opportunity to reflect on and review life [49] as well as improve participant self-understanding and self-esteem [65]. Results further suggest that witnesses to playback can improve understanding of others’ situations and increase tolerance of negative emotions [11]. It has also been documented that the understanding of generosity can have a positive impact on a playback performer’s development [8].

The puppetry sub-category contained two articles (see Table 4 [Tab. 4]). While there was not a clear impact on measured symptoms, clients with severe mental illness (e.g. depression with psychotic symptoms, PTSD, bipolar disorder) self-reported benefitting from puppetry [32]. Additionally, utilization of puppets allowed participants to work through the psychological impact of trauma [56].

The role theory and role sub-category contained four articles (see Table 4 [Tab. 4]) demonstrating how the use of role has broad therapeutic applications across a variety of populations and settings. One study collected data from therapists using the ritual framework of playback theatre to define the roles of older adult participants as they re-live life stories [49]. Another study demonstrated improved ability to regulate emotions in relationship to others, lessen anxiety, and heightened a sense of self-confidence after participating in role-theory based drama therapy [52]. This approach was also reported as beneficial in shaping healthy identities in participants in treatment for addiction [67] and those dealing with the effects of harmful racial stereotypes [59].

The story-making and story-telling sub-category contained four articles (see Table 5 [Tab. 5]). Findings indicate that story-making and storytelling can bring about the emergence of previously unnamed roles [57] and it can be a meaning-making and engaging experience [79] that can support social and emotional development [26], [54].

The lone schema-focused drama therapy article (see Table 5 [Tab. 5]) demonstrated preliminary evidence that schema-focused drama therapy groups may be helpful in increasing healthy emotional expression and decreasing destructive coping patterns [21].

The Sesame approach sub-category contained two articles (see Table 6 [Tab. 6]). One study suggested that this approach builds a sense of community, positive feelings, reminiscence, and self-understanding [95]. In a study involving interviews with drama therapists practicing a Sesame approach, commonalities were found as to the exploratory, non-linear, and transpersonal nature of Movement with Touch and Sound (MTS) [76].

The theatre of the oppressed sub-category contained two articles (see Table 6 [Tab. 6]). A study of theatre of the oppressed demonstrated that image theatre could be used to process acculturation experiences [41] and also can be helpful in exploration of intersections of identity, racism, and oppression [59].

The therapeutic theatre sub-category contained three articles (see Table 6 [Tab. 6]). The findings suggest that participation in a therapeutic theatre project may reduce participants’ anger [80], bring about happiness and positive self-regard [89], and therapeutic theatre can be used to explore and re-conceptualize family roles [47].

The category, special populations and special contexts, was comprised of 72 unique articles, that are divided into sub-categories indicating the primary setting, presenting concern, or population that the listed research focuses on. The 18 sub-categories of this section were titled: academic achievement and language acquisition; addictions; autism spectrum disorder; children and adolescents; eating disorders; families; forensic settings; foster care system; intellectual and developmental disabilities; interpersonal violence; migration: assimilation, identity, marginalization, and acculturative stress; mothers of children with mental health struggles or children at risk; neurological trauma or degeneration; older adults; social justice; trauma; psychiatric disorders; and school settings.

The academic achievement and language acquisition sub-category contained a single article (see Table 7 [Tab. 7]) that demonstrated significant improvement across a number of domains critical to secondary language mastery among bilingual Iranian children enrolled in a speech/language focused drama therapy group [78].

The addictions sub-category contained two articles (see Table 7 [Tab. 7]). Findings point to the efficacy of drama therapy as a forum for the re-envisioning and re-creation of post-addiction identity [67], with one study isolating storytelling and face painting as tools that successfully promoted positive emotional states [57].

The autism spectrum disorder (ASD) sub-category contained seven articles (see Table 8 [Tab. 8]). Drama therapy demonstrated promising results for children and adolescents within this population in improving social skills [17], [96], problem behaviors [17], developing confidence when in a group process with neurotypical peers [22], and supporting an ability to play and utilize imaginative thinking [54]. From the perspective of caregivers of children with ASD, a qualitative investigation found that involvement in drama therapy promoted social inclusion and skills development, safety and containment, structure in the form of predictability, and an overall support for the whole system [31]. Adults on the Autism spectrum were reported to benefit from developing a sense of agency [77]. A questionnaire was distributed to drama therapists in the United Kingdom about their work with this population; respondents reported on range of difficulties, client evaluations, case vignettes, procedures for progress monitoring and evaluation, how drama therapy supports this population, and sub-populations served [1].

The eating disorders sub-category contained one article (see Table 9 [Tab. 9]). We recognize that there is an argument to be made for including eating disorders within either/both the psychiatric disorder or addictions sub-categories. However, given that the article had a distinct focus from the research in the other sub-categories, eating disorders was given a separate sub-category. The researchers found that engagement in a drama therapy-informed theatre workshop for psychiatrically hospitalized adolescents diagnosed with an eating disorder was overall satisfactory to patients, decreased defense mechanisms, lowered identified symptoms, and improved quality of life during length of stay [75].

The families sub-category contained two articles (see Table 9 [Tab. 9]). Findings indicated that family roles were able to be re-conceptualized, dimensionalized, and transformed following a therapeutic theatre process [47], while general emotional and behavioral functioning for a pre-adolescent improved after participation in a psychiatric group setting focused on family intervention [36].

The forensic settings sub-category contained five articles (see Table 9 [Tab. 9]). It was reported that participation in therapeutic theatre projects may help participants reduce and manage anger [10], [80]. Further, studies have shown an increase in responsivity and reflection on process issues for mentally disordered sexual offenders [16] and a rise in emotional vulnerability for offenders with cluster B personality disorder traits (i.e. DSM-IV Anti-social, Borderline, or Narcissistic traits) [50]. Results of a study with middle schoolers who were being educated about the criminal justice system reported a significant decrease in their tolerance for aggression following exposure to playback theatre [11].

The foster care system sub-category contained three articles (see Table 10 [Tab. 10]). This research demonstrated that drama therapy can be a source of support for vulnerable youth with experiences in foster care. Involvement in drama therapy can help participants explore their identity [84] and can bring about a stronger sense of self-identity [85], self-efficacy, and positive self-image [71].

The intellectual and developmental disabilities sub-category contained four articles (see Table 10 [Tab. 10]). For adults with developmental disabilities, participation in therapeutic theatre can bring about self-confidence, positive self-regard, and can be an enjoyable experience [88], [89] that helps to develop perceptions of new roles of the performers for participants and audience members alike [88]. Another study with this population demonstrated improvements in communication skills and a strengthened ability to follow social and institution-based norms [26]. Finally, a case study illustrated that drama therapy may help participants with intellectual disabilities express themselves and organize their inner reality [24].

The interpersonal violence sub-category contained three articles (see Table 10 [Tab. 10]). Drama therapy was proposed to have aided children exposed to domestic violence by providing a supportive forum [40] and helping children to express their emotional experience as well as breaking the cycle of violence within their families [20]. Further, adult survivors of domestic abuse demonstrated improved psychosocial outcomes across a variety of adaptive domains [51].

The migration: assimilation, identity, marginalization, and acculturative stress sub-category contained five articles (see Table 11 [Tab. 11]). Analysis showed impairment decreasing in the experimental group, with participant observation notes indicating that teacher engagement in role-play, improvisation, and enactment of student stories seemed to illicit the greatest positive impact for the students [81]. Drama processes improved school performance [82] and increased emotional expression and awareness in students participating in school-based workshops for emotional regulation intervention [63]. Workshops using playback theatre, Boal’s forum theatre, and other drama therapy tools provided a unique environment for migrant students to experience safety, pluralism, and an opportunity to act out shared experiences related to migration [83]. Image theatre was used as a research tool to identify themes related to acculturation stress experienced by Taiwanese performing arts students [41].

The mothers of children with mental health struggles or children at-risk sub-category contained two articles (see Table 11 [Tab. 11]). One study reported preliminary data supporting an increase of empathic understanding and dimensionalization of parents’ perspectives of their children’s point of view [25], and the second study illustrated that working with mothers’ attachment styles to inform dramatic distance can be helpful in building therapeutic alliances [35].

The neurological trauma or degeneration sub-category contained two articles (see Table 11 [Tab. 11]). The first study was with adults on a neuro-rehabilitation unit and the second with a geriatric client with Parkinson’s disease. The former [34] reported an increase in an individual sense of empowerment and self-esteem, while the latter [53], noted an emotional benefit from expression and emotional relief.

The older adults sub-category contained eight articles (see Table 12 [Tab. 12]). Qualitative findings suggest that a drama therapy group was a positive, fun experience for participants, and brought about reminiscence, but did not have a statistically significant impact on symptoms related to mental health and cognitive functioning [39], [95]. Drama therapy can provide an opportunity for reminiscing, reconstructing, and reviewing life [49], [70], [79], bring about meaningful connections among participants [48], [70], and a sense of positivity and confidence [13].

The social justice sub-category contained one article (see Table 12 [Tab. 12]). This auto-ethnographic study explored the complexities of Black women’s identity, and demonstrated that dramatherapy can support clients in overcoming lived oppressions [59].

The trauma sub-category contained twelve articles (see Table 13 [Tab. 13]). It was shown that drama therapy can be a meaningful intervention for supporting those that have witnessed domestic abuse [40]. Further, female survivors of domestic abuse demonstrated significant improvements across a series of domains, including subjective well-being, psychological symptoms, overall life functioning, and risk of harm [51]. Drama therapy has been effective in lowering depression levels, hostility, and psychotic thinking with adolescent girls who have been sexually abused [58] and resolving selective mutism in youth [72]. Therapeutic theatre aided child survivors of the Holocaust in their adulthood in the exploration of past roles and the identification of positive associations with their current roles [74]. Further, drama therapy encouraged processing and self-healing for Taiwanese “comfort women” from World War II through a stage-based process [37] and afforded a Japanese/Korean-American female client the ability to “defreeze” [55] her traumatic experience and gain objectivity in an effort to advance her recovery. The use of metaphor within a drama therapy intervention with a woman diagnosed with Borderline Personality Disorder was identified as an important affordance for affective processing and expression, supporting therapeutic engagement [66]; face-painting was also identified as a means to process psychological trauma [56]. Emotional vulnerability was elevated for offenders with personality disorder traits [50]. A perception among participants of increased mood and communication skills followed a drama therapy group experience for clients with chronic aphasia [15]. Lastly, among patients with dementia, meaningful communication and a culture of reciprocity was developed via the engagement in a combined drama therapy and narrative therapy life story process [70].

The psychiatric disorder sub-category contained 13 articles (see Table 14 [Tab. 14]) where the population or participants in focus were diagnosed with a severe mental illness that was not otherwise represented by another sub-category (e.g. addictions, eating disorders). Findings illustrated that drama therapy had an impact on the presenting problem for outpatients with a Cluster C personality disorder [21] and brought about mixed results, but client-reported benefits for those with severe mental illness (SMI; e.g. depression with psychotic symptoms, PTSD, bipolar disorder) [32]. Playback theatre was helpful for SMI recovery by providing social context in a recovery-oriented environment, with a focus on competency rather than disability [65]. Drama therapy brought relief and control over symptoms for a client with a personality and anxiety disorder [52] and a decline in self-stigma and increase in self-esteem for clients with mental illness [73]. Drama therapy was also helpful in organizing the inner reality of a client with a diagnosis of obsessive compulsive disorder [24] and brought about improvements in social behaviors and clinical symptoms for individuals with schizophrenia [68]. One study explored the role of transference in facilitating new insights through an individual’s participation in an adolescent drama therapy group following hospitalization after a suicide attempt [23] and another study found that metaphor in drama therapy helped an individual with a diagnosis of Borderline Personality Disorder and PTSD express herself [66]. Playfulness in drama therapy was found to be a helpful component for individuals with anxiety disorders [94]. Also in this sub-category was a study of the application of a role-play test in differentiating those with a diagnosis of schizophrenia from others [44] and two studies illustrating the utility of the 6-Part Story Making for individuals with Borderline Personality Disorder [18], [19].

The school settings sub-category contained eight articles (see Table 15 [Tab. 15]). Not surprisingly, the content of this sub-category overlaps substantially with the content of the children and adolescents sub-category. Articles illustrated classroom and school interventions that address behavioral concerns [60], stigma [4], social integration [22], and support immigrant and refugee children and adolescents [63], [81], [82], [83]. One study in this sub-category also outlined in-school programming for students with Autism Spectrum Disorder resulting in a positive response from participants and the emergence of five main themes under the following categories: feelings, peers, social skills, structure, and families [31].

The children and adolescents sub-category contained 23 articles (see Table 16 [Tab. 16]). As most of the articles in this section are further explicated in descriptions of other sub-categories, the following references will be supported by an identification of general population and/or setting. A summation of findings includes utilizing mindfulness and drama therapy for adolescents [61], exploring the use of drama therapy with children and youth diagnosed with Autism Spectrum Disorder or their caretakers [1], [17], [22], [31], and providing drama therapy for children in an outdoor setting [5]. Additionally, research has presented drama therapeutic engagement with young women in foster or residential care [64], [84], [85], [87], participants who have witnessed domestic violence [20], [40], adolescents and children with emotional or behavioral challenges [57], [60], adolescent girls who were sexually abused [58], a child with selective mutism [72], bilingual Iranian students enrolled in a speech/language-focused group [78], and a review of an outcome measure for children’s generic impressions of mental health interventions [30]. A number of articles have focused on school-based, adolescent immigrant populations [63], [81], [82], [83] and further research reviewed drama therapy-based work with children using a dramaturgical role instrument in an outpatient clinic setting [33].

The category the profession of drama therapy contained a total of 16 unique articles divided into sub-categories that examine the study of the profession of drama therapy. The five sub-categories of this section were titled: core processes; drama therapist skills and qualities; the drama therapist: marginalized communities, identities, and systems; supervision; and teaching and training.

The core processes sub-category contained seven articles (see Table 17 [Tab. 17]). Findings suggest that drama therapists use the core processes in analyzing their clinical practices and understanding client change [45], [46]. Specifically, that embodiment and projection can be operationalized [3] and they are linked to both experiencing [3] and emotional arousal [2]. Drama therapists understand interventions involving dramatic reality to be helpful in managing symptoms of depression [14] and preliminary research also suggests that there is a relationship between distancing techniques and client attachment style [35]. One study also suggests that dramatic transference is an important part of the therapeutic relationship in drama therapy [23].

The qualities and skills of the drama therapist sub-category contained a single article (see Table 18 [Tab. 18]). A survey research study identified that drama therapists’ valued motivation, self-insight, empathy, and listening among the important roles and qualities for drama therapists and they use a variety of strategies/skills in their intervention work [93]. This research suggests that drama therapists believe in drama therapy core processes and that preliminary evidence connects these processes to other constructs that are well-understood in the field of psychotherapy.

The drama therapist: marginalized communities, identities, and systems sub-category, contained four articles (see Table 18 [Tab. 18]) which explored the barriers faced by professionals within the drama therapy community. Barriers identified included lack of professional licensure [28], the possible perception of a glass escalator effect [27], a need for additional education and support around work with the LGBTQI and gender non-conforming (GNC) communities [6], and the fact that institutional attitudes and actions have a negative impact on LGBTQI and GNC identified drama therapists [7].

The supervision sub-category contained two articles (see Table 18 [Tab. 18]). An arts-based study found that embodied supervision helped the supervisee build empathy and understanding of case complexity [92]. A supervision case study with a grounded theory approach demonstrated that the use of fairy tales and metaphor in supervision can be used as means to explore countertransference and therapeutic alliance [86]. The teaching and training sub-category contained two articles (see Table 18 [Tab. 18]). One phenomenological study explored the lived experiences of drama therapy students with experiential learning, finding that personal material can enrich and distract from classroom experiences [12]. Also, an A/r/tography study explored a teaching practice [9]; the theme of valuing experiential/arts in learning, investigating optimal ways to teach drama therapy, and a specific exploration on experience and arts in teaching and learning reinforced a value for the artistic merits of theatre as a teaching tool.

The main findings from the reviewed empirical research all related to deriving knowledge about a drama therapy intervention/approach/method, a particular presenting problem or context, or the profession of drama therapy itself. Befitting the diversity of approaches in the drama therapy field, drama therapy empirical research also investigated a variety of techniques, interventions, processes, and methods. It appears that there is no single approach or intervention that has a plethora of empirical support. We further noted that there are many forms of drama therapy for which we did not find any empirical research according to our criteria (e.g. developmental transformations; self-revelatory performance).

Furthermore, these findings suggest that drama therapy research has been carried out in numerous contexts and with a variety of populations. The broad sub-categories of trauma, and children and adolescents were noted as areas of research with the most empirical studies, but no specific population, diagnosis, or context emerged as having a plethora of empirical support.

The research on the profession of drama therapy findings suggest that drama therapists believe in the core work of their profession and that they value qualities and roles similar to those of other helping professions (e.g. empathy and listening). Additionally, the findings from this section also suggest that, as a profession, drama therapists are looking critically at ways to use the arts in their teaching and supervision and that the community is interested in identifying barriers and means to improve the supports within the profession.

There are a number of limitations to the findings of our general review. As this search only includes articles written in English, publications in another language were not included thereby qualifying this review as non-exhaustive. Moreover, this general review only included peer-reviewed articles. We acknowledge that empirical work, whether it be quantitative, qualitative, or arts-based research exists in other venues, such as book chapters and online sources. Also, while doctoral and master’s research projects were not included in this general review, a search on ProQuest Dissertations & Theses Global for the search terms “drama therapy” and “dramatherapy” led to 1603 references, none of which were reviewed. It is likely that additional empirical evidence exists that has not been peer-reviewed outside of an academic purview. Additionally, our consideration and adoption of definitional criteria may depart from or contrast with other researchers with similar questions. Therefore, our review is comprehensive and applicable within the confines in which we have crafted our inclusion and exclusion standards. Lastly, and as previously mentioned, our work is informed and conducted from a North American orientation. Although we sought and included articles from a variety of regional journals, we acknowledge our worldview as playing a role in shaping our process.

This general review of drama therapy literature provides an overview of the existing empirical research in the field. Empirical research of this nature may be used in support of the recognition of the profession of drama therapy, and may specifically help drama therapists move through professional barriers (e.g. legislation, access to jobs, funding). This review may serve as a resource for researchers, as a map of pre-existing empirical literature, as a starting point for identifying gaps in empirical knowledge, and for formulating new research questions. The NADTA research committee plans to continue updating the compilation of references as new articles are published.

The NADTA research committee’s next project will build on this general review and will assess the subset of drama therapy empirical research that focuses on efficacy and effectiveness. This next project will involve discussion and critique of the literature, and propose future research directions for the North American drama therapy research community.

The NADTA committee is hopeful that the global drama therapy community will continue to produce and support drama therapy empirical research that will demonstrate the impact of drama therapy processes and interventions. We welcome feedback on our ongoing work, and invite suggestions for additional research to be included in our compilation of references going forward.

The authors declare that they have no competing interests.

The authors would like to acknowledge the contributions of NADTA research committee member, Shea Wood, who – next to the authors – participated in the reviewing and categorization of articles in the original project that inspired this paper.