The Effectiveness of Psychodrama on Life Satisfaction, Self-Compassion, and Positive Emotions in Depressed Patients

Introduction

One of the most common psychological disorders worldwide is depression. According to the World Health Organization (2021), approximately 3.8% of the global population suffers from depression, with a prevalence of 5% in adults and 5.7% in individuals over 60 years old. Based on these statistics, around 280 million people worldwide suffer from this condition (World Health Organization, 2021). Everyone experiences depression, and they can usually attribute it to specific events. Experiences such as job loss or the loss of loved ones can trigger episodes of sadness often accompanied by repetitive negative thoughts. Moreover, failure or lack of success can lead individuals to despair and negative emotions. Sometimes these thoughts and feelings are fleeting, while other times they persist and affect all aspects of a person's life (Ganji, 2022). Life satisfaction (Vasconcelos et al., 2020), self-compassion (Bagheri et al., 2022), and positive and negative emotions (Bahrami et al., 2009) play roles in the onset and persistence of depression, and improving these symptoms leads to a reduction in depression.

According to the World Health Organization, health is a state of complete physical, mental, and social well-being. In reality, health is not merely the absence of disease or physical disability but also includes factors such as life satisfaction, hope for life, and social health. In defining mental health, life satisfaction is associated with positive emotions such as joy, tranquility, vitality, and happiness (Heidarnia, Rad, & Azargashb, 2016).

Life satisfaction is a form of judgment about the overall course of an individual's life. This judgment can create or estimate the level of well-being (Vasconcelos et al., 2020). Life satisfaction can be influenced by factors such as personality traits (Cho et al., 2018, as cited in Hashemi et al., 2023), social relationships (Shahin et al., 2012, as cited in Hashemi et al., 2023), and cultural intelligence (Chen et al., 2020, as cited in Hashemi et al., 2023) and can positively impact physical and mental health (Hashemi et al., 2023). In adults, it is not only a factor in growth and overcoming problems but also a factor in focusing on solutions, thereby improving coping and problem-solving skills (Maknes et al., 2016). This factor is directly related to self-satisfaction and positive emotions and can enhance the quality of life (Senmar et al., 2023), as well as adaptation, health, and stability in social relationships (Boccaccio et al., 2021). Negative emotions towards oneself and depression can reduce life satisfaction (Rogowska et al., 2021).

Self-compassion involves recognizing and responding empathetically and correctly to one's own pain and suffering. It means that individuals should care for themselves as much as they care for others and their problems. Through self-compassion, unrealistic expectations that lead to dissatisfaction are set aside, and individuals empathize with themselves just as they do with others. Self-compassion has three main components: self-kindness, recognition of common humanity, and mindfulness (Salimi et al., 2022).

Ekman et al. (1971) identified six basic emotions that are universal: anger, disgust, fear, happiness, sadness, and surprise. These findings were predicted by Charles Darwin (1872). However, it should be noted that although the facial expressions of emotions are universal, they do not manifest completely and uniformly in all faces (Khosravi, 2016). Later, Lazarus (1991) identified a broader spectrum of emotions, including anger, anxiety, fear, guilt, shame, sadness, jealousy, envy, hatred, happiness, pride, comfort, hope, love, and empathy (Franken, 2020).

Psychodrama is a therapeutic method derived from group therapy. This method emphasizes the here and now and attempts to bring all past conflicts or future concerns into the present, allowing the protagonist to creatively and spontaneously achieve catharsis. Many of the techniques in this method follow the theoretical basis of Gestalt psychology. This therapeutic method can be considered a combination of art therapy, group therapy, and psychotherapy (Perez & Naranjo, 2016). Psychodrama, unlike theater, is not a performance art, and its goal is the protagonist's role selection and transformation. The protagonist's internal conflicts (such as decisions about the future) define the subject, and the protagonist stands at the center of the psychodrama, seen and analyzed, with conflicts and issues resolved through specific techniques and settings chosen by the director. This can be done in a group or individually. Individual psychodrama includes three types: monodrama, where the client plays all roles through role reversal; individual psychodrama, where the director assumes the role of the auxiliary ego; and autodrama, where the client controls all instructions and structure while the director observes. Additionally, individual psychodrama factors (e.g., role reversal, empty chair) can also be employed (Amen & Ebel, 2023). Individual psychodrama or dyadic psychodrama involves the protagonist and director, using empty chairs or props as auxiliary egos. The director, in addition to being the therapist and director, also plays the auxiliary ego role and assists in role reversals. Each session addresses a new topic and conflict, with feedback, idea sharing, empathetic feedback, and efforts to create new perspectives between the protagonist and director (Chesner, 2019). The aim of this research was to investigate the effectiveness of individual psychodrama on life satisfaction, self-compassion, and positive emotions in depressed patients.

Methods and Materials

Study design and Participant

The present research method is quasi-experimental, utilizing a pre-test-post-test design. Among all clients who visited a therapy clinic in Tehran, 30 women aged 25 to 45 years old, who showed a significant level of depression on the Beck Depression Inventory and were clinically diagnosed with depression by a clinical psychologist, were randomly selected from 73 individuals. These participants were clinically interviewed to assess their physical and mental health status (psychological disorder or physical illness). All completed the Diener Satisfaction with Life Scale, Neff Self-Compassion Scale, and Watson and Clark Positive and Negative Affect Schedule. Participants were then randomly assigned to either the experimental or control group (15 participants per group). Treatment sessions followed the individual psychodrama session protocol (Chesner, 2019). The control group received no therapeutic intervention.

The statistical population included individuals showing significant depression levels on the Beck Depression Inventory, diagnosed with depression by a clinical therapist through a clinical interview. From these individuals, 30 were randomly selected and assigned to two groups (control and experimental). Pre-test variables were evaluated using the Diener Satisfaction with Life Scale, Neff Self-Compassion Scale, and Watson and Clark Positive and Negative Affect Schedule. Beck Depression scores were recorded as pre-test depression scores.

In this study, a simple random sampling method from an available sample was employed, with participants randomly assigned to two groups. The sample size was consistent with the standard sample size for intervention studies. Inclusion criteria included:

Women

Individuals showing significant levels of depression on the Beck Depression Inventory

Age range between 25 to 45 years

No serious psychological disorders, history of hospitalization, or specific medication treatments

No severe or incurable physical illnesses

No history of violence, crime, or assault

No history of alcohol or substance abuse

Willingness to participate in the study

Exclusion criteria included:

Absence from sessions

Individuals with very intense emotions and feelings

Minorities or individuals from different cultures

Unwillingness to participate in the study

Measures

Depression

Goldman and Metcalf (1965) determined that a score of 17 differentiates between depressed and healthy individuals. Metcalf also found a high correlation between psychiatric clinical questions and the Beck questionnaire. May et al. (1969) emphasized that this test is diagnostically valid and predictive. Beck, Steer, and Garbin (1988) found internal consistency coefficients ranging from 0.73 to 0.92, with a mean of 0.86 (Beck et al., 1988). A revised Persian version of the BDI reported acceptable and desirable validity and reliability (Amini Faskhodi & Bakhshi Pour Roodsari, 2015).

Self-Compassion

Developed by Neff et al. in 2003, this scale includes 26 items and six components: self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification, rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) (Neff, 2003; Neff et al., 2021; Khosravi et al., 2013).

Positive Emotions

A 20-item tool designed to measure two mood dimensions: positive affect and negative affect, with 10 items for each dimension. Items are rated on a 5-point Likert scale from 1 (very slightly or not at all) to 5 (extremely). It can measure both state and trait affects (Watson et al., 1989, 1999; Abolmasoomi & Saberi, 2014).

Satisfaction with Life

This scale, developed by Diener et al. (1989), measures components of psychological well-being. It is a 5-item scale designed to measure an individual's overall cognitive judgment of life, completed in approximately five minutes. Scoring is on a 7-point Likert scale, with scores ranging from 1 (strongly disagree) to 7 (strongly agree). The total score ranges from 5 to 35 (Diener et al., 1989). Research has shown that the SWLS is useful in Iranian psychological studies (Diener et al., 1989; Abolmasoomi & Saberi, 2014).

Interventions

Psychodrama

According to the protocol, psychodrama involves three stages: warm-up, action, and integration (Amen & Ebel, 2023; Chesner, 2019; Fathi, 2020; Blanner, 2023; Amraei, 2023; 2020; 2019). The only difference in individual sessions is that they do not require familiarity with the group, involving only the director (therapist) and protagonist (client). In individual sessions, more time is allotted for the action stage (Chesner, 2019), and the integration stage concludes with a discussion between the therapist and the client.

Session 1: In the first session, the protagonist is introduced to the director, establishing a therapeutic alliance. The session covers the rules and structure of the sessions, the schedule, setting goals, and forming a contract (either verbal or written). This foundational meeting sets the stage for trust and collaboration throughout the therapy process.

Session 2: The focus is on building intimacy and practicing attention-enhancing exercises. Activities include playing a ball game to enhance sensory and motor precision, performing rhythmic and coordinated movements, practicing breathing exercises, and listing shared therapeutic goals. These activities help in strengthening the therapeutic bond and setting a cooperative atmosphere.

Session 3: This session involves creative activities to foster or increase creativity. The protagonist engages in open-ended questions and divergent thinking exercises, including thinking aloud to vent thoughts and build trust. These exercises help the protagonist in exploring and expressing their inner world more freely.

Session 4: The session emphasizes body awareness, with exercises focusing on breathing and mindfulness of each body part. Activities include writing with the non-dominant hand, balance exercises, and enhancing the five senses, along with relaxation techniques. This fosters a deeper connection with the body and its sensations.

Session 5: In this session, emotions and feelings are expressed non-verbally. The protagonist uses facial expressions, body movements, and pantomime to communicate their emotions without speaking. This exercise aims to enhance emotional awareness and expression through non-verbal channels.

Session 6: The protagonist enters their psychological and cognitive space from their perspective. Exercises include the "magic shop," role-playing as a buyer and seller with role reversals between the director and the protagonist. This fosters understanding of different viewpoints and enhances cognitive flexibility.

Session 7: This session focuses on the protagonist's desires and guided imaginations. The director asks the protagonist to discuss a general topic and use imagination to explore details. This encourages the exploration of hopes and dreams and helps in visualizing positive outcomes.

Session 8: The session deals with confronting fears using the "back-to-the-stage" technique. If a role is challenging or involves anxiety, tension, or taboo subjects, the protagonist performs with their back to the stage. This technique helps in reducing performance anxiety and allows safer exploration of difficult topics.

Session 9: The focus is on creating a sense of security and handling emotional issues. The "future projection" technique is used to visualize and solve potential future problems by emotionally regulating through guided imagery. This helps the protagonist in preparing for and managing future challenges.

Session 10: This session aims to recall conflicting memories and practice assertiveness. Techniques include using supportive, investigative, and critical dual-role exercises and employing the empty chair or props for tension and aggression management. These exercises build courage and problem-solving skills.

Session 11: Creating a safe space for confrontation is the focus, using the "dark corridor" technique. The scene is slightly darkened (though sufficiently lit) to ease the fear of confrontation. This allows the protagonist to perform roles involving shame or fear more comfortably, feeling less visible and thus more secure.

Session 12: The final session uses dual-role techniques and role reversal, fostering catharsis and receiving feedback for developing new perspectives. The protagonist shares emotions and experiences with the director, receiving empathetic feedback. This session consolidates therapeutic gains and fosters a deeper understanding and integration of the therapeutic journey.

Data Analysis

The collected data were analyzed at both descriptive (mean and standard deviation) and inferential levels (repeated measures ANOVA). Calculations were performed using SPSS software.

Findings and Results

The demographic characteristics of the study participants are presented as follows. The sample consisted of 30 women aged between 25 and 45 years. The majority of the participants were between the ages of 30 and 35 (43.33%, n = 13), followed by those aged 36 to 40 (30.00%, n = 9), those aged 25 to 29 (16.67%, n = 5), and the least were in the age group of 41 to 45 years (10.00%, n = 3). All participants were female, as per the inclusion criteria of the study.

The descriptive statistics for the variables of life satisfaction, self-compassion, and positive emotions are presented in Table 1.

The mean life satisfaction score for the experimental group was 26.45 (SD = 3.89), compared to 21.73 (SD = 3.75) for the control group. For self-compassion, the experimental group had a mean score of 28.57 (SD = 4.16), while the control group scored 23.10 (SD = 3.98). The mean score for positive emotions was 31.65 (SD = 4.02) for the experimental group and 25.87 (SD = 3.96) for the control group.

Assumptions for conducting the ANOVA were checked and confirmed. The assumption of normality was tested using the Shapiro-Wilk test, with p-values for life satisfaction (p = .247), self-compassion (p = .142), and positive emotions (p = .217) all indicating that the data were normally distributed. Homogeneity of variances was assessed using Levene's test, with p-values of .329 for life satisfaction, .421 for self-compassion, and .356 for positive emotions, confirming equal variances across groups. Additionally, the assumption of independence was maintained, as participants were randomly assigned to experimental and control groups.

The ANOVA results presented in Table 2 indicate significant differences between the experimental and control groups. For life satisfaction, the F-ratio was 12.69 with a p-value of .001, indicating a significant difference. For self-compassion, the F-ratio was 18.78 with a p-value of less than .001, also showing a significant difference. Positive emotions had an F-ratio of 6.53 and a p-value of .015, indicating a significant difference between the groups.

The Bonferroni post-hoc test results in Table 3 show that the mean differences between the experimental and control groups were significant for all variables. The mean difference for life satisfaction was 4.72 (SE = 1.28, p = .001), for self-compassion it was 5.47 (SE = 1.24, p < .001), and for positive emotions, it was 5.78 (SE = 1.67, p = .015). These results suggest that the psychodrama intervention had a significant positive impact on life satisfaction, self-compassion, and positive emotions in the experimental group compared to the control group.

Discussion and Conclusion

The findings of the research were examined, and the results indicated the effectiveness of individual psychodrama on life satisfaction, self-compassion, and positive emotions in depressed patients. These results align with Chesner's (2019) specialized studies on individual psychodrama (Chesner, 2019). This research is also consistent with the findings of Pedaran (2022). Pedaran (2022) reported therapeutic effects of individual psychodrama in creating better self-feelings, improving couples' behaviors, and increasing marital life satisfaction through consulting ten couples (Pedaran, 2022). Various variables such as motivation, anxiety, self-esteem, and well-being have shown favorable changes with the help of individual psychodrama (Seloum & Daouair, 2024). Life satisfaction also showed significant improvement through psychodrama (Tahvilian et al., 2023; Jiang et al., 2023). This method has even enhanced life satisfaction in individuals coping with death (Rasicchini et al., 2022; Wang et al., 2020).

Although few findings have evaluated the effectiveness of individual psychodrama on psychological disorders, the results of this research are consistent with those of Cohen and colleagues (2013). Cohen et al. (2013) examined the effectiveness of individual psychodrama on an individual with obsessive-compulsive disorder. This case study not only showed a significant reduction in obsessions but also signs of decreased depression and increased empathy and self-kindness (Cohen et al., 2013). The "power of encouragement" integrated interventions aimed at playfulness, cognitive flexibility, and improved emotional expression and awareness to enhance self-compassion through individual psychodrama, leading to improved self-compassion and reduced depressive symptoms (Yanik, 2023). The level of mental health, well-being, happiness, and many human emotions in interpersonal and intrapersonal relationships improved with the help of psychodrama (Dorost & Hodgins, 2022). Ulker (2021) discussed the effectiveness of individual psychodrama on well-being, mental health, happiness, and self-compassion (Ulker, 2021). Self-compassion, intimacy with oneself, self-forgiveness, and enhanced empathy (Parlak & Gul, 2021).

The findings of the present study regarding the effectiveness of individual psychodrama on positive emotions align with the longitudinal studies of Gonzalez et al. (2018). Gonzalez and colleagues, in a case study, examined three women and two men with psychological problems over five years. The longitudinal findings indicated improved mental health, increased spontaneity and self-motivation, reduced psychological problems, a significant decrease in negative emotions and thoughts, increased positive self-feelings, and experiencing positive emotions (Gonzalez et al., 2018).

Numerous studies indicate the direct effectiveness of psychodrama on neurotic disorders, particularly depression (Deaton, 2015; Dehnavi et al., 2016; Erby et al., 2018; Giacomucci et al., 2022; Wang et al., 2020; Testoni et al., 2016, 2020; Sombas & Olsy, 2023). Although this study did not directly address depression, factors such as life satisfaction (Vasconcelos et al., 2020), self-compassion (Bagheri et al., 2022), and experiencing positive emotions (Bahrami et al., 2009) can indirectly affect the level of depression. Since individual psychodrama positively impacted life satisfaction, self-compassion, and positive emotions in this study, it can be said that it is effective in reducing depressive symptoms. This result aligns with the findings of Zalali et al. (2022). Zalali et al. (2022) discussed the effectiveness of psychodrama in individual consultations for neurotic disorders, particularly depression and anxiety (Zalali et al., 2022). In a 2022 study on individuals with Alzheimer's, researchers examined the effectiveness of individual psychodrama and assessed their levels of depression, anxiety, social anxiety, and social avoidance. Individual psychodrama significantly impacted their depression (Brown et al., 2022).

Psychodrama's foundation is based on the "here and now"; all conflicts, desires, experiences, and concerns of an individual, whether related to the past or the future, are reconstructed and enacted in the "here and now" space. Reality transforms into "surreality" or "double reality." Everything is considered real, and with the therapist's support and the help of symbolic props, the individual can enact what they want and need in a safe space, free from judgments, resistances, potential responses, and past experiences. The role-playing must be "creative" and "spontaneous" to achieve greater catharsis. The therapist helps the client or the story's protagonist express more emotions and feelings. Suppressed emotions, unexpressed feelings, compensatory actions for past experiences, and things they wished to repeat can all create greater catharsis in the client.

During therapy sessions, clients initially spoke of the interesting nature of this therapy method and, in most cases, reported feeling better and more comfortable after the sessions. Gradually, these better feelings and increased comfort in expressing emotions and confronting problems or conflicts revealed their latent capabilities in real life. They could bring what they played on stage into their real life and experience it.

Using symbolic stories in Persian literature, familiar metaphors from childhood stories, or those containing past memories, added intimacy and novelty to the therapy sessions, making the "warm-up stage" simple and impactful. In the "action stage," the supportive presence of the therapist or director guided the client's creativity and spontaneity, and clients confidently gained the courage to perform themselves. Nearly all believed that the psychodrama stage was a suitable place to practice and prepare for real life. Most clients reported that what they played on the psychodrama stage with the therapist's help prepared them for better and more realistic performance in real life, and this predictability of events and examination of potential behaviors was a strength for them.

In the "integration stage," everything that transpired in the client's mind, emotions, and role-playing during each session was reviewed and analyzed, uncovering many ambiguities. This stage often led to a change in perspective or the formation of a new insight into matters, clearing many misunderstandings and misinterpretations.

Clients' interest in therapy sessions, the interesting and unpredictable nature of the therapy process, what spontaneously and creatively took shape, practicing and repeating their desirable version, and visualizing real life in a space outside time (bringing the past and future into the present), revealing ambiguous points, and changing perspectives towards events all created a better feeling in the individual towards themselves and their life. Practicing compassionate coping methods with themselves and more empathy increased individuals' self-compassion. During the sessions, they could vent negative emotions, express positive emotions, become more aware of positive emotions within themselves, and express more positive emotions. Ultimately, all these changes, as intermediary variables, could reduce the individual's depression levels.

Limitations and Suggestions

Despite the positive findings, this study has several limitations. The sample size was relatively small, consisting of only 30 participants, which may limit the generalizability of the results. The study was also limited to female participants aged 25 to 45 years, excluding other demographics that might respond differently to individual psychodrama. Additionally, the study relied on self-reported measures, which can introduce bias. The absence of a follow-up period beyond three months restricts our understanding of the long-term effects of psychodrama. Finally, the study did not include a diverse range of psychological conditions, focusing solely on depression, which limits the scope of the findings.

Future research should consider larger and more diverse samples, including both male and female participants from various age groups and different cultural backgrounds. Longitudinal studies with extended follow-up periods would provide more insights into the long-term effectiveness of psychodrama. It would be beneficial to compare the effectiveness of individual psychodrama with other therapeutic modalities across different psychological disorders, not just depression. Additionally, incorporating objective measures, such as physiological indicators of stress and well-being, alongside self-reported data, could provide a more comprehensive understanding of psychodrama's impact. Exploring the mechanisms through which psychodrama influences psychological outcomes would also be a valuable avenue for future research.

The findings of this study suggest that individual psychodrama can be an effective intervention for improving life satisfaction, self-compassion, and positive emotions in depressed patients. Mental health practitioners should consider integrating psychodrama techniques into their therapeutic practices, particularly for clients struggling with depression. Training programs for therapists could include modules on psychodrama to enhance their skill sets. Policymakers and healthcare providers should support the inclusion of psychodrama in mental health treatment plans, recognizing its potential benefits. Additionally, educational institutions could incorporate psychodrama techniques in their curricula to help students develop emotional awareness and coping skills, promoting mental health and well-being from an early age.

Authors’ Contributions

Authors contributed equally to this article.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.

Transparency Statement

Data are available for research purposes upon reasonable request to the corresponding author.

Acknowledgments

We would like to express our gratitude to all individuals helped us to do the project.

Declaration of Interest

The authors report no conflict of interest.

Funding

According to the authors, this article has no financial support.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.