Psychodrama in the treatment of smoking addiction: an open question due to insufficient data| Tabaccologia

Article

Smoking is an addictive disease, as outlined in the International Classification of Diseases (ICD-10) by the World Health Organization (WHO) [1] and the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association (APA) [2], and is one of the leading preventable and modifiable causes of disease and mortality worldwide. Despite widespread prevention campaigns and increased awareness of the health risks associated with smoking, quitting remains challenging for most smokers due to the addictive properties of tobacco and the complex psychological dynamics involved. Among the non-pharmacological strategies used to promote smoking cessation there is also psychodrama (PD); created by Jacob Levi Moreno in the 1920s, it is considered by the majority of authors as the father of various group psychotherapies. Inspired by improvisational theater, Moreno understood that, just as Aristotle’s concept of catharsis describes the particular effect of Greek drama on spectators, psychodrama has a unique healing effect—not on the audience, but on the actors who produce the drama—because its goal is to explore and resolve personal and interpersonal conflicts [3]. PD is typically conducted in groups but focuses on the individual, who carries fears, difficulties and potentialities shaped by complex relationships in life (he or she is a father or mother, son or daughter, spouse, etc.).

During a session, a person is helped to imagine and enact a problem rather than just talk about it; everything unfolds through improvisation, and both what the participant says during the dramatization and how the action develops are important. By engaging their physicality and imagination as if the situation were happening in real-time, the protagonist becomes aware of hidden ideas and feelings that are usually inaccessible through verbal expression [4]. For this reason, key elements of PD are spontaneity and creativity, which are essential for the participants, under the guidance of a trained therapist who plays the role of stage director, to act out situations from their lives on stage, not only by recounting personal events but by re-living them and acting on them, seeking a resolution of the conflict represented; different techniques, such as role reversal and the double, soliloquy, and the mirror, are used to assist the protagonist in dramatizing the conflict that needs to be resolved [5]. For all these aspects, psychodrama is considered an individual therapy that takes place within a group, and as such it is also used as an intervention to help people quit smoking. Therefore, we searched the literature for scientific articles relating to the use of PD in this context.

We considered the period from 2000 to 2024 and different search engines: PubMed, Google Scholar and Science Direct, using as keywords “psychodrama and tobacco cessation”, “psychodrama and smoking cessation”. The so-called grey literature (conference proceedings and theses) and works not in English were excluded a priori. After excluding duplicates and irrelevant works, i.e. when the aim of the study was not smoking cessation, and works for which it was not possible to have a full test, only 4 works carried out in different settings and in selected populations were left for the analysis: in US schools [6], in Turkish pulmonology clinics [7], in an Indian factory [8], and in a Nigerian prison [9]. Since they concern populations with very different demographic and social characteristics, these works are not comparable, and from their analysis we can only draw suggestions. In all the studies, it is not possible to effectively extrapolate the effects of PD as a single supportive therapy in the treatment of smoking, because the different psychotherapeutic interventions were evaluated comprehensively. The sexes are not always equally represented; in fact, two studies were almost exclusively on male subjects (in Onyechi’s study, males represented 100% of the prison population studied, and in Pimple’s study, 98% of the workers). When both sexes were represented, the analysis was not carried out using disaggregated data, reiterating the lack of data in the literature on the influence of sex, biological variability, and gender, a social construct, on the effectiveness of a treatment such as PD. In the work on pneumological patients by Aytemur [7], a group treated with pharmacotherapy associated with cognitive behavioral therapy was compared with another with the same therapeutic program to which PD sessions were added. 62% of the total population included in the study were females, and the prevalence rose to 68% in the group also treated with PD against 53% in the control arm. The group also treated with PD showed a statistically significant higher prevalence of smoking cessation when the survey was carried out close to the intervention (80.3% vs 59.6% at 1 month and 63.9% vs 46.2% at 3 months), but lost statistical significance at 6 months (50.8% vs 38.5%); however, according to the Cochrane review [10] on the use of group behavioral therapies in the treatment of smoking cessation, the addition of PD in Aytemur’s study (the only one using PD among those analyzed by Stead in his meta-analysis) did not improve smoking cessation outcomes. However, since the data were not analyzed disaggregated by sex, it is not possible to evaluate whether the efficacy of the treatment in the intervention arm, including PD, is due to the greater representation of the female sex in this group [7].

In Johnson’s work, the interventions adopted to induce high school students to quit smoking were multiple and varied (quiz games, videos, PD, etc.) and often included performance bonuses, but they led to a modest reduction in smoking that did not reach statistical significance. This, as the authors suggested, could depend on the inadequate power of the sample (despite having evaluated students from 20 schools, 10 in the intervention arm and 10 in the control arm), the low student participation, the low number of actions compared to the overall school curriculum, and also the low media coverage. The results achieved were in line with those achieved in other similar works in schools, but despite the limited success, the authors underlined the value and the necessity of continuing with such educational programs [6].

Pimple’s work evaluated the effectiveness of an individual and group behavioral therapy program (psychotherapy, cognitive behavioral therapy, and psychodrama) conducted in the workplace, but again, due to the study’s design, it is not possible to extrapolate the effectiveness of psychodrama alone. At the end of the program, smoking cessation had been achieved in 17% of participants, although at an intermediate stage it had reached 42.4%. The authors emphasize the sustainability of the project in the workplace and therefore the advantages of such a structured program [8].

Finally, Onyechi’s work on 20 prisoners (10 in the intervention arm and 10 in the control group) evaluated the effects of a health education program using group cognitive behavioral therapy that also included PD, compared to counseling alone. Although a statistically significant smoking cessation was achieved, the study has several limitations: the small size of the sample studied may not be representative of the prison population, and when the data were segregated by age group, the youngest (< 25 years old) did not benefit from the educational- behavioral program. However, the small size of the sample does not allow for any generalizations [9].

In conclusion, the results of literature review on the use of PD as a tool to promote smoking cessation are disappointing due to the small number of published studies (this could also result from the fact that we selected the works that used only PD, which works with “real” representations performed on stage, distinguishing it from therapy that uses dramatization - drama therapy - which is based on metaphor and uses personal scenes that can be both fictitious and symbolic). Furthermore, for the majority of the studies, the aim of the study was to evaluate how PD improves subjective well-being, quality of life, and behavior, while its effectiveness on smoking habits was not evaluated, as it is considered an expression of malaise.

Since some of the excluded original studies were methodological in nature, it is reasonable to concur with Orkibi’s opinion expressed in his review, which suggests that psychodramatists tend to focus more on describing and analyzing the procedures and techniques of psychodrama rather than conducting clinical trials to assess its effects. Furthermore, psychodramatists are predominantly oriented toward clinical practice rather than research, and thus, often do not perform clinical trials or publish their data [11].

Given the impact of tobacco smoking on health, it is necessary to unite efforts to treat addiction. Given its characteristics and the evidence gathered thus far, PD cannot be considered a replacement for treatments already implemented in national and international guidelines, but it can be a valuable complement to treatment, especially with regard to the approach to the experience that often underlies the phenomenon of addiction. Further studies are therefore needed to assess the potential of PD, evaluate whether there are sex and/or gender differences, and whether certain social groups with specific characteristics may benefit more from this form of psychotherapy.

References

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