To date, there continues to be controversy in the healthcare field concerning the best way to support individuals experiencing grief, loss, and bereavement as well as the overall efficacy of grief therapies, especially in comparison with the natural passage of time (Currier et al., 2008). Research shows evidence of inaccurate beliefs about grief and bereavement in healthcare professionals and the general public (Wortman and Silver, 2001) and a need for an expanded toolbox of effective, theory-based methods for grief therapists (Neimeyer et al., 2009). This study, The Embodiment of Grief, investigated the experience and pathology of grief, loss, and/or bereavement in the general public, the efficacy of drama therapy for grief processing, and the ability of ethnographic theatrical performance to elicit perceptual change in healthcare providers. The researchers utilized the Ethnodramatherapy (EDT; Snow, 2022) research model in conjunction with The Integrative Five Phase Model (IFPM; Emunah, 2022). Four adults were recruited and assessed for their unique experience of grief and measures of anxiety (i.e., Generalized Anxiety Scale7; GAD-7), depression (i.e., Patient Health Questionnaire-9; PHQ-9), and resilience (i.e., Adult Resilience Measure-Revised; ARM-R) at pre and post-treatment. Participants reported a high rate of treatment satisfaction and showed a decrease in anxiety scores and an increase in depression and resilience scores. Additionally, seven professionals acted as audience member research participants at the ethnodrama presentation and were evaluated pre- and post-presentation for perceptions, beliefs, and attitudes toward grief, loss, and bereavement, perspectives in current approaches to care, and any perceptual change as a result of witnessing the presentation utilizing a researcher-developed questionnaire. The results of this pilot study substantiate future research evaluating the efficacy of EDT as an approach to grief processing and for the facilitation of perceptual change in healthcare professionals.

The Embodiment of Grief investigated the experience and pathology of grief, loss, and bereavement by means of ethnodramatherapy. Per the ethnodramatherapy research process, we conducted qualitative interviews individually with each research participant prior to the drama therapy group process to assess the participants’ experience and perception of grief, loss, and/or bereavement. The information gathered during the interviews was coded to identify themes that were further validated and explored in the therapeutic group activities (See list of themes below). Informant validation occurred through the use of sociodramatic activities (i.e., spectrogram) and through a written vote. 

The Integrative Five Phase Model of Drama Therapy (Emunah, 2020) was the guiding framework for the group process during which informant validated themes were explored by use of role-play, improvisation, psychodrama, playback, creative writing, and sociodrama. Groups involved physical and vocal warm ups and containment rituals to prepare the group members for dramatic enactments. Dramatic enactments were utilized to honor, witness, and support each other in the group's collective and individual experiences of loss. Each group built upon the content and drama skills explored in the previous sessions, creating a scaffold for the participants' exploration of their stories and the development of the final presentation.

Themes Derived From Group Participant Interviews

**It is important for me to have space for my grief.

**I don’t feel like I have space to experience my grief.

Expressing my grief comes easily to me.

*There are situations where I find difficulty expressing my grief.

**Grief is confusing. 

*Grief is ambiguous. 

*I want to talk about my loss.

I believe we have cultural language to talk about grief and loss.

**I worry about making people feel uncomfortable when talking about my loss.

People grieve differently.

Each loss is resolved before the next. 

**There is an expectation for me to be done with my grief. 

**I compare my grief to the grief of others.

I have experienced myself or others ranking the pain of their grief. 

*My cultural identity impacts my experience of grief and loss.

*My cultural identity impacts my perception of grief and loss.

**Most voted themes by the sample through informant validation

*Second most voted themes by the sample through informant validation

Consistent Perceptions, Beliefs, and Attitudes

• Comfortable seeking professional support for symptoms associated with grief, loss, and/or bereavement; including support for death by suicide, drug use, or murder.

• Likelihood of working with a client who has experienced grief, loss, and/or bereavement.

• Strongly disagree that the grieving process should resolve within one year or less.

• Strongly disagree that the grieving process is linear and follows a progression of stages

• Strongly disagree that children and adolescents do not grieve as deeply as adults and that children should be protected from the pain and suffering that death or loss creates.

• Agreed that they felt confident about their abilities to show support to someone experiencing grief as well as their ability to assess the impact of their support.

Shifts in Perceptions, Beliefs, and Attitudes

• Increased awareness of the cultural influences on grief responses.

  • • This could indicate that a predominating perspective is that grief is universal and that witnessing this type of performance and participating in open and compassionate forum discussions can bring cultural nuances of grieving to the forefront.

• Contradicting views on seeking support for non-death loss.

  • • It is important to note that non-death loss was not included in the group’s presentation as all group participants had experienced death related loss. We, the researchers, infer that witnessing people in their grieving of death losses had a dual effect. While it may normalize seeking general grief support for some, the exclusion of non-death loss might have also inadvertently promoted stigma regarding acceptable forms of loss and grief. 

• Increased disagreement with the belief that most people develop a mental disorder or need professional help to cope with grief.

  • • These results allude to the ability of the presentation to destigmatize grief as a disorder and simultaneously display the power of community. Both of these results have implications for healthcare professionals and best practices for supporting grieving individuals.

• Increased belief in the benefits of community support as opposed to healthcare professionals.

  • • Audience member research participants either became neutral about this topic or shifted entirely to believe that community resources best support these individuals. These results indicate that the presentation successfully demonstrated the healing power that community can offer to those experiencing grief, loss, and bereavement.

• Decreased belief that grief should be processed privately.

  • • The shift in response could imply that witnessing the presentation created a felt-sense of camaraderie and universality even within audience members, influencing them to further disagree that grief should be processed privately.

• Increased uncertainty regarding the best approach and type of care for grieving individuals. 

  • • One audience member research participant intentionally commented on the innate isolating nature of our society and lack of community resources, while another commented on the necessity of both community and professional support. We believe this could be attributed to the fact that these types of support are typically conceptualized as two separate entities. Contrastingly, our group drama therapy process and presentation were designedly an incorporation of both, thus further contributing to the paradox of “best support.” Our society’s stigma regarding death and loss, which has produced deficient resources and poor education on the topic, is another probable contributing factor. Two audience member research participants remained neutral on this question and we, the researchers, feel curious about this. Is their neutrality due to a lack of knowledge regarding available community resources? Or how to connect individuals to community resources? Is their neutrality due to the aforementioned general confusion and ambiguity around best practices for the support of grieving individuals? A final consideration for these results is the implication that the role of healthcare professionals who work with this population needs to shift. It is our opinion, based on these results, that creating communal spaces for grievers and acting as a bridge between community and professional support might be a better direction.

• Promising reliability in Part One due to the structure of EDT and IFPM. 

• Limited reliability in Part Two due to the variability of individuals’ and group experiences of grief that influence the content and format of research dissemination. 

• Inclusion of a control group in future studies may increase validity.

• Balancing the research agenda with the therapeutic goal of grief processing. 

  • • One validated theme important to the therapeutic exploration was the experience of disconnection that results from a socially or medically expected timeframe for grieving a loss. With this in mind we were conscientious of how the rigid timeline of the ethnodrama could be countertherapeutic. We embodied a more directorial role as the group progressed into content creation for the ethnodrama, in order to provide the structure and guidance that would allow group members to focus on the therapeutic exploration of their loss narratives.

• Limitations in the research process with scheduling, tardiness, and client absences.

• Multiple losses during the group process impacting group stability.

  • • One group participant withdrew from the research study after group six due to personal health concerns and bereavement. This called for dedicated group time to process the loss of a member and collaboratively restore group dynamics.

    • Additionally, another group member reported a significant pet loss in group seven resulting in a redefinition of her current state of grief and what she felt called to express in the ethnodrama.

• Client resistance in engaging in drama therapy activities.

The results of this study support further research on the efficacy of drama therapy for grief processing and ethnodrama as a vehicle for perceptual change in favor of effective care for those experiencing grief, loss, and/or bereavement. The integration of the IFPM and ethnodramatherapy techniques allowed for a comprehensive exploration of the participants' experiences. The insights gained from this research study contribute to the understanding of grief, loss, and bereavement and add to the foundation for future studies in this field.

There are a few changes we would consider in future projects of this nature. The recruiting and interviewing felt rushed due to scheduling constraints with the University. In future therapeutic theater, we would increase the time allotted for recruiting and interviewing research participants prior to starting the therapeutic group process. We would also increase the amount of time spent in the group drama therapy process. We ended up having eight sessions for validating themes, therapeutic processing, and presentation creation. While we made this work, it was not nearly enough time. We would suggest a minimum of 12 sessions before the presentation. Regarding the presentation, we would have a more explicit conversation about the therapeutic value of inviting personal active witnesses. This experience can offer validation that brings a sense of profound meaning not only to the client’s story, bt also serves to strengthen the bond between client and their significant relationships. We wonder how the experience would have been different for some of the participants who did not have any personal active witnesses attend.

Ethnodramatherapy aims to be a form of research that involves participants as researchers (PAR) and/or co-researchers in order to increase the capacity for a socially just research modality (Snow, 2022). We did not include the group participants in the analysis of the audience participant pre- and post- performance questionnaires and therefore, did not include them fully in the research process. We are curious about the ethics of claiming group participants as co-researchers without involving them fully in the research process. We intend to discuss this with other drama therapists and researchers to generate ideas and perspectives on how to conduct ethnodramatherapy in the most ethical manner.

The researchers hope to move forward with conducting future ethnodramas focused on grief, loss, and bereavement to collect more robust data and further support our understanding of EDT as a powerful modality for grief processing and social activism.

If you are interested in learning more or collaborating with the researchers on future studies, please reach out. We would love to hear from you!

References

Currier, J. M., Holland, J. P., & Neimeyer, R. A. (2010). Do CBT-Based Interventions Alleviate Distress Following Bereavement? A Review of the Current Evidence. International Journal of Cognitive Therapy, 3(1), 77–93. https://doi.org/10.1521/ijct.2010.3.1.77

Emunah, R. (2020). Acting for real: Drama therapy process, technique, and performance (2nd Ed.). Routledge. 

Neimeyer, R. A. & Currier, J. M. (2009). Grief therapy: Evidence of efficacy and emerging directions. Current directions in psychological science, 18(6), 352-356.

Snow, S. (2022). Ethnodramatherapy: Integrating research, therapy, theatre, and social activism into one method. Routledge.

Wortman, C. B., & Silver, R. C. (1989). The myths of coping with loss. Journal of Consulting and Clinical Psychology, 57(3), 349–357. https://doi.org/10.1037/0022-006x.57.3.349