Therapeutic Factors and Therapeutic Techniques in Psychodrama

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By: Galabina Tarashoeva, Petra Marinova-Djambazova and Katerina Ilieva
first published: Academic journal of Creative arts therapies june 2022

Abstract

In recent years, research data show the effectiveness of Psychodrama Therapy has been cumulating. However, there is still not enough evidence on why this method is effective and how it works. This article inquires after answers to the questions: “Which are the therapeutic factors in psychodrama activating the healing process?” “Which are the “instruments” in psychodrama, activating the different therapeutic factors?” The main therapeutic factors in psychodrama are essentially the same as in other psychotherapeutic methods: catharsis, insight, corrective emotional experience, re-integration, and re-learning. The difference in psychodrama is that these factors are in their action versions. Our understanding is that a therapeutic factor is the smallest, inseparable agent of change, leading to a therapeutic effect. The causing of the therapeutic effect occurs inside, in the experiential world of the protagonist, as a result of the use of techniques and leads to a therapeutic change. We distinguish between the therapeutic factors that are the drivers of change within the protagonist and the techniques and interventions used by the therapist or the group.

 

Psychodrama has become a popular method, and in the recent years, evidence showing its effectiveness is growing (Newburger, 1987; Kipper & Ritchie, 2003; Wieser, 2002, 2007; Kipper & Giladi,1978; Costa et al., 2006; Izydorczyk, 2011; Vieira et al., 2013; Testoni et al., 2012, 2013а, 2013b; Yokoyama, 2015; Orkibi et al., 2017; Tarashoeva et al., 2017a), but there is still scarce data why this method is effective, how it works. The purpose of this article is to explore answers to the questions: “Which are the therapeutic factors in psychodrama that activate the healing process?“, “Which are the ‘instruments’ in psychodrama, that activate the different therapeutic factors?”
Looking for answers to these questions, we suggest our concept for Therapeutic Factors and Therapeutic techniques in psychodrama. The aim is to distinguish the different components of the Therapeutic Process clearly. We focus only on the Therapeutic Factor s in the stage of the protagonist centered psychodrama work , not on group therapy in general. We conducted a pilot study, “Therapeutic Factors in psychodrama observation, and analysis of the work in groups in Psychodrama Center Orpheus, sharing of
experi ence ..”
The Therapeutic Process can be seen as a counteracting to a pathogenic process, in which the therapeutic change is achieved under the influence of a set of Therapeutic Factors activated by various Therapeutic Instruments and Interventions. Just as psychopathology can result from exposure to single or a combination of different pathogens (early childhood trauma, broken relationships, depression, or maladaptation), the healing process can also be influenced by sometimes single but more often a combination of different Therapeutic Factors. Various Therapeutic Factors may vary for different patients, in the work of different therapists, in different groups, and different living environments. In one patient, the central determinant of the therapeutic change may be the Action Insight, while in another – the Corrective Emotional Experience (Tarashoeva 2002).

Theoretical Background

Pathogenic Process

The pathogenic process is often a disintegration of mental processes after traumatic experiences, leading to intra-role and inter-role conflicts, insufficient role plasticity, or high role rigidity. For these or other reasons, the process of spontaneity can be disrupted. In the “unfinished process” in the relationship with significant other, unexpressed emotions can remain deeply suppressed for a long time, thus determining the individual’s perceptions, thoughts, attitudes, and behavior. With their research, Van der Kolk et al. (1996) and his collaborators demonstrated that emotionally overwhelming experiences have never been adequately coded and, therefore, could not have been removed from intellectually coded memory. Rather than being repressed, they are stuck on the sensorimotor level. Their research has shown that exposure to a terrifying experience freezes the normal biochemical, physical, perceptual, cognitive, emotional, psychological, and behavioral processes. This results in an adverse effect on the neurotransmitters and a disruption of brain pathways, leaving sensorimotor memory unprocessed. Images, emotions, and memories that are too painful are pushed out of awareness but remain hidden in the body as foreign substances with psychosomatic manifestations (van der Kolk 1996). Studies have shown that the process of absorbing and the subsequent coding (learning) of all experiences in the brain is a physiological, chemical, and neurological phenomenon that follows a consistent pattern (van der Kolk et al. 1996). The interpretation of the meaning of the recorded experiences is a psychological product, the outcome again of physiological, chemical, and neurological processes. Meaning manifests as “inferences that become attitudes, philosophical outlooks and guidance to future conduct” (D. Kipper 2007 p.42). The event’s record and the experience’s memory may not be erased, but the psychological significance attributed to it, and its interpretation can be changed through psychotherapy. Successful psychotherapy requires rearranging the client’s old, unsatisfactory “survival pool.” Like other psychotherapeutic methods, psychodrama explores the harmful effects of significant negative experiences, but a considerable part of therapeutic work also strengthens meaningful positive experiences. (D. Kipper 2007)

Therapeutic Process

The process of psychodrama therapy essentially does not differ qualitatively from the therapeutic processes described in other psychotherapeutic modalities. The therapeutic process described by the various forms of group psychotherapy is similar. It is assumed that significant past experiences have led to mental issues in the present, so group members explore, replace, correct or enrich their experiential experience (Kipper, 2007). Psychodrama is distinguished by the fact that these processes are not only at the imaginary-verbal level but the level of the overall experience in action. Working at such a level requires a previous warm-up phase to achieve it and a subsequent sharing stage to smoothly exit it.
Human experiences occur in a specific context, real (exact situation) or imaginary (dream or fantasy), which becomes an integral part of the subsequent memory of the experience (Kipper, 2007). Since the interaction with the specific situation is inextricably linked to the experience, the return to it is greatly facilitated by recreating the original context on the psychodramatic stage as accurately as possible. According to David Kipper (2001), the prerequisite for effective Experiential Reintegrative Action Therapy (ERAT) is the ability in the therapeutic room to be produced experiences that are of the same emotional and cognitive quality as naturally occurring in life, activating the sensory, kinesthetic, emotional and intellectual functions of the brain.

In psychodrama, this is achieved in a surplus reality, built on the psychodramatic stage, in which the boundaries of time fall away, and “here and now” events are reproduced and experienced, no matter how distant they are in the real space, as well as in both directions of real-time. The surplus reality (Kipper, 2001) stems from the temporary and protected removal of external and internal psychological boundaries. However, it is essential to remember that this removal of boundaries and inhabitation in the surplus reality can happen only in the active space of the psychodramatic stage, in the therapy room, during the psychodramatic session. Returning to the group space during sharing restores the boundaries of real-time and space and is a smooth transition and preparation for a return to external reality.

Therapeutic Factors

A therapeutic aspect (or factor) may be defined as an element that causes a therapeutic effect. Thus, therapeutic aspects are ‘agents of change,’ ‘curative factors,’ or ‘growth mechanisms’ that contribute to a positive outcome in psychotherapy. Such aspects are closely related to processes within the patient and the therapist’s interventions (Kellermann 1992). In his book, Kellerman reviewed the Therapeutic Factors in different psychotherapeutic approaches and investigated whether these factors could also be regarded as helpful by participants in psychodrama. The two studies (Kellermann, 1985; 1987) conducted among former protagonists of psychodrama showed that emotional abreaction, cognitive insight, and interpersonal relationships are perceived to be more helpful than other aspects of the therapeutic process. From the point of view of group members, catharsis, insight, and interpersonal relations are therapeutic factors central to psychodramatic group psychotherapy. In psychodrama, we speak of action insight, action learning, or action catharsis. It is an integrative process brought about by synthesizing numerous techniques at the height of the protagonist’s warm-up.” (Moreno Z. 1982). According to J. Moreno and Z. Moreno (1969), the goal of psychodrama therapy is to make the client more spontaneous, while for David Kipper (2007), it is to emphasize reshaping and correct, hence reorganizing, client’s pool of significant experiences.

However, interpreting the meaning of the recorded experiences is a psychological product, the outcome of physiological, chemical, and neurological processes. The ERAT addresses this psychological component of the experience by changing the experience itself. Reintegration is the cognitive reappraisal of the meaning of new or altered experiences. The newly offered experience will have a high-impact capability with sufficient emotional intensity to eradicate or substantially alter the old ones. (Kipper 2007).
According to Kellerman, while therapeutic factors are complex and multifaceted, they could be divided into the following seven broad categories:
1. therapist skills (competence, personality);
2. emotional abreaction (catharsis, release of stored up effect);
3. cognitive insight (self understanding awareness, integration, perceptual restructuring);
4. interpersonal relationships (learning through encounter, tele, and transference countertransference ex plorations);
5. behavioral/action learning (learning a new behavior through reward and punishment, acting out);
6. imaginary simulation (“as if’ behavior, play, symbolic presentations, make believe);
7. non specific healing aids (global secondary factors).

These factors suggest a model for understanding the complex therapeutic process of psychodrama. Witte and colleagues give other definitions in their systematic review:
The common factor ̶ A therapeutic/change factor common to all psychotherapy approaches. Also termed non-specific factor or universal factor (a-theoretical).
Specific factor ̶ A well-specified therapeutic/ change factor theorized to produce therapeutic benefits in a particular psychotherapy approach.
Joint factor ̶ This report shares a therapeutic/ change factor across the CATs disciplines (de Witte M, Orkibi H, et al. l, 2021).
The Mechanism of change could be defined as a theory-driven causal chain or sequence of events or processes (or mediating variables) that explain, in greater detail than factors or mediators alone, how or why therapeutic change occurs (de Witte M., Orkibi H., et al., 2021).

Our Concept

In the literature, many things are helpful in the therapy but belong to different categories and are named therapeutic factors, and there are still controversies in the definitions. Helping factors may play different roles in the therapeutic process. Mixing different categories could bring confusion. Because of that, we suggest some definitions of the terms and their place and role in the change during the therapeutic process.

Definitions

  • A Therapeutic Factor is the smallest, indivisible element that causes a therapeutic effect.
  • Thus, Therapeutic Factors are ‘agents of change,’‘curative factors’ that contribute to a positive outcome in psychotherapy but are not ‘mechanisms.’ We see Mechanism as a process, the results of one or more activated therapeutic factors.
  • Therapeutic fact ors are related to processes within the patient, and they are activated as a result of interventions of the therapist using different techniques.
  • The cause of the therapeutic effect occurs inside, in the experiential world of the protagonist, as a result o f the use of techniques and leads to a therapeutic change Тарашоева 2002.

The main therapeutic factors in psychodrama are essentially the same as in other psychotherapeutic methods. The difference in psychodrama is that these factors are in their action versions:

  • Action Catharsis,
  • Action Insight,
  • Action Re learning ̶ emotional, cognitive, interpersonal
  • Corrective emotional experience,
  • Re Integration of the new experiences

To the Therapeutic Factors presented by Kellerman and Zerka Moreno (the first three), we add the last two from David Kipper. We distinguish between:

  •  Therapeutic factors that are the drivers of change within the protagonist
  • Techniques and interventions used by the therapist or group and are outside of the
    protagonist Tarashoeva, Marinova – Djambazova, 2017).

Psychodramatic work could be seen as the consequence of using therapeutic tools (instruments) grouped in therapeutic interventions, leading to the activation of certain therapeutic factors and the development of the therapeutic process as a result of them.

Therapeutic Instruments are not only psychotherapeutic techniques but also tools for therapeuticinfluence, including the therapeutic group, the therapist’s person ality, therapeutic interactions , etc.
Therapeutic Intervention is the use of therapeutic instruments in a particular order, in the necessary therapeutic environment, to activate Therapeutic Factors to influence the development of the therapeutic process within the individual.

In short, the Technique is what the director does, and the Therapeutic Factor is what happens inside the protagonist as a result of the use of the technique and leads to the therapeutic change.

The therapeutic Process is the counteraction to a pathogenic process, where therapeutic change is achieved through the influence of a mixture of therapeutic factors.
The therapeutic process in psychodrama passes successively through the following stages: Emotional warming up leads to the active representation of an event from the present, recent past, or future – here and now, in the surplus reality of the psychodramatic stage (the space of the room on which psychodramatic action is developing). Following “keys” (verbal and non-verbal), which unlock the associative flow of experiences, representing different manifestations of the pathogenetic process at various stages of life, scene by scene, from the present (the periphery), going down the spiral back in time, and the depths of the protagonist’s experiential world, we reach the core of the problem – a traumatic experience, often a scene in early childhood.
Here, a deep, Action Catharsis of long-suppressed emotions is often, but not obligatory experienced. Action catharsis (psychomotor, vegetative, emotional, verbal) frees the individual from the latent and swallowed emotions that distort perceptions and paves the way for the action of other therapeutic factors.

After the adequate flow and the blurred emotions are released, a correction in the messages’ perceptions and interpretations becomes possible – an Action Insight is achieved.
By “Re-Doing” the same traumatic event from childhood, but in a new, satisfying way, a Corrective Emotional Experience is achieved and “recorded” in a new, non-traumatic way. The protagonist defends himself not only in front of the therapist and the group but also in front of the reproduced image of the parent, represented by the Auxiliary Ego (group member or co-therapist). For exp., the correction in the record of traumatic parental attitudes in childhood, creating psychological problems in adulthood, is made by the Auxiliary Ego, who acts as a parent, this time as the child needs to grow up healthy.
Action learning – emotional, cognitive, and interpersonal takes place at different levels throughout the Therapeutic Process. Therapeutic change is possible when the learning is on a “basic level” – bodily and perceptual-motor, based on sensations, belonging to the preverbal, early phase of a child.
What follows is the Reintegration of the new experience into the protagonist’s subjective reality. Everything that has been released must be reintegrated: unblocked emotions and inner emotional order, corrective emotional experience, and the new, satisfying, and non-traumatic “record” of early childhood experience, insights, and self-knowledge, “already completed unfinished business,” reworked conflicts and discovered new coping strategies.
With the reintegrated new experience, the protagonist returns to the scene of the present and manages to “Re-Do” the current problem situation, changing it in a satisfying way, namely through his newly acquired experience.

Our Research

In Psychodrama Center Orpheus, we conducted retrospective research on the therapeutic factors in psychodrama. We analyzed the frequency of achieving the following four therapeutic factors: action catharsis, action insight, corrective emotional experience, and action re-learning in our groups. We also analyzed which of the four techniques used (doubling, mirroring, role reversal, and monologue) activated them most often.

Method

We reviewed the frequency of the therapeutic factors in the protagonist-centered works in two groups to develop the personal potential and the psychodrama techniques that activated them. For this purpose, we used the written protocols from the sessions on the working weekends.
The groups are intended to develop personal potential and gain personal experience in psychodrama. The people, who participated in them, were:

  • Professionals planning to continue with psychodrama training,
  • Healthy people, seeking personal development and overcoming personal problems
  • Patients who had been on medical treatment or individual psychotherapy and were willing to work on their psychological problems in a group.

In the two groups, 20 persons participated as a whole, 17 females and three males, at the age of 21 – 52 (there was no upper limit for the age).
A working weekend lasts 20 working hours of 45 minutes and consists of 8 working sessions. In the studied groups, 25 working weekends were conducted, during which there were 57 protagonist-centered works (PCW). In the sessions, when there is no protagonist-centered work, warming up, group-centered work, vignettes, sociodrama, group dynamic work, group discussions, or sharing, feedback for the day or the weekend is directed.
In our practice in Orpheus, the coleader takes short notes during the session, and immediately after the session, we discuss them, fill in missing parts, and process them in the team meeting. Later, one of us creates a protocol (minutes) for the session a written
description of the session.
Using the minutes from the 57 protagonist ce ntered works in the two groups for developing personal potential with 20 participants, we reviewed the frequency of the Therapeutic Factors and the psychodrama techniques that activated them.
Reading the descriptions in the protocols (minutes) of the prota gonist’s verbal and nonverbal expressions and behavior, as well as his sharing and reflections after his work, we recognize the Therapeutic factor after an agreement is reached in discussion between
the two directors. For example, deep crying and asking fo r forgiveness for something wrong done in the past by somebody who is no anymore alive, we evaluate for catharsis. We check in the protocol which techniques were used before described behavior,
considered as catharsis, and for example, see that this is dou bling just before the catharsis. In this way, for this case, we connect the Therapeutic factor of Catharsis with the technique of Doubling. If Doubling is in the position of Role Reversal, we count these two techniques as activating the Therapeutic factor Catharsis. Catharsis may come after Doubling in Monologue immediately after Role Reversal; in this case, we have three techniques, activating one Therapeutic Factor Catharsis.
We calculated how often each of the fourtherapeutic factors (Action Catharsis , Action Insight,Corrective Emotional Experience, and Re learning) was activated by each of the four techniques (Mirroring, Role Reversal, and Monologue), and more than one technique could be considered as activating one factor, as explained abo ve. We also calculated how many factors were activated in each of the PCW and how often each of the four factors
was achieved.

Results

1. Frequency of the therapeutic factors
The most common Therapeutic Factor is Action Catharsis (in 86% of cases); it is involved in almost all combinations with other therapeutic factors (most often with Active Insight), but alone usually is not sufficient to achieve a Therapeutic change. The next one is Action Insight – in 79% of cases, followed by Re-learning in 60%, and Corrective Emotional Experience -37%.

Figure 1 – Frequency of the therapeutic factors:

2. Action Catharsis

Figure 2 – Action Catharsis

The Therapeutic Factor Action Catharsis most frequently was activated by the Technique MONOLOGUE – in 90%.
In Action catharsis, the release of repressed and accumulated affective content through full expression (psychomotor, vegetative, emotional, verbal) of the protagonist on the psychodramatic stage is much more complete and more effective than in the purely verbal version.

3. Action Insight
The Therapeutic Factor Action Insight most frequently was activated by the Technique of Doubling – in half of the cases, followed by ROLE REVERSAL – in 44%, Monologue in 31%, and Mirror in 27%.

Figure 3 – Action Insight

4. Corrective Emotional Experience

Figure 4 – Corrective Emotional Experience

The Therapeutic Factor Corrective Emotional Experience (CEE) most frequently was activated by the technique ROLE REVERSAL – in 81% of the cases, and significantly less by the other three techniques – in 29% by DOUBLING, in 14% by MIRROR and 10% by MONOLOGUE.

5. Action Re-learning

Figure 5 – Action Re-learning

The therapeutic factor RE- LEARNING was activated at approximately the same frequency by each of the four techniques.

6. Combinations of Therapeutic Factors in different types of Interventions

Figure 6 Combinations of Therapeutic Factors in different types of Interventions

In 6 cases in a protagonist-centered work, there was 1 Therapeutic Factor acting; in 21 cases, there was a combination of 2 Therapeutic Factors; in 18 cases – of 3 different Therapeutic Factors; and in 12 cases – of all four various Therapeutic Factors. When there was 1 Therapeutic Factor (in 6 cases), it was Action Insight – in 4 cases or Action Catharsis – in 2 cases.
More often, when there were 2 Therapeutic Factors (in 21 cases), it was a combination of Action Catharsis and Action Insight – in 13 cases.
When there were 3 Therapeutic Factors (in 18 cases):
– most often, two were Action Catharsis and Action Insight – in 14 cases.
– most often, it was a combination of Action Catharsis, Action Insight, and Re-learning – in 14 cases.

Discussion

Our result that each of the following three therapeutic factors– Action Catharsis, Action Insight, and Re-learning is found in more than half of the studied PCW confirms the results of Peter Felix Kellerman’s two studies, showing that from the point of view of group members, catharsis, insight, and interpersonal relations are therapeutic factors, central to psychodramatic group psychotherapy (Kellerman 1985, 1987). According to Kellerman, interpersonal relationships include learning through encounter, tele,
and transference countertransference explorations.
It is not surprising that the most common Therapeutic Factor is Action Catharsis but alone is not sufficient to achieve a Therapeutic change; as we know from Kellerman, the therapeutic factor of Action Catharsis alone does not lead to lasting results; it acts only in combination with others (Kellerman, 1984). In our results, Action Catharsis participates in all combinations with the other Therapeutic factors. Only in 2 cases is it alone.
The monologue is the technique in which the protagonist allows himself to touch his deep, unexpressed feelings and experiences and name them aloud in front of empathetic witnesses. The protagonist is often surprised by the power of these feelings and the incontinence with which they flood him. This could explain why 90 % of Action Catharsis is activated by Monologue.
In psychodrama, the process of self-discovery (“Aha” – experience) is achieved through the language of action and not as a result of verbal interpretation or introspective analysis, sitting on a chair, or lying on the couch. Psychodrama stimulates the protagonist’s analytical process. Together with the director, he reflects on what he just has experienced and explores his behavior for new meanings. Action interpretation is an indirect way for the protagonist to become acquainted with the meaning of his behavior and to come into contact with the unconscious on an emotional and physical level. As Kellermann (1992) points out, psychodramatic Action Insight cannot be transferred from one person to another and cannot be given to the client by the therapist through interpretation. Achieving it is possible in a context that stimulates spontaneity and lowers resistance. Action insight can be either a momentary flash of understanding or a continuous process of gradual and consistent self-understanding and communication with oneself (Kellermann, 1992).

Doubling is the technique that allows the director to offer the protagonist interpretation through action, from first person singular, which makes it more acceptable. Psychodrama is the most interpretative method, but the director acts upon his interpretations in constructing the scenes. Because his interpretation is in the act, it is frequently redundant (Moreno Z. 1982)
Our results that the Therapeutic Factor Action Insight most frequently was activated by the Techniques Doubling and Role Reversal find confirmation in the findings of a recent systematic review that drama therapists and psychodramatists encourage understanding, self-awareness, perspective, and empathy through doubling, role-reconstruction, encounter, and role-reversal (de Witte M, Orkibi H, et al., 2021).

Psychodramatic “surplus reality” provides the ideal conditions for the Correction of Emotional Experience and “recording” in a new, non-traumatic way. The new “record” presence, even if it does not cancel the first, weakens its pathogenic pressure. This allows the individual to continue to grow from the point where the development has stopped. Zerka Moreno repeatedly emphasizes that the psychodramatic stage and its “surplus reality” was created so that everything that could not have happened but should have happened in the living reality of the protagonist happens in it (personal contact in training seminars, 1992, 1994, 1997). In the action of Re-Doing, the protagonist in the role of “ideal” significant other can feel compassion for himself and give himself what he missed, longed for, and needed. After that to receives it from the “ideal” significant other, represented by the Auxiliary Ego that he has chosen.

The Corrective Emotional Experience is achieved as the basis for “unlearning” the old maladaptive models of relationships and mastering new, adaptive ones in the scenes afterward. To master them, it is necessary to test their different variants in a protected, “laboratory” environment, sometimes for a long time. Role training and practicing the new behavior as a result of reintegrated new experience in Re-doing the actual problematic situation provides all the necessary conditions for new learning of interpersonal skills.

We could see Re-learning in the 3 of the seven categories of Therapeutic Factors of Kellerman:
̶ cognitive insight (self-understanding awareness, integration, perceptual restructuring);
̶ interpersonal relationships (learning through encounter, tele, and transference – counter-transference explorations);
̶ behavioral/actional learning (learning a new behavior through reward and punishment, acting out);

There is another therapeutic factor, Reintegration (Kipper 2007), which in theory is distinguishable from the factor of Re-learning.
Re-learning could be seen as the final result of Catharsis, Action Insight, and Re-Integration. The protagonist in action could learn how deep his painful emotions are buried and how healing the relief after their expressions are. The protagonist is learning through sudden discovery or slow realization of something new in the moments of Action Insight. But real permanent Re-learning happens in action Re-Integration of all new experiences in the inner experiential world of the protagonist on all levels – emotional, cognitive, sensorimotor, and biochemical. Going through the new experiences during the psychodramatic stage is not enough to achieve a lasting result (Kipper, 2001). It is necessary to integrate the new, satisfying experience into the old system of memories and to form a new, satisfying “experience pool.” As these are satisfying experiences, integration takes place spontaneously due to the natural tendency to prefer them to unsatisfactory memories and roles. The cognitive process initiated by the therapist can enhance and facilitate the Reintegration of the new experience (Kipper, 2001). In Orpheus for Reintegration, we often use the technique “walk through the years with the new experience,” arriving with it in the Re-doing the first scene of an actual problematic situation.
This complexity of Re-Learning, involving the other Therapeutic Factors activated by different Techniques, could be some explanation for why the Therapeutic factor RE-LEARNING was activated in approximately the same frequency by each of the four techniques.
For the observer is challenging to separate the visible signs of Re-Integration from signs of Re-learning. Practically as feedback and reflection of the protagonist in his wording, it is not easy to separate reintegration from re-learning. Further investigations are needed to deepen our understanding of the possibilities to validly detect these two factors as separate.

Limitations of the Current Research

Quantitative research in psychotherapy has a lot of challenges. The fact that the researchers are the therapists creates a bias. Still, on the other hand, in the complex process of assessing items like therapeutic factors, the therapist has a fuller inner picture of the process than just the minutes of the sessions and could better detect the factors. A non-therapist researcher could be considered for future works, including a non-biased view. Besides, for future research, we consider using content analysis of recorded sessions and the protagonists’ responses to provide fuller material for better detection of the factors and the related techniques.
Another limitation is that we did not include the reintegration as a separate factor and could not distinguish it clearly from the available information from the re-learning factor. We need to deepen our understanding of methodological possibilities to validly differentiate between these two factors within the protagonist-centered work.

Conclusions

The most frequent Therapeutic Factor was Action Catharsis; it was activated in almost all Protagonist-centered work and participated in all of the combinations of Therapeutic Factors. It appears that Action Catharsis “opens the door” for the following Therapeutic Factors. But at the same time, Action, Catharsis is not enough as the only Therapeutic Factor for achieving Therapeutic change.
Usually, there were combinations of at least two Therapeutic Factors; activating one Therapeutic Factor was an exception.
The combination of Action catharsis and Action insight was activated in almost all the cases.
Good knowledge of the Therapeutic Factors, skillful management of the Therapeutic Process, and mastery of Therapeutic Tools and Interventions will contribute to achieving more therapeutic effects for our clients.

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About the authors:

Contact details research: Galabina Tarashoeva: orpheuspsychodrama@gmail.com

Galabina Tarashoeva, MD, Ph.D., Psychodrama Center & Psychiatric Practice Orpheus, Sofia, Bulgaria Petra Marinova-Djambazova, MD, PhD. Medical University Sofia, Department of Psychiatry, Sofia, Bulgaria; Aleksandrovska Hospital, Psychiatric Clinic, Sofia, Bulgaria; Psychodrama Center & Psychiatric Practice Orpheus, Sofia, Bulgaria

Katerina Ilieva, Psychodrama Center Orpheus, Sofia, Bulgaria.