gms | German Medical Science

“People don’t fake depression... they fake being ok!”

Depressive disorders (ICD-10, F32.0 and F32.1), especially unipolar depression, are among the most common and distressing mental illnesses [1]. Depression is a potentially chronic disorder, which is classified under affective disorders according to ICD-10. Depression affects the general quality of life as well as social, physical, and mental functioning. Studies estimate the lifetime risk in adults of developing depression in the course of their life to be over 20% [2]. The occurrence is increasing in Germany and throughout the world and is estimated by the World Health Organization (WHO) to be the “number one widespread disease” by 2030 [3], [4]. An increased risk for depression is particularly associated with people who work hard, function socially, and feel high pressure to perform [5].

Many people experience stress in contemporary social interaction (for example due to lack of close interpersonal relationships and increased use of social media) and react with excessive self-criticism that increases depressive symptoms [6], [7]. Interpersonal behaviors, such as abnormal emotional reactions [8], negative appraisal of emotional events [9], and suppression of emotional expression [9] lead to social isolation, joylessness, feelings of worthlessness, and thoughts of suicide. In 2015, 10,080 people committed suicide in Germany, where the majority occurred because of a lack of treatment [4].

Psychological, social and biological changes accompany a depressive illness. This can mean that everything experienced psychologically in the social environment can be accompanied by changes in brain metabolism. More precisely, the metabolism of neurotransmitters in the brain may be out of balance, e.g., raising blood pressure or serotonin [10]. Therefore, psychotherapeutic treatment is usually supplemented by antidepressants. However, the use of psychotropic drugs does not replace psychotherapy. Specific psychotherapy, such as cognitive behavioral, interpersonal, psychodynamic, and modified analytic therapies, are now part of the “state of the art” treatment. These procedures are recommended in the S3 guideline/national health care guideline for the treatment of unipolar depression by the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology [10].

Another promising treatment is Compassion-Focused Therapy (CFT). This method was developed by P. Gilbert to help people with chronic and complex mental health problems, which are usually associated with high levels of shame and self-criticism [11]. Currently, a growing number of studies (e.g., Neff [12], Kogan at al. [13], Cocker and Canvello [14]) suggest that developing compassion for yourself and others can have a profound impact on physiology, mental health, emotion regulation, and wellbeing [13]. CFT serves to improve interpersonal and social relationships [14]. A study of sixty-nine individuals with unipolar depression, suggests that systematically promoting self-compassion through specific compassion-focused interventions may facilitate a reduction in depressive symptoms by improving the individual's ability to regulate and tolerate their negative emotions [15].

Compassion and self-compassion have been conceptualized from different perspectives. Neff [12] describes self-compassion in terms of the following three components:

1.

Self-kindness: being kind to oneself rather than being too self-critical

2.

Mindfulness: discerning painful feelings in moderation

3.

Shared humanity: seeing your suffering as part of being human and not personal

Neff [12] writes, “In moments when we are suffering, to care for ourselves as we would for a loved one. Self-compassion includes a loving approach to oneself, a sense of human belonging, and mindfulness.” In contrast, Gilbert [16] defines compassion against the background of Buddhist thought as “a sensitivity to suffering in oneself and others, with a commitment to try to alleviate and prevent it” [16]. Compassion-Focused Therapy by Gilbert [16], a current intervention with theoretical and empirical support, offers exercises that alleviate suffering through motivation and intention. Although, as demonstrated, there is ample evidence of the importance of self-compassion in the context of depression, little is known about the potential impact of drama therapy interventions to develop self-compassion.

Drama therapy is the art that facilitates nonverbal communication. The German Association for Dramatherapy (DGfT e.V.) [17] writes: “Drama therapy, through its playful and body-oriented approach, overcomes the limits of rational understanding so that emotional openness can be achieved and new perspectives and new possibilities for action can be accepted.” For these processes, patients and drama therapists enter the dramatic reality (the dramatic reality arises when the players take on a role and also perceive each other in the play as this role in a shared imaginary reality). In this safe experimental space, the encouragement to be aware and cognitive of unconscious inner emotional processes takes place [18]. Dramatic reality is a core concept here, along with the core processes of embodiment (Interaction of body, psyche and environment, our experiences and thoughts influence our bodies) and dramatic projection (stories, symbols, metaphors, puppets, figures etc. create distance to the topic) [19]. Its use as a tool for therapeutic induction of change is considered essential in the literature [18], [19], [20]. Accordingly, the combination of the concept of self-compassion with concepts of drama therapy could be useful in the treatment of depression, because, protected by “so-doing-as-if” (protective space in which to deal with problems or issues), the integration of self-compassion can be experienced as playful and corrective. In dramatic reality, difficult feelings can be confronted and explored in a playful way. Conflicts that are difficult to resolve in everyday life can be tested, experienced and revised in a play with self-compassion.

Furthermore, the present research work should serve to raise the scientific profile of drama therapy in Germany [21]. Based on this, impact studies could be conducted in the treatment of depression. The aim of this research is to develop a drama therapy program for patients diagnosed with depression, with the goal of strengthening self-compassion.

The present study has an inventory design and follows the first four steps of the Intervention Mapping (IM) protocol method according to Bartholomew et al. [22]. The IM is a systematic method for developing, implementing, and evaluating health care interventions through the integration of theoretical and empirical evidence.

The IM protocol describes the path from problem identification to problem resolution and comprises six steps [22]. Completion of the tasks for each step results in a final product that serves as a guide for the subsequent step, such that completion of all steps serves as a blueprint for designing, implementing, and evaluating an intervention based on a foundation of theoretical, empirical, and practical information [22].

1.

Conduct a needs assessment or problem analysis.

2.

Create backgrounds of change targets by linking behaviors with behavioral causes.

3.

Select intervention methods and translate them into practical applications.

4.

Integrate methods and applications into an organized program,

5.

Plan program rollout, implementation, and sustainability.

6.

Create an evaluation plan.

A search was conducted of three databases, HANquest, Google.Scholar and Pubmed by Boolean search, using the search terms “depression”, “self-criticism”, “emotion regulation”, “depression models”, “self-compassion”, “drama therapy”, “psychodrama” and “compassion focused therapy”. Inclusion criteria were articles published between 2010 and 2020 in English or German for population of adults with depression according to DSM-V or ICD-10 in the form of quantitative or qualitative peer-reviewed research, including systematic reviews. Exclusion criteria were studies in languages other than English or German and studies that included children.

A search was conducted of three databases, HANquest, Google Scholar and PubMed^® by Boolean search, using the search terms “depression”, “depression models”, “drama therapy goals”, “determinants of dysfunctional behavioral”, “change targets” and “somatic, cognitive, emotional”. Inclusion criteria were articles published between 2010 and 2020 in English or German for population of adults with depression according to DSM-V or ICD-10 in the form of quantitative or qualitative peer-reviewed research, including systematic reviews. Exclusion criteria were studies in languages other than English or German and studies that included children.

Expert interviews were conducted using a semi-structured guided interview method [23]. Inquiries were published via the websites and newsletters of the German Association for Dramatherapy (DGfT e.V.), the Institute for Drama Therapy (ITT), and the Scientific Society for Artistic Therapies (WFKT). The Linked-In platform was also used to draw attention to this study in Germany, Switzerland and the Netherlands. This resulted in interviews with seven professionally trained drama therapists. All therapists were female (German, Dutch and Swiss nationality) between the ages of 30–55 who worked with depressed people in clinical or outpatient settings for at least four years. To create a pleasant, open and trusting atmosphere, a brief introductory meeting was held so the basis for an in-depth interview could be set. Participants chose their preferred location for the subsequent in-depth interview (at home or in practice rooms). A set of ethical values for interviews was created and communicated to all therapists. All participating drama therapists were informed in writing before interviews that participation was voluntary and that participants could withdraw from the study at any time. Participants were fully and accurately informed of the content of the study and were invited to ask questions. All participants were asked to sign an informed consent form (available for review upon request). The privacy and interests of the drama therapists involved in this study were anonymous. Interviews were conducted individually via Zoom or MS Teams, with an agreement to record. Data collection was based on semi-structured expert interviews [23]. The focus was to collect self-compassion development exercises, intervention methods, and drama therapy objectives applied in the practice field. The interview guide was based on categories of interventions described in the guidelines of the Dutch Association of Professional Therapists [24]. The interviews had a dynamic in-depth character, as the interviewer is an experienced drama therapist and the participants were motivated to share their experiences. Each interview lasted an average of one hour and was recorded and then transcribed [23]. Transcripts were coded, inventoried, and evaluated using the author’s computer program ATLAS.ti. As quality criteria, the transcribed interviews were also in excerpts coded for triangulation by colleagues (master students). To increase objectivity, the transcripts were reviewed and approved by the experts to record the intention of the information collected and analyzed. The data was secured anonymously by colleagues (who were not involved in the study) in the peer debriefing procedure [23]. To ensure the repeatability of the study, a diary was kept.

The theoretical models and inventoried drama therapy exercises of step 3 are translated into a manual for the intervention. The manual is based on information’s from steps 1 to 3. The following books were consulted for program development: therapy tools – self-compassion [25] and drama therapy practice – a collection of exercises [26].

The theoretical drama therapy methods and strategies resulted in a practical and organized intervention, described in the program “Power of Encouragement”.

These four steps that comprise the intervention mapping method used to answer the research question and develop a drama therapy intervention based on the literature review and the analysis of the expert interviews.

The basis for the diagnosis in the German health care system is the ICD-10 (International Classification of Diseases) published by the WHO. Depression is one of the emotional disorders (ICD-10 F 32. and F33). The predominant clinical picture can be described on the one hand by assessing the severity (mild, moderate, severe with psychotic symptoms), and by the frequency (recurrent, chronic or seasonal) [10]. In the S3 Guideline/National Health Care Guideline Unipolar Depression [10] for the treatment of depression (F 32 depressive episode), the following main symptoms and additional symptoms are named:

• Main symptoms: depression, joylessness, decreased drive, increased fatigue.
• Additional symptoms: decreased concentration, self-esteem, and self-confidence with feelings of guilt, worthlessness, pessimistic outlook, suicidal thoughts, self-harm, suicidal acts, sleep disturbances, and decreased appetite.
• Depressive syndromes: 70% of patients suffer from multiple other mental illnesses - such as personality disorders, anxiety disorders, compulsions, eating disorders, addiction, psychophysiological disorders, somatoform disorders, schizophrenia, dementias, and chronic (physical) illnesses [10].
• Therapy: the therapy concept includes care in the acute phase, maintenance therapy after the depressive episode has subsided, and prophylaxis of future episodes. According to the national S3 guideline [10], the general goals of treatment are reduction of depressive symptoms, prevention of mortality (especially through suicide), restoration of occupational and psychosocial performance, recovery of mental equilibrium, and reduction of the probability of relapse.

The development of depression is assumed to be multifactorial. Biological (e.g., genetic predispositions), psychological (e.g., cognitive deficits), and social (e.g., unemployment, partnership problems) factors interact. To date, there is no unified, empirically supported theory of the development of depression [10].

These multifactorial depression models assume an “interaction of dispositional and environmental factors” [27] and focus on learning theory processes in addition to cognitive processes. These models determine the starting point for depression through social isolation, critical life events, and so-called “daily hassles”. Everyday behavior is interrupted by triggering events and spontaneously elicit affective (poorly differentiated) reactions [27]. These reactions bring up negative memories of past events which increase self-awareness, and the experiences are further internalized, from which further self-critical thoughts grow. This critical self-view blocks healthy behavior, which may result in depressive symptomatology because positive reinforcement is absent [27]. In the context of depression, positive (social) reinforcement is absent due to social withdrawal. The social environment increasingly avoids depressives if they complain or ask for help too frequently [28]. Thus, depressive symptoms can be cognitive, emotional, or behavioral [27]. According to vulnerability-stress models [29], depressive disorders arise from the interaction of current or chronic stresses (stressors, precipitating factors) with neurobiological or psychological changes as well as other modifying variables (previous mental disorders, etc.) against the background of a person's predisposition (vulnerability). Thus, it becomes clear that existing models differ in the extent to which biological, psychological, or social aspects are emphasized, as well as in the extent to which therapeutic consequences are to be drawn from them.

Measures against the spread of COVID-19 lead to deficits in care and depression-specific burdens at the time of writing of this study, which meant serious health disadvantages for 5.3 million people with depression in Germany [4]. From September 2020 to February 2021, 5,135 people aged 18–69 years were interviewed for the depression barometer in Germany [4] – 44% diagnosed with depression spoke of worsening illness in the last 6 months

• 16% had a relapse
• 16% experienced worsening depressive symptoms
• 8% had suicidal thoughts or impulses
• 22% of respondents had gone without treatment due to missed specialist appointments [4].

In the Netherlands, drama therapy for depression is included in the national guidelines GGZ Standaarden [30], and in Germany, drama therapy is included in the S3 guideline/national health care guideline Psychosocial Therapies for Severe Mental Disorders [31]. Building on this, in order to continue to help shape the health care system, it is recommended that further research be conducted on the effectiveness of drama therapy interventions in promoting self-compassion and in drama therapy impact studies on depressive symptoms in general. Already proven is the effect of self-compassion by S. Hayen in an art therapy program developed after intervention mapping for patients with personality disorders [32].

To establish program goals and the causes of dysfunctional behavior following section. To follow the above multifactorial models, the different levels (somatic, cognitive, emotional, and behavioral) of the depressive syndrome are listed individually.

The next step determines the most important and modifiable behavioral goals for patients with depression, the reasons from Table 1 [Tab. 1] are summarized into general therapeutic change goals:

• Develop self-compassion
• Experience playfulness
• Develop flexibility in thinking
• Perceive, recognize and, express emotions

These general change goals were translated into more specific performance goals to be taught in drama therapy (see Table 2 [Tab. 2]). The general change goals can be described as follows.

The overall change goals were identified to be: use the active, experimental, and reflexive drama therapy process to help depressed patients to integrate their emotional cognitive and, physical experiences. In particular, the goal was to use the safe “do-as-if” drama therapy space to offer people with depression a playful space in which to:

• Regulate and express unconscious and conscious emotions
• Brighten mood
• Gain symptom relief
• Emotional and physical integration
• Personal growth [19]

Mindful self-compassion creates more courage to make mistakes, and “not be perfect”. The patient knows this is part of the human experience: all people suffer, make mistakes, have shortcomings, and are not the only ones [16]. This common humanity is seen in group therapy, where the individual meets people with comparable life experiences. He experiences that others fear similar situations and have similar thoughts (e.g., “I must be doing something wrong”, “I am incompetent”, “the others don’t like me”). Patients realize they also exhibit feelings of (e.g., fear, shame), physical reactions (e.g., blushing, sweating, trembling), and behavior (e.g., avoidance and safety behaviors). This reinforces a sense of belonging [16].

Gilbert [16] describes that patients can thus develop a compassionate part of their personality, which is associated with the qualities such as wisdom, strength, and commitment. The skills trained in drama therapy, such as concentration, imagination and awareness of behavioral patterns support patients in this process [20].

Strong self-compassion is the powerful, action-oriented side of caring and standing up for yourself, saying no, setting boundaries, feeling self-love, empathy, and mindfulness. Playfulness can be practiced with interactive games for concentration, mindfulness, fostering creativity and the power of imagination [20].

This means that in drama therapy patients learn to better understand and accept internalized reaction patterns (feelings, thoughts, body reactions, behavior) in social situations.

The patient learns to improvise and listen to inner impulses; this enables a reconnection to one's own resources. Creativity requires the ability to change the perspective through different roles – as actor, author, director, spectator, and stage designer, the patient experiences in the “present moment”. Important here is the non-judgmental, warm and benevolent feedback by the qualified drama therapist and the group. The compassionate atmosphere of a group that fosters mutual acceptance and goodwill allows for a change of role and perspective in drama therapy. This in turn provides an opportunity for self-examination [20].

This means that drama therapy possibly, with dramatic reality, offers a safe space wherein patients can face more difficult feelings playfully and with the necessary detachment [19]. Focusing on temporary experiences without judgment, with curiosity and acceptance, feelings that are perceived as threatening and impulsive can be recognized and expressed in the safety of “dramatic reality” [18]. With this mindful attitude, patients with depression can widen their view and in the future be able to realize the positives and not only the negatives [33].

In this step, the general change goals from Step 2 were translated into practical strategies through the selection of theory-based intervention methods. Theoretical foundations and empirically evaluated methods and strategies for these change goals were obtained through literature review and expert interviews. The data from the experts were analyzed, evaluated, and used for program development.

• An inventory of exercises that yielded 119 drama therapy exercises that encourage self-compassion.
• Use of ATLAS.ti to code data according to the following themes (directed by the interview guide): therapeutic attitude, drama therapy goals, general goals, theories and methods, framework conditions, and space. Four experts stated that they worked according to the phases of Emunah, so the investigator decided to ground the program to be developed with this method.

From the interviews with the experts in addition to the literature, it is clear that drama therapy, according to the five phases of Emunah [20] is a suitable method for the target group to develop self-compassion. The reason for this is that the integrative five-phase model of drama therapy is a developmental course of treatment in which the therapeutic process is gradual and progressive, giving patients a sense of gradual unfolding.

The findings from Step 3 were translated by the author (a drama therapist with 20 years of professional experience) into a drama therapy program containing a group intervention. In group therapy, the focus is on interactive dramatic play:

• (Phase 1) Begins with the development of theatrical scenes
• (Phase 2) Progresses to role-playing
• (Phase 3) Addresses personal situations into dramatic enactments
• (Phase 4) Explores core issues and ends with a dramatic ritual
• (Phase 5) Facilitates integration and closure

The use of the integrative five-phase model is eclectic (adapted to the therapeutic situation) and encompasses a wide range of processes, techniques, and healing properties associated with drama therapy. Conducted under the professional guidance of a trained drama therapist [20]. Gilbert's CFT protocol [16] was used as the framework for each program item.

As a result of the expert interviews, an 8-week program was developed (1 per week; 90 min; inpatient or outpatient setting; maximum of 8 participants). The evaluation of the interviews resulted in a clear treatment structure (arrival, warming-up, preparatory exercise, main exercise, compassionate sharing, closing ritual), change goals that are agreed with the patients, and a therapeutic attitude/style that fits the target group and the goals.

Inclusion criteria are: Adults 18 years and older with a diagnosis of depression (mild to moderate). Exclusion criteria are severe depression with psychotic symptoms and acute crises with serious suicidal ideation.

The therapy setting should be transparent, authentic, and safe. The therapeutic relationship is characterized by respectful appreciative interactions, humorous hopeful moments, and a challenge to openly try new things.

The program should be conducted by a trained and experienced drama therapist who has worked with this target group. The drama therapist takes a non-judgmental stance that is not performance-oriented, and focuses on the “play itself”. The drama therapist is energetic, motivating, and able to adapt to the patient’s energy level without identifying with the patient's feelings; he maintains a professional distance. He conveys courage, and hope while strengthening the patient’s resources.

The therapist and patient enter a co-evolutionary process [25]. Neither have all the answers, and the encounter takes place as equally as possible without power imbalance. This creates an atmosphere of encouragement, trust, understanding, and opportunities to communicate crisis or conflict. Participation in drama therapy is voluntary so that a free play and flow moment can occur.

This is a semi-open group in a clinical setting, inpatient and/or outpatient – if possible, also as a closed group. Individual conversations are held with the patients in advance to discuss the method and individual goals and to clarify questions.

The intervention description summarized below is intended for experienced drama therapists. A detailed description of the exercises can be found in the program “Power of Encouragement”, which can be requested from the author. Here is an overview of the program in tabular form, refer to Table 3 [Tab. 3].

This study describes the development of a self-compassion-based drama therapy treatment program aimed at people suffering from depression to be carried out by trained drama therapists. It methodologically followed the first four steps of Intervention Mapping (IM) to develop a theoretically and empirically examined intervention description. It should be emphasized that a compassion-focused drama therapy program for depressed people was developed for the first time in this form. It captures potentially effective methods from drama and compassion-focused therapy for this population and integrates them into an intervention description.

Consideration was given in the development of the intervention description to the incorporation of “change goals” and the prospect of immediate implementation by qualified drama therapists. The program is considered applicable within and outside of the clinical settings within a flexible number of sessions (8–12).

Steps 5 and 6 of the IM method, covering implementation and evaluation, were omitted for reasons of time. The author worked independently on Step 1, although the IM specifies a planning group for this step. Experiences from the perspective of the affected target group were not recorded. The author is an experienced drama therapist and thus decisions may have arisen from established routine experiential knowledge. Interviewer bias is possible for the same reason.

In conclusion, with successful implementation and evaluation of this intervention, a valuable contribution to the treatment of people with depression has been developed. It is recommended that further research be conducted on the effectiveness of drama therapy interventions in promoting self-compassion and in drama therapy impact studies on depressive symptoms in general.

The author declares that she has no competing interests.

My heartfelt THANK YOU, to all who have supported, accompanied, and believed in me on this path, especially in difficult moments.