This study aims to investigate the efficacy of drama therapy in treating young adults who engage in nonsuicidal self-injury. Twenty individuals between the ages of 18 and 25 who meet the criteria outlined in the proposed diagnosis for nonsuicidal self-injury (NSSI) disorder as presented in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are selected to participate in the study. The participants partake in a ten session long drama therapy program based on the Integrative Five Phase Model of Drama Therapy, with each of the five phases being designated two sessions each. Surveys are completed before and after the drama therapy program to assess the degree of the participants' self-injurious urges and behaviors. The hypothesis is that the participants will experience a decrease in both self-injurious urges and behaviors after completing the drama therapy program. These findings could impact the future of treatment programs for individuals who engage in NSSI.
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Theatre has been a vital form of self expression and entertainment in various cultures dating back to some of the earliest civilizations. The plays of ancient Greece, which were often used as a way to celebrate and share stories about their gods and mythology, date back to 472 BC (McLeish, 2003). Utilizing the dramatic arts as part of therapy has been shown to have encouraging results (Orkibi & Feniger-Schaal, 2019). Therapy has been used to treat a wide variety of issues, from psychiatric conditions such as bulimia and anxiety disorders to issues such as general stress (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). While theatre had long been seen as a means of expression, it was not until recently that it began to be considered as a therapeutic option for individuals struggling with mental illness. The present study will focus on drama therapy as a possible treatment for young adults who struggle with self-injury. Based on previous studies, it is predicted that drama therapy will be an effective treatment for individuals who self-injure.
Nonsuicidal Self Injury
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies Nonsuicidal Self-Injury (NSSI) as a condition for further study indicating that, with further research, it may be formally included in a future DSM (American Psychiatric Association [APA], 2013). The proposed criteria indicate an individual could be diagnosed with NSSI if they have engaged in self-injurious behaviors, such as cutting, burning, or hitting, for five or more days in the last year, without suicidal intentions behind the actions (APA, 2013). NSSI most commonly affects adolescents and young adults, as well as members of the LGBT community and people who suffer from other psychiatric conditions (Klonsky, Victor, & Saffer, 2014). Rates of self-injury appear to be similar across socio-economic and ethnic backgrounds (Klonsky, 2011). Although many people associate self injury with young women, it has been suggested that self injury may be equally prevalent amongst men, however the methods vary. Women are more likely to partake in cutting and men are more likely to partake in hitting and burning (Klonsky et al., 2014). Individuals who self injure may display some degree of dependence on the act and may be preoccupied by thinking about self injury even when not engaging in self injurious behaviors (APA, 2013). The most commonly reported reason for engaging in self-injurious behavior is to provide relief from negative emotions (Klonsky et al., 2014). Individuals who self injure often struggle with issues such as self-criticism, emotional regulation, depression, and anxiety (Klonsky et al., 2014). NSSI is common amongst individuals with borderline personality disorder (BPD), however many people without BPD self-injure (APA, 2013). Self-injurious behaviors have been found to be a notable risk factor for future suicide attempts and a common indicator of past suicide attempts (Klonsky et al., 2014).
Drama therapy refers to a type of therapy that utilizes the dramatic arts through techniques such as role-playing (Chang, Liu, & Yang, 2019). Drama therapy has been used as a part of treatment for a wide variety of psychiatric and neurological conditions, from Alzheimer's Disease (Burns et al., 2019) to autism (Chasen, 2011). Drama therapy has shown to be effective amongst adolescents (Butler, Bakker, & Viljoen, 2013). Drama therapy has produced encouraging results in treating individuals with drug addictions by increasing the potential for abstinence from addictive substances as well as improving the quality of life of the individual (Leather & Kewley, 2019). Adolescents with eating disorders who engaged in drama therapy reported that the therapy allowed them to feel free to openly express themselves and 93% reported enjoying the program. (Pellicciari et al., 2013). Drama therapy has been shown to increase emotional vulnerability in individuals with personality disorders such as borderline personality disorder, narcissistic personality disorder, and antisocial personality disorder (Keulen-de Vos, van den Broek, Bernstein, Vallentin, & Arntz, 2017).
The current study is focused on the efficacy of drama therapy as a treatment for young adults struggling with NSSI. This specific topic has not been studied before, however research suggests that it could be successful. Drama therapy has been used to help individuals suffering from drug addictions (Leather & Kewley, 2019), which is relevant as individuals who struggle with NSSI often display a dependence on the behavior (APA, 2013). Drama therapy has also been used to treat individuals with borderline personality disorder (Keulen-de Vos et al., 2017), which many individuals who self injure suffer from (APA, 2013). While prior research has been done that supports the use of drama therapy as a means of treatment for several disorders, it has never been researched as a treatment for young adults who struggle with NSSI. Based on previous studies, it is predicted that drama therapy will have a positive impact on individuals who self injure. It is predicted that the use of drama therapy will decrease instances of self injury in the treatment group.
The study will use a quantitative within-group design, which means that every participant is receiving the same treatment (Morling, 2017). This research design was chosen as it was not seen as ethical to place certain participants in a control group where they would not be receiving any treatment for self-injurious behaviors. A self-reported pretest and posttest will be administered as certain aspects being analyzed, such as urges to self-injure, can only be known by the participants experiencing them. The independent variable in this study is the use of drama therapy, and the dependent variable is self-injurious actions / urges.
The participants in this study are individuals between the ages of 18 and 25 who meet the proposed criteria for NSSI as outlined in the DSM-5 (APA, 2013). The study was approved by the Institutional Review Board before beginning recruitment.
The study will begin recruiting by placing flyers around college campuses, as college campuses are typically frequented by the age group being studied. These flyers will inform students about the study and offer a monetary incentive for those who volunteer. The study will then uses a snowball method of sampling. Snowball sampling refers to the sampling method in which the individuals who have already agreed to participate in the program encourage friends and peers who have similar experiences to participate as well. (Morling, 2017). The snowball method was chosen for this study because of the stigma of the issue being studied. Men who self-harm in particular are less likely to seek treatment than women who self-harm, and clinicians are less likely to ask men about possible self-injurious behaviors because the issue is incorrectly gendered (Green & Jakupcak, 2016). It is important to achieve a fairly balanced representation of men and women in this study, and may be more easily achieved by contacting individuals' peer than by contacting clinicians.
Twenty individuals who meet the proposed criteria for NSSI will be selected. Individuals diagnosed with mental health conditions will not automatically excluded, however the self-injurious behavior must not be associated with motor stereotypies, drug or alcohol withdrawal symptoms, or psychosis. The sample will have an equal representation of men and women.
The Alexian Brothers Urge to Self-Injure Scale (Washburn, Juzwin, Styer, & Aldridge, 2010) and the Alexian Brothers Assessment of Self-Injury (Washburn, Potthoff, Juzwin, & Styer, 2015) were developed at the Alexian Brothers Behavioral Health Hospital. The Alexian Brothers Urge to Self-Injure Scale is used to determine how often an individual has an urge to self-injure and the strength of those urges. The Alexian Brothers Assessment of Self-Injury determines the number of times and individual self-harms and the methods that are being used. For this study, The Alexian Brothers Assessment of Self-Injury is modified to ask the participants about their patterns of self-injurious behaviors in the last week rather than in the last year.
The participants will first be assessed to determine the severity and frequency of their self-injurious behaviors using the Alexian Brothers Urge to Self-Injure Scale and the modified version of the Alexian Brothers Assessment of Self-Injury. The participants then will partake in a month long drama therapy program. The program will meet for a total of ten sessions, and will adhere to the integrative five phase model of drama therapy. This model combines humanistic, psychodynamic, and cognitive-behavioral techniques (Johnson & Emunah, 2009).The program will spend two sessions devoted to exploring each one of the stages: dramatic play, scenework, roleplay, psychodrama, and dramatic ritual (Johnson & Emunah, 2009). The participants will then be reassessed for the severity and frequency of their self-injurious behaviors using the Alexian brothers scales once again. Each participant will be given monetary payment upon completion of the program.
The current study is attempting to determine the efficacy of drama therapy in treating young adults struggling with NSSI. The hypothesis that drama therapy is an effective treatment for individuals struggling with NSSI is predicted to be supported because previous research has implicated drama therapy as a means for expressing powerful and painful emotions in a safe way (Morris, 2018). Urges to self injure and instances of self injury are hypothesized to decrease amongst young adults partaking in a 10 session drama therapy program.
Strengths and Limitations
This study is focusing on a topic that has not yet been adequately researched in the field of psychology, making this an original study. The Alexian Brothers scales have high construct validity in this case, as they not only measure the amount of times someone self injures but also the amount of times someone experiences an urge to self injure. Although the sample population is not entirely representative due to the use of snowball sampling, the sample population will reflect the diversity within people who self-injure by including an equal representation of men and women and ensuring the inclusion of individuals within the LGBT community and individuals who struggle with other mental illnesses.
The small sample size of the current study decreases the study's external validity, indicating that these results may be difficult to generalize to a larger population. The use of self-reported data could potentially impact the study's validity.
The anticipated decrease in self injurious behaviors amongst young adults in the drama therapy treatment program may help individuals recover from NSSI. As many as 10% of young people have engaged in self-injurious behaviors (Curtis et. al, 2018). This behavior needs to be addressed, especially since it is often a predictor of future suicide attempts (Klonsky et al., 2014). Cultivating new and better treatment options for adolescents and young adults who are struggling with NSSI is vital.
Future studies should improve upon the external validity of the current study by studying other populations to achieve a wider sample population. Specifically, research should be done into the possible effectiveness of drama therapy for adolescents who struggle with self injury, as adolescents are particularly susceptible for self injurious behaviors (Klonsky, Victor, & Saffer, 2014). Drama therapy may be beneficial to adolescents struggling with NSSI if it proves to be beneficial for young adults struggling with NSSI.
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