Introduction

Worldwide, child and adolescent mental health is worsening (World Health Organisation, 2021) and, as such, there is a growing need for accessible and effective treatments options. Dramatherapy, a creative form of psychotherapy which is currently delivered to a range of groups including children and young people, is under researched but has been shown to be effective in this area. Identifying the active ingredients by which effect is achieved in dramatherapy, is worthwhile. Doing so would allow for the honing of clinical practice, the development of more focused research and the emergence of theory all of which may progress the field and further develop the evidence base. With such prospects in mind, this study aims to identify participant reported active ingredients of dramatherapy via the synthesis of secondary qualitative data.

Following the Covid-19 pandemic, rates of diagnosable mental disorders and levels of mental distress in children and young people have increased dramatically (Samji et al., 2022) from a range of one in nine (11.6%) in 2017, to one in six (17.4%) in 2021 (NHS Digital, 2021). The most common mental disorders experienced by children and young people are emotional disorders characterized by symptoms such as anxiety and depression, closely followed by post-traumatic stress (Merikangas et al., 2010). Experiencing symptoms of emotional disorders can have a profound and detrimental impact on children and young people’s quality of life and on their social and personal development. Reduced school attendance (Finning et al., 2019), social withdrawal (Hards et al., 2022), lack of life satisfaction (Hoseini-Esfidarjani et al., 2022) and, perhaps most severely, suicide (Centers for Disease Control & Prevention, 2022) are just some ways in which symptoms of emotional disorders can affect the lives of children and young people.

A range of accessible and effective mental health treatments are required in order to reduce the long-term human suffering (Kessler et al., 2012) and the significant economic impact (Konnopka & König, 2020) associated with children and young people’s experience of the symptoms of emotional disorders. One treatment which may be useful in such reduction is dramatherapy. Dramatherapy is a creative form of psychotherapy where aspects of drama, such as movement, story and metaphor, are used to facilitate the therapeutic process (British Association of Dramatherapists, 2020). Dramatherapy is one of four arts therapy modalities (alongside music therapy, art therapy and dance movement psychotherapy) and it is accredited in the UK by the Health and Care Professions Council (HCPC). Dramatherapists work in a range of settings; in the UK, just under 50% are employed in schools, 38% are employed in healthcare settings and just over 40% hold private practice (British Association of Dramatherapists, 2022b). Similarly, dramatherapists work with a range of groups including adults with mental illness, people with neurodevelopmental or learning disabilities older people and families to name just a few (British Association of Dramatherapists, 2022b).

Although suitable for work with any age group, dramatherapy is particularly well suited to work with children and young people. Dramatherapy is frequently non-verbal and does not rely on participants expressing themselves in spoken form (Russo, 2018). This is useful as some children and young people, particularly those who are younger, do not have the language skills required to fully express themselves in a verbal manner. Similarly, and depending on the nature of their lived experience, some children and young people may find it traumatic to translate their experience into words and thus, it is safer and preferable to communicate through an art form. Dramatherapy is also an embodied therapy (Dokter, 2016) which encourages both the use of, and one’s connection with, the body in the therapeutic process. Sensorimotor experiences are particularly important for children and young people’s physical and emotional development (Booker, 2011) and they encourage the connection of mind and body experiences. Finally, the creative nature of dramatherapy is also key to its suitability for work with children and young people; being creative allows children and young people to express themselves (Dix, 2015), to stimulate their unconscious mind (Andreasen, 2011) and process their lived and emotional experiences in therapy. Holding space for and encouraging their creativity also allows children and young people to have agency and to experience a sense of empowerment (Ellinor, 2019). Like all therapies, dramatherapy also involves the development of a safe and reliable therapeutic relationship which is particularly important for children and young people; some may not have such a relationship with another adult elsewhere in their life despite such a relationship being critical for healthy social and personal development (Orben et al., 2020). Above all, dramatherapy is client led and offers great choice to participants in the way that they engage with the intervention; this is often of great value when working with children as the agency that young people experience can hold therapeutic value in itself (Jones et al., 2020).

At present, the empirical evidence base for dramatherapy is small but developing. Research into dramatherapy with children and young people, in particular, is a growing area of interest and a number of systematic reviews have recently been conducted. The effect of dramatherapy for children and young people (8–18 years) with emotional distress was recently investigated as part of a systematic review (Keiller et al., 2023). Notwithstanding the need for methodological improvements, this review demonstrated that dramatherapy has clinical promise, particularly for symptom reduction following trauma or for high-level symptoms of emotional disorders. A second review, which sought to identify the effects of dramatherapy for children with a broad range of psychosocial problems has also been conducted (Berghs et al., 2022). Positive effects were found with regards to a range of psychosocial problems and the benefits of dramatherapy to social functioning were also identified. Whilst this review included some studies related to child and adolescent mental health, studies also related to children and young people with conditions such as Asperger’s syndrome, conduct disorder and learning disability; mental health was not a primary focus. The reviews detailed above also revealed a range of effects sizes which point towards variation in effect. Such variation led the authors to question the means by which effect is achieved in dramatherapy and, thus, to conduct the research presented. By utilizing secondary qualitative data, this study seeks to explore active ingredients, as reported by participants, in dramatherapy for children and young people experiencing symptoms of emotional disorders.

Active ingredients are the components of an intervention which are responsible for change. In pharmacological interventions, the active ingredient is responsible for causing the desired effect of a medicine and can be easily identified (Beresford et al., 2018). For complex interventions, which, amongst other things, may be context dependent or involve several interacting elements, identifying active ingredients is more challenging (McCleary et al., 2013). Although challenging, identifying active ingredients for complex interventions, as outlined in the Medical Research Council’s updated guidance on developing and evaluating complex interventions (Skivington et al., 2021) is important. Identifying active ingredients for dramatherapy has the potential to drive significant improvement in both research and treatment. In research, knowing the key factors contributing to effect may allow for the development of more focused research questions, the careful tailoring of interventions and the effective use of time and research funding. Such information can also be used to inform both the hypothesis and design of future trials and, thus, may enhance research quality. In treatment, knowing how and why change occurs can allow clinicians to refine their practice, develop personalized programs and optimize the benefits of dramatherapy to improve treatment outcomes.

Several researchers have begun to identify factors which are hypothesized to contribute to change in the arts therapies. Although existing studies, which focus largely on adults, have not necessarily utilized the term “active ingredients”, synonymous research is steadily emerging. Amongst others, the terms thus far selected by researchers are “change processes”, “change mechanisms”, “therapeutic factors” or “practice principles”. A large scoping review which explored a range of creative arts therapies, identified 19 domains of therapeutic factors which were theorized to produce therapeutic benefit (de Witte et al., 2021). Of the factors identified, three (embodiment, concretization, symbolism and metaphors) were deemed to be unique to the arts therapies. Although important findings, only four dramatherapy-specific studies were included in this review and none related to children and young people. A second study, which related to a number of arts therapy modalities, identified shared principles of the arts therapies via arts-based consensus methods (Carr et al., 2021). A range of common principles such as “engagement, interest and warmth”, “active promotion of group cohesion” and “arousal regulation” were identified. However, there was also limited representation of dramatherapists in this study.

A number of more focused studies have sought to identify change processes in dramatherapy; many of them utilize the core processes of dramatherapy as identified by Jones (1991, 2007, 2016). The nine core processes which, amongst others include “dramatic projection” and “active witnessing” are frequently applied in dramatherapy in order to describe and understand practice (Mayor & Frydman, 2021). According to Jones, they also provide an “inclusive framework to engage with, and account for, change”, (Jones, 2016, p. 78), however, some researchers suggest that questions remain as to whether ‘these core processes impact client change’ (Frydman et al., 2022, p. 9). As such, researchers have applied the framework offered by the core processes to further explore features which may be responsible for therapeutic change in dramatherapy. Such work drew primarily from vignettes (Jones, 2008), case studies (Cassidy et al., 2014) and, in one case, video recordings (Armstrong et al., 2016). Only one study utilized participant perspectives (Cassidy et al., 2017) and none of the studies considered dramatherapy with children and young people. This research acknowledges the core processes as useful descriptors of dramatherapy practice but elects to set these aside in order to work iteratively to identify participant-reported active ingredients of this intervention.

Current Study

This study aimed to develop an understanding of the active ingredients of dramatherapy for children and young people experiencing symptoms of emotional disorders. Whilst existing reviews point towards the potential effect of dramatherapy for emotional distress and psychosocial disorders, little empirical investigation into the active ingredients or mechanisms responsible for such effect have been conducted in this age group. To address this gap, this study synthesized participant-reported qualitative data which was collected during or after dramatherapy interventions. By synthesizing children and young people’s own perspectives regarding their treatment, and by placing their voices at the center of this study, it seeks to obtain rich insight into the experience of dramatherapy. Such insight may also drive subsequent quantitative studies that more directly assess active ingredients as mediators of change. As such, the research question posed in this meta-synthesis was “What do participants report are the active ingredients in dramatherapy when used as a treatment for symptoms of emotional disorders in children and young people?”.

Methods

Study Selection

An exhaustive search for all articles relevant to this synthesis was conducted. A total of seven electronic databases (PsychInfo, PubMed, Scopus, Web of Science, CINAHL, EMBASE and Cochrane) and three journals (Dramatherapy, Drama Therapy Review and Arts in Psychotherapy) were searched in Spring 2022. An updated search was conducted in Spring 2023; this led to the inclusion of one new study.

The patient/population, intervention, comparison and outcomes (PICO) framework was used to identify relevant search terms and the search strategy outlined in Table 1 was employed.

Table 1 Search strategy employed in this review
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Inclusion and Exclusion Criteria

In order to be eligible for this meta-synthesis articles were required to be a) peer reviewed, b) published in English on any date, c) related to children and young people aged 8 to 18 years (or where the mean age of participants fell within this range) and d) about dramatherapy which was used as a treatment for symptoms of emotional disorders. As this is a meta-synthesis, studies were also required to contain direct and / or indirect qualitative feedback that had not been subject to prior analysis (only raw qualitative data was extracted in order to remain as close to participant experience as possible). Studies were not eligible for this synthesis if they did not contain empirical data (for example, therapist reflections) or if they contained only quantitative data.

The age range of 8 to 18 years was selected for this synthesis in line with existing research which suggests that, from 8 years, children’s ability to reliably self-report on their experience is established (Riley, 2004). The upper parameter of 18 was selected in order to reflect the age of majority in most countries as this is typically when children and young people move into adult health services.

Quality Appraisal

Quality appraisal of all studies included in this review was conducted using the Joanna Briggs Institute’s (JBI) checklist for qualitative research (Joanna Briggs Institute, 2020). The JBI qualitative appraisal tool investigates studies in relation to the clear presentation of research methodology and subsequently congruent research questions. It also seeks a clear description of the philosophical approach and the cultural context of the researcher as well as transparent reporting of raw data and clear interpretation of research findings. The appraisal process was completed independently by two reviewers [EK, MT] and rating discrepancies were agreed upon through discussion. No studies were excluded from this synthesis as a result of quality appraisal.

Data Extraction

Data extraction was completed independently by two reviewers [EK, MT] using a piloted data extraction form. Any discrepancies in data extraction were agreed upon via discussion. All qualitative direct and indirect participant feedback on dramatherapy was extracted. In one study (Godfrey & Haythorne, 2013), the parents of children with autism spectrum disorder (ASD) provided written feedback after their child had received dramatherapy. This data was deemed suitable for inclusion in this synthesis as the children and young people to whom it related may not have been able to provide their own feedback due to difficulties in verbal or written communication.

Synthesis Methods

Once extracted, all data was placed into NVivo which is a specialist computer software package for the in-depth analysis of qualitative data.

Thematic synthesis (Thomas & Harden, 2008) was selected for the data analysis as it is inductive (Nicholson et al., 2016) and allows researchers to be guided by data in the development of new theories or hypotheses (Barnett-Page & Thomas, 2009). Thematic synthesis comprises largely of three, somewhat interlinking, stages (Fig. 1). The first stage is line by line coding of the data for context and meaning; this was conducted independently by two authors [EK, AM]. The second stage entails the, previously independent, coders sharing their coding thus far and agreeing upon a shared coding strategy; these codes are known as “descriptive themes”. The data is then recoded, independently, using the agreed codes. Once coded, cross-checks for consistency are completed. In the final stage, the coders are said to “go beyond” (Lachal et al., 2017) the primary data by grouping, or synthesizing, their codes into “analytical themes” (Thomas & Harden, 2008). In this stage, codes which have, until now, remained close to the primary data are transformed into thematic findings which directly address the research question(s). An example application of the coding strategy is presented in Fig. 2.

Fig. 1
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Method of thematic synthesis employed in this review

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Fig. 2
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Example application of coding strategy

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Reflexivity

This research is written and conducted with the understanding that is not effective (Olmos-Vega et al., 2022), nor ethical (Guillemin & Gillam, 2004), to attempt to eliminate researcher subjectivity from qualitative research. Having been loosely guided by Walsh’s (2003) typology of reflexive practices, presented below, in narrative form, is the contextual positionality of the researchers and the tangible impact this has had on this research.

The lead author is a 28-year-old white British woman. She is cis-gendered, heterosexual, able-bodied and without children. Professionally, she is a qualified dramatherapist; she trained in the UK and has previously worked with children and young people in education settings. This professional background, no doubt, affects the neutrality with which she has attempted to analyze the data presented. The second author is a 24-year-old white British woman. She too is cis-gendered, heterosexual, able-bodied and without children. Her area of interest is in arts-based research and she has previously worked with primary school-aged children in a variety of settings. Both authors’ interest in arts has, unequivocally, driven their engagement and enthusiasm for research in this area. Similarly, the value they place on the study’s findings are, no doubt, influenced by their implicit belief in the relationship between arts and health.

The epistemological perspective from which this research was conceived and conducted was largely interpretivist. By adopting an interpretivist approach, the researchers attest that the knowledge, or “truth”, that they seek to uncover is constructed by individuals rather than located in a shared or common “reality” (Hiller, 2016). Amongst other aspects, the research question, method of analysis and presentation of the findings are informed by this interpretivist paradigm.

Culturally, this study took place in a free and democratic society where, in line with the UN Convention on the Rights of the Child (1989), the voices of children are sought out, respected and valued. The centering of children and young people’s perspectives in this study is, no doubt, informed by this cultural outlook. Finally, the study took place in a society in which it is largely agreed that mental wellbeing is important and where population mental health is declining. There is a clear need to develop effective and accessible mental health treatments and the wish to do so informs this study.

Reporting Guidelines

This research adheres to both ENTREQ and SRQR reporting guidelines which support the transparent and in-depth reporting of qualitative research and analysis.

Results

A total of eight studies were deemed suitable for inclusion in this meta-synthesis. A detailed PRISMA flow diagram (Moher et al., 2009), illustrating both the stages and reasons for exclusion of other studies, is provided in Fig. 3.

Fig. 3
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Systematic search process reported according to PRISMA guidelines

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Study Characteristics

The eight studies included in this synthesis varied in their relation to their demographic and characteristic information which can be viewed in Table 2. Of the eight studies, four were published in the UK, one in Canada, one in the USA, one in Italy and one in Germany. The date of the studies ranged from 1987 to 2023, however, only one study predated 2013. All studies included participant (or, in one case, parent) reported qualitative data which was collected during or following a dramatherapy intervention. Of the eight studies, three took place in schools, two in clinical settings, two in residential settings and one in a university building.

Table 2 Characteristics of included studies and nature of data supplied to synthesis
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Population Characteristics

The total number of participants included in this synthesis is 127; of these, 85 were children and young people and 42 were parents. The age of the children and young people ranged between 7 and 18 years and the mean age was approximately 12.4 years. 43 children and young people were female, 33 were male and two were non-binary. The gender of seven children and young people could not be determined. The age and gender of the 42 parents could also not be determined, however, the children for whom they were providing feedback were mixed gender and of primary and secondary school age. Although all studies provided dramatherapy for symptoms of emotional disorders, a range of diagnoses and presenting problems were present in the sample (Table 2).

Synthesis Results

This study sought to determine participant-reported active ingredients in dramatherapy when used as a treatment for symptoms of emotional disorders. In response to this question, qualitative data were extracted and subjected to thematic synthesis. It is important to note that the proportion of data available in each study was not uniform and some studies contributed more data than others. The largest proportion of data (calculated using the number of words contributed) (52%) came from Godfrey and Haythorne’s study (2013) where parents provided feedback following dramatherapy for children with ASD. A breakdown of the data available in the synthesis, and the amount contributed by each study, is illustrated in Fig. 4.

Fig. 4
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Proportion of data contributed to overall synthesis per study

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A total of six analytical themes and twelve descriptive themes were identified via thematic synthesis. The full coding strategy is presented in Fig. 5. Each theme is also presented below alongside informant quotations lifted directly from the included studies.

Fig. 5
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Coding strategy used in synthesis

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Analytical Theme 1: Dramatherapy is a Learning Experience

The first analytical theme which arose from the synthesis was “Dramatherapy is a learning experience”. In the data which informed this theme, participants spoke of transferable skills, developing socially and growing in confidence. In total, this analytical theme was present in six studies and was the largest theme in the synthesis. This analytical theme was made up of three descriptive themes, each of which is presented below, alongside the data with which they were informed.

Building Confidence and Self-Esteem

Growing in confidence was frequently reported by participants as a key ingredient in their dramatherapy. Many children and young people (and parents) spoke of dramatherapy as a place in which they had developed self-esteem and had grown beyond their comfort zone. This descriptive theme was present in five studies.

“D is gaining more confidence and willing to try new things and experiences.” (Godfrey & Haythorne, 2013, p. 27)

“[Dramatherapy is] a way to win shyness.” (Pellicciari et al., 2013, p. 5)

“The group benefited me because it made me confident and I can try out new things in the future.” (Burch et al., 2019, p. 131)

“I am proud and happy” (Birnkammer & Calvano, 2023, p. 16)

Relevance to Life

Dramatherapy as being relevant to life outside of therapy was also present in the data. Participants commented on the usefulness of activities and the value of being able to apply them in their lives. This descriptive theme was present in four studies.

“[The] techniques that can be implemented at any given time.” (McLachlan & Laletin, 2015, p. 84)

“I have taken a lot away from the group which will be helpful in future.” (McLachlan & Laletin, 2015, p. 84)

“It enabled him to explore many issues, but particularly helped address his anxieties about transition to secondary school.” (Godfrey & Haythorne, 2013, p. 26)

“This process showed me what life is like and how you have to overcome obstacles and don’t judge.” (Burch et al., 2019, p. 131)

Introduction to New Skills and Experiences

The final descriptive theme in this category relates to dramatherapy as an introduction to new skills and experiences. Participants spoke of dramatherapy as a means of being exposed to, and trying out, new things and the skills they developed whilst doing so. This code was present in three studies.

“[Dramatherapy offered] a practical approach to develop a variety of skills which he can find challenging in class.” (Godfrey & Haythorne, 2013, p. 25)

“Dramatherapy brings to him a variety of scenarios that would take far longer for him to experience in the real world.” (Godfrey & Haythorne, 2013, p. 26)

“Since attending dramatherapy, A has developed skills as a storyteller and is able to play different characters.” (Godfrey & Haythorne, 2013, p. 26)

In answer to “What did you get from your experience [of dramatherapy]?” “[An] interest in arts.” (Pellicciari et al., 2013, p. 5)

“I discovered my body all new today—like a newborn!” (Birnkammer & Calvano, 2023, p. 16)

Analytical Theme 2: Dramatherapy is Experienced Positively

The second analytical theme which arose from the synthesis was “Dramatherapy is experienced positively”. In data relating to this theme, participants spoke of having fun and liking dramatherapy sessions. Positive associations also arose as participants related to the safety of the space and in the care that they received there.

Safe and Welcoming Space

The largest theme in this category related to dramatherapy as a safe space. Under this code, participants spoke of feeling welcome, included and of dramatherapy as having a calm or pleasant atmosphere. This code arose in two studies.

“Dramatherapy has given J a “safe place” to explore” (Godfrey & Haythorne, 2013, p. 25)

“…a safe and caring environment” (Godfrey & Haythorne, 2013, p. 25)

“H benefitted from 1:1 dramatherapy in a quiet, calm environment.” (Godfrey & Haythorne, 2013, p. 26)

“[There was] a lovely atmosphere” (McLachlan & Laletin, 2015, p. 84)

Fun

Dramatherapy as a place to have fun and enjoy oneself was another theme in this category. Alongside “fun“ participant responses also related to “joking” and feeling happy. This code was applied in four studies.

“They [group leaders] were able to joke around whilst keeping on target.” (McLachlan & Laletin, 2015, p. 84)

In answer to “What did you get from your experience [of dramatherapy]?” “Happiness, fun.” (Pellicciari et al., 2013, p. 5)

“Simon wrote that this therapy had helped him; that he liked everything we did, and it made him happy.” (Moore, 2019, p. 215)

“I take with me today that role-playing is fun!” (Birnkammer & Calvano, 2023, p. 16)

Creative

Dramatherapy as a space in which to be creative and to use one’s imagination also arose in the synthesis. This theme arose in three studies.

“The sessions have also encouraged her to be creative and to use her imagination.” (Godfrey & Haythorne, 2013, p. 25)

“It has allowed him to be creative” (Godfrey & Haythorne, 2013, p. 25)

In answer to “What did you get from your experience [of dramatherapy]?” “Creativity” (Pellicciari et al., 2013, p. 5)

“I can represent something with my body, too!” (Birnkammer & Calvano, 2023, p. 16)

Analytical Theme 3: Dramatherapy Encourages Expression of Self

Dramatherapy as a place where participants can express themselves was the third analytical theme. Participants valued the chance for self- and emotional expression and spoke of having freedom.

Self-Expression and Self-Understanding

Self-expression was prominent in the data and participants spoke, in particular, of dramatherapy as a place in which they could freely express their emotions. Understanding oneself and authentically “being” oneself was also a recurring theme. This code was applied across four studies.

“I have been prompted to think about things such as my values.” (McLachlan & Laletin, 2015, p. 84)

“He has benefited from being able to express himself” (Godfrey & Haythorne, 2013, p. 25)

“He enjoyed being a dinosaur and expressing himself freely and enthusiastically” (Godfrey & Haythorne, 2013, p. 26)

In answer to “What did you get from your experience [of dramatherapy]?”“A way to express emotions [and] know oneself.” (Pellicciari et al., 2013, p. 5)

Freedom/Agency

Having freedom in dramatherapy was also a recurring theme. Participants spoke of having freedom to “be” oneself as well as having freedom, or agency, over how they engaged in dramatherapy. This theme occurred in two studies.

“He has limited play skills and interests and it was a positive experience to be able to explore activities and resources in his own time without adult direction.” (Godfrey & Haythorne, 2013, p. 26)

“He was given the freedom to be himself and this was extremely valuable.” (Godfrey & Haythorne, 2013, p. 26)

In answer to “What did you get from your experience [of dramatherapy]?” “Freedom” (Pellicciari et al., 2013, p. 5)

In answer to “What did you get from your experience [of dramatherapy]?” “Spontaneity” (Pellicciari et al., 2013, p. 5)

Analytical Theme 4: Dramatherapy Supports Emotion Regulation

Dramatherapy as a tool for emotion regulation was the fourth analytical theme which emerged from the data. In relation to this theme, participants spoke of using drama to share and understand themselves and their experiences. Similarly, learning about emotions and the mind–body connection was also present.

Processing Difficult Emotional Experiences Through Drama

Dramatherapy exercises, such as storytelling, supported participants to share their personal stories, communicate fears and to develop confidence. This theme arose in four studies.

“I could tell my own story through my own puppet but nobody knows if it’s a true story or if I made it all up.” (Moula, 2021, p. 21)

“During the show, I had my head down and I was so scared to look up but when I did everything just left. The moment, it was a beautiful moment, I connected with the audience” (Burch et al., 2019, p. 131)

“She can act out anything and this will normally flag up her worries.” (Godfrey & Haythorne, 2013, p. 27)

Psychoeducation

Participants described learning about their mental health and their emotions in dramatherapy; they spoke of understanding how their brain works and of the importance of mindful breathing which is commonly encouraged in dramatherapy.

In answer to “What did you get from your experience [of dramatherapy]?” “To understand one’s own body, to know about the disease mechanisms” (Pellicciari et al., 2013, p. 5)

“[Dramatherapy] is an outlet for him to express his feelings and to understand how to deal with them.” (Godfrey & Haythorne, 2013, p. 26)

In McLachlan and Laletin’s study (2015), where dramatherapy was delivered to female adolescents experiencing anxiety and low mood, participants were asked about their “most meaningful new learning” and identified the following:

“…being aware of the importance of surroundings and experiences ‒ i.e. to shower in a mindful way.” (p. 85)

“…understanding how the human brain works.” (p. 85)

“…the importance of breathing.” (p. 85)

Analytical Theme 5: Dramatherapy is a Social Experience

The social nature of dramatherapy and the importance of it being a shared or relational experience also arose in this synthesis. This analytical theme arose in four studies.

Group and Social Relations

Participants spoke of being cared for by others and making friends through dramatherapy. Participants also spoke of dramatherapy as a space in which they learnt how to be sociable and in which they practiced being alongside others.

“One of the girls summed it up when she said “. . . and I know everyone cares ....” (Mackay et al., 1987, p. 82)

“The sessions have helped her to better understand social interaction and get used to how other children behave without the confines of school.” (Godfrey & Haythorne, 2013, p. 25)

In answer to “What did you get from your experience [of dramatherapy]?” “Learn[t] how to stay with the others” (Pellicciari et al., 2013, p. 5)

“I feel ever since I came to this school, and started ENACT last year, I feel I have developed more socially and been able to make more friends.” (Burch et al., 2019, p. 131)

Analytical Theme 6: Dramatherapists are Professional and Knowledgeable

The final analytical theme related primarily to the role of the dramatherapist. Participants spoke of their dramatherapists as being skilled and knowledgeable and placed value on the therapists’ understanding of their “issues”. This theme arose in three studies.

Professional Knowledge and Support

Alongside their skills and professionalism, the effectiveness of dramatherapists and their willingness to help participants were key themes.

“It was fantastic to have the opportunity to attend a small group activity geared towards his specific requirements and needs with tutors trained to understand him.” (Godfrey & Haythorne, 2013, p. 26)

“As a parent, it has been a relief to receive some positive pro-active support to help L rather than just fire-fighting his problems at school.” (Godfrey & Haythorne, 2013, p. 26)

“In all just a lovely atmosphere with professional advice…” (McLachlan & Laletin, 2015, p. 84)

Quality Appraisal Results

The studies involved in this synthesis were assessed for quality using the JBI checklist for qualitative research (Joanna Briggs Institute, 2020); the results of this assessment are shown in Fig. 6. All studies scored positively with regard to congruity between their stated research methodology, their research question and with the methods used to collect data. All but one study (McLachlan & Laletin, 2015), also scored positively in relation to congruity between their methodology and their representation and analysis of data (for Mackay et al. (1987), this question was deemed not applicable). All studies were deemed to be strong in relation to their interpretation of the results and regarding the coherence with which overall conclusions were drawn. Whilst data was well-handled, bias which related to the wider conduct of studies was present. For example, just three studies, (Godfrey & Haythorne, 2013; Mackay et al., 1987; Moore, 2019) contained a statement which located the researcher culturally or theoretically and only one (Burch et al., 2019) acknowledged the influence of the researcher on the research. Similarly, statements regarding ethical approval were present in only three studies (Birnkammer & Calvano, 2023; Burch et al., 2019; Moula, 2021). Overall, the studies involved in this synthesis were deemed to be methodologically strong; more clarity regarding the conduct of studies and regarding researcher influence was also welcome.

Fig. 6
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Results of JBI quality appraisal assessment

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Discussion

Exploration of the active ingredients of complex interventions such as dramatherapy are warranted in order to improve both clinical application and research (Skivington et al., 2021). Whilst some studies have begun to explore and identify such ingredients for the arts therapies as a whole, and occasionally for dramatherapy, children and young people’s dramatherapy has not been a focus of such research. As such, this meta-synthesis explored secondary qualitative data in order to elicit children and young people’s perceived active ingredients of the intervention. The synthesis revealed a total of six analytical themes and twelve related descriptive themes (Fig. 5). Here, the themes are discussed in the context of dramatherapy practice and research. They are then compared to other leading mental health interventions before the limitations of this study and the potential direction of future research are discussed.

Potential Active Ingredients of Dramatherapy: Benchmarking Against the Broader Arts Therapies

Dramatherapy as a learning experience was a leading analytical theme; the descriptive themes which contributed to this finding were that dramatherapy builds confidence, is relevant to life and introduces participants to new skills and experiences. The second analytical theme was that dramatherapy is experienced positively; descriptive themes were the creation of a safe space, having fun and being creative. Dramatherapy’s encouragement of self-expression also arose as a theme; understanding and expressing oneself and having agency both emerged as descriptive themes. The fourth finding was that dramatherapy supports participants to regulate their emotions; descriptive themes were using drama to process difficult emotional experiences and receiving psychoeducation. The final two themes were that dramatherapy is, importantly, a social experience and that dramatherapists are skilled professionals.

The findings of this synthesis generally correspond to existing dramatherapy literature and to the diverse practice within the field. The first finding of this synthesis, regarding the importance of learning in dramatherapy is supported by recent research by de Witte et al. (2021). In this study, the development of artistic skills (such as those related to music or movement), personal skills (such as those related to behavior and emotional intelligence) and interpersonal skills (such as those related to communication and social connection) were identified as therapeutic factors across the arts therapies. These findings also correspond to the descriptive themes identified in this synthesis such as the importance of dramatherapy as a social experience and the importance of providing psychoeducation. Alongside existing research, common dramatherapy techniques also support these findings. A popular technique, such as role play, exposes participants to a range of experiences (such as social interaction) in which they can learn and develop a multitude of skills. Similarly, with regards to psychoeducation, dramatherapy techniques such as embodiment (Dokter, 2016), breath work (Andersen-Warren et al., 2000) and emotional expression (Dix, 2015) all support participants in this way. Whilst existing research on the arts therapies (most commonly for adults) has identified learning as a key feature, this may be particularly important for dramatherapy with children and young people. Not only do children and young people need to acquire a range of skills in order to become mature and capable adults, but they are also typically more receptive to learning than adult counterparts. Learning skills, such as those outlined above, not only builds children and young people’s self-confidence but also their resilience and their ability to meet and overcome life’s challenges.

The finding, that dramatherapy is experienced as a positive intervention also corresponds with existing arts therapies literature. Although relating primarily to music therapy, a study by Windle et al. (2020) identified that participants experienced group music therapy as “a happy and safe place” (Windle et al., 2020, p. 3). This corresponds with the descriptive theme regarding the importance of creating a safe and welcoming space in dramatherapy. Common features of dramatherapy such as the therapeutic alliance (de Witte et al., 2021), unconditional positive regard (Rogers, 1957) and predictability in session time and space (Roundabout, 2020) also correspond and support this. Working with distance in dramatherapy, or, to apply the language of this synthesis, processing difficult emotional experiences through drama, also creates safety for participants and corresponds with existing research (Cassidy et al., 2017; Jones, 2016). A particularly unique feature of dramatherapy is the presence and use of the “dramatic reality” (Pendzik, 2006). The “dramatic reality” is the realm in which the “make-believe” of dramatherapy takes place; common techniques such as improvisation, puppetry, role-play and enactment all operate here. Exercises in the dramatic reality allow participants to gain distance from their own, often painful, experiences whilst also processing emotional material through creative methods. Creating safety in dramatherapy may be particularly important when working with children and young people who have experienced trauma or anxiety. Calming the nervous system and supporting participants to remain emotionally regulated is something that dramatherapists may wish to actively promote in their sessions; this also may also be an important mechanism to test in future research.

Having fun and being creative (two descriptive themes which also contributed to participants positive experience) are also supported in existing literature. In research by Koch (2017), pleasure, play, joy and fun were deemed to be important factors in the effectiveness of the arts therapies. In dramatherapy practice, and primarily informed by Winnicott’s (1971) work on play, fun is often incorporated into sessions. Exercises such as games (Andersen-Warren et al., 2000), puppets (Moula, 2021) and sand trays (Cassidy et al., 2017) are just a few methods used by dramatherapists to facilitate this. Similarly, participants in this synthesis experienced being creative in dramatherapy as a pleasurable and positive experience. Existing research also affirms the importance of creativity (de Witte et al., 2021) and, as dramatherapy is an inherently creative practice, many aspects of practice, such as improvisation and spontaneous play (Johnson, 1991) inform this. Enjoying dramatherapy (whether having fun through games or creativity) may be particularly important in dramatherapy with children and young people who have symptoms of emotional disorders. Not only does a pleasurable experience potentially improve symptoms such as low mood, but it may also drive and maintain engagement with the intervention. Indeed, previous research has identified levels of engagement as a key feature in the effectiveness of the arts therapies (Cassidy et al., 2017; de Witte et al., 2021).

The importance of encouraging self-expression in dramatherapy also arose in this synthesis and is supported in existing literature (Carr et al., 2021; Koch, 2017). Of particular note for this synthesis, which sought to explore dramatherapy with children and young people, was that having agency, and the ability to make choices arose as a finding. Dramatherapy is a person-centered practice (Ball, 2012) and, according to the British Association of Dramatherapists (2022a), children and young people must provide assent for their participation. In addition, recent literature has posited children as “active agents” in the arts therapies and suggests that empowering children and young people to have a voice in therapy is critical (Jones et al., 2020). Whilst offering and respecting choice is important in dramatherapy with participants of all ages, facilitating agency may be of particular importance to dramatherapy with children and young people. Younger people have typically less agency over their lives than adults and thus, experiencing agency in dramatherapy may be particularly beneficial or enjoyable for this age group.

One active ingredient of dramatherapy that was uncovered by this synthesis relates to dramatherapists themselves. Much like previous research, which has recognized the importance of therapist characteristics and competence (Carr et al., 2021), this synthesis found that therapist knowledge, professionalism and pro-active attitude were regarded as important factors in the therapeutic process. Dramatherapists are trained to Master’s level. During training, they complete 100+hours of in-session training and attend personal and group psychotherapy for at least one year. In the UK, dramatherapists must be registered with the HCPC and, to remain registered, must complete annual continuing professional development. Whilst many of the dramatherapy techniques referred to throughout this discussion may be easily utilized, for example by teachers or care givers, arts therapists are uniquely positioned in having both psychotherapy and arts-based training. The knowledge and skill that is acquired through such training was regarded by participants in this synthesis, as an active ingredient of dramatherapy; those seeking to further develop arts-based interventions such as the arts therapies may wish to note this.

Potential Active Ingredients Of Dramatherapy: Benchmarking Against other Interventions

Alongside identifying active ingredients, this study also sought to understand the unique aspects of dramatherapy and to explore commonalties with other interventions. As such, the findings of this meta-synthesis were benchmarked against existing literature in the field of psychodynamic psychotherapy (Løvgren et al., 2019), cognitive behavioral therapy (CBT) (Ferguson et al., 2023) and against participatory arts interventions (Pote, 2022). This process reflects that of a recent study in which common factors of psychotherapy were used to illustrate specific factors of the creative arts therapies (de Witte et al., 2021). Unlike said study, this synthesis used child-focused studies for this process. Psychodynamic psychotherapy, although often less accessible to children and young people than CBT, is rooted in similar principles to dramatherapy and shares concepts such as transference and the unconscious mind (Holmes, 2001). CBT was selected as a second comparison as it is a leading frontline treatment for children and young people with symptoms of emotional disorders (Saavedra et al., 2010; Yang et al., 2017) however, its effectiveness varies and it is not always accessible. This study also examines dramatherapy against non-clinical arts-based interventions such as art clubs or classes. It was hoped that by exploring both the similarities and differences between these ranging interventions, the active ingredients, which are not only beneficial to children and young people but are also unique to dramatherapy, would be uncovered. The outcome of this benchmarking can be seen in Table 3 and the findings are discussed below.

Table 3 Active ingredients of interventions used for benchmarking (shaded cells represent that the active ingredient was not identified in the literature used for the benchmarking process)
Full size table

In a recent qualitative study, Løvgren et al. (2019) explored adolescent participants’ experiences of psychodynamic psychotherapy. Much like this synthesis, the study sought to determine aspects of the intervention that participants identified as being helpful in their therapeutic process. The six analytical findings of this synthesis were all identified, albeit with slightly different language, in the psychodynamic psychotherapy intervention that they investigated. A key finding for Løvgren et al. (2019) was that participants benefitted from “Focusing on everyday life” in their therapy. Learning (such as how to regulate oneself) and developing practical skills (such as self-care mechanisms) were identified by the adolescents as useful features of the intervention. These findings correlate strongly to this synthesis where the importance of learning via dramatherapy was identified. Similarly, feeling safe in psychotherapy was also identified as being important to the adolescents involved. Safety was cultivated particularly by the adolescents’ trust in the experience and dependability of their therapist; this links with the finding of this synthesis regarding the knowledge, professionalism and pro-active attitude of dramatherapists. A third notable similarity between the two interventions was the development of mental health literacy and psychoeducation; much like the participants in this synthesis, the adolescents valued the opportunity develop insight and learn more about their feelings through psychotherapy. The commonalities identified in these two interventions may be useful to both researchers and clinicians alike; knowing more about the mechanisms of each intervention, particularly what works in each, may effectively inform both future research and practice. However, with a move towards personalized medicine, and in order to ensure the best engagement in the intervention offered to children and young people, the uniqueness of both interventions is also of value.

The second intervention used for the benchmarking process, and one that is commonly offered to children and young people with symptoms of emotional disorders, is CBT. A recent study by Ferguson et al. (2023) explored perspectives of adolescents with depression on their CBT treatment in order to elicit important features of the intervention. Much like in psychodynamic psychotherapy and dramatherapy, adolescents receiving CBT also benefitted from the skills learnt through the intervention and the applicability that it had to life outside of therapy. Also similar were the importance of skilled clinicians, psychoeducation and the trust that is developed between the client and therapist. Interestingly, and unlike in both psychodynamic psychotherapy and dramatherapy, the importance of fostering freedom and self-expression was not identified as being present in CBT. CBT primarily entails the learning and application of techniques to modify thought and behavior and, as such, it may not seek to develop participants self-expression. This synthesis suggests that participants gain therapeutic benefit from expressing themselves. As such, dramatherapists and psychodynamic therapists may wish to maintain this part of their practice. In addition, developing CBT interventions which do encourage participants to express themselves may also be of benefit.

As well as psychotherapeutic interventions, participatory arts interventions, which are not psychotherapeutic in nature but may support participants’ wellbeing and offer therapeutic benefit, were also used in the benchmarking. A recent report, which was commissioned by the Wellcome Trust, explored active ingredients of participatory arts interventions for youth anxiety and depression (Pote, 2022). Just three of the analytical findings from the current synthesis were also found to be present in participatory arts interventions. Whilst relevance to life, the fostering of self-expression and relational experience were present, the fostering of safety, presence of psychoeducation and skill of the facilitator were not. Whilst this does suggest that participatory arts interventions share some useful qualities with the arts therapies (and may be usefully applied for preventative means or in response to mild symptoms of emotional disorders), it also points towards the importance of having professionals, who are adept in both psychotherapy and the arts, when delivering high-level or complex mental health interventions.

Whilst the six analytical themes identified in this synthesis are present, in part, in other interventions, a number of the descriptive themes were deemed to be unique to dramatherapy. The importance of having fun, for example, which was a finding of this synthesis was not present in the CBT, psychodynamic or participatory arts literature used for this benchmarking. Being a “fun“ intervention may be a unique active ingredient of dramatherapy and thus, dramatherapists, particularly those who work with children and young people, may wish to harness this aspect of their work. Similarly, building confidence and processing difficult emotional experiences through drama were also unique to dramatherapy and may be harnessed as such. The importance of the social or relational aspect of the intervention was present in the CBT, psychodynamic and participatory arts interventions. However, in both CBT and psychodynamic psychotherapy, the relationship was deemed to exist primarily between therapist and client; for arts interventions, the relationship is primarily between participants. Dramatherapy, in particular, as offering both the therapeutic relationship and interpersonal relationship with other group members is particularly adept in this area. In addition to these triadic interpersonal relationships, dramatherapy also offers the triangular or multi-dimensional relationship as identified by the core processes (Frydman et al., 2022). This relationship is the one which exists triadically between the art form, the therapist and the participants. Through this relationship (which is unique to the arts therapies if not solely to dramatherapy) collective engagement with drama and the dramatic reality facilitates and further strengthens the development of the existing interpersonal therapeutic relationships.

Recommendations for Future Research

This meta-synthesis has revealed a series of active ingredients that are present in dramatherapy (Fig. 5). Whilst some of the ingredients identified, such as applicability to life and the social or relational factor, are present in other interventions some, such as being fun, building confidence and providing containment through drama are unique to dramatherapy. Further research, which investigates the active ingredients presented in this study and determines their causal relationship to therapeutic outcomes is now warranted. In addition, exploring from other perspectives may also elicit valuable insight.

Limitations

This study has a number of limitations; the first relates to the data that was available for the synthesis. Not only was a limited amount of data available, as can be seen in Fig. 4, the proportion of data available from each study was unequal. As such, some studies contributed just 1% (Mackay et al., 1987) or 2% (Moula, 2021) of the data whilst one study, (Godfrey & Haythorne, 2013) contributed 52%. Such an unequal division creates the potential for bias and the risk of amplification of some findings over others. Of particular note for this synthesis, is that the study which contributed 52% of the data contained parent-reported, rather than participant-reported data; this study also contributed one third of the participants that were involved in this study. This study related to participants who had ASD alongside symptoms of emotional disorders such as anxiety; this data was included in order to ensure a wide variety of perspectives were represented in this study. A second limitation relates to the primary purpose of the data that was used in this synthesis. As this is, to the best of the author’s knowledge, the first study exploring active ingredients of dramatherapy with children and young people, none of the qualitative data available was collected for the initial purpose of investigating active ingredients. By changing the context of the data, the authors may have altered the intended meaning and created bias in the findings. One should also consider the potential for selective reporting in the studies used for this synthesis. Little to no “negative” data was present and, as the authors of this study did not have access to full or original data sets, the data used may not fully represent the field. The final limitation of this study lies in the decision to extract only raw data which had not been subjected to prior analysis. This ensured that the data was as close to its empirical context as possible, however, study findings are not always best represented by raw data and thus valid and interesting data may have been excluded. One study was excluded from the synthesis on this basis.

Conclusion

Uncovering both unique and common active ingredients of dramatherapy for children and young people with symptoms of emotional disorders may be of great value to the field and may drive significant improvements in both practice and research. This meta-synthesis applied thematic synthesis to secondary qualitative data in order to elicit participant-reported active ingredients of dramatherapy for children and young people with symptoms of emotional disorders. Across eight studies, a total of 127 participants were involved; 85 were children and young people and 42 were parents whose children had ASD. The synthesis revealed a total of six analytical themes and twelve descriptive themes which can be understood, at this stage, to be active ingredients of dramatherapy for children and young people with symptoms of emotional disorders. The six analytical themes related to the importance of dramatherapy as a learning (1) and social (2) experience and dramatherapy as a positive intervention (3) which supports self-expression (4) and emotion regulation (5); the importance of the dramatherapist being skilled and knowledgeable was also identified (6). This synthesis also benchmarked the findings to other common interventions including psychodynamic psychotherapy, CBT and participatory arts interventions. Whilst the six analytical findings were present, at least in part, in the other inventions, three descriptive themes (dramatherapy is fun, dramatherapy builds confidence and participants process difficulties through drama) were unique to dramatherapy. The findings elicited in this synthesis offer insight into both dramatherapy as a whole and into the child and adolescent perspective on the practice. The findings may now be used to enhance the clinical delivery of dramatherapy with this client group (as dramatherapists may wish to tailor their practice for more effective outcomes or engagement) and for the future research of the field. Further research, which is either conducted with the primary purpose of identifying active ingredients, or which tests the active ingredients identified in this synthesis for mediation is now encouraged. Further investigation of this topic, and knowing exactly which factors of this complex intervention account for change, will benefit both dramatherapy researchers and clinicians alike. Similarly, and perhaps most importantly, children and young people experiencing symptoms of emotional disorders will also benefit from better generalized knowledge about the change mechanisms which are in action within this intervention.