Psychodrama, trauma therapy and post -traumatic stress
Introduction
Psychodrama (PD) is a type of psychotherapy based on theater, psychology and sociology, created by Jacob Levy Moreno in 1921 and which consists of the dramatization of the patient’s psychological conflicts. It is a group format modality, focused on the staging and representation of real or imaginary situations with the objective that patients realize their own thoughts, feelings and behaviors. Each session includes: three contexts (the social, the group and the dramatic);Five instruments (protagonists, scenario, ego-auxiliary, director and audience) and three phases (warming, action and comments). Use techniques such as the role play in which the patient represents a person or object that is problematic for this. Within other main techniques,
This type of psychotherapy can be used for depression management, anxiety disorder, duel, phobias, eating disorders, among other clinical applications. A field in which it has been used is to treat trauma and post -traumatic stress disorder (4). Psychological trauma is considered as the result of having been exposed to a stressful event of threatening characteristics, which can generate psychic discomfort in affected people. One of the most severe sequelae is posttraumatic stress disorder (PTSD) that develops approximately 14% of cases, being more intense in traumatic situations produced by third parties such as war, terrorism, crime, sexual abuse, etc.
Developing.
The PTSD is characterized by a constellation of symptoms after exposure to one or more potentially threatening events for life, in which intrusive memories, avoidance behaviors, autonomic hyperactivity, sleep disorders, mood disorders and negative cognitions are presentedrelated to the traumatic event (7). PREPT has a prevalence throughout life around 1.3 to 12%, according to the social context and the country of residence. The most frequently reported situations as traumatic are accidents, physical and sexual abuse .
Due to the severity of symptomatology, this disorder correlates with a considerable degree of disability that can last for years. Current guides recommend cognitive-behavioral therapy focused on trauma as the first line of treatment and include prolonged exposure, cognitive processing therapy, desensitization and reprocessing with eye movements (EMDR).
However, the failure and abandonment rate of these therapies is high, so alternative modalities such as psychodrama could be useful in favoring trauma management through sensory processes. For this reason, the present study aims.
Methodology
A systematic review of scientific literature was carried out with the objective of evaluating the effectiveness of psychodrama in patients with psychological trauma, acute stress disorder and PTSD.
Search strategy
The bibliographic search was made between the months of February and April 2019 in the medline databases, Embase, Cochrane Central, Scopus, Lilacs and Ovid. To increase the scope of the search, studies were also included from the secondary search in the references of the studies included.
The databases were explored using a combination of the following terms Mesh "Psychodrama", "Role Playing", "Psychological Trauma", "Stress Disorders, Traumatic Acute", "Stress Disorders, Post-Traumatic". The following spanish decs "psychedrama", "paper performance", "psychological trauma", "post -traumatic stress disorder" and "acute traumatic stress disorder" were also used for the search in Lilacs.
Study selection criteria
Systematic reviews of literature, meta-analysis, random, quasiaeative clinical trials and obsevational studies that evaluate the response to the intervention were included. Those made in subjects of any age, with diagnoses of posttraumatic stress, acute stress or psychological traum. The studies had to have been published before April 2019. Case reports were excluded and those studies in which there was no clarity in the inclusion criteria or that had insufficient data.
Selection of studies, data collection and analysis
Two reviewers examined all the titles and summaries of the articles recovered according to the selection criteria independently. Then, the articles were discussed and in those in which doubts were presented, they were chosen in which consensus was reached. The two reviewers made extraction of the data of interest from the studies included using ad hoc standardized forms. All data collection was double and independent. One of the reviewers introduced the data of the calculation sheets forms. If, when doing this, the reviewer found some discrepancy between his information and that of the other reviewer, then a consensus was reached by reviewing the original article.
A total of 324 articles were identified in the systematic search, of which 215 were included for review according to the title and summary. 21 studies were selected for their full text review and these were chosen by the 14 that met the inclusion criteria for the study.The studies found had a publication interval from 1990 to the present. More than half these were made in children and only four were in people over 40 years.
Six of the articles included patients who had clinical diagnosis of PTSD. The rest of the investigations included people who had been exposed to trauma (sexual and physical abuse, family death, family suicide, traumatic events during the war) without having the diagnosis of PTSD. In addition, one of the publications was made in healthy people with anxiety to seek emotional representation of what the concept of "death annihilator" means. The other disorders that accompanied the PTSD in the intervened group included: anxiety, dissociative and somatomorphic disorders.
Discussion
The main objective of this systematic review was to evaluate the effectiveness of psychodrama -based interventions for the treatment of reactions to acute or chronic stress, specifically PPE. With the results it can be concluded that the studies were of low level of evidence for the use of this intervention in the treatment of trauma reactions.
PTSD is the most serious mental pathology associated with exposure to traumatic events. Interventions have been based on reducing symptoms, avoiding dissociation, promoting adaptive coping mechanisms, increasing safety sensation;and pharmacological strategies and psychotherapeutic interventions focused on trauma such as cognitive behavioral therapy and desensitization and reprocessing by eye movements have been used. In addition, other alternative therapies such as psychodrama have been postulated, without consistent evidence .
Although psychodrama is an intervention known since 1921, few studies have been carried out and published, but with methodological limitations (26), such as the size of the sample, that they do not have an adequate monitoring period, which are not randomized, that they do not havecomparator and have been accompanied by other types of psychotherapy . Therefore, it will be necessary that research with greater methodological rigor be designed to be able to define with acceptable evidence the usefulness of this type of therapy. It would be recommended that the next research include randomization, demonstrating the technical skills of the therapist, long -term monitoring, adhesion report, adverse situations and tolerability of treatment. It is important to evaluate the psychodrama without any other accompanying intervention, which would help to define the real impact of it more precision.
The number of individuals intervened in each study was very low, except in a meta -analysis (n = 144), which corroborates the fact that there is little evidence of the effect of psychodrama for emotional reactions to stressful events . Although the psychodrama developed by Moreno has very specific techniques, most studies did not use the same psychodramatic tools systematically. This reinforces the need to homogenize these techniques so that the studies are comparable.
More than half of the publications were made in children and only four were made in people over 40, which shows that investigations have focused on the Etareo group of minors and would be necessary to extrapolate it to adult groups.
As for the results, clarifying that there were no objective scales prior to interventions, some of the studies concluded that there were no significant changes in symptomatology in intervened people. Two of the studies showed contradictory results and the other studies reported that the treatment could better symptoms against trauma and some other associated symptoms, without specifically quantifying these changes.
Based on the findings of this systematic review, the idea is reinforced that there are multiple barriers that prevent strong evidence on the effect of psychodrama on the treatment of symptoms against trauma (30).
Due to the specific particularities of this intervention where artistic, conceptual, doctors (31) are combined, it is necessary to homogenize the variables to determine their real effectiveness. However, in these studies a discreet potential effect is suggested to treat the symptoms generated by trauma.
Conclusions.
In this systematic review there was no evidence of the response to psychotherapy intervention based on psychedrama in the face of stress symptoms after trauma. This technique can be useful in some cases, but sowing adjuvant treatments and has been more studied in children and adolescents. However, research with more rigorous methodological design should be carried out, to know the real impact of this psychotherapeutic technique in the face of symptoms against trauma.
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