Use of Psychodrama in medicine in Brazil: a review of the literature

Uso de Psicodrama em medicina no Brasil: uma revisão de literatura

Uso del Psicodrama en la medicina en Brasil: una revisión de la literatura.

Abstracts

Objective

To review the literature on experiences of the use of psychodrama in medical education in Brazil.

Methods

Papers published between 2003 and 2013 were identified in the main databases.

Results

Seven papers were identified. Role playing and sociodrama were the psychodrama techniques reported. They were used to address aspects of relationships such as emotions and behavior and to improve some communication and clinical skills. Psychodrama provided the students with opportunities for critical reflection, questioning of professional practices and sharing of experiences, and also decreased their anxiety and fear. Role playing was used among students and among teachers undergoing academic development, while sociodrama was only used among students.

Conclusions

There are still few papers reporting on experiences from the use of psychodrama in Brazilian medical schools.

Psychodrama; Sociodrama; Medical education; Role playing

Objetivo

Realizar uma revisão da literatura sobre experiências com o uso de psicodrama na educação médica brasileira.

Metodologia

Artigos publicados entre 2003 e 2013 foram identificados a partir das principais bases de dados.

Resultados

Foram encontrados sete artigos. O role playing e o sociodrama foram as técnicas de psicodrama reportadas e utilizadas para abordar aspectos do relacionamento como emoções e comportamentos e para melhorar algumas habilidades de comunicação e habilidades clínicas. O psicodrama propiciou, aos estudantes, oportunidades para reflexão crítica, questionamento da prática profissional, troca de experiências, e também diminuiu sua ansiedade e seu medo. O role playing foi usado com estudantes e com professores em desenvolvimento docente, enquanto o sociodrama foi usado apenas com alunos.

Conclusão

Ainda há poucos artigos divulgando experiências com o uso de psicodrama nas escolas médicas brasileiras.

Psicodrama; Sociodrama; Educação médica; Desempenho de papéis

Objetivo

Realizar una revisión de la literatura sobre experiencias con el uso del psicodrama en la educación médica brasileña.

Metodología

Artículos publicados entre 2003 y 2013 se identificaron a partir de las principales bases de datos.

Resultados

Se encontraron siete artículos. El role playing y el sociodrama fueron las técnicas de psicodrama reportadas y utilizadas para abordar aspectos de la relación tales como emociones y comportamientos y para mejorar algunas habilidades de comunicación y habilidades clínicas. El psicodrama propició a los estudiantes oportunidades para reflexión crítica, cuestionamiento de la práctica profesional, intercambio de experiencias y también disminuyó su ansiedad y su miedo. El role playing fue utilizado con estudiantes y profesores en desarrollo docente, mientras que el sociodrama se utilizó solamente con alumnos.

Conclusión

todavía hay pocos artículos divulgando experiencias con el uso de psicodrama en las escuelas médicas brasileñas.

Psicodrama; Sociodrama; Educación médica; Desempeño de papeles

Introduction

During medical school, students experience different teaching-learning methods and environments¹ to maximize their acquisition of knowledge, skills, and attitudes².

The use of arts (such as role playing, theater, videos, movies, poetry, narrative essays, and music) is a strategy used in contexts aiming at working out meanings and human emotions^3-6. Some authors emphasize that this approach of emotions and their sharing among students potentiate compassion and empathy^7-9.

Psychodrama, developed with groups, has shown promising results in the education of health professionals. It was created by Jacob Levy Moreno to work out conflicts and more severe pathological states, and it can be considered “a therapy of action, where the individual, instead of reporting their conflicts to the therapist, express them through dramatization”¹⁰ (p. 485). In psychodrama, group members interact, and knowledge is constructed through action, which includes finding new ways to deal with several difficulties¹¹. Its power of transformation lies in the fact that, by dramatizing, people widen their insight about themselves and their reality¹².

Romaña, cited by Gomes et al.¹³, proposed the use of educational psychodrama (a union between theater and education) based on Moreno’s therapeutic psychodrama. It is developed in an atmosphere of play and freedom, to achieve expressiveness when articulated in the dramatic or theatrical background, with originality and creativity¹⁴. Psychodrama provides opportunities for reflective practice and meaningful learning^15-17 and can be used for teaching various communication skills, including listening skills, asking questions, counseling, care, and communication in sensitive situations^18-20. The process of dramatization can also provide an increase in learning of abstract concepts because role playing provides the experience of aspects that cannot be easily expressed in words²¹.

Working arrangements within psychodrama can be used in learning situations to facilitate comprehension of phenomena that involve interpersonal relationships, and include sociodrama, role playing, spontaneous theater, live journal, and drama games²².

Sociodrama is characterized as a group work, where the group is involved in a dramatic situation (problematic situations) and individual aspects of the participants are not exposed^23,24. According to Nery, Conceição²⁵, the aim of sociodrama is to enable participants to express themselves or to try to resolve conflicts in dramatized scenes or directed interactions. There are neither spectators nor actors but rather subjects who participate as protagonists of the scene²⁶. In this type of psychodrama, contents of the formal education (teaching) can be worked out in the observing the groups and their network of relationships, from a perspective of education by and for action²⁷. In sociodrama, we do not deal with preconceived hypotheses, but with contents that emerge and that the group directs from the warm-up and, thus, dramatization ideas arise^26,27.

The sociodrama process includes four stages, as proposed by Moreno: 1) warm-up, during which participants get prepared; 2) dramatization: experiencing via dramatic scenes acted out by the group members so as to understand the phenomenology of the conflict and attempt its resolution; 3) sharing (return of the protagonist to the group): analysis of the impact of the event on the participants, with feedback on the participation; and 4) theoretical processing: socionomic reading (analysis of the relationships among the group members, their preferences and avoidances)^28,29.

“Role playing”, or role-play, game, performance, interpretation or role exchange, is another form of psychodrama, being the most widely used in many areas of knowledge²³. It has proven useful for consolidating knowledge and developing certain skills and attitudes, as well as an awareness strategy^30-32. In medicine, it has been used for teaching and learning different situations of medical practice, allowing an analysis of the communication process and the factors that hinder or improve the doctor-patient relationship^33-35. In this mode, each member of the group plays a specific role and contributes either individually or collectively. Within each group, a full network of roles that dynamically act and relate to each other is obtained³⁶. The strategy is freer. After distributing the students in groups, the characters are presented characterized according to their roles³⁷.

Joyner and Young³⁸ claim that the key to success of role playing is the warm-up. Studies using role playing describe various forms of warm-up, and it is usually used to present and explain the structure of the strategy and then act out the predetermined dramatization^{2,19,24,39,40}. Since in this process the participant represents “the other”, it allows the development of empathy⁴⁰. Among its advantages are the practice in a safe and controlled environment, absence of risks to the patient, and opportunity for reflection and feedback⁴¹. In their review paper, Kissane et al.⁴² show that role playing has been used by oncologists for developing their communication skills, because this strategy allows feedback, reflection and re-enactment of the exercise until the improvement of the skill.

Aiming to build knowledge on the use of psychodrama in medical education in Brazil, the objective of this study was to review the literature about experiences with the use of psychodrama in medical education in Brazil.

Methodology

The methodology used herein was the literature review, which plays a key role in the process of synthesis by identifying and summarizing studies published on topics focused on what is happening in field research⁴³.

Search Strategies

We searched general bases usual in systematic reviews in health and related areas, as well as specific bases focused on the subject matter in databases as Scientific Electronic Library Online (Scielo), Biblioteca Virtual em Saúde - theVirtual Health Library – (Bireme, which includes the following bases: Medline, Lilacs, IBECS; BDENF). In order to enhance the study, we also used Google Scholar. The procedures related to searches in databases complied with the following steps:

First step - the authors identified controlled descriptors in the DeCS base and uncontrolled descriptors, taking into account keywords most often cited in the reference literature, such as ‘psychodrama’, ‘social drama’, ‘role-playing’, ‘role playing’ and ‘medical education’. The logical operators AND, OR, and AND NOT were used to combine keywords and terms used for screening publications. As a search strategy, we combined the keywords with each other whenever the bases allowed it. For all keywords, we used the same methodology in all available languages, and ranked the studies found by title, author, source, country of origin, year of publication.

Second step - the search was refined to make it more specific and focused on the present study. The following inclusion criteria were used: a) papers written in Portuguese, Spanish or English about experiences with psychodrama in Brazil, between January 2003 and July 2013; b) papers that directly addressed the drama theme, communication skills, humanism and medical education; c) full papers, which used drama a strategy for teaching communication skills in Brazilian medical schools.

Studies focusing on psychology, patient treatment, and studies of fields other than medicine were excluded, as they did not match the scope of this study.

In order to enrich the introduction and the dialogue with the international literature in the discussion, international experiences with psychodrama were also reviewed.

Results and discussion

Scielo was the broadest database hosting such studies. Among the seven papers identified, six (85.72%) were from medical schools in the Southeast (São Paulo and Rio de Janeiro) regions and one (14.28%) in the Northeast region. Chart 1 shows that the papers were published between 2005 and 2011 and that role playing was the most frequently used form of psychodrama (71.43%).

Chart 1
Characteristics of the papers on dramatization in medical schools selected for this study.

Year	Database	Journal	Teaching strategy	Study
2005	Scielo	Interface - Comunic., Saúde, Educ.	Sociodrama	Ramos-Cerqueira et al.29
2009	Scielo	Revista Brasileira de Educação Médica	Role playing	Aragão et al.39
2009	Scielo	Revista Brasileira de Educação Médica	Role playing	Colares and Andrade2
2009	Scielo	Revista Brasileira de Educação Médica	Sociodrama	Ramos-Cerqueira et al.26
2010	Scielo	Revista Brasileira de Educação Médica	Role playing	Jucá et al.24
2010	Scielo	Interface - Comunic., Saúde, Educ.	Role playing	De Marco et al.19
2011	Scielo	Interface - Comunic., Saúde, Educ.	Role playing	Francischetti et al.40

The two studies we found that used sociodrama were by Ramos-Cerqueira et al.^26,29. One of these studies (Ramos-Cerqueira et al.²⁹) reports the use of sociodrama to identify positive and negative aspects of academic life and feelings related to them, as well as to rescue the class identity as a whole, from sharing these experiences and affections among students of the 6^th year of Botucatu’s Medical School (São Paulo, Brazil). In the warm-up process, the authors suggested that the students share their thoughts on the process of becoming and “being a doctor” and that they choose a fairy tale of their liking. After that, groups were formed according to the similarity of the tales and, then, part of this tale was staged. The task ended by the participants explaining the feelings evoked in them by the dramatic scenes and preparing a passage, which would form the valedictory address. Based on the statements of the participants, the authors reported as results of their study the facilitation of exchanging experiences among the students, the acceptance of their shared anxieties with regard to the final residency exams and the national students’ performance test by the Brazilian Ministry of Education (MEC), as well as a prevailing attitude of optimism, solidarity and a feeling of invigoration arising from the group’s cohesion and common identity.

In the second study, Ramos-Cerqueira et al.²⁶ reported the experience of using sociodrama to discuss expectations, concerns, feelings, difficulties, and challenges during home visits This activity is done with ninety students of the 1^st year of Botucatu’s School of Medicine (FMB), to introduce medical education in the community. The use of sociodrama aimed at preparing the student to get in touch with the multiple and complex determinants of the health-disease process in the health care area in an interdisciplinary perspective. During the warm-up process (initial phase of sociodrama), the authors suggested that the students walked around in the classroom, thought about a situation they feared to face during home visits, and then synthetized it into a single word. After that, the words were grouped by category (poverty, violence, rejection, fear, insecurity, etc.). The students were then grouped according to the categories and asked to act out scenes based on these categories, choosing the setting, the characters, the lines, or even a revealing static image of the scene. After presenting the scenes, the students expressed the feelings they experienced. According to the authors, the feelings most usually expressed were impotence and frustration in certain situations of poverty. The tutors gave an appreciative feedback. Also based on the testimonies of the participants, as results the authors reported the rich exchange of experiences, greater self-knowledge, an opportunity for critical reflection, and decreased anxiety and fear.

Both studies by Ramos-Cerqueira et al.^26,29 pointed out some difficulties found with the use of sociodrama, such as the initial reluctance of the students in participating in the warm-up phase and in the choice of scenes. The authors commented that this reluctance was expressed in long silences, slowness in rising from their chairs, and/or their claiming to be tired. This attitudes were overcome with the teacher’s conduction of the process and the students’ evaluation of the activity was positive.

As the literature shows, sociodrama has also been used as a teaching strategy in the training of other health care professionals. Several topics have been addressed, E.g. the matter of gender, with psychology students⁴⁴; the feelings while working in Family Health Care Program, with workers in a Family Health Care Unity (community health workers, administrative assistants, nursing assistants, nurses and nurse trainees, and doctors)⁴⁵; and the humanization of health care, with the emergency room staff of a hospital⁴⁶. Among nursing students, sociodrama was used in the teaching-learning process in Occupational Health⁴⁷, in order to be able to face the daily routine in health services⁴⁸and for the integration of theory and practice in the nursing profession⁴⁹.

Role playing

Chart 2 summarizes the five studies, which contain reports on the experience with role playing. The majority of participants were medical students. Only one study reported the experience with teachers of a medical school.

Chart 2
Studies using role-playing in schools of medicine

Study	Aragão et al.39	Colares and Andrade2	De Marco et al.19	Jucá et al.24	Francischetti et al.40
Objective	To evaluate student perceptions when undergoing a simulated gynecological exam and potential behavioral changes.	To encourage the students to talk about their role as students and their admission in medical school	To rehearse ways of acting during the medical interview that favor the development of communication skills	To review the abilities of communication and listening during the doctor-patient relationship, when addressing issues related to diseases (leukemia, HIV/AIDS, amputations, fetal loss)	To allow the tutor to experience the role of student in the tutoring activity and, thus, not only increasing their awareness but also expanding their perceptions of the teaching process, their strengths and weaknesses
Participants	60 students (of the Gynecology and Obstetrics unit of the internship program)	10 students of the 2nd and 4th year	20 students and teacher of Medical Psychology 2nd year	40 students of the 3rd semester of the discipline of Social and Health Sciences	32 teachers from the 1st–4th semester of the medical and nursing schools
Institution	Centro Universitário de Volta Redonda, Rio de Janeiro – University Centre of Volta Redonda, Rio de Janeiro	Universidade de São Paulo – University of São Paulo	Unifesp, São Paulo – Federal University of São Paulo, São Paulo	Universidade Estadual do Ceará (UECE) – State University of Ceará	Faculdade de Medicina de Marília (FAMEMA) – Medicine College of Marília
Initial Phase Warm-up	Brief exposure about drama and the protagonists roles	Choices of roles and think of scenes and characters based on their everyday routine	Open dialogue about the importance of communication in medical task	Exposition about role-playing, the activity and the roles of actors and observers	Tutoring sessions whose problem case refers to the structure of Problem-Based Learning
Main Phase Role-Playing	Enactment of a gynecological examination - Teacher: - guided participants regarding potential pathologies - Corrected the technique during the exam, simulating an actual exam on an outpatient	Dramatization of - Entrance in medical school, - Entrance in medical school, - First year students life, - Relationship with veteran students, school, family and community	Staging - Organization of a waiting room - Cases of early consultation - Recording the scenes	Staging in groups of three - Role reversal (physician, patient, observer)	Several tutors acted as students, while others played the tutor’s role.
Final Phase (sharing)	Group discussion on: - Experience of each student - The statements of the students were recorded, transcribed and reviewed	Reflection: - Each student commented on how he felt when put in the role of the other	Brief Summary - Most important issues, - Feedback based on analysis of the recorded scenes	Sharing with the large group - Experience, emotions and difficulties with the method	At the end of the activities, they answered - Issues for analysis of their discourses in relation to the activity performed
Advantages	- The dynamics was fully incorporated and played by the participants - Showing that solutions for topics addressed can be found inside each student who goes through a situation of role reversal with their patients	- share the difficulties of medical training - Integration of students from different years - Favors positive ties - Greater critical reflection on the development of the professional role	-teachers begin staging bogeymen to minimize student resistance - Role-playing and filming facilitated training in communication techniques and interviews	- participants developed active listening, trying to understand how the patients feel and interpret their disease - They showed difficulty in giving bad news, at the same time, they value the doctor-patient construction	- A facilitator of the learning process, as the tutor was put in the student’s role, favoring new perspectives and perceptions, and raising their awareness to the tutoring process
Limitations	Not reported in the article	- small size sample due to low volunteers adhesion	- stress and resistance of students in relation to recordings and feedback	- anxiety among participants - Inhibition because of the use of body expression	- Low adherence - Difficulty in understanding the activity - Difficulty in role reversing

The role playing was used for: working out the expectations of the student entering medical school; the life of first year students and their relationship with veteran students, as well with other in the institution, with their family and the society²; teaching communication skills encompassing interviews³¹, active listening, how to respond to emotions and how to give bad news an handle emotions in diseases such as leukemia, HIV, amputations²⁴; teaching attitudes and communication during the gynecological examination³⁹; and, faculty development to use role playing⁴⁰.

As for the warm-up process, the authors used dialogues among the participants about the experience and exposure to the method used. After that, the roles were determined and the scenes were enacted. Some difficulties pointed out by the authors were the low enthusiasm of the students in participating in the role playing^2,40; resistance to recording the scenes and to feedback¹⁹; anxiety and inhibition when acting out the scene in front of colleagues²⁴; difficulty in understanding the organization of the proposed activity and role reversal⁴⁰. In one study, the authors reported that teachers/tutors initiated the scene enactment as a strategy to decrease students’ anxiety and resistance¹⁹.

One of the authors did not report any difficulties with dramatization in the teaching method by role playing³⁹. The majority reported that due to the leading of the teachers/tutors, the results were positive, as usually evidenced in the testimonies of the participants. Among the results reported were the richness of exchanging experiences, greater self-knowledge, opportunity for critical reflection, and decreased anxiety and fear.

The experience reported by the Humanities group of the Medicine program of the University of Ceará (UCE) indicates the use of role playing for teaching communication skills for patient-oriented consultations, which includes among others, the use of open and closed questions and active listening, and the skills for communicating bad news¹⁸.

The opportunities for role playing-mediated teaching and learning have made it widely used in the world, in many fields of knowledge, subjects and activities⁵⁰. A few examples that illustrate how broad is the range of goals that can be achieved using role playing deserve mentioning. In India, authors reported the use of role playing for medical students better understand the concepts and characteristics of neurological abnormalities related to different parts of the brain⁵¹; in Punjab, authors used role playing to teach cardiopulmonary physiology⁵²; in South Korea, it was used to train cardiopulmonary resuscitation⁵³; in Germany, to teach the insertion of nasogastric tube⁵⁴; and in England, to teach how to speak in public, how to interview patients, and to discuss ethical issues of the doctors’ work⁵⁵.

The objective of the study by Francischetti et al.⁴⁰ – to prepare tutors for developing role playing with students – was pointed out as the key to their success. The successful preparation of tutors of diverse groups has been described in the literature. Owen and Reay⁵⁶ trained users of mental health services (called mental health consumers) as tutors to teach psychiatry students of the 4^th year of the medical program at the University of Australia. One of the strategies they learned to use was role playing. The authors found that tutors enjoyed the experience, and, also, they were well accepted by the students, who, at the end of the program, showed increased appreciation of the tutors, had a clearer perspective on consumer opinions, and had the opportunity to see mentally-ill people in a recovery process. Bylund et al.⁵⁰successfully trained medical doctors of several specialties in a cancer treatment center through a workshop so that they could facilitate the teaching of communication skills using role playing for peers and residents. Weyrich et al.⁵⁷ trained medical students to work as tutors with their peers in the same year of training and concluded that undergraduate education had technical peers with the same clinical knowledge and that this tutoring was feasible and widely accepted among learners, provided that tutors received sufficient training and supervision.

The present review shows that psychodrama facilitated the teaching and learning and, even though tutors find resistance by some participants, it can be overcome with enough training. Still, since we have found reports on experiences in only seven papers, we suggest that more publications be done in this area.

Conclusion

The psychodrama strategies used in Brazilian medical schools that reported their experiences in the literature were sociodrama and role playing. They were used to approach aspects of relationship such as emotions and behaviors and to improve some communication and clinical skills. The psychodrama provided the students opportunities for critical reflection, questioning professional practice and sharing of experiences, and also decreased their anxiety and fear. Therefore, it contributed to cognitive, attitudinal and procedural aspects of medical education. The publishing of more articles describing the experiences in the Brazilian medical schools would allow spreading and sharing this knowledge and would encourage their utilization in other schools.

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• Funding sources
• The authors did not receive external sources of financing to conduct this study. Rafaela Liberali has a doctoral scholarship from the following Brazilian development agencies: Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina (FAPESC, the Foundation for the Support and Innovation of Research of the State of Santa Catarina; and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, the Federal Agency for the Support and Advancement of Graduate Education).

Publication Dates

• Publication in this collection
  12 May 2015
• Date of issue
  Jul-Sep 2015

History

• Received
  11 July 2014
• Accepted
  01 Nov 2014