<h4>Background</h4>Medication is the mainstay of treatment for schizophrenia or schizophrenia-like illnesses, but many people continue to experience symptoms in spite of medication (Johnstone 1998). In addition to medication, creative therapies, such as drama therapy may prove beneficial. Drama therapy is a form of treatment that encourages spontaneity and creativity. It can promote emotional expression, but does not necessarily require the participant to have insight into their condition or psychological-mindset.<h4>Objectives</h4>To review the effects of drama therapy and related approaches as an adjunctive treatment for schizophrenia compared with standard care and other psychosocial interventions.<h4>Search strategy</h4>We searched the Cochrane Schizophrenia Group's Register (October 2006), hand searched reference lists, hand searched Dramatherapy (the journal of the British Association of Dramatherapists) and Arts in Psychotherapy and contacted relevant authors.<h4>Selection criteria</h4>We included all randomised controlled trials that compared drama therapy, psychodrama and related approaches with standard care or other psychosocial interventions for schizophrenia.<h4>Data collection and analysis</h4>We reliably selected, quality assessed and extracted data from the studies. We excluded data where more than 50% of participants in any group were lost to follow up. For continuous outcomes we calculated a weighted mean difference and its 95% confidence interval. For binary outcomes we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and a number needed to treat (NNT).<h4>Main results</h4>The search identified 183 references but only five studies (total n=210) met the inclusion criteria. All of the studies were on inpatient populations and compared the intervention with standard inpatient care. One study had drama therapy as the intervention, one had role-playing, one had a social drama group and two used psychodrama. Two of the includ Keywords: Humans, Drama, Antipsychotic Agents, Antipsychotic Agents/therapeutic use, Hospitalization, Psychodrama, Psychodrama/methods, Psychotherapy, Randomized Controlled Trials as Topic, Schizophrenia, Schizophrenia/therapy, Schizophrenic Psychology Plain language summary Drama therapy for schizophrenia or schizophrenia‐like illnesses Drama therapy is one of the creative therapies suggested to be of value as an adjunctive treatment for people with schizophrenia or schizophrenia‐like illnesses. Randomised studies have been successfully conducted in this area but poor study reporting meant that no conclusions could be drawn from them. It is a method of working and playing that uses action methods to facilitate creativity, imagination, learning, insight and growth." Regardless of whether it was formally described as drama therapy, we considered any intervention using role play, drama games, improvisation, dramatic text, story making or any similar approaches. We also included studies of psychodrama if the intervention was judged to fall within the definition of drama therapy above. We compared this against one or more of the following: 2. Standard care This includes the type of care that fits with normal 'custom and practice'. Qu 2000 studied the effectiveness of psychodrama for improving mental state in chronic schizophrenia. Nitsun 1974 compared group movement and drama therapy with a modified psychotherapy group to look at effects on clinical, psychological and social functioning. Gutride 1973 used structured learning therapy (modelling and role playing social interactions with social reinforcement) to enhance social interactions. Whetstone 1986 used social dramatics as a clinical nursing tool for developing social skills of the chronically mentally ill. 5.2 Method Nitsun 1974 was group randomised to receive treatment. All participants also received treatment as usual (including occupational and industrial therapy and attending hospital socials), but psychiatrists agreed to make no changes to their medication during the course of the therapy. In Qu 2000 all participants received antipsychotic drugs but the experimental group also received psychodrama. These were two hour sessions, five times a week, for three months. The therapy consisted of the patients first identifying psychological barriers and symptoms, the therapists then designed scenes and roles to explore these and then in groups of three to four participants the patients performed the various roles and explored the way they felt about them. All participants also received treatment as usual (including occupational and industrial therapy and attending hospital socials) and, like the patients in the drama therapy group, psychiatrists agreed to make no changes to their medication during the course of the therapy. In Qu 2000 and Zhou 2002 the comparison groups only had antipsychotic medication and no additional time given to them to compensate for the time given to the participants in the psychodrama intervention. Applicability It is clear from the description of psychodrama in the two Chinese studies ( Qu 2000 , Zhou 2002 ) that the therapists play a very directive role in defining what is appropriate behaviour in particular situations. Also looking at the lack of dropouts from these studies it might be reasonable to assume that the treatment was compulsory. Both of these factors are very different from the practice of drama therapy in Europe and the US where participants are offered therapy as a choice and are helped to come to their own conclusions about the pros and cons of different behaviours in different scenarios. 4.2 Mental state: Skewed endpoint data, SANS & SAPS, medium term Qu 2000 (N=60) suggests that psychodrama as an adjunct to antipsychotic medication and inpatient care has a beneficial effect on improving negative symptoms of schizophrenia but not positive symptoms. The data is intention to treat data but because the results are not normally

The aim of this study was to carry out a systematic review of controlled clinical trials in order to identify both specific populations and social issues which may benefit from the effective use of psychodrama psychotherapy. A search was conducted in the WoS, SCOPUS, PsychINFO, Medline, Academic Search Ultimate, ProQuest, and PubPsych databases, complemented by a manual search on relevant websites and in the reference lists of the selected studies. Randomized controlled trials (RCTs) and quasi-RCTs of group-based psychodrama psychotherapy were included. The Effective Public Health Practice Project (EPHPP) tool was adopted to assess the methodological quality of the included studies. The search identified 14 RCTs and one quasi-RCT evaluating the effects of group-based psychodrama psychotherapy. The total number of participants in the studies was 642 people. Seven studies were conducted in Turkey, two in the USA, two in Finland, one in Canada, one in Brazil, one in Italy, and one in Iran. The heterogeneity of the issues analyzed indicates that psychodrama improves the symptoms associated with a wide range of problems. Despite psychodrama's long history, most clinical trials in this field have been published this century, which suggests not only that this psychotherapeutic practice remains relevant today but also that it continues to attract substantial interest among the scientific community. Nevertheless, further research efforts are required to understand its potential benefits for psychosocial well-being. A total of 11 principal techniques were identified, namely soliloquy, double, mirror, role reversal, resistance interpolation, sculpture, social atom, intermediate objects, games, sociometry, and role training. Finally, in 2019, Orkibi and Feniger-Schaal [ 24 ] carried out another systematic review covering research using diverse methodologies (qualitative, case studies, controlled trials, single-group designs, etc.) published during the first decade of the 21st century. The review did not focus exclusively on psychodrama, but rather included all methods which use drama as a therapeutic tool, including drama therapy. Inclusion criteria were as follows: (a) participants, no limits were established as regards age (i.e., minors, adults, people Eight treatment groups were created (four psychodrama groups and four analytic groups) along with a control group; the intervention lasted nearly nine months. In the article on sense of coherence, the psychodrama groups were found to improve more quickly during the intervention, although recovery in the analytic groups lasted longer. The changes observed in the study on psychological well-being also affected the control group. However, as in the other study by the same team, these changes were found to occur more quickly in the psychodrama groups but were more stable during follow-up in the analytic groups. Finally, four clinical trials were carried out with community samples. The aim was to help participants develop professional competencies [ 72 , 74 ] or personal strengths that would have a positive impact on their mental health [ 64 , 75 ]. Thus, Özbas and Tel [ 72 ] implemented a program of psychodrama treatment designed to improve the quality of professional care provided by oncology nurses. The aim of the program was to increase perceived levels of psychological and work-related empowerment and decrease burnout levels among nursing staff. The results reported by Dogan [ 74 ] were positive, with psychodrama being found to instill professional competencies such as empathy and self-awareness in students enrolled in a psychological counseling and guidance course. In a previous study, this same author [ 64 ] analyzed the consequences of an intervention on romantic attachment among adults. The aim was to explore the benefits of psychodrama for fostering secure and healthy attachment behaviors. The results revealed significant improvements in one of the dimensions evaluated: anxiety, measured after the treatment, although no differences were observed between the experimental and control groups. Documents deemed ineligible included studies with no control group, trials which used only one specific psychodrama technique, exclusively qualitative studies and controlled trials in which psychodrama was implemented in conjunction with another type of treatment. Furthermore, we also detected a large number of non-relevant studies (31.62% of the initial references returned by the search) related to other topics such as sociodrama, drama therapy, play drama and different artistic or creative methods, etc. Although they use similar techniques, these methods do not correspond fully to what scientific literature understands to be classic psychodrama, which was the object of our study. Secondly, we analyzed those trials in which psychodrama was applied to people suffering from a certain degree of psychological distress, but without reaching the level required for their problem to be considered psychopathology. In these cases, psychodrama was used to help them control their aggressive impulses and defiant conduct (e.g., impulsivity, defiant behavior, parent-adolescent conflicts, etc.) or to reduce the distress caused by the presence of chronic stressors. In studies focusing on aggressiveness, many therapists have used intervention programs in both clinical practice [ 82 ] and controlled research trials [ 4 , 12 , 32 , 83 ]. [ 71 , 73 ] assessed burnout through two modulating variables: sense of coherence and psychological well-being, both of which mitigate burnout and are particularly effective for preventing emotional exhaustion, always under the hypothesis of an inverse relationship existing between the two constructs. The authors highlight the importance of providing this kind of group therapy since it is a cost-effective intervention in the context of medical care; thus, treatment with psychodrama may have a major impact on workers’ mental health.

Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts Si… Systemic therapy seeks to address people not just individually, as is often the focus of other forms of therapy, but in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy and marriage counseling). Community psychology is a type of systemic psychology. The term group therapy was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the US, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S. H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two "Northfield Experiments", which provided the impetus The Oxford English Dictionary defines it as "The treatment of disorders of the mind or personality by psychological means...", however, in earlier use, it denoted the treatment of disease through hypnotic suggestion. Psychotherapy is often dubbed as a "talking therapy" or "talk therapy", particularly for a general audience, though not all forms of psychotherapy rely on verbal communication. Children or adults who do not engage in verbal communication (or not in the usual way) are not excluded from psychotherapy; indeed some types are designed for such cases. Psychotherapy may address spirituality as a significant part of someone's mental / psychological life, and some forms are derived from spiritual philosophies, but practices based on treating the spiritual as a separate dimension are not necessarily considered as traditional or 'legitimate' forms of psychotherapy. == Delivery == Psychotherapy may be delivered in person (one on one, or with couples, with families, or, in groups) or via telephone counseling or online counseling (see also § Telepsychotherapy). Thus psychotherapy initially meant "the treatment of disease by psychic or hypnotic influence, or by suggestion". Sigmund Freud visited the Nancy School and his early neurological practice involved the use of hypnotism. However following the work of his mentor Josef Breuer—in particular a case where symptoms appeared partially resolved by what the patient, Bertha Pappenheim, dubbed a "talking cure"—Freud began focusing on conditions that appeared to have psychological causes originating in childhood experiences and the unconscious mind. He went on to develop techniques such as free association, dream interpretation, transference and analysis of the id, ego and superego. Humanistic psychology can, in turn, be rooted in existentialism—the belief that human beings can only find meaning by creating it. This is the goal of existential therapy. Existential therapy is in turn philosophically associated with phenomenology. Person-centered therapy, also known as client-centered, focuses on the therapist showing openness, empathy and "unconditional positive regard", to help clients express and develop their own self. Humanistic Psychodrama (HPD) is based on the human image of humanistic There are several formal frameworks for evaluating whether a psychotherapist is a good fit for a patient. One example is the Scarsdale Psychotherapy Self-Evaluation (SPSE). However, some scales, such as the SPS, elicit information specific to certain schools of psychotherapy alone (e.g. the superego). Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice. The handbook stated that "little evidence suggests that any one treatment consistently outperforms any other for any specific psychological disorders". This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes. Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions. Systems of Psychotherapy: A Transtheoretical Analysis (9th ed.). Oxford University Press. ISBN 978-0-19-088041-5. Rastogi, Mudita; Wieling, Elizabeth, eds. (2005). Voices of Color: First-Person Accounts of Ethnic Minority Therapists. ISBN 0-7619-2890-1. Slavney, Phillip R. (2005). Psychotherapy: An Introduction for Psychiatry Residents and Other Mental Health Trainees. JHU Press. ISBN 0-8018-8096-3. Wampold, Bruce E. (2019). The Basics of Psychotherapy: An Introduction to Theory and Practice (2nd ed.). American Psychological Association. ISBN 978-1-4338-3019-8.

<h4>Background</h4>Role-playing has been employed across diverse psychotherapeutic traditions, yet no comprehensive synthesis has examined contemporary applications with adult populations and analyzed which theoretical orientations have reported beneficial or positive outcomes and under what implementation modalities.<h4>Objective</h4>This systematic review with narrative synthesis aimed to summarize empirical evidence (2015-2025) on the use of role-playing in adult psychotherapy, examining implementation patterns (clinical populations, design and duration, descriptions of role-playing procedures), therapeutic outcomes, and emerging trends across theoretical frameworks.<h4>Methods</h4>Following PRISMA 2020 guidelines, a systematic search was conducted in PubMed, PsycINFO, Scopus, and Web of Science for empirical studies published between January 2015 and May 2025. Eligible studies included adults (≥18 years) receiving psychotherapeutic interventions that incorporated role-playing or related enactment techniques (e.g., psychodrama, empty-chair technique, behavioral rehearsal), defined as therapeutic interventions in which the therapist assigns and guides the enactment of roles to foster psychological change.<h4>Results</h4>Twenty-six studies met the inclusion criteria. Most (≈77-80%) adopted psychodramatic frameworks, primarily in group settings (73%), addressing conditions such as depression, trauma, substance use, chronic illness, dementia, fibromyalgia, infertility, and complicated grief. Across studies, consistent improvements were observed in symptom reduction, emotional regulation, interpersonal functioning, and empowerment, with preliminary evidence for psychophysiological changes (e.g., cortisol reduction, neural connectivity). Role-playing was most frequently conceptualized within psychodramatic or experiential models, but promising integrative applications combined psychodrama with cognitive-behavioral, emotion-focused, and person-centered approaches.<h4>Co Inclusion criteria Studies were included if: (a) Clinical population: adults (≥18 years) receiving psychotherapy or psychological treatment for clinical or health-related psychological difficulties; (b) Setting: individual or group psychotherapy; in-person or remote; (c) Intervention type: enactment-based psychotherapeutic interventions involving therapist-guided role assumption and enactment; (d) Role of role-playing: role-playing/enactment must represent a central procedural component of the intervention; (e) Type of study: reported empirical data (quantitative, qualitative, or mixed-methods); and were peer-reviewed and published in English between 2015 and 2025; (f) Outcomes: any clinical/psychological outcomes reported. Search strings used: Pubmed (“role play”[tiab] OR “role playing”[tiab] OR “role - playing”[tiab] OR “role enactment”[tiab] OR “identity enactment”[tiab] OR “acting as if”[tiab] OR “as-if technique”[tiab] OR “prescriptive role”[tiab] OR “strategic enactment”[tiab] OR “role reversal”[tiab] OR dramatization[tiab] OR “role playing technique”[tiab] OR “empty chair”[tiab] OR “behavioral rehearsal”[tiab] OR psychodrama[tiab] OR psychodramatic[tiab] OR “drama therapy”[tiab] OR “drama-based”[tiab]) AND (psychotherapy[tiab] OR psychotherapeutic[tiab] OR “psychological treatment”[tiab] OR “psychological intervention”[tiab] OR “clinical psychology”[tiab] OR “counseling psychology”[tiab] OR psychology[tiab] OR psychological[tiab] OR “psychological technique”[tiab]) AND Psychodrama (Moreno-based group psychotherapy) delivered within an institutional treatment program Core (psychodrama constituted the primary therapeutic intervention). Mirroring; doubling; role reversal; soliloquy; auxiliary ego work; protagonist-centered enactments. Group; in-person 21 weekly psychodrama sessions; session duration ranged from 90 min to 2 h Pre–post improvements were reported on measures of psychological distress (CORE-OM), spontaneity (SAI-R), perceived self-efficacy (GSE), and alexithymia (TAS-20). Qualitative analyses (Change Coding System; Helpful Aspects of Therapy) documented perceived therapeutic change processes. 8 Biancalani et al. Group; in-person Twelve-week protocol with weekly group sessions. Case-level analyses indicated clinically significant improvements in depressive symptoms and psychological well-being at post-treatment and follow-up in one case, and improvements in self-esteem and relationship satisfaction at post-treatment (not maintained at follow-up) in the second case. 20 Giacomucci et al. (2022) USA Inpatients in a residential drug and alcohol treatment center enrolled in a specialty trauma track; N = 68 (Cohort 1 pre-pandemic n = 48; Cohort 2 during-pandemic n = 20). Naturalistic mixed-methods pre–post study comparing two non-randomized cohorts (pre-COVID-19 vs. during COVID-19); no randomized control group; qualitative exit survey included. Trauma-focused psychodrama group psychotherapy (Moreno-based) delivered within an inpatient trauma program alongside standard residential treatment services. Core (psychodrama programming constituted the focal intervention evaluated). Group psychodrama programming incorporating sociometry, psychodrama warm-ups, and a full psychodrama enactment session followed by sharing and closure; sessions delivered by a board-certified psychodramatist or supervised trainee. Group; in-person Two psychodrama sessions per week (approximately 1.75 h + 2.75 h; ~4.5 h/week); mean attendance approximately 4.5 sessions per participant (range 2–9 pre-pandemic; 2–8 during-pandemic). Significant pre–post reductions were reported in PTSD symptoms (PCL) and depressive symptoms (PHQ-9) in both cohorts. Post-treatment outcomes were comparable across cohorts after controlling for baseline differences. Improvements in depressive symptoms were greater than those observed in a benchmark group of inpatients who did not participate in psychodrama programming (facility comparison). 21 Grigorescu et al.