Skip to main content
NCBI home page
International Journal of Developmental Disabilities logoLink to International Journal of Developmental Disabilities
. 2022 Jun 10;70(2):278–286. doi: 10.1080/20473869.2022.2082826

An improvisational theatre intervention in people with intellectual disabilities and mental health problems

Regina Fabian 1,✉, Daria Tarasova 1, Thomas Bergmann 1, Tanja Sappok 1
PMCID: PMC10930151  PMID: 38481454

Abstract

People with intellectual disability (ID) generally tend to have difficulties expressing their thoughts and feelings verbally. Art-based therapies rely less on cognitive ability and verbal skills and aim to promote mental health. Drama therapy provides a playful framework to communicate problematic issues and to foster social skills. Improvisational theatre (improv) methods applied in therapy settings were reported to show positive effects on social competences and self-esteem. This pilot study investigates the feasibility (N = 24) and appropriateness (n = 12) of an intervention using improv methods in people with mild to moderate ID. Feasibility was measured on the basis of the average participation period, while appropriateness was assessed through a standardised patient satisfaction questionnaire (CSQ-8) and a self-developed questionnaire. The frequency of the applied methods was compared in two subgroups with participants requiring different support. The average participation rate of 19 months indicated a good feasibility. High CSQ-8 scores (M = 27.6/max. 32) and positive feedback on the self-developed questionnaire indicated the overall appropriateness. The frequency analysis of the applied methods reflected the adaptive nature of the intervention. Further research on the efficacy of improv methods contributing to mental health in people with ID is recommended.

Keywords: intellectual disabilities, mental health, treatment, improvisational theatre, drama therapy

Introduction

Developmental disabilities and mental health are independent phenomena; people with developmental disabilities can experience a high quality of life and can serve as possible individual role models with their own strengths, life paths and values. Nonetheless, people with intellectual disability (ID) are more vulnerable to developing mental disorders compared to the general population (Mazza et al. 2020, Dilling et al. 2015). The presence of mental health issues in a high proportion of people with ID demonstrates ‘the importance of providing effective support and treatment strategies for addressing mental health needs’ (Costello and Bouras 2006, p. 248). Despite this, there is a shortage of appropriate treatment methods for people with ID and comorbid mental health problems and/or severe challenging behaviours (Schützwohl and Sappock 2020). Došen (2007) criticised a monodisciplinary treatment based on psychotropic medication and behaviour modification programmes and argued for an integrative treatment approach due to the complexity of behavioural and psychiatric problems in this population. Hence, besides people’s cognitive abilities, their social and emotional skills and mentalizing abilities should also be considered (Došen 2018, Sappok et al. 2021). Creative arts therapies using music, dance, art and drama can provide effective therapy to people with disabled cognitive abilities that ‘does not necessarily rely on words or intellectual abilities’ (Feniger-Schaal 2016, p. 40). Crimmens (2006) mphasized that creative arts therapy generally addresses the whole personality and uses emotional, motor and cognitive abilities, which correspond to the multidimensional needs of people with developmental disabilities. Karkou and Sanderson (2005) provided an overview of the implementation of arts-based therapies used with a range of client groups, such as people with profound learning disabilities.

Dramatherapy in people with ID and mental health problems

Dramatherapy can be briefly defined as ‘the intentional use of drama and theatre processes to achieve therapeutic goals’ (Armstrong et al. 2019, p. 1). It comprises a number of approaches and intervention models and enables the participants to experiment with different roles and attitudes: ‘Through play clients try out new ways of being experimenting and detaching from the constraints placed on them in their life outside of therapy’ (Cassidy et al. 2017, p. 183). Dramatherapy uses the potential of drama to reflect and transform the experiences of the participants (Jones 1996). A connection between the patient’s problematic concerns and the activity in dramatherapy is created (Jones 1996). Concerning changes in dramatherapy, Cassidy et al. (2017) reported two key mechanisms, namely, ‘developing a new awareness and a language through which to communicate to self and others’ (p. 182), for example increased coping abilities and an increased ability to socialise.

One essential method applied in dramatherapy is improvisation (Johnson and Emunah 2009). Chesner (1995) considered improvisation as an important method in group dramatherapy with people with learning disabilities and stated that ‘the skills learnt in improvisation are of value in the wider social context outside the group’ (p. 139). Several approaches in dramatherapy using improvisation have been developed. Created by Johnson (2009), Developmental Transformations (DvT) is a relational approach, whereby the therapist and client engage in continuous and free flowing improvisation. DvT focusses more on bodily expression than on language, and the therapist ‘is managing the state of play, not the content of the play’ (Johnson 2009, p. 98). Wiener (2009) developed ‘Rehearsal for growth’, a method of relationship therapy and dramatherapy, and applied methods of improvisational theatre (improv). In his approach, Wiener (2009) reported that improvisational tasks are used to ‘playfully explore alternatives to clients’ problematic patterns of interaction’ (p. 371).

In dramatherapy, people with ID are empowered to explore their concerns using a wide range of expression through play, storytelling, or improvisation, and to find their individual way to communicate their issues (Feniger-Schaal 2016). Through dramatherapy, patients explore creativity (Jones 1996) and experience empowerment, which is an important factor in quality of life among people with ID (Geiger et al. 2020). Therefore, dramatherapy may be a promising treatment approach for persons with ID and mental health problems.

Chesner (1995) emphasised that for dramatherapy with people with ID, a step-by-step structuring of the session provides a framework to promote group cohesion and a gradual personal and interpersonal exploration. There are few studies in dramatherapy for people with developmental disabilities and mental health problems (c.f. review Armstrong et al. 2019, Mino-Roy et al. 2021). In dramatherapy with individuals with ID, a wide range of methods are used. In different studies, improved self-esteem and self-confidence were reported (Mino-Roy et al. 2021). For example, Snow et al. (2003) noted the positive effects on communication skills (2003). Meanwhile, in their study on dramatherapy using storytelling with adults with severe ID, Foloştină et al. (2015) observed an increase in social and communication skills and a decrease in disruptive behaviours. Similarly, a study on group dramatherapy with children with mild to severe intellectual and developmental disability found an increase in communication and cooperation rates during and after the intervention, and positive effects on concentration and creativity were observed (Wu et al. 2020). Cook (2020), in her study on an inclusive therapeutic theatre production with young adults, reported a positive change in assertiveness. Feniger-Schaal (2016) mentioned in her case study involving a young man with ID and mental health problems that there was a ‘significant relief in his psychiatric symptoms and improvement in his general functioning’ (p. 44). Snow et al. (2017), in their study with adults with developmental disabilities, used a new method, ethnodramatherapy, which integrates ethnodrama and dramatherapy; the authors reported empowering effects for people living with developmental disabilities. Another study (Bourne et al. 2020) focussed on the possibility of the support staff being part of a dramatherapy group with adults with learning disabilities, who move from hospital back to home. Bourne et al. (2020) discussed the results of the study in terms of fostering the relationship between the people with disabilities and the caregivers as well as in terms of reflection of the support staff on the concerns of the adults with learning disabilities. Taking a new perspective, Strevett-Smith (2010) considered the combination of different methods in dramatherapy. She reported in her article on various cases where methods of family therapy and dramatherapy were combined in therapeutic work. Indeed, she emphasised the similarities between family therapy and dramatherapy. Proctor et al. (2008) referred in their article to the possibilities of using the methods of Augusto Boal’s Theatre of the Oppressed in clinical supervision of family therapy, and the authors reported the benefits of using theatre methods in family therapy settings.

Using improvisational theatre (improv) methods in therapeutic settings

Improv is characterised by creative and spontaneous acting in which the dialogue, story and characters are unscripted (Johnstone 1993; Spolin 1993). The main focus of improv lies in spontaneous interaction in the here and now (Romanelli et al. 2017) and the subsequent interpersonal processes (Wiener 2009). According to Sheesley et al. (2016), using improv methods offers the possibility to ‘create opportunities for personal growth and exploration’ (p. 159). Krueger et al. (2017) described improv exercises as a promising method for patients with different cognitive abilities; improv exercises do not require any content preparation, a longer attention span, knowledge of storytelling, or an in-depth study of roles, and nor is there any need to learn a dialogue text. Improv methods can therefore be described as low threshold. Acceptance, flexibility, responsiveness and the capability to associate are the main aspects of improv. Supporting the ideas and decisions made by the partners is a basic rule of improv; the improv methods aim to reduce self-criticism and judgement. Using improv methods, an attentiveness to others can be rehearsed in a non-judgmental context (Wiener 2009). Interventions using improv methods focus on the activation of resources and mutual support (Schwenke et al. 2020). It is expected that improv may shape processes that are associated with enhanced well-being (Bermant 2013) and mental health (Sheesley et al. 2016, Schwenke et al. 2020). According to Schwenke et al. (2020), because improv is subsumable to performing arts, the similarities between improv-based interventions and dramatherapy seem apparent.

Baving et al. (2013) applied improv methods in children with mental health problems, Tang et al. (2019) in children with an elevated risk of psychosis, and Krueger et al. (2017) in adults with anxiety disorders and depression. In all these studies, the use of improv methods led to positive changes in the patients’ mood, self-confidence and self-esteem and their relationships with other people. Schwenke et al. (2020) assumed that ‘improv could be a valuable enrichment especially for patients who benefit from treatments that focus on the development of structural abilities, like general coping skills that are necessary for effective emotional regulation or regulation of self-esteem’ (p. 12). Tang et al. (2019) pointed out the potential of improvisation to reframe previous beliefs, especially in stressful social interactions. However, the studies mentioned above were neither randomised nor controlled. The novelty of using improv in a therapeutic setting emphasises the need to first develop targeted and appropriate treatment concepts based on improv. Combining improv methods may support psychological wellbeing in different groups of clients and seems to be a promising enrichment strategy also for dramatherapy. Nonetheless, to our knowledge, there is currently no study on the therapeutic use of improv methods with people with ID.

Current study

This pilot study aims to examine the feasibility and appropriateness of an improv intervention in adults with ID and additional mental health problems. Additionally, this pilot study examines whether the treatment can be adapted to the different needs of patients with different levels of functioning.

Methods

The study was carried out at an outpatient clinic of the Berlin Treatment Center for Mental Health in Developmental Disabilities in Berlin, Germany. This centre includes an inpatient and an outpatient clinic for adults with ID and additional mental disorders and/or severe challenging behaviours. Over a period of five years, the intervention, using improv methods, was conducted by a family therapist qualified in improvisational theatre in the outpatient clinic (first author). Structured group sessions were applied in two groups with individuals with different levels of functioning. At the beginning, each patient had to commit to frequent participation. The applied theatre methods were continuously adjusted by the therapist to the needs of the participants of both groups.

Ethical approval and informed consent

The study was approved by the local ethics committee (October 29, 2018) and conducted according to the recommendations of the Declaration of Helsinki. The procedure of the study was explained to each patient verbally in simple language at the beginning of the study. The intervention was part of the non-medical standard treatment and posed no additional burden to the participants. The patients or their legal custodians gave their written informed consent.

Sample characteristics

A feasibility assessment was based on a sample of 24 patients who participated in the intervention program from 2014 to 2019. Participants were divided into two therapy groups according to the severity of ID and the clinical estimation of their level of emotional development: group 1 comprised participants requiring substantial support, and group 2 comprised people requiring support.

All participants enrolled in the therapy program from July 2018 to December 2019 (subsample n = 12) were involved in appropriateness assessments. Table 1 contains a detailed description of the total sample and the subsample.

Table 1.

Sample characteristics.

  Total sample (N = 24)
 Subsample (n = 12)
  Group 1 Group 2 p Group 1 Group 2 p
ID severity     0.05*a     0.14a
 Mild 3 7   1 4  
 Moderate 7 5   3 2  
 Severe 2 1   2 0  
Age M (SD) 38.0
(8.52)		 38.5
(10.98)		 0.91b 35.33
(6.12)		 45.00
(11.78)		 0.11b
Gender (Female) 7 9 0.67a 3 6 0.18a
Open in a new tab

Note. Group 1 with participants requiring substantial support, group 2 with participants requiring support; SD, standard deviation.

a

Chi2 test.

b

Two-sided t-test.

Intervention

The group sessions lasted 75 min and took place every two weeks. Each session was divided into different phases, following Chesner (1995) and Jones (1996), who recommended a step-by-step structure or a five-phase format. The session included a warm-up, a focussing and an improvisation phase, a reflection round and a farewell ritual (c.f. Figure 1).

Figure 1.

Figure 1.

Open in a new tab

The five phases of the improv intervention.

The duration of each phase could differ between sessions; however, the focus and the improvisation phase were the most prominent. Drama exercises were applied in the first three phases of the intervention, while methods from family therapy (i.e. scaling questions) were used in the reflection phase.

During the warm-up, the participants shared their individual topics and emotional states, and the first exercises were offered to encourage contact and to create a playful and trustful atmosphere (e.g. ball games).

In the focus phase, the participants explored social interaction in a playful way. A variety of group, pair or solo exercises focussing on bodily and non-verbal expression as well as pantomime exercises were offered. Mirroring exercises and synchronous movement exercises in pairs or as a group were regularly performed to generate a sense of togetherness. Training was given in bodily awareness, such as distancing oneself from others and emotional expression. The interventions alternated with short reflections about the experiences during the exercises.

Improv exercises were the centre of the improvisation phase, which offered the opportunity to explore different behaviours in improvised social situations inspired by the participants of the session. The space was divided into a presenting and a spectator area. The exercises were chosen according to the current topics of interest to the participants. The therapist offered roles connected to the personal subject with the opportunity to try novel patterns of interaction. Participants can formulate their own ideas in the improvised scenes or present a new, e.g. leading, behaviour. In this way, they experience that their expressions are given meaning. The participants changed perspective by alternating between the roles of actor and spectator.

During the reflecting round at the end of each session, the clients expressed and exchanged their experience verbally. Thus, ideas concerning the transfer of the experienced encounters into daily life situations could be developed together. The therapist used methods from family therapy (e.g. scaling questions) to reflect the interaction and the different perspectives of the improvised situations with the intention of revealing existing resources and opening up language spaces as described by Gaese and Wehmeyer (2019) and Retzlaff (2010). Hermes (2017) pointed out the applicability of methods of family therapy with people with developmental disabilities in therapeutic and counselling processes to reflect on their own behaviour and develop new options for action.

A ritual of hand-clapping in a circle was the common closing element of each session. At the beginning of the therapeutic process and every six months thereafter, the personal process and therapeutic goals were reflected in individual therapy sessions.

Assessment of feasibility and appropriateness

The feasibility was measured by the average participation period for all participants over the complete implementation period (N = 24). The appropriateness of the applied methods was evaluated in a subsample of 12 participants (cf. sample characteristics) from July 2018 to December 2019 by the participants. The patients’ judgement of appropriateness was assessed with a standardised questionnaire for patient satisfaction (for details cf. below), a self-developed questionnaire concerning the applied methods and the group atmosphere. The application frequency of the particular methods in each group was considered as an indicator of the adaptive nature of the intervention programme.

Assessment scales

  1. Severity of ID. Depending on the level of functioning, the severity of ID was assessed by established IQ tests: the Hamburg-Wechsler Intelligenztest für Erwachsene (HAWIE-R; Tewes 1991), Wechsler Intelligenztest für Erwachsene (WIE; Aster et al. 2006), Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV; Petermann 2012), non-verbal intelligence tests SON-R 2½-7 (Tellegen et al. 2006) and SON-R 6-40 (Tellegen et al. 2012), Kaufman-Assessment Battery for Children (K-ABC; Kaufman Assessment Battery for Children; Kaufman and Kaufman 2004), and Coloured Progressive Matrices (CPM; Raven et al. 2002). The cited manuals contain detailed reports providing evidence of the tests’ psychometric qualities as well instructions for administration in persons with ID.

  2. Treatment satisfaction. The Client Satisfaction Questionnaire (CSQ-8; Schmidt et al. 1989) includes eight questions to assesses the patients’ satisfaction with various aspects of the treatment on a 4-point Likert scale. A maximum of 32 points was achievable, with higher scores indicating greater satisfaction. The CSQ is a uni-dimensional scale with a single factor accounting for 60% of variance (Kriz et al. 2008). Moreover, Kriz et al. (2008) reported good reliability (Cronbach’s Alpha = 0.90), low missing-data quote (3.4% at item-level), as well as evidence of convergent and divergent validity in a sufficiently big sample (N = 60,423) of patients from various rehabilitation clinics. In order to improve the applicability of the CSQ in persons with ID, the questionnaire was translated into simple language and supplemented with ‘smileys’ added to the 4-point Likert scale (Schmidt et al. 2020). The modified version was completed by 64 patients, after which, the ratings obtained using the adapted and the original version were compared. For three items, the ratings were significantly lower when the adapted version was used, which could be attributed to a better understanding of the questions and reduced bias (Schmidt et al. 2020). Therefore, the adapted version in simple language was used in this study. If the participants appeared confused answering the questions, examples were provided, and follow-up questions were asked to ensure that the participants understood the questions well.

  3. Participant feedback. At the end of each session, a not-validated, self-developed questionnaire was conducted with all participants present. The questionnaire consisted of three questions and assessed the participants’ judgment regarding appealing methods, irritations and group atmosphere during the session. All questions were asked orally, as most of the participants had difficulty reading:

Question 1 (Appealing methods): What exercises did you enjoy today?

Question 2 (Irritations): During which exercises did you feel tension, insecurity, or stress?

Question 3 (Group atmosphere): How did you feel in the group today?

The patients’ judgement on the different methods was collected for every exercise after each session. The participants’ responses regarding the group atmosphere were logged and subsequently assigned to one of the following categories: 1 – ‘very good’, 2 – ‘good’, 3 – ‘not so good’ and 4 – ‘bad’. Overall, 66 ratings of group atmosphere were collected.

Data analysis

Feasibility was analysed using descriptive statistics [mean values, standard deviations (SD), range]. Frequency analysis and descriptive statistics were used for the appropriateness assessments. The frequencies with which the participants named particular methods were calculated. In total, 100 responses were collected. Subsequently, a ranking of appealing methods was built for each group. The frequencies in both groups were compared using Chi-square tests. It was impossible to meaningfully analyse group differences regarding irritations, since participants in each group reported irritations only on single occasions. The ratings of group atmosphere in both the groups were compared using the MWU-Test. Frequencies of the application of the methods in each group were compared using the Chi-square test. Descriptive statistics (means, SD, range) were calculated for the CSQ sum scores and interpreted in relation to the maximal attainable score.

Results

Feasibility

The average duration of participation was 19 months [Standard deviation (SD) = 10 months, range: 6–36 months] for group 1 and 20 months (SD = 16 months, range: 6–52 months) for group 2.

Appropriateness

CSQ-8

Overall, the average CSQ score was 27.63 with an SD of 2.88 and a range of 22–31. The participants in group 1 reported an average satisfaction rate of 28.20 points (SD = 2.28, range 25–31); in group 2, the mean satisfaction rating was 26.67 (SD = 4.04, range 22–29). One of the participants of group 2 left out one of the questions. She appeared to be struggling with the questions, as could be seen by her asking clarifying questions on several occasions. Furthermore, two participants in group 1 gave implausible replies to question 4 (recommendation to a friend): the participants said they would not recommend a group to a friend despite reporting high satisfaction in other questions.

Self-developed questionnaire

Appealing methods

The ranking of the appealing methods in both groups is listed in Table 2. Both groups named ‘improvisation’ as one of the most appealing methods. The most appealing methods in group 1, were ball games (n = 16) and improvisation (n = 15) and in group 2, improvisation (n = 18) and synchronous movements (n = 10). The participants of group 1 named ball games and mirroring exercises as appealing more often than did the participants of group 2 (p = 0.04 and p = 0.03, respectively).

Table 2.

Rating of participants: Appealing methods.

Method Rated as appealing
Group 1		 Rated as appealing
Group 2		 Chi2 (df)a p
Ball games 16 4 4.29 (1) .04*
Mirroring 13 3 4.81 (1) .03*
Synchronous movements 8 10 0.86 (1) .36
Pantomime 0 2 0.01 (1) .92
Games with play identity 2 4 0.61 (1) .43
Improvisation 15 18 2.02 (1) .16
Open in a new tab

Note. * p < .05; group 1 with participants requiring substantial support, group 2 with participants requiring support.

aCorrected for continuity.

Irritations

In both groups, irritations during the exercises were reported only a few times. No irritations were described for ball games and massage exercises. Group 1 indicated irritations during mirroring games (n = 2) and simple games involving play identities (n = 1), and group 2 during synchronous movements (n = 1), pantomime (n = 1), simple games involving play identities (n = 1), and improvisation (n = 3). The frequency of reported irritations did not differ significantly between the two groups.

Group atmosphere

The ratings of group atmosphere ranged from ‘very good’ to ‘bad’ (see Figure 2). Ratings in group 1 varied from 2 (‘good’) to 4 (‘bad’), with a mean of 2.5 (‘good’ to ‘not so good’). The ratings in group 2 ranged from 1 (‘very good’) to 3 (‘not so good’), with a mean of 1.7 (‘good’). The group differences in the group atmosphere ratings were statistically significant (U = 214.5, p < 0.001).

Figure 2.

Figure 2.

Open in a new tab

Group atmosphere rated by the participants.

Note. Group 1 with participants requiring substantial support, group 2 with participants requiring support.

Frequencies of applied methods

Massage exercises (Chi2(1) = 26.10, p < 0.001) and pantomime (Chi2(1) = 14.35, p < 0.001) exercises were presented more often in group 2. Other exercises were offered in both groups with comparable frequencies.

Discussion

The improv intervention is feasible and appropriate for adults with mild to moderate ID and mental health problems. Based on the high average participation rate of 19 months, it can be concluded that the intervention is suitable for participants with a wide range of different levels of cognitive impairment. Moreover, the average duration of participation of more than one and a half years in both groups can be interpreted as indicating that the intervention should be offered as a long-term treatment. The results of the CSQ-8 (M = 27.6) indicate the acceptability of the treatment, and the positive feedback on the self-developed questionnaire demonstrates the overall appropriateness. The results of the frequency analysis of the applied methods show differences between both groups in the application of two applied exercises, suggesting that treatment can be adapted to the diverse needs of patients with different levels of functioning. However, the results of the CSQ-8 should be interpreted with caution. Firstly, a question left out by one of the participants distorted the sum score. Moreover, despite using the adapted version of the questionnaire in simple language, some participants struggled to understand the questions. The question regarding recommendation to a friend proved to be particularly challenging, giving rise to noticeable difficulties in two participants. Thus, further adaptations should be considered to optimise the application of the CSQ-8 in adults with ID.

Interestingly, we observed significant differences between the two groups in their ratings of the group atmosphere from the self-developed questionnaire. Apparently, the group situation and the interactional challenges with peers seemed to be more challenging and stressful for people with more severe cognitive impairments. This is supported by the therapist`s general observation of both groups. Participants of group 1 expressed a great desire to repeat always the same exercises and seemed to need a more structured and predicable framework, and group dynamics often caused them uncertainty and irritability. In contrast, participants of group 2 asked for more changes to the exercises during a session, and they were able to handle changes in the course of a session with more flexibility. The severity of the cognitive impairment seems to affect not only the cognitive demands but also the social and interactional tasks, which can reduce resilience in social situations. This aspect should be taken into account in therapy.

Regarding the appropriateness of the applied methods, improvisation was rated as one of the most appealing methods by all participants across various levels of functioning (see Table 2), and no considerable recurring irritations were reported. These results suggest that the use of improv methods is applicable and appropriate for people with different levels of ID. This is in line with Krueger et al. (2017), who described improvisational theatre exercises as a promising method for patients with diverse cognitive abilities leading to in vivo behavioural activation. These results are also consistent with Chesner’s (1995) consideration of the importance of improvisation in dramatherapy for people with ID. Moreover, Schwenke et al. (2020) assumed that ‘improv could provide a treasured and efficient treatment especially for mental health patients that are difficult to reach with standard mental health approaches’ (p. 12). However, future research on the efficacy of improv interventions is needed.

Based on the significant group differences in the ratings of the applied methods, people requiring substantial support seemed to profit especially from simple and structured exercises to establish contact (ball games) and to develop a feeling of togetherness (mirroring). Similar to our observations, Jones (1996) reported that imitation of gesture was a promising method in people with severe learning disabilities, as it supported the early stages of contact. Behrend (2012) underlined the potential of body synchrony to promote cooperative ability, assuming that ‘mirroring processes support empathic capabilities’ (p. 112). The importance of imitating or copying in the context of relationship, belonging and learning from others was emphasised by Musicka-Williams (2020), who referred to using ‘dramatic imitation to move participants from a state of play in which they engage in acts of high-fidelity imitation to an exploration of their own capacity for imitative flexibility’ (p. 4) as an important therapeutic goal in dramatherapy.

The differences in the frequencies of the methods’ applications in the two groups indicate a flexible and adjusted use of methods. Behrend et al. (2012) refer to the importance of ‘finding a balance between simplification and manualisation on the one hand and the improvisational application of diverse methods and techniques on the other hand’ (p. 114). Therefore, an intervention using improv methods should consider the different levels of functioning of the participants and their associated needs.

Taken together, improv methods used in a therapy context were well accepted and appropriate for people with mild to moderate ID and mental health problems. This pilot study underlines the importance of clearly structured treatment methods for this population as well as the importance of the adaptive nature of the intervention. We are convinced of the potential of improv methods in fostering social skills and contributing to mental health in this highly vulnerable group.

Future research should be conducted to systematically examine improvisational theatre interventions with people with intellectual disabilities under a broader range of treatment conditions to obtain profound results. In addition, further systematic research is needed to evaluate the efficacy of improvisational theatre interventions in people with ID, especially on social skills, self-confidence and self-esteem. In order to broaden the theoretical context in relation to mental health and social interaction, a parameter such as Quality of Life and the social cultural context should be included in future research on the mental health of people with ID and appropriate treatment methods in the field of applied theatre and improv.

Limitations

The results are limited by a relatively small sample size. Additionally, the number of patients who took part in the assessments and the length of the different assessments varied. Due to the lack of standardised instruments for assessment of the appropriateness of dramatherapy methods in persons with ID, self-developed measures had to be applied. This may limit the objectivity of our results. Future research should address the development of such scales to create a sound methodological basis for assessing the appropriateness of therapies. No further investigations or interviews on the reported irritations were conducted. Any further assessment of what caused the irritation can therefore be based only on assumption. During the application of the CSQ-8, it became obvious that some participants had trouble understanding some of the questions. Furthermore, satisfaction assessments based on questionnaires can be prone to bias due to social desirability. Moreover, it is possible that the social desirability was facilitated by the relationship the participants had with R.F., who was involved in the study as both a researcher and a therapist. Therefore, caution should be shown when interpreting the results.

Conclusion

Overall, the current pilot study presents a newly developed improv intervention for people with ID and mental health problems which was highly feasible and well accepted in long-term participation. The results of the frequency analysis of the applied methods point to the need to adapt the applied methods to the participants’ level of functioning. Findings from this study provide promising results, suggesting that improv methods may foster social competences in people with different cognitive and socioemotional abilities.

Acknowledgement

We would like to thank all the participants and their legal custodians for participation in the study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure statement

None of the authors or other persons involved in this study have any interests that might be interpreted as influencing the research.

References

  1. Armstrong, C. R., Frydman, J. S. and Rowe, C.. 2019. A snapshot of empirical drama therapy research: Conducting a general review of the literature. GMS Journal of Arts Therapies, 1, 1–16. [Google Scholar]
  2. Aster, M., von Neubauer, A. and Horn, R.. 2006. Wechsler Intelligenztest für Erwachsene (WIE). Manual. Frankfurt am Main: Harcourt Test Services. [Google Scholar]
  3. Baving, L., Maurischat, C., Molzow, I. and Prehn-Kristensen, A.. 2013. Das Improvisationstheater in der kinder- und jugendpsychiatrischen stationären Regelversorgung - eine explorative Vergleichsstudie. Gruppenpsychotherapie und Gruppendynamik, 49, 221–237. [Google Scholar]
  4. Behrend, A., Müller, S. and Dziobek, I.. 2012. Moving in and out of synchrony: A concept for a new intervention fostering empathy through interactional movement and dance. The Arts in Psychotherapy, 39, 107–116. [Google Scholar]
  5. Bermant, G. 2013. Working with(out) a net: Improvisational theater and enhanced well-being. Frontiers in Psychology, 4, 1–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bourne, J., Selman, M. and Hackett, S.. 2020. Learning from support workers: Can a dramatherapy group offer a community provision to support changes in care for people with learning disabilities and mental health difficulties? British Journal of Learning Disabilities, 48, 59–68. [Google Scholar]
  7. Cassidy, S., Gumley, A., and Turnbull, S.. 2017. Safety, play, enablement, and active involvement: Themes from a Grounded Theory study of practitioner and client experiences of change processes in dramatherapy. The Arts in Psychotherapy, 55, 174–185. [Google Scholar]
  8. Chesner, A. 1995. Dramatherapy for people with learning disabilities. A world of difference. London: Jessica Kingsley Publisher. [Google Scholar]
  9. Cook, A. 2020. Using an inclusive therapeutic theatre production to teach self-advocacy skills in young people with disabilities. The Arts in Psychotherapy, 71, 1–8. [Google Scholar]
  10. Costello, H. and Bouras, N.. 2006. Assessment of mental health problems in people with intellectual disabilities. The Israel Journal of Psychiatry and Related Sciences, 43, 241–251. [PubMed] [Google Scholar]
  11. Crimmens, P. 2006. Drama therapy and storymaking in Special Education. London: Jessica Kingsley Publishers. [Google Scholar]
  12. Dilling, H., Mombour, W. and Schmidt, M. H.. 2015. Internationale Klassifikation psychischer Störungen: ICD-10 Kapitel V (F). Klinisch-diagnostische Leitlinien. Göttingen: Hogrefe. [Google Scholar]
  13. Došen, A. 2007. Integrative treatment in persons with intellectual disability and mental health problems. Journal of Intellectual Disability Research: JIDR, 51, 61–66. [DOI] [PubMed] [Google Scholar]; Došen, A. 2018. Psychische Störungen und Verhaltensauffälligkeiten bei Menschen mit intellektueller Beeinträchtigung: Ein integrativer Ansatz für Kinder und Erwachsene. Göttingen: Hogrefe. [Google Scholar]
  14. Feniger-Schaal, R. 2016. A dramatherapy case study with a young man who has dual diagnosis of intellectual disability and mental health problems. The Arts in Psychotherapy, 50, 40–45. [Google Scholar]
  15. Foloştină, R., Tudorache, L., Michel, T., Erzsébet, B. and Duţă, N.. 2015. Using drama therapy and storytelling in developing social competences in adults with intellectual disabilities of residential centers. Procedia - Social and Behavioral Sciences, 186, 1268–1274. [Google Scholar]
  16. Gaese, F. and Wehmeyer, M.. 2019. Systemische Therapie. In: Sappok T., ed. Psychische Gesundheit bei intellektueller Entwicklungsstörung. Ein Lehrbuch für die Praxis. Stuttgart: Kohlhammer, pp.387–392. [Google Scholar]
  17. Geiger, A., Shpigelman, C-N., Feniger-Schaal, R.. 2020. The socio-emotional world of adolescents with intellectual disability: A drama therapy-based participatory action research. The Arts in Psychop therapy, 71, 1–8. [Google Scholar]
  18. Hermes, V. 2017. Beratung und Therapie bei Erwachsenen mit geistiger Behinderung. Göttingen: Hogrefe. [Google Scholar]
  19. Johnson, D. R. 2009. Developmental transformations: Towards the body as presence. In Johnson D. and Emunah R., eds. Current approaches in drama therapy. Springfield, IL: Charles C. Thomas. pp. 89–116. [Google Scholar]
  20. Johnson, D. R. and Emunah, R.. 2009. The current state of the field of drama therapy. In Johnson D. and Emunah R., eds. Current approaches in drama therapy. Springfield, IL: Charles C. Thomas, pp. 24–33. [Google Scholar]
  21. Johnstone, K. 1993. Improvisation und Theater. Berlin: Alexander. [Google Scholar]
  22. Jones, P. 1996. Drama as therapy: Theater as living. New York: Routledge. [Google Scholar]
  23. Karkou, K. and Sanderson, P.. 2005. Arts therapies: A research-based map of the field. Oxford: Churchill Livingstone. [Google Scholar]
  24. Kaufman, A. S. and Kaufman, N. L.. 2004. Kaufman assessment battery for children. 2nd ed. Circle Pines, MN: American Guidance Service. [Google Scholar]
  25. Kriz, D., Nübling, R., Steffanowski, A., Wittmann, W. W. and Schmidt, J.. 2008. Patientenzufriedenheit in der stationären Rehabilitation: Psychometrische Reanalyse des ZUF-8 auf der Basis multizentrischer Stichproben verschiedener Indikation. Zeitschrift für medizinische Psychologie, 17, 67–79. [Google Scholar]
  26. Krueger, K., Murphy, J. and Bink, A.. 2017. Thera-prov: A pilot study of improv used to treat anxiety and depression. Journal of Mental Health, 4, 1–6. [DOI] [PubMed] [Google Scholar]
  27. Mazza, M. G., Rossetti, A., Crespi, G. and Clerici, M.. 2020. Prevalence of co-occurring psychiatric disorders in adults and adolescents with intellectual disability: A systematic review and meta-analysis. Journal of Applied Research in Intellectual Disabilities : JARID, 33, 126–138. [DOI] [PubMed] [Google Scholar]
  28. Mino-Roy, J., St-Jean, J., Lemus-Flgar, O., Caron, K., Constant-Nolett, O., Després, J.-P. and Gauthier-Boudrealt, C.. 2021. Effects of music, dance and drama therapies for people with an intellectual disability: A scoping review. British Journal of Learning Disabilities, 0, 1–17. [Google Scholar]
  29. Musicka-Williams, A. 2020. “We copy to join in, to not be lonely”: Adolescents in special education reflect on using dramatic imitation in group dramatherapy to enhance relational connection and belonging. Frontiers in Psychology, 11, 588650. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Petermann, F. ed. 2012. Wechsler adult intelligence scale – Fourth Edition (WAIS-IV). Deutschsprachige Adaptation der WAIS-IV nach D. Wechsler. Frankfurt am Main: Pearson Assessment. [Google Scholar]
  31. Proctor, K., Perlesz, A., Moloney, B., McIlwaine, F. and O’Neill, I.. 2008. Exploring theatre of the oppressed in family therapy clinical work and supervision. Counselling and Psychotherapy Research, 8, 43–52. [Google Scholar]
  32. Raven, J. C.Raven, J. and Court, J. H.. 2002. Colored Progressive Matrices Manual. Raven’s Progressive Matrices und Vocabulary Scales. Frankfurt am Main: Swets Test Services. [Google Scholar]
  33. Retzlaff, R. 2010. Familien-Stärken: Behinderung, Resilienz und systemische Therapie. Stuttgart: Klett-Cotta. [Google Scholar]
  34. Romanelli, A., Tishby, O. and Moran, G. S.. 2017. “Coming home to myself”: A qualitative analysis of therapists’ experience and interventions following training in theatre improvisation skills. The Arts in Psychotherapy, 53, 12–22. [Google Scholar]
  35. Sappok, T., Zepperitz, S. and Hudson, M.. 2021. Meeting emotional needs in intellectual disability. Göttingen: Hogrefe Publisher. [Google Scholar]
  36. Schmidt, J., Lamprecht, F. and Wittmann, W. W.. 1989. Satisfaction with inpatient management. Development of a questionnaire and initial validity studies. Psychotherapie, Psychosomatik, Medizinische Psychologie, 39, 248–255. [PubMed] [Google Scholar]
  37. Schmidt, M., Tarasova, D., Feuerherd, C., Michalik, S., Klee, B. and Sappok, T.. 2020. Patientenzufriedenheit von Menschen mit intellektuellen Entwicklungsstörungen in der stationär psychiatrischen Behandlung. Inklusive Medizin, 17, 26–37. [Google Scholar]
  38. Schützwohl, M. and Sappok, T.. 2020. Psychische Gesundheit bei Personen mit Intelligenzminderung. Der Nervenarzt, 91, 271–281. [DOI] [PubMed] [Google Scholar]
  39. Schwenke, D., Dshemuchadse, M., Rasehorn, L., Klarhöter, D. and Scherbaum, S.. 2020. Improv to improve: The impact of improvisational theater on creativity, acceptance, and psychological well-being. Journal of Creativity in Mental Health, 16, 1–18. [Google Scholar]
  40. Sheesley, A. P., Pfeffer, M. and Barish, B.. 2016. Comedic improv therapy for the treatment of social anxiety disorder. Journal of Creativity in Mental Health, 11, 157–169. [Google Scholar]
  41. Snow, S., D’Amico, M., Mongerson, E., Anthony, E., Rozenberg, M., Opolko, C. and Anandampillai, S.. 2017. Ethnodramatherapy applied in a project focusing on relationships in the lives of adults with, especially romance, intimacy and sexuality. Drama Therapy Review, 3, 241–260. [Google Scholar]
  42. Snow, S., D’Amico, M. and Tanguay, D.. 2003. Therapeutic theater and well-being. The Arts in Psychotherapy, 30, 73–82. [Google Scholar]
  43. Spolin, V. 1993. Improvisationstechniken für Pädagogik, Therapie und Theater. Paderborn: Junfermann. [Google Scholar]
  44. Strevett-Smith, A. 2010. Dramatherapy in the context of systemic family therapy: Towards systemic dramatherapy. Dramatherapy, 32, 8–13. [Google Scholar]
  45. Tang, S. X., Seelaus, K. H., Taylor, J., Moog, C., O’Connor, D., Burkholder, M., Kohler, C. G., Grant, P. M., Eliash, D., Calkins, M. E., Gur, R. E. and Gur, R. C.. 2019. Theater improvisation training to promote social cognition: A novel recovery-oriented intervention for youths at clinical risk for psychosis. Early Intervention in Psychiatry, 2019, 1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Tellegen, P. J., Laros, J. A. and Petermann, F.. 2006. Deutsche Normierung und Validierung des SON-R 2½-7. Göttingen: Hogrefe. [Google Scholar]
  47. Tellegen, P. J., Laros, J. A. and Petermann, F.. 2012. SON-R 6–40. Non-verbaler Intelligenztest. Göttingen: Hogrefe. [Google Scholar]
  48. Tewes, U. 1991. Hamburg Wechsler Intelligenztest für Erwachsene, Revision 1991 (HAWIE-R). Handbuch und Testanweisung. Göttingen: Hans Huber. [Google Scholar]
  49. Wiener, D. J. 2009. Rehearsals for growth: Drama therapy with couples. In Johnson D. R. and Emunah R., eds. Current Approaches in Drama Therapy. Springfield: Charles C Thomas. pp. 355–373. [Google Scholar]
  50. Wu, J., Chen, K., Ma, Y. and Vomočilová, J.. 2020. Early intervention for children with intellectual and developmental disability using drama therapy techniques. Children and Youth Services Review, 109(C). [Google Scholar]

Articles from International Journal of Developmental Disabilities are provided here courtesy of The British Society of Developmental Disabilities

RESOURCES