1 Introduction

Due to the pandemic situation, the authorities have implemented severe measures. Schools have been closed and online schooling has become the new reality for youth. Some factors such as social distancing and restrictions (quarantine), fear of infection, lack of recreational activities outside of the home and parental stress were considered a risk with regard to emotional and social effects on child and youth development. Several studies from different countries reported a worsening in mental health of children and adolescents due to the Covid-19 pandemic (Fegert et al. 2020). According to Cui et al. (2020), it has been reported that more than 10% of children who have experienced trauma due to the infection and its consequences might be diagnosed with posttraumatic stress disorder (PTSD) in the context of China. Another study that evaluated the impact of Covid-19 on quality of life and mental health in German children and adolescents observed that 70.7% felt burdened by the pandemic, 82.8% reported few social contacts, 39.3% mentioned impaired relationships with friends and 27.6% reported more arguments in the family (Ravens-Sieberer et al. 2021).

Specialized mental health services which care for children and adolescents have managed their best in order to increase mental health and offer therapeutic facilities to identified groups. One of the identified groups deserving our concern consists of the adolescent population, where we can identify numerous potential mental health threats associated with the current pandemic and subsequent restrictions. Adolescence can be characterized as a period of rapid and profound changes in physical, psycho-affective and social development, along with the set of new roles that young people must play in society. Within the pandemic context, the teenager’s social interaction with friends and peers has been restricted. Along with other pandemic consequences previously referred to, these can be risk factors for mental health distress.

According to Moreno (1978, p. 47), “a great deal of psycho- and socio-pathology can be ascribed to the underdevelopment and fear of spontaneity (sponte, free will) and a kind of addictive clinging to old solutions”. “Moreno prescribes spontaneity training as a way to exercise our ability to respond adequately to new situations and learn new responses to old situations” (Baim et al. 2007), spontaneity being a synonym of mental health where Moreno’s theory is concerned. Combining the exceptional pandemic situation with the Moreno model we could theorise that the pandemic situation itself represents a test of our capacity of spontaneity as it asks us to adapt to a very new situation.

We wondered if the Morenian psychodrama approach could be a protective intervention model that potentially enabled teenagers of living what has not yet been lived, matching the desire of trying new roles and making it possible within the therapeutic setting. Morenian psychodrama is today a well-implemented form of psychotherapy based on action. It is preferably carried out in a group and the main attention is given to dramatizing the individual experiences of each participant. The evidence base for psychodrama as a psychotherapy approach is limited. However, a systematic review by Orkibi and Feniger-Schaal (2019) mentioned that psychodrama intervention research in the last decade suggests there are promising results in all methodologies. Also, several authors have already demonstrated that Morenian psychodrama has a positive impact in different areas of human behaviour and in the improvement of symptoms belonging to the psycho-affective sphere (Godinho and Vieira 1999; Kipper and Ritchie 2003).

In October 2020 we started a Morenian psychodrama group for teenagers at an adolescent psychiatry clinic in a public hospital in Lisbon. One of the challenges that we as a therapeutic team and participants encountered was the need to adapt the face-to-face group intervention to the online modality for a period of three months due to pandemic measures. This occurred in January 2021, following after a face-to-face group intervention that also took place during a period of three months. Finally, in April 2021, following the reduction of pandemic restrictions in Portugal, we returned to the face-to-face psychodrama sessions. We carried out a study with six group participants to characterize the spontaneity and clinical status before the group began and over nine months of therapy. As a research question we wondered if psychodrama therapy during a pandemic situation could improve spontaneity and if this could help to mitigate the possible consequent negative effects on youth mental health.

Acknowledgements: Published with the support of the of the Federation of European and Mediterranean Psychodrama Training Organizations (FEPTO).

2 Aims and hypothesis

Our hypothesis was that the psychodrama method improves spontaneity in adolescents, spontaneity being the capacity to “respond with some degree of adequacy to a new situation or with some degree of novelty to an old situation” (Moreno 1964). As specific aims, we questioned if improving spontaneity contributes to a good clinical evolution for adolescents regarding subjective well-being, symptomatology that suggests mental health distress, life functioning and risk of harm. We also intended to understand the impact subjectively perceived by each participant of this same intervention both in face-to-face and online modalities, which simply meant an adjustment to contingency measures imposed by the COVID-19 pandemic.

3 Design

We conducted a pilot, prospective and longitudinal cohort study. The demographic data considered were age and sex. Our primary outcome measure was improving spontaneity in each participant from T0 to T3 (SAI‑R total score, Kipper et al., 2006). The secondary outcome measure was improving subjective well-being, problems/symptoms, life functioning and risk of harm (CORE-OM total score, https://www.coreims.co.uk).

4 Methodology

Participants took part in a Morenian psychodrama group whose activity started on October the 14th, 2020 Each session, which occurred once a week, lasted for ninety minutes. Each participant had to complete two questionnaires before therapy session began at time zero (T0), at three months (T1), at six months (T2) and at the end of nine months of group therapeutic intervention (T3). The questionnaires used were the Revised Spontaneity Assessment Inventory (SAI-R) (Kipper et al., 2006) and CORE-OM (https://www.coreims.co.uk). The collected data was imported into a Microsoft Excel database. The statistical analysis was performed using Microsoft Excel and IBM’s Statistical Package for the Social Sciences (SPSS). We included descriptive analysis and applied Friedman tests to compare the median group score of each scale in four different times (four paired samples).

Instruments

SAI‑R is the only instrument that was built to assess psychodrama specific outcomes and it is meant to measure spontaneity. It consists of an 18-item questionnaire which measures spontaneity in that precise moment. A high index value means great spontaneity. Despite its validity, from a statistical point of view, the results are not very reliable so the situations have to be observed case by case and with great care. “The idea of measuring spontaneity in the form of an action-based spontaneity test was introduced by Moreno more than 6 decades ago” (Kipper et al., 2006). According to this author (Kipper et al., 2006), “observers watched and rated the responses for adequacy, novelty, and speed, and their evaluations formed what Moreno called a spontaneity quotient. Proposing such a test reflected awareness for the need to have a psychometrically valid measure of spontaneity”.

The CORE Outcome measure (CORE-OM) is a client self-report questionnaire designed to be administered before and after therapy. The client is asked to respond to 34 questions about how he/she has been feeling over the previous week, using a 5-point scale ranging from ‘not at all’ to ‘most or all of the time’. The 34 questions have four dimensions: subjective well-being (W), problems/symptoms (P), life functioning (F) and risk/harm (R) (https://www.coreims.co.uk). It is an outcome measure so we cannot assume diagnosis through its results. In any case, we could easily find that participants were having a positive or negative clinical evolution. Male and female CORE-OM cut-off scores between clinical and non-clinical populations according to Evans et al. (2002) are shown in Table 1.

Table 1 Male and female CORE-OM cut-off scores between clinical and non-clinical populations according to Evans et al. (2002). Regarding each subscale (subjective well-being [W], problems/symptoms [P], life functioning [F] and risk/harm [R]), the final score results from dividing the sum of the subscale responses by the number of items in each subscale. CORE-OM scores below the cut-off value suggest an outcome in a non-clinical range. Consequently, results above the cut-off value suggest risk to the clinical situation
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5 Procedure

We conducted a face-to-face or online interview (whenever a face-to-face appointment was not possible) with each adolescent and their parents before the group began. We collected the biographical and clinical history, family background, referral reasons to the group, patient’s expectations and motivations.

We applied the study questionnaires to the selected participants in the face-to-face modality at time T0, T1 and T3. Before the session started, each participant silently and individually filled in both SAI‑R and CORE-OM questionnaires in a different room from the one in which the psychodrama sessions took place. After each participant finished filling out the questionnaires, one of the therapists led them to the psychodrama room. Due to pandemic contingency measures, at T2 we had to apply the questionnaires online. At this time, we emailed each participant the same questionnaires in digital form with answers submission at the end. These were also filled out individually just before the online session started. On average, the time taken to complete both questionnaires was 15 to 20 min.

In order to better understand adolescents’ behaviour with family over time, we contacted their parents every 3 months, during the week of applying the questionnaires.

In addition, at the end of nine months of therapy, we interviewed each participant one by one in face-to-face modality and used a semi-structured questionnaire containing 10 free-answer questions. Each interview took about 30 min. First of all, we intended to know how they were feeling through the experience of belonging to a psychodrama group, the most striking events (dramatization/sharing), the impact on spontaneity, anxiety and depressive symptomatology, and with regard to the resolution of interpersonal problems. Finally, we asked participants about their subjective perception of the impact of therapy in the face-to-face versus online modality.

To manage fidelity, we recorded the techniques we used in each session and discussed the reason they had been chosen with our supervisor (we had ninety minutes of supervision every two weeks).

The present study was approved by the Ethics Committee of the Central Lisbon University Hospital Centre on May the 31st, 2021, who stated that the project presented itself in accordance with the committee’s ethical criteria.

6 Participants

The sample size was for convenience (access to the questionnaire) of n = 6, one male and five female (of whom one was a trans boy). From a total universe of 10 young people that belonged to the group, only 6 participants comprised the group from the initial moment (T0) to the end of nine months of therapy (T3). Thus, these were the participants included in the study. Regarding the remaining, three elements were discharged and another element only joined the group in March 2021. We had no control group. The inclusion criteria were Portuguese patients that speak Portuguese and that had Child and Adolescent Psychiatry counselling at our department. All the participants had to be adolescents aged between 13 to 16 years old. The exclusion criteria were children with intellectual disability (IQ < 70), Autism Spectrum Disorder, Psychosis or recent grief.

Participants included in the therapy group were referred to our psychodrama group from the Child and Adolescent Psychiatry consultation for several reasons. A summarized description of each one follows:

  • Participant 1 (P1): She was a 16-year-old girl who had severe anxiety, panic and conversive crisis daily. She gave up school in January 2020 due to these difficulties. In addition to group therapy, she followed clinical psychology sessions using cognitive behaviour therapy and also took medication (sertraline 100 mg and risperidone 1 mg). She lived with her parents and an older sister aged 23.

  • Participant 2 (P2): He was a 13-year-old boy who entered the group due to generalized anxiety, attention deficit and low autonomy. He also took medication along with group therapy (sertraline 50 mg). He lived with his parents and a younger sister aged 4 years.

  • Participant 3 (P3): He was a 13-year-old trans boy (female sex). He entered the group due to social anxiety and being unable to keep long-term relationships. He also showed lack of impulse control and had a very difficult relationship with his mother. He took medication (paliperidone 6 mg) and had individual psychotherapy along with the group therapy. He lived with his mother. Had no sisters or brothers. His parents divorced when he was 1 year old.

  • Participant 4 (P4): She was a 15-year-old girl with a life story marked by discontinuities. Also, she was not able to keep a relationship. She has been diagnosed with borderline personality disorder and depressive disorder. She took medication (sertraline 50 mg and quetiapine SL 50 mg). She lived with her mother.

  • Participant 5 (P5): She was a 15-year-old girl integrated in the group due to severe anxiety symptoms, body dysmorphia, and constant worries about what other people thought of her. She took medication (bupropion 150 mg) and had individual psychomotricity sessions every fortnight. She lived with her mother and grandmother.

  • Participant 6 (P6): She was a 14-year-old girl who entered the group due to difficulties in relating to her family and friends, anxiety states and symptoms of depression. She had an 18-year-old sister who was hospitalized with a severe oncology disease. P6 took medication (quetiapine 150 mg) and had no other psychotherapy intervention.

7 Results

The study results will be presented in three different phases. First of all, we intend to show each participant’s evolution throughout therapy (individual results). In a next step, we present the description of the group context (group results). Finally, the parents’ feedback and the semi-structured interview qualitative data (parents’ responses and the semi-structured interview results).

Individual results

The SAI‑R and CORE-OM total scores of each participant, at time zero (T0) before therapy began, at three months (T1), at six months (T2) and at the end of nine months of group therapeutic evolution (T3) are shown in Table 2 and Fig. 1.

Table 2 SAI‑R and CORE-OM individual scores at T0, T1, T2 and T3
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Fig. 1
figure 1

Graphics of SAI‑R and CORE-OM scores of each participant at T0, T1, T2 and T3

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Group results

Regarding group results, we will hereafter present the descriptive analysis with mean and standard deviation, median and 25th percentile–75th percentile, minimum and maximum of total score of each scale and CORE-OM subscale across the four moments of the investigation—T0, T1, T2, T3 (Table 3).

Table 3 Descriptive analysis of each scale and subscale across the four moments of the investigation
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In Fig. 2 the SAI‑R total group scores (spontaneity measure) are shown across the four moments of the investigation (T0, T1, T2 and T3).

Fig. 2
figure 2

SAI‑R total group scores at T0, T1, T2 and T3

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When comparing medians, the only scale that had statistical significance was SAI‑R (Friedman test sig. 0.033, p < 0.05). The Friedman test shows that there was a difference in terms of medians of SAI‑R from one group to another. Multiple comparisons between the various times (T0, T1, T2 and T3) have been carried out, where we found that difference was significant from time T2 to T3. Regarding CORE-OM, no difference was found in statistical terms, but in clinical terms there was an improvement from T0 to T3 as can be seen in Table 3, which was relevant.

Parents’ responses and the semi-structured interview results

Every three months we contacted the parents of each participant, at the same time as we provided the questionnaires to the participants. We wanted to know to what extent they had noticed progress, what was the level of interactions between the adolescents and their families and what benefits they could recognize through psychodrama. Overall, the parents’ feedback was encouraging concerning the group’s benefits for their children. They pointed to some positive factors they had observed: motivation to go to the group, feeling of belonging and security within the group, gains in parental communication with their children, increasing self-esteem, ability to think more about other people and the possibility to practice role reversal and role playing.

Regarding data from the subjective impression of the participants returned in the semi-structured interviews carried out by the authors:

  • P1 initially found it difficult to be in the session. She felt exposed to strangers and had frequent panic attacks in the middle of the role-play when she was not the protagonist. Following the sessions, these episodes decreased in intensity and frequency. A member of the group held her hand and whispered a few sentences without interrupting the session. For P1, the most striking moment was a social atom of another colleague with a high emotional charge in which P1 was able to autonomously control and prevent the onset of a crisis. The most positive aspect she felt was being supported by others that prevented her from having a crisis. Also, she said psychodrama gave her insight into aspects of her personality.

  • P2 at first felt difficulty in paying attention to sharing. During the first month he needed to leave in the middle of the sessions and during the online sessions he turned off the camera. He mentioned that the cause of his behaviour was based on an emotional load during the sessions and that this caused him discomfort and anxiety. In the last three months of the face-to-face therapy P2 showed a favourable evolution, he managed to stay in the sessions until the end and found ways to reduce anxiety when tension arose. As an example, he kept a bottle of water under his chair and used to drink some water when he felt anxiety. For P2, the group increased his knowledge of others “by listening to the other’s stories, it helped me to understand certain things in my life, such as the relationship with my parents, I felt I was not the only one to have doubts and fears”.

  • P3, a trans boy aged 13, stated that his most positive impressions of his participation in the group were “observing the personal experiences of others in the drama, not just being me, me, me”. During the first months P3 showed a tendency to be an emerging protagonist in all warmups, becoming more adequate in the process and being able to give more space to others. P3 shared “I felt the total acceptance of the group, especially in a dramatization in which I was the protagonist and we dramatized a situation where I was offended by a stranger on the street for being dressed extravagantly. The group told me that here I would always be accepted as I am, and that made me feel that I really like being here!” A sign of improvement in his telic ability, he said he was not aware that other adolescents could feel so much anxiety and be psychologically distressed, making him feel less alone.

  • P4 understood that others could also go through very difficult situations. She highlighted that the group helped her to find appropriate solutions to the difficulties she had, such as thinking before acting, avoiding episodes of extreme impulsiveness, such as verbal responses to teachers at school. She explained that the psychodrama group helped her in the way she felt and processed her own problems through enactments. The most striking event for her was her own social atom, as she realized the difficulty that she had to put herself in the role of her relative ones. Role reversal technique gave her different perspectives from her own and helped her to understand how others could feel in a conflict situation, she said.

  • P5 shared with the group that she found it difficult to expose herself in front of others because she was always thinking about what others thought of her. This feeling caused in her a lack of spontaneity, in various aspects of her life.

    As the most remarkable event she mentioned a session in which she dramatized a dream of her own with herself as the protagonist. She felt creative and powerful. This self-awareness evoked a significant change in her behaviour in the sessions that followed. She showed much more confidence in herself in the initial warmups and also in socializing with others.

  • P6 shared that “it was a great challenge to participate in the group, I was not a person to expose myself and talk about my problems because I didn’t trust anyone, I really enjoyed feeling that I belonged here and to see that others welcomed what I was sharing”. She reported that listening to the feedback of others about herself helped her to find alternatives to her own behaviours, as they reduced the anxiety she felt about appearing in social contexts.

8 Discussion

Adolescence can be characterized as a period of rapid and profound changes in physical, psycho-affective and social development, along with the set of new roles that young people must play in the society in which they are inserted. The importance of the cultural context, academic and family requirements, as well as current events form the background of psychodrama sessions with adolescents. Şimşek et al. (2019) stated that “the results of controlled studies on psychodrama by therapists who have received a current training on this subject reveal that it is an effective method in the field of child and adolescent psychotherapy with its wide flexibility and expansions in the direction of development, growth and emotional learning”.

If we think of the pandemic situation and its social restrictions as a test to spontaneity in people’s lives, it will not be surprising that we find the quarantine and periods of stricter measures the most challenging ones. Regarding the results of this study, at the beginning (T0), participants showed higher levels of spontaneity (SAI‑R results in Table 2 and Fig. 1) when compared to T2. Also, it is interesting to see from the group results (Table 3), that there was an overall SAI‑R median decrease from T0 to T2 (SAI‑R group median 47.50 at T0; 48.50 at T1; and 38.50 at T2) which suggests a worsening in spontaneity after 6 months of therapy. This happened although we observed improvements in the context of the therapeutic group. We want to highlight the possible impact of the stricter measures implemented in Portugal from January to April 2021 due to the worsening pandemic situation. Then children had to stay at home, were prevented from face-to-face interaction with peers and therefore had online classes. Possibly, these social factors contributed to an impairment in the group’s results at T2. We could also theorise that during the three months that preceded the assessment at T2, the participants were under similar and very particular circumstances, as they stayed confined at home the whole time. Their capacity for spontaneity was tested in real life within their social context. Teenagers who had less developed spontaneity were the ones that we could expect to suffer more during the stricter measures.

From April 2021 onwards, the measures were less strict and as we returned to the face-to-face intervention we continued to test and train spontaneity in different given situations, until the end of the 9 months of psychodrama therapy (T3). We found an improvement in most participants at the T3 assessment. The only scale that had statistical significance was SAI‑R (Friedman test sig. 0.033, p < 0.05), when comparing medians. There was a difference in terms of medians of SAI‑R from time T2 to T3. There were many different reasons that could have contributed to this finding. At first, the pandemic situation imposed rigid measures which is a challenge to spontaneity. According to Moreno’s definition of cultural conserve it is the “category of that which has already been created” but Moreno “saw as a problem the tendency to rely on the conserve” (Baim et al. 2007). In a different way, as it was for public health reasons, but with similar consequences as a rigid cultural conserve, the exceptional pandemic situation consisted in a threat to potentially block the originality and creativity of people. From T2 to T3, the shifts observed in the participants’ spontaneity could reflect the period of “freedom” they felt after confinement, returning to school and also the benefits of resuming the face-to-face psychodrama sessions. We wondered in which way the group, along with the improvement of the pandemic situation at that time, could contribute to this shifting and improving in spontaneity.

Individually, when looking at the SAI‑R scores, an improvement can clearly be identified in spontaneity from T0 to T3 in all participants except participant 5. This is in line with what we, the therapeutic team, observed during sessions. Each participant felt more relaxed, both in the warm-ups and in the possibility of becoming the protagonist in the enactment phase. In addition to the SAI‑R results for P5, which showed a decrease in her spontaneity, we think that, nevertheless, her spontaneity increased in the group context, as she became more participative in an adjusted way. She told the group that she felt positive changes that have been very gratifying for her. It should be noted that the worsening of P5’s SAI‑R and CORE-OM results at T3 took place in a phase when P5 was going through a lot of vicissitudes as she changed school and area (from sciences to arts), and also, she was worried about her grandmother who had COVID-19 at that time with intensive care needs.

When looking at each participant’s CORE-OM total scores (Table 2 and Fig. 1) we observed that at (T0), before the group began, every participant had a total CORE-OM score above the clinical cut-off (see cut-offs in Table 1). By the end of nine months of intervention at T3, only two participants (P2 and P5) showed CORE-OM total high scores above the cohort, one showing improvement with a result slightly above the threshold of clinical risk (P4), and the rest of the participants showing improvement and results outside of the clinical risk range (P1, P3 and P6). Regarding CORE-OM group results, no difference was found in statistical terms, but in clinical terms there was an improvement from T0 to T3 as can be seen in Table 3, which was relevant.

We have taken as much care as possible to involve the families. There is no doubt that the family plays an important role in a child’s identity matrix and the child’s relations with their family are an important part of their lives where role learning/role taking is concerned. As soon as each young person reaches adolescence, she or he recognizes the channels of communication with others that facilitate new roles taking and the establishment of new bonds. Gonçalves (1988) stated that “generally the complaints brought by the parents refer to the attitudes and behaviours of the child that generate complaints in the school/family environment”. By the same author (Gonçalves 1988), “the parents’ difficulties are mainly situated on two levels: 1) that of poor role performance (poorly developed role); 2) that of inadequacy in role performance (quality of performance)”. Considering these, we found the parents’ feedback extremely useful not only with regard to the reflections we made on our therapeutic hypothesis in each session, but also in relation to the possibility of finding other factors which could contribute to the attitude and sharing of our participants in the group.

According to Karp et al. (1998), “tele describes the flow of feeling between people and expresses itself in terms of authentic here-and-now exchanges, or encounters”. From a telic perspective regarding the subjective impression of the adolescents, all participants felt that group involvement encouraged each other’s knowledge about how others function or feel, in a more comprehensive way. As suggested by P1, observing other people’s feelings and suffering made her feel less lonely in her own suffering. Or P3 who, when he realized that other adolescents were in psychological distress, did not feel so alone. Also, P2 came to the conclusion that he was not alone in his doubts and fears. Some group members said that the sessions gave them a greater understanding of themselves. The relational aspect thus resulted as one of the central advantages of the intervention.

Considering the impact in comparing face-to-face and online sessions, all participants thought that face-to-face sessions were more interesting and relevant. However, they also felt that if there was no possibility of having face-to-face sessions, online sessions would be preferred to group suspension. Despite the group’s difficulties in adapting themselves to the online sessions, the continuity provided them with medium- and long-term gains from therapy. The meeting of the various members of the group should be mentioned.

9 Conclusions

The Morenian psychodrama methodology improved SAI‑R total scores (measure of spontaneity) in 5 participants within a group of 6, from T0 (before the therapy began) to the end of nine months of intervention (T3). That was our primary outcome measure. The group median SAI‑R total scores along the therapy process varied, with a scoring incrementation from T0 to T1 (three months of therapy). On the other hand, a worsening from T1 to T2 (six months) was detected, that co-occurred with the striking containment measures. We found improvement in group median SAI‑R total scores at T3, with better results than before therapy began and also with a significant difference when comparing T2 median to T3 median (Friedman test). Regarding individual total and subscale CORE-OM scores, the results varied considerably between participants. We didn’t find better scores generally. Concerning group total CORE-OM scores there was a decrease in the group median from T0 to T3, which suggests a clinical improvement of well-being and symptomatology. The results could not have any statistically significance due to the small sample and the absence of a control group. However, clinically an important improvement was evident. We concluded that Morenian The psychodrama method contributed to a good clinical evolution of 6 adolescents. Also, the parents’ feedback and the participants’ subjective impressions were positive with respect to the hypothesis that psychodrama helped them in different ways. Finally, we understood that the impact subjectively perceived by each participant of this therapeutic intervention was greater with the face-to-face than with the online modality.

As limitations we must mention the small sample and not having a control group. We wondered if the instruments we used were the best option as we clinically perceived improvements that weren’t evident in score results. To manage method fidelity, we think that the process could be more rigorous when using videotaping or doing a systematic checklist with the definition and number of times each technique was applied in a session.

The young participants were in the process of re-enrolling their bonds which we observed not only during the sessions but also through the reports of their families. Finally, we think that Morenian psychodrama contributed to improve the capacity for spontaneity during the COVID-19 pandemic in 5 adolescents. It was not only effective as a method to address the psycho-emotional difficulties of adolescents, but also offered them ways to express themselves and to play new roles within the safe group environment.