Adolescents’ dramatic engagement predicts their in-session productive behaviors: A psychodrama change process study

Accepted Manuscript Title: Adolescents’ Dramatic Engagement Predicts their In-Session Productive Behaviors: A Psychodrama Change Process Study Authors: Hod Orkibi, Bracha Azoulay, Dafna Regev, Sharon Snir PII: DOI: Reference:

S0197-4556(17)30038-2 http://dx.doi.org/doi:10.1016/j.aip.2017.04.001 AIP 1438

To appear in:

The Arts in Psychotherapy

Received date: Revised date: Accepted date:

9-2-2017 27-3-2017 2-4-2017

Please cite this article as: Orkibi, Hod., Azoulay, Bracha., Regev, Dafna., & Snir, Sharon., Adolescents’ Dramatic Engagement Predicts their In-Session Productive Behaviors: A Psychodrama Change Process Study.The Arts in Psychotherapy http://dx.doi.org/10.1016/j.aip.2017.04.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

1 Adolescents’ Dramatic Engagement Predicts their In-Session Productive Behaviors: A Psychodrama Change Process Study

Hod Orkibi Bracha Azoulay Dafna Regev University of Haifa, Israel

Sharon Snir Tel-Hai College, Israel

Author Note Hod Orkibi, Bracha Azoulay, Dafna Regev, Graduate School of Creative Art Therapies, University of Haifa, Israel. Sharon Snir, Tel-Hai College, Israel. This research was supported by Alony-Hetz Ltd. and the Emili Sagol Creative Arts Therapies Research Center. Corresponding author: Hod Orkibi, School of Creative Art Therapies, University of Haifa, 199 Aba Khoushy Av. Mount Carmel, Haifa 3498838, Israel. Ph: + 972.544.393.621, e-mail: [email protected]

2 Highlights

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Psychodrama change process study with adolescents at-risk. Client dramatic engagement (DE) significantly linked with therapist bonding. Greater client DE increased the odds for client in-session productive behaviors. Greater client DE decreased the odds for client resistance in sessions.

Abstract This psychodrama change process pilot study examined the association between client insession dramatic engagement, client in-session behaviors, and the client-therapist therapeutic bond. Sixteen Israeli adolescents at-risk (aged 13-16) received psychodrama group therapy in schools. The findings suggest that over the course of therapy, both insession client dramatic engagement and general client involvement increased significantly. Client dramatic engagement significantly correlated with therapist-reported bonding with the client, but not with client-reported bonding with the therapist. Greater client dramatic engagement increased the likelihood for client in-session productive behaviors (cognitive-behavioral exploration, emotional exploration, insight, and therapeutic change) and decreased the likelihood for client resistance in sessions. The results highlight the possible relationships between change process variables that are understudied in the psychodrama and drama therapy literature. After reviewing the key factors that may increase resistance in adolescents, as well as therapist bonding and engagement strategies, the study limitations and future directions are discussed.

Keywords: Adolescents; client involvement; therapeutic alliance; psychodrama; drama therapy; change process.

3

Adolescents’ Dramatic Engagement Predicts their In-Session Productive Behaviors: A Psychodrama Change Process Study In the last two decades there has been growing interest in psychotherapy research that goes beyond treatment outcomes (Stiles, Hill, & Elliott, 2015). Whereas psychotherapy outcome research inquires whether or not treatment leads to change, psychotherapy change process research inquires how or why psychotherapy leads to change (Elliott, 2010; Kazdin, 2009). The former has been referred to as big “O” (outcome) research on post-treatment assessment of change, and the latter has been dubbed little “o” research on post-session assessment of immediate client change (Greenberg & Pinsof, 1986). The importance of examining how change develops over the course of therapy sessions has consistently been acknowledged by leading psychotherapy scholars (Barber, 2009; Boswell, 2015; Hill, Chui, & Baumann, 2013; Kazdin, 2009). Recent psychotherapy change process research has focused on factors such as the therapeutic relationship, client motivation and expectations, client level of involvement, client in-session behaviors, therapist techniques, therapist adherence, cohesion and climate in group therapy, to name a few (see Gelo, Pritz, & Rieken, 2015; Hill, 2005; Lambert, 2013). The present pilot study examined the links between clients' in-session dramatic engagement and their in-session behaviors in 16 Israeli at-risk adolescents taking part in psychodrama group therapy in schools. The study provides a close examination of three in-session change process variables that have been largely neglected in psychodrama and drama therapy research: client in-session dramatic engagement, client in-session behaviors, and the client-therapist therapeutic bond. Whereas the first factor is specific to

4 drama-based therapies, the two other factors are nonspecific because they are considered “common factors” across many forms of psychotherapy (Asay & Lambert, 1999; Lambert, 2013). Empirical examination that documents and explains client change is crucial to further understanding the possible mechanisms of change in psychodrama and other experiential drama-based therapies. Client Dramatic Engagement Both psychodrama and drama therapy use dramatic techniques and processes for therapeutic change. Both are primarily known as group therapies but have also been applied with individuals, couples, and families (Orkibi, Bar, & Eliakim, 2014). Psychodrama takes place in what J. L. Moreno, the creator of psychodrama, called surplus reality: the reality beyond everyday reality, an extended realm of dramatic action in which clients actively explore their feared or hoped-for past, present, or future. Within this fail-safe reality of play and pretend, clients can explore different ways of coping with problems “without risking serious consequence or disaster, as they might in life itself” (Moreno & Moreno, 1975/2012, p. 19). The Morenian concept of surplus reality is very similar to concepts later introduced by drama therapists such as play space, fantastic reality, and dramatic reality (see Pendzik, 2006). Unlike psychodrama, drama therapy is not based on one theory or a specified set of techniques created by one person. Rather, it covers several theoretical and clinical approaches created by different founders (see Johnson & Emunah, 2009). Clinically, in psychodrama clients typically use role-play to enact themselves, parts of themselves or significant others in their real lives, and hence work more directly on their issues. In contrast, drama therapy is more fantasy-based and clients typically use role-play to enact fictional and symbolic roles, engage in storytelling,

5 puppetry, and rituals to work more indirectly and with greater distance from their issues (for a comparison of the two disciplines see Kedem-Tahar & Kellermann, 1996). In this study, the term dramatic engagement refers to the degree to which a client actively engages with and is immersed in the dramatic activities in a session. Thus the focus is primarily on the observable behavioral indices of engagement. Although this new construct is operationalized specifically for drama-based therapies, it corresponds to a construct termed client involvement which has been widely recognized as a common factor that is important to session- and treatment-level outcomes across theoretical orientations (for a review see Morris, Fitzpatrick, & Renaud, 2016). Evidence linking client involvement to positive outcomes is limited compared to other process variables (Fjermestad, McLeod, Tully, & Liber, 2016). However, psychotherapy research has suggested that client involvement significantly predicts the positive evaluation of sessions, as rated by both adult clients and therapists across different theoretical orientations (Eugster & Wampold, 1996). Adults with greater involvement in the action planning phase of individual dreamwork sessions also reported greater intentions to carry out their action plan outside the session (Wonnell & Hill, 2005). In samples of children and adolescents, the Karver, Handelsman, Fields, and Bickman (2006) meta-analysis found a moderate association between treatment participation (encompassing involvement) and therapeutic outcome across 10 individual and family treatment studies. Another study on individual therapy, not included in this meta-analysis, showed that observer-rated child involvement at mid-treatment was positively associated with diagnostic improvement in primary anxiety disorder, but earlier involvement was not (Chu & Kendall, 2004). In a different study, observer-rated

6 child involvement in early group therapy sessions predicted low anxiety scores at posttreatment but not at follow-up (Tobon et al., 2011). Similarly, initial high levels of child involvement in individual therapy predicted positive clinical improvement in posttreatment and follow-up coping, as well as follow-up teacher reported symptoms (Hudson et al., 2014). In contrast, other studies on individual therapy have not found significant associations between adolescent client involvement and outcomes (Karver et al., 2008; Shirk, Crisostomo, Jungbluth, & Gudmundsen, 2013). To sum up, the findings are mixed and more research is needed. Although psychodrama research is scant, one noteworthy recent drama therapy study

(Armstrong et al., 2016) suggests that dramatic projection and dramatic

embodiment – two core process theorized to account for client change in drama therapy (P. Jones, 2007) – can be consistently identified, and that these processes may lead to higher levels of client experiencing in individual drama therapy. The construct of client experiencing, as commonly measured by the Client Experiencing Scale (Klein, MathieuCoughlan, & Kiesler, 1986), refers to the level and quality of client involvement in the exploration of new feelings, perspectives, and meanings as revealed in verbal expressions. The level of experiencing depth ranges from impersonal, detached, and superficial involvement at the lowest level to purposeful deep exploration of new feelings, perspectives, and meanings at the highest level (Klein et al., 1986). Several narrative reviews have highlighted the empirical association between client experiencing and treatment outcomes in other psychotherapies (Elliott, Greenberg, Watson, Timulak, & Freire, 2013; Hendricks, 2002, 2009). To sum, a recent meta-analysis concluded:

7 “client experiencing is a small to medium predictor of treatment outcomes and a probable common factor” (Pascual-Leone & Yeryomenko, 2016, p. 1). Client In-Session Behaviors Documenting and assessing client behaviors in sessions is essential for a better understanding of the ways in which clients respond to therapist interventions and how clients change over the course of treatment

(Hill, 2001). Using a pan-theoretical

approach, Hill and colleagues developed the Client Behavior System that comprises eight nominal, mutually exclusive behavioral categories theorized to cover all client responses in therapy: four productive behaviors and four less productive behaviors (Hill et al., 1992). The productive behaviors are termed cognitive-behavioral exploration, emotional exploration, insight, and change in therapeutically significant areas. The four less productive behaviors are termed resistance, and three behaviors called “simple responses”; namely, agreement (response indicating understanding or approval of what the therapist has said), appropriate request (response with a request for clarification, information, or advice), and recounting (response with small talk, answers to questions, or factual information about past events). Hill et al. (1992) found that judge-rated client emotional exploration and insight were associated with significantly higher levels of judge-rated client experiencing than resistance, cognitive-behavioral exploration, and the three simple responses. Furthermore, interventions preceding judge-rated resistance and cognitive-behavioral exploration reactions were rated by clients as more helpful than other interventions. Note that according to Hill’s theory, more productive behaviors are expected to increase and less productive behaviors are expected to decreases with time.

8 A study that compared emotion-focused group bibliotherapy with emotionfocused group therapy showed that adult clients in bibliotherapy were less resistant, used fewer simple responses, and employed more emotional exploration. Emotional exploration increased with time, regardless of the type of group.

No significant

correlations were found between clients’ in-session behaviors and their evaluation of session quality (Shechtman & Nir-Shfrir, 2008). In a study on Israeli adolescents, client resistance correlated negatively with both client sense of bonding with the group and bonding with the therapist, whereas emotional exploration and therapeutic change correlated positively with bonding, and a composite score of productive client behaviors correlated positively with academic achievement (Leichtentritt & Shechtman, 2010). A related group therapy study showed that cognitive-behavioral exploration influenced emotional exploration and that both influenced therapeutic change; client behaviors, however, did not have any impact on outcomes (Shechtman & Leichtentritt, 2010). Finally, in a recent psychodrama study on Israeli at-risk adolescents, resistance was negatively associated with gains in social self-concept, whereas emotional exploration and cognitive-behavioral exploration were positively associated with gains in academic self-concept (masked for review). These findings thus call for further clarification of the association between in-session client behaviors and other process variables. Therapeutic Alliance The therapist-client relationship – commonly referred to as the therapeutic or working alliance – is the most widely researched and well-established in-session process variable influencing therapy outcomes (Horvath, Del Re, Flückiger, & Symonds, 2011). The therapeutic alliance is a common factor that includes the collaborative nature of

9 interaction, agreement on goals and tasks, and the personal bond that emerges in treatment (Doran, 2016; Muran & Barber, 2010). A review of the literature suggests that a significant, albeit modest, correlation between therapeutic alliance and client involvement (or experiencing) tends not to emerge in early phases of treatment but rather during the working phase of treatment (Pascual-Leone & Yeryomenko, 2016, p. 11). Hill (2005) argued that the therapeutic alliance and client involvement interact on an ongoing basis throughout therapy. However, one unresolved question is that of directionality and causality; namely, whether a strong alliance promotes greater involvement, whether greater involvement enhances alliance, or whether there is a bidirectional relationship between these factors (e.g., Karver et al., 2008; Morris et al., 2016). Because children and adolescents are often referred for therapy by adults, the therapeutic relationship is even more critical with them than with adults (Meeks & Bernet, 2001). The results of meta-analysis of 23 studies examining associations between therapeutic relationship variables and treatment outcomes in child and adolescent individual and family therapies indicated that the overall strength of the relationshipoutcome associations was modest and similar to results obtained with adults (Shirk & Karver, 2003). In a study on Israeli adolescents, bonding with the therapist contributed to outcomes more than bonding with group members (Shechtman & Katz, 2007). In another study, higher scores on bonding predicted decreased anxiety and aggression as well as increased social competence (Leichtentritt & Shechtman, 2010). In a study on group art therapy, bonding as reported by both child and therapist predicted decreases in childreported internalizing and externalizing behavioral symptoms (Freilich & Shechtman,

10 2010). In a different study on Israeli children and teens (aged 9-14), their reported bonding with the group and bonding with the therapist failed to predict outcomes (Shechtman & Mor, 2010). A meta-analysis of the alliance-outcome relationship in adolescent psychotherapy indicated a modest effect, which seemed to vary according to theoretical and methodological factors across the 38 studies examined (McLeod, 2011). Finally, a recent drama therapy study argued that a strong therapeutic alliance can serve as a foundation for using dramatic techniques that decrease esthetic distance (Henson & Fitzpatrick, 2016). Current Study Hypotheses Based on the above associations between client involvement, client behaviors, and the therapeutic bond, the following hypotheses were formulated and tested: Hypothesis 1: over the course of therapy, client dramatic engagement and client involvement should increase. Hypothesis 2: client dramatic engagement and therapeutic bonding (as perceived by clients and therapists) should be correlated. Hypothesis 3: an increase in client dramatic engagement should increase the likelihood of client productive behaviors and decrease the likelihood of client resistance in sessions. Method Participants This pilot study is part of a larger naturalistic study on the effectiveness of psychodrama and art therapy in the Israeli educational system. The current report focuses on 16 at-risk adolescents (12 boys, 4 girls) aged 13-16 (M = 14.8, SD = 1.04), all of whom were Jewish, 15 of whom were born in Israel and one in Ethiopia. Twelve

11 participants had married parents and 4 had divorced parents. Most participants (n = 14) stated their family’s financial situation was “similar” to that of their peers and “high school” was indicated as the highest education level of most mothers and fathers (56% for each parent). According to the participants, most mothers and fathers had stable employment (56% - 62%, respectively). Procedure The adolescents participated in a weekly 90-minute psychodrama group therapy, which varied in length from 16 to 22 sessions along the school year (as noted in the Data Analysis section, the effects of case differences, including treatment duration were statistically controlled for). There were three therapists: one male with four years of post-graduation experience and two females enrolled in their post-graduation internship year. The therapists reported weekly data on their clients using online data collection software while encrypting client identity with numerical codes. The therapists received weekly individual supervision sessions by a certified psychodrama supervisor and met monthly with the chief researcher to share their experiences of reporting the weekly data. Given the qualifications of the therapists in the current study, “dramatic activities” included more psychodramatic than drama therapeutic work. As in routine practice, the adolescent students were assigned to the treatment groups by school counselors or psychologists based on their assessment of the students’ socio-psychological needs. For this study, the Israel Ministry of Education permitted us to collect naturalistic data from students who had already participated in routine treatment programs rather than running and evaluating a study-specific intervention. Given the naturalistic nature of this study, the psychodrama therapies were not prescribed by

12 protocol. Therapists facilitated the psychodrama intervention according to their best evaluation of participant needs (Sales, Goncalves, Fragoeiro, Noronha, & Elliott, 2007).

Ethical Considerations This study was approved by the Israel Ministry of Education and by the University’s Ethics Committee (approval #211/14). Students gave their verbal assent to participate and parents provided written consent. Each student was assigned a numerical code that was securely guarded by the research team to protect students’ privacy and confidentiality. Students were assured of complete confidentiality and the right to withdraw from the study and/or from treatment at any time without negative consequences. Written consent was also obtained from each therapist.

Measures Dramatic Engagement was measured on a questionnaire designed by the first author for the current study. The questionnaire has two parts. The first part is qualitative, where therapists are asked to “briefly describe in writing the session’s issues, themes, images and metaphors, conflicts, characters, roles (psychological, social, and functional roles: actor, director, audience), dramatic activities and action.” This qualitative part aimed to provide context by describing the dramatic activities and the psycho-esthetic content of the session (not reported here). The second part is quantitative, where therapists are asked to rate, for each client in the group, the extent to which six engagement items were present in the session. The six items were rated on a 6-point scale, from 0 (not at all present) to 5 (very much present)

13 with higher scores representing higher dramatic engagement. The therapists evaluated each client in the group after each session. The scale showed strong internal consistency reliability, with a Cronbach’s alpha of .83. As can be seen in the online supplementary file, there was initial evidence for the scale’s homogeneity, with significant positive item-total correlation ,which is the correlations between each item and the total scale score (Field, 2009). In addition, dramatic engagement significantly correlated with client involvement (B = .31, t = 4.53, p < .001(, providing preliminary evidence for the convergent validity of the new Dramatic Engagement Scale. Future studies should examine inter-rater reliability to assess the extent to which raters are consistent in their observations and scoring. Client involvement was measured with the Child Involvement Rating Scale, a 6item measure of client involvement or participation in a therapy session (Chu & Kendall, 2004). Originally, trained coders used the scale to assesses audiotaped sessions on four items of positive involvement (reflecting behaviors that indicate the child’s active participation in therapy-related tasks; e.g., “does the child initiate discussion or introduce new topics?”) and two reverse-scored items of negative involvement (reflecting behaviors that indicate the child’s withdrawal from, or avoidance of, therapy-related tasks; e.g., “the child is inhibited or avoidant as regards participation”). The items were rated on a 6point scale indicating their presence in the session, from 0 (not at all present) to 5 (a great deal present) with higher scores representing higher involvement.

Because

recorded sessions were not available in the current study due to ethical restrictions, the therapists evaluated each participant after each session. The original version of the scale showed moderately strong internal consistency reliability (α = .73), strong inter-rater

14 reliability (interclass correlation coefficient [ICC] = .76), and moderate retest reliability (ICC = .59; Chu & Kendall, 2004). The current version of the scale showed strong internal consistency reliability with a Cronbach’s α = .93. Bonding was measured on the 12-item Therapeutic Bond subscale of the Working Alliance Inventory (Horvath & Greenberg, 1989) which originally consisted of 36 items measuring three dimensions: agreement on tasks, goals, and bonding between therapist and client. In line with previous studies in Israel, only the third dimension was used, because the other two subscales are less appropriate for therapy with a child or adolescent population (Shechtman & Katz, 2007; Shechtman & Leichtentritt, 2010). On the Therapeutic Bond subscale, both the Therapist form (e.g., “I feel I really understand the client”) and the Client form (e.g., “the therapist and I understand each other”) were administered twice: at the middle and at the end of treatment. The items were rated on a 5-point scale, from 1 (not at all describes my feeling) to 5 (very much describes my feeling) with higher scores representing higher bonding; there are three reverse-scored items. In the current study, internal consistency reliability was α = .82 for the Therapist bonding form, and α = .84 for the Client bonding form. For each form, a change score was used in the analyses. Client behavior in the group was measured on the Client Behavior System that includes four productive behaviors (cognitive behavioral exploration, emotional exploration, insight, and change) and four less productive behaviors (resistance, agreement, appropriate request, and recounting). Whereas the system was originally designed for analyses of transcripts of individual therapy, it has been used successfully in group therapy in several studies on Israeli children and adolescents (e.g., Leichtentritt

15 & Shechtman, 2010). Following Shechtman, and given the small sample size and the lesser importance of the simple responses to the therapy process, we only measured resistance and each of the four productive behaviors. Because transcripts or videos were not available in the current naturalistic study, we also asked the therapists to evaluate each participant on the five behaviors using a ‘‘yes’’ (coded as 1) or ‘‘no’’ (coded as 0) response (Shechtman & Leichtentritt, 2010). The therapists completed the scales after each session for each participant. Data Analysis For Hypothesis 1, to examine the trends in dramatic engagement and client involvement over sessions, the Linear Mixed Models (LMM) approach was used via SAS’s PROC MIXED procedure (A. Jones & Huddleston, 2009), taking into account a nested data structure (i.e., sessions nested in clients, which were nested in therapists). For Hypothesis 2, to examine the relationship between dramatic engagement and therapeutic bond, a similar statistical framework was implemented (i.e., LMM). For Hypothesis 3, because client behaviors are categorical outcome variables, Generalized Linear Mixed Models assuming a binomial residual outcome distribution was applied to examine the likelihood that dramatic engagement predicted the presence of each client's behavior. The odds ratio was calculated to obtain the odds of predicting each client’s behavior by dramatic engagement (Szumilas, 2010). Results and Discussion Hypothesis 1: Trajectories of Dramatic Engagement and Client Involvement Based on therapist-reported data on16 clients, we examined (a) the trajectories in dramatic engagement and client involvement over the course of therapy, and (b) the

16 correlation between these two variables.

As seen in Figure 1, Hypothesis 1 was

supported, in that both dramatic engagement (B = .09, t = 6.00, p < .001) and client involvement (B = .04, t = 3.5, p <.001) showed a significant positive trend over sessions, after controlling for differences in clients, therapists, and number of sessions. These results are reasonable, given the decrease in resistance reported below. Hypothesis 2: Correlation between Dramatic Engagement and Therapeutic Bonding Preliminary analyses indicated that therapist perceived bonding at time 1 (M = 3.96, SD = .75) and time 2 (M = 4.20, SD = .56) increased, but not significantly. A similar pattern was found for client perceived bonding at time 1 (M = 4.48, SD = .42) and time 2 (M = 4.61, SD = .24). There was no significant difference in the overall change scores of client perceived bonding versus therapist perceived bonding, t(10) = .306, p = .77. As for Hypothesis 2, results of Spearman's rho correlation analyses showed that increased dramatic engagement (slope value) correlated significantly and positively with change (increase) in therapist perceived bonding with the client (rs = .50, p = .03). However, dramatic engagement did not correlate significantly with client perceived bonding with the therapist. Thus, Hypothesis 2 was partly supported. These results are not entirely surprising given the fact that dramatic engagement and perceived bonding with the client shared the same (therapist-rated) method of measurement, and measures of the same source indeed tend to correlate more than measures of different sources (Park, Chun, & Lee, 2016), possibly reflecting a common method bias (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). A meta-analysis covering 53 psychotherapy studies showed significant moderate correlations (r = .36) between

17 clients’ and therapists’ ratings of the working alliance where clients’ ratings were higher than ratings by their therapists (Tryon, Collins Blackwell, & Felleman Hammel, 2007). Studies have also shown inconsistent associations between clients’ and therapists’ ratings of alliance and session- as well as treatment-level outcomes, partly because different measures of alliance were used (Atzil-Slonim et al., 2015; Fjermestad, Lerner, et al., 2016; Marmarosh & Kivlighan Jr, 2012; Ormhaug, Shirk, & Wentzel-Larsen, 2015; Zandberg, Skriner, & Chu, 2015). Thus overall, our results are generally consistent with the claim that the therapeutic alliance is associated with client involvement (Hill, 2005; Pascual-Leone & Yeryomenko, 2016). However, the issues of directionality and causality remain unresolved and further investigation is warranted. Furthermore, because it is still not clear whether the adolescent alliance is best assessed from the perspective of the client or an observer, triangulation of multiple perspectives on the alliance such as selfreports with observed behavioral markers (Karver et al., 2008) could shed additional light. Hypothesis 3: Dramatic Engagement and Client Behavior In-session An increase in client dramatic engagement was hypothesized to decrease the likelihood of in-session client resistance and increase the likelihood of in-session client productive behaviors that included cognitive-behavioral exploration, emotional exploration, therapeutic changes, and insight. Because the therapist-reported client behaviors were dichotomous variables, logistic regressions were implemented to examine the probability that dramatic engagement predicted the presence of each client behavior. An odds ratio (OR), which is an effect-size statistic, was calculated to determine the odds of predicting each client's behavior by dramatic engagement, while controlling for the

18 effects of case differences; namely, clients, therapists, and treatment duration (i.e., number of sessions). This served to examine the hypothesis independently of case differences. As seen in Table 1, a one unit increase in the dramatic engagement score predicted about a 4.30 fold increase in the odds of the therapist reporting client cognitivebehavioral exploration. A one unit increase in the dramatic engagement score predicted about a 2.00 fold increase in the odds of the therapist reporting client therapeutic changes. Regarding resistance, a one unit increase in the dramatic engagement score predicted about a 1.43 fold decrease in the odds of the therapist reporting client resistance (calculated as 1/OR 0.70 = 1.43). Note that the 95% confidence interval (CI) was used to estimate the precision of the OR, where a large CI indicates a low level of precision of the OR, and a small CI indicates a higher precision of the OR (Szumilas, 2010). The findings show that dramatic engagement had the highest odds of predicting cognitive-behavioral exploration, followed by therapeutic changes, insight, emotional exploration and, finally, resistance. These findings make sense, given that the Dramatic Engagement Scale focuses primarily on observable behavioral indices of engagement, for example: “The client readily engaged in dramatic exploration of an adaptive behavior/role that is typically less accessible to him/her” (item 5). Here, client engagement with behaviors or roles that are typically less accessible to him or her can be viewed as a session-level therapeutic change. This view corresponds to Azoulay and Orkibi’s (2015) psychodramatic conceptualization of maladaptive behaviors or problems as “roles” –

a term which is intuitively understood

by most clients and is less

pathologizing and stigmatizing. The conceptualization of problems as roles acknowledges clients’ ability to differentiate themselves from their behaviors, step back and reflect on

19 their actions while taking on what Blatner (2006) called the “choosing self” or “metarole” (i.e., the coordinator of all the other roles, the inner-playwright/ director of roles) so as to reevaluate, redefine and modify the different roles they play. The alternation of roles demonstrates role flexibility and client expansion of role repertoire, which is also a primary goal in drama therapy (Landy, 1990). The findings that dramatic engagement predicted a decrease in resistance is consistent with the notion that resistance in psychodrama (and probably other experiential therapies) manifests itself in client reluctance to engage in session activities. In the words of J. L. Moreno, the originator of psychodrama, resistance means “that the protagonist does not want to participate in the production” (Moreno, 1972/1994, p. viii). From a psychodramatic perspective, resistance prevents the client from

warming-up for an

action and inhibits spontaneous action in the here-and-now (Kellermann, 2000). In fact, low spontaneity has been theoretically and empirically associated with high levels of anxiety (Christoforou & Kipper, 2006; Kipper, 2006). Adolescent Resistance and Engagement Generally, because adolescents are often referred to therapy by adults, some can be highly resistant and difficult to engage in treatment. More specifically, several reasons have been highlighted in the literature as to why adolescents may resist psychodrama. These reasons include a lack of sufficient emotional or mental warm-up, viewing roleplaying as childish or silly, embarrassment when being the center of attention, anxiety over performance and public exposure, and because acting like or becoming someone else essentially conflicts with teens' search for self-identity, which characterizes the developmental period of adolescence (Emunah, 1985; Kellermann, 2000).

20 Moreno described several ways to resolve resistance, one of which is through the use of “symbolic situations and roles”, “so that fear of private involvement is eliminated as a cause of resistance” (Moreno, 1972/1994, pp. ix, 338-339). Here Moreno’s use of the term “symbolic” appears to coincide with what drama therapists call “distancing” when referring to instances where clients “play roles that are not themselves within imagined settings that are not their own” (Landy, 1983, p. 368). In this same light, the capacity to lessen distancing in drama therapy has been recently linked to the formation of a strong therapeutic alliance (Henson & Fitzpatrick, 2016) – a relationship that warrants further empirical examination. Karver and colleagues suggested implementing empirically-based strategies to build a therapeutic relationship with adolescents and enhance their engagement in psychotherapy (Karver & Caporino, 2010; Karver et al., 2008). When adapting these strategies for psychodrama, these could include the following: 

Collaborating to set goals;



Validating clients’ feelings and behaviors, but balancing the use of validation with an emphasis on the need for change;



Joining, which involves using clients’ language and style of communication before, after or during dramatic enactment;



Orienting clients to treatment processes and their role in- and between sessions; establishing credibility by providing a rationale for in-session and between session activities;



Adapting dramatic activities in response to individual differences among clients;

21 

Tracing potential causes of resistance to facilitate in-session engagement or between session completion of “homework” or in-vivo (“real-life”) assignments.

Limitations and Future Directions

There are a number of limitations to this study that should be taken into account when interpreting the findings. The small sample size of this pilot study limited the statistical power to examine a mediational model that could detect direct and indirect associations between the process variables. Another limitation is the sole reliance on therapists’ judgments of client in-session behaviors and the lack of videorecorded sessions. Although it has been recognized that “changes in in-session process reflect the most direct and observable changes that the clinician observes” (Hill et al., 2013, p. 75), future studies should strive to include observer ratings of client behaviors and subsequent inter-rater reliability analyses. Finally, while the lack of treatment protocol may limit the replicability of the results, the measures used in this study are indeed applicable to other drama-based studies. Overall, these results highlight the possible relationships between change process variables that are understudied in the psychodrama and drama therapy literature. Does a strong client-therapist bond lead to greater dramatic engagement that in turn increases insession productive behaviors and decreases resistance? Or, perhaps, does greater dramatic engagement enhance the client-therapist bond, which in turn could influence client insession behaviors? Future process research should also examine the ways in which clients respond to different interventions. For example, it would be worth exploring how

22 direct versus distanced dramatic interventions predict client in-session behaviors, as well as client change both within and over the course of sessions.

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33

Figure 1 Trajectories of dramatic engagement and client involvement levels over psychodrama sessions.

34

Table 1 In-session Dramatic Engagement Predicting Client Behaviors Client behaviors

Dramatic Engagement Estimate Odds Ratio

95% CI

Cognitive-behavioral exploration

54.1**

.430

[2.85, 6.46]

Therapeutic changes

0.70**

2.00

[1.51, 2.60]

Insight

0460**

5480

[1.41, 2.30]

Emotional exploration

0.45**

1.60

[1.25, 1.98]

Resistance

– 0.40*

0.70

[0.50, 0.94]

Note. CI = confidence interval. N =16 *p < 0.1, **p < 0.001.