The Role of Group Sharing: An Action Research Study of Psychodrama Group Therapy in a Psychiatric Inpatient Ward

: Numerous studies point to the acute distress associated with the experience of coping with severe mental illness and psychiatric hospitalization. Another strand of research notes the therapeutic beneﬁts of psychodrama and its efﬁcacy in increasing empathy and self-awareness, improving interpersonal relationships, reducing stress and anxiety, and in treating particularly vulnerable populations for whom traditional psychotherapy’s usefulness is limited. The goal of this paper is to provide a framework for understanding the potential of group sharing in dealing with the experience of loneliness and distress, and to serve as a space for relatedness and self-expression in psychodrama group therapy. A qualitative action research study following an open inpatients’ psychodrama group in a psychiatric hospital in Israel demonstrates the role of group sharing in creating an accommodating space of self-expression, relatedness, and mutual support, which offers relief for the distress of psychiatric inpatients. Within the inpatients’ group, the participants used sharing to distribute the burden among the group members along with the resources to cope with it. The paper seeks to illuminate the unique contribution of a therapeutic tool rarely dealt with by the existing literature–the group sharing—in dealing with situations of acute mental distress.


Introduction
This paper seeks to shed light on the potential role of group sharing within the framework of psychodrama group therapy, in alleviating the experiences of distress among psychiatric inpatients.The paper is based on a year-long qualitative action research (AR) study, conducted in an acute ward in a psychiatric hospital.While this study's observational design is not intended to establish causality or to provide a precise measurement of the effect of psychodrama therapy on psychiatric inpatients, it allows for a holistic and in-depth investigation of complex phenomena within its real-life context.More specifically, it enables a unique encounter with the therapeutic processes that take place within the setting of psychodrama group therapy in a psychiatric inpatient ward.
The paper is divided into several sections: The Introduction presents the primary objective of the study as well as an overview of the relevant research literature; the Materials and Methods section presents the AR method and the single case study approach, as well as the study setting, the participants, and the qualitative content analysis (QCA) method used in this study; in the Results section, the main themes that emerged from the analysis are illustrated through examples taken from the verbatim transcripts of all of the group sessions that took place during the course of the study; in the Discussion and the Limitations sections, the main findings and their interpretation in the perspective of previous studies, as well as the limitations of this study, are discussed, respectively; and finally, the unique contribution of the study, as well as the main conclusions and recommendations, are presented in the Conclusion section.

Psychiatric Hospitalization and Group Therapy in Psychiatric Wards
Coping with mental illness is often accompanied by a loss of internal and interpersonal dialogue, and a personal experience of one-dimensionality and emptiness.Individuals feel empty and hollow, and see themselves as outside observers of their own lives [1,2].This may be intensified by the effects of social rejection, stigmatization, and self-stigmatization in particular, further exacerbating the difficulty of coping with mental illness [3][4][5].Selfstigma provokes a sense of hopelessness and low self-esteem resulting in a loss of identity, it shapes one's attitudes to recovery, and leads to social withdrawal and depletion of social connections [6,7].Moreover, the hospitalization and treatment experience is often in itself a traumatic experience.Psychiatric inpatients undergo difficult treatments, involuntary hospitalization, they are medicated, suffering adverse effects which can result in a feeling of alienation from one's own recognizable self, and may be also subject to verbal threats as well as physical or emotional abuse by other patients or staff members [8,9].
In the context of mental distress related to the life circumstances in Israel, the effects of the ethnopolitical conflict between Israel and the Palestinians should be noted.Intractable ethnopolitical conflicts, such as the long-running dispute between Israelis and Palestinians, are often protracted, deeply-set conflicts involving hostility and repeated violence.Studies have found a significant association between exposure to intractable conflicts and psychological dimensions, where greater exposure to the conflict has been associated with more negative psychological outcomes, including developing diagnosable psychopathology, such as depression or post-traumatic stress disorder (PTSD) [10].The context of the long history of the Arab-Israeli wars and the ongoing exposure to violence that characterizes the Israeli-Palestinian conflict entail severe psychological effects on the entire population, manifested by continuous arousal of symptoms, such as ongoing stress, PTSD, and a chronic sense of insecurity and anxiety.A high fraction of Israelis, over one-third, is estimated to suffer from trauma-and stress-related mental health symptoms [10,11].
Patients suffering from mental distress or illness can benefit from therapy that conjures diverse situations of rich dialogue, offering partners to mirror one another, and providing visibility and a voice to convey the patient's inner narrative [2].Many studies have revealed the immense benefit of group therapy in people coping with shared distress, especially patients suffering from severe mental illness [12][13][14][15].The interpersonal dimension-a group member's sense of acceptance and belonging; a personal allegiance and commitment to the group; and the trust, support, and compatibility felt among the group-plays a significant role in the therapeutic process that occurs in group settings [16].Dreikurs emphasized the dimension of equality that exists in group therapy, in which individuals are valued for who they are in the group and for their self-disclosure and honesty, and not for what they have achieved in their lives [17,18].Other studies have found that individuals who felt understood and protected in group therapy reported a greater improvement in overall well-being [19,20].
Yalom, in his books, details the circumstances surrounding group therapy in psychiatric wards.He describes the power-struggles that arise between the various members of medical and para-medical professions, the rapidly changing group membership due to increasingly shorter hospitalizations, and the psychopathological heterogeneity in the various departments.Other factors include the presence of multiple groups that leads to a blurring of membership among the different groups, the time spent together when outside the group, and the norms for sharing information among staff-members [21,22].In the midst of these limitations, Yalom describes the benefits that group therapy offers to these psychiatric inpatients.In addition to Yalom's definition of 11 "therapeutic factors" of group therapy in general (instillation of hope, universality, imparting information, altruism, corrective recapitulation of the primary family group, development of socializing techniques, imitative behaviors, interpersonal learning, group cohesiveness, catharsis, and existential factors), he highlights a few goals for group therapy specifically within an inpatient ward.These include encouraging patients to be involved in their treatment and recovery process; encouraging a desire to maintain and continue with treatment even after discharge; demon-strating to the patient that talking about one's problems and sharing can help; identifying problems with the help of the group, in order to work on them later in one-on-one therapy; alleviating loneliness and bridging barriers between fellow inpatients; providing a tool for patients to help and support one other, which empowers patients, giving them a sense of capability and self-value; and lastly, easing the anxiety that is experienced in psychiatric hospitals by offering a safe and protected space within it [21,22].

Psychodrama and Group Sharing for Patients with Mental Illness
Psychodrama group therapy is a method in which the therapeutic stage is used to enact and re-enact life events with the aim of enabling the reconstruction of roles that people accept or take on in their lives.As an action-based method, psychodrama allows patients to recreate their life roles in an integrative way, through role-playing, rather than discuss it in a detached way [23,24].The therapeutic process in psychodrama moves away from the classic treatment of the individual in isolation to treatment of the individual in the context of a group, with the aim of providing a quality of social support that can contribute to the reduction in anxiety, stress, guilt, and self-blame, and have a strong positive influence on the psychological health and well-being of the participants [25,26].Kellerman emphasizes the integrative dimension of experiential learning which is embodied in the psychodramatic action, as compared to that of talk-based analysis [27].Psychodrama therapy offers a safe environment in which the foundation of one's beliefs can be re-examined by re-enacting roles and events on the stage, thus has the potential to facilitate a change in self-narratives and beliefs [28][29][30].
A number of empirical studies with quantitative methodology, that have examined the effect of psychodrama as a therapeutic method, have noted its efficacy in reducing depression [31,32], aggression [33], anxiety and stress [34,35], treating trauma and PTSD [36,37] as well as increasing self-awareness and empathy [38], and improving interpersonal experiences and relationships [39,40].The unique nature of psychodramatic group therapy is beneficial in ways that traditional psychotherapy is often inadequate.The psychodrama group acts as an accommodating space for coping with the experience of distress of the participants by creating a space for self-expression and a human encounter, mutual support, and sharing [41].Roine and others describe the ability of psychodrama to evoke spontaneity and uncover creativity in difficult patients [26,[42][43][44].Farmer [45] highlights the way in which the psychodramatic stage allows patients to approach their feelings and thoughts in situations where the verbal dialogue of analytic psychotherapy is limited.These techniques are especially beneficial for challenging populations, such as at-risk adolescents, alcoholics, drug addicts, patients coping with anorexia and those coping with severe mental illness [39,46,47].
J.L. Moreno, the founder of psychodrama, claimed that the focus of the psychodynamic therapy process, which also allows it to be of value in working with difficult mental illnesses and psychotic cases, does not take place in the transference between the client and the therapist, but rather in the encounter that takes place between the people and between the roles.Using the "tele", the emotion that arises in interpersonal encounters and in the interaction between different roles, psychodrama aspires to induce the recovery process even in those people with mental illnesses that Freudian psychoanalysis avoided addressing [48].This therapeutic dimension of interaction and interpersonal encounter is expressed via various components of the psychodrama work, among them the auxiliary ego, the double, role reversal, encounter, and psychodramatic sharing [26].
Sharing has become a widespread, fundamental concept throughout therapeutic culture and discourse, even beyond the psychodramatic sphere.Nicholas John dubbed the contemporary era "the age of sharing" and connected the prominence of the therapeutic ethos of sharing emotions to, among others, the digital culture and sharing on the internet, especially on social networks [49].This, in a manner that corresponds to the Lacanian notion of extimacy (extimité), as a human condition in which the center of the subject is both external and internal to itself simultaneously.John joins Samuel Mateus in arguing that the subject only gets in touch with their selfhood by making it public and sharing it with others [49,50].
John and others date the initial formulation of sharing as a concept-as it relates to the therapeutic context of sharing emotions in a group-to the Oxford Group founded in the United States of America in 1922, out of which emerged Alcoholics Anonymous (AA) about a decade later.This notwithstanding, we should note that during that period the notion of sharing was already quite clearly a component of Moreno's approach to psychodramatic group work.
The psychodramatic sharing, also known as the sharing phase, is the phase in which the group members share their experiences and issues from their lives that relate to the work of the protagonist [26,51].Moreno describes sharing as the phase in which the focus moves from the stage to the audience, the phase in which "the strangers" in the group reveal their emotions and cease to be strangers.They repay the protagonist with love, and they gift both the protagonist and themselves the experience of group catharsis [52].By sharing personal experiences relevant to the protagonist's work, the group members ensure that the protagonist does not feel lonely or embarrassed at the end of their work, rather they feel like one of the many people who experience similar challenges.
The sharing helps the protagonist break free from their role and expedites their return to reality and to the group as one of its members.The protagonist who was previously-during the psychodramatic work-detached from the group, undergoes an accelerated reintegration back into the group structure via the sharing [53].Sharing is an important phase for the group members as well.It grants them the opportunity to speak their own minds as if each and every one of them is the protagonist for a moment.
Sharing is rarely dealt with in the research literature on psychodramatic therapy, and there is very little evidence-based study that sheds light on the influence of this therapeutic component.One of the very few findings on the matter appears in a recent study that measured the ongoing influence of the psychodramatic therapeutic process on the participants [54].In this study, the HAT (Helpful Aspects of Therapy) test was used to help the participants report on the events that occurred in the therapeutic framework, granting the events a score on the scale of one to five, as events that either helped or hindered the therapeutic process.The results of the HAT test revealed that out of ten therapeutic categories-which included the main psychodramatic tools and the performance of psychodramatic vignettes on the stage-the two therapeutic components that comprised the largest number of events reported as helpful to the process were "the sharing of the other group members" (24% of the events in the therapy) and "the participant's own sharing in the group" (18.5% of the total number of helpful therapeutic events occurred in this category).If we combine these two categories, we find that 42.5% of the events that were reported as helpful to the treatment were related to sharing-either the protagonist's sharing or the group members' sharing.
The findings described above attest to the beneficial influence that group sharing should have in the framework of psychodrama therapy; however, these are isolated findings.As a rule, the research literature does not address the contribution of the psychodramatic sharing to the therapeutic process.The current study looks at the potential role of group sharing within the framework of psychodrama group therapy, in alleviating experiences of distress and loneliness among psychiatric inpatients.Various studies describe the acute distress associated with the experience of coping with mental illness and psychiatric hospitalization [4][5][6]8,9].Another strand of research describes the therapeutic benefit of psychodramatic techniques [23,24,27] and its efficacy in reducing depression, aggression, stress, and anxiety [31][32][33][34][35][36], and in treating particularly vulnerable populations for whom traditional psychotherapy's usefulness is limited [36,39,46].However, the existing literature devotes little attention to the therapeutic contribution of the psychodramatic sharing [54].The primary objective of this study was to examine how the circle of group sharing within the framework of psychodrama group therapy can act as a receptacle for self-expression and empathy, mutual support and relatedness among participants, and to offer at least partial relief for the experience of acute isolation and distress of psychiatric inpatients.

Action Research and the Single Case Study
This study was conducted using an action research (AR) approach that combines methodical investigation with practical action in the societal or communal setting.The concept of AR originates with the work of Lewin [55] and John Collier [56] on the subject of intergroup dynamics, and is associated with activities designed to produce social change, liberate oppressed groups, and create an egalitarian society.Today, the term AR is used in a broader sense, to describe various kinds of research carried out by practitioners [57,58].This investigational approach, which in the past was commonly found mainly in education and teaching research, is now an accepted method in various fields such as social work, organizational behavior, healthcare, public health, mental health, and others [59][60][61].
AR sees the practitioner-researcher as the primary research tool.The research is characteristically descriptive, drawing its data from the natural framework of the field work, emphasizing the process itself, and attaching importance to the subjects' own interpretation of the observations [62,63].
The present AR study was conducted in line with the Single Case Study approach.The term "case study" has been widely used across multiple disciplines [64].Robert K. Yin defines the case study as "an empirical inquiry that investigates a contemporary phenomenon within its real-life context" (p.18) [65].Crowe and her colleagues describe the case study approach as a research approach that is used to generate an in-depth, multifaceted understanding of complex issues in their unique context [66].Explanatory in nature, the case study is used to obtain an understanding of phenomena in real-life settings and to catch the uniqueness and complexity of a single case [67].Case study research is a versatile form of qualitative inquiry most suitable for a holistic and in-depth investigation of complex phenomena [68].
Using the Single Case Study approach, this research followed a psychodrama therapy group over a 12-month period in an acute ward in a psychiatric hospital.

The Study Setting and Participants
The hospital is located in the center of Israel.Patients admitted to the acute ward are adults over age 20 suffering from some acute crisis leading them to be hospitalized voluntarily for a period usually lasting from one to three months.The circumstances leading to their hospitalization were varied, including, among others, depression, disorders such as schizophrenia and bipolar disorder, anxiety and other stress disorders, as well as various psychotic states.The psychodrama group was an open group, allowing for variability and a high turnover of participants joining and leaving frequently throughout the course of the group, thus the duration of participation in the group varied from patient to patient [69,70].The study followed this group for nearly a year, during which the group met 40 times, with 85 different participants overall, 51 men and 34 women.Their ages ranged from 22 to over 70.The number of participants in each session ranged from 4 to 11.
The group sessions were led by the author of this paper, and took place once a week in the morning, lasting about an hour.The group meetings began with introductions and a "group pulse-check" in which the participants shared with the group how they were.This was followed by an active warm-up, then enactment of a psychodrama activity, and group sharing for closure.The contents of each session were processed in individual supervision meetings that took place on a weekly basis.

Materials and Data Analysis
The study utilized participant observation.The materials include detailed verbatim transcripts of all of the therapy sessions that took place during the course of the study, as well as other documents including drawings and letters written by the participants during the group sessions and collected by the therapist.The materials created by the participants during the group sessions were collected in order to keep them for the participants and were returned to them.These materials were also analyzed as part of the supervision process to help the therapist gain a better understanding of the participants and their needs.Although the findings of the study are illustrated through examples taken from the verbatim transcripts, it is important to note that all of the documents collected were carefully analyzed as part of the process of revealing the thematic categories which are presented in the following section.
The analysis is based on the grounded theory approach which emphasizes the generation of hypotheses and concepts based on the data derived from the research [71].In line with this approach, several stages of qualitative content analysis (QCA) were undertaken [72][73][74].The first phase included a thematic analysis of each document.In the written documents, units of analysis were paragraphs or segments of text from the transcript.At the same time, the entire text was also treated as a single segment.The intention was to enable the necessary dismantling of each session into specific units of content while retaining the ability to see them in their original context [72].
The initial analysis revealed numerous thematic categories emerging from each transcript.After rereading a given transcript, the number of categories was reduced by combining similar categories and focusing on those that emerged most relevant.Next, the transcripts were integrated based on the categories that they had in common.These categories were scrutinized again for the connections between them, and for their relevance to theory [72,75].

Results
The results of the study are illustrated through the examples taken from the verbatim transcripts and presented in four main thematic categories based on their centrality (repeated appearances across group sessions) and their relevance to the study's topic.The main categories are: (1) Manifestations of distress in the group; (2) Patients supporting one another; (3) Universality; and (4) Sharing as a ritual.The indented and italicized passages are excerpts from verbatim transcripts, transcribed immediately after each session.Pseudonyms have been employed to protect patient confidentiality.

Manifestations of Distress in the Group
Before describing the role of group sharing in the therapeutic process it is important to address some of the manifestations of distress in the group.The group space was almost always suffused with challenging emotions such as depression, loneliness, despair and fatigue, helplessness, fear, and guilt.Oftentimes the agonizing feeling of loneliness was present in the room.Sometimes it was the loneliness of life beyond the hospital wall, and sometimes it was the loneliness of the hospitalization itself and the disconnect it created from the outside world.Oftentimes it was internal loneliness, the disconnect of a person from themselves, from their vitality, and their joie de vivre.
Sometimes, loneliness found loneliness staring right back at it: Rachel, a new participant, talks about the fact that she is very alone, and that for a lengthy period of time she had not left her rented room; that she has an internal voice ("not psychotic", she emphasizes, "an internal voice like everyone has") that makes her despair.
I ask: "What does the internal voice say?" Rachel answers: "It says that it will be bad".
Michael says that he does not know what it is like to not be alone, he had not learned how to get help from others, he lives his entire life with a fundamental sense of being alone, even when he had good periods and even though he has a family.He took part in the wars in 1967 and 1973 and that did not help him at all.Now, at the age of seventy-two, he feels like he has no friends.It is something deep in the soul, he says.
Rachel responds emotionally to Michael's words, saying that she feels exactly the same way.
In the group, Rachel and Michael express the loneliness they feel beyond the hospital walls, a deep, internal sense of isolation that constantly haunts them: Rachel's "internal voice" which says "it will be bad", and Michael's "it is something deep in the soul".Later during the session, we listen to the song Rikmah Enoshit Achat that speaks about all human beings as one living human tissue or organ.Rachel rejects the song's message angrily, saying "In reality you are alone, everyone is on his own".Hackneyed phrases that preach "one living human tissue" do not speak to her.In contrast, her authentic encounter with Michael's loneliness did manage to touch her.
The expressions of loneliness were often accompanied by those of despair, weariness, and hopelessness.These may arise as a result of the illness, and in trying to cope with the outside world, or secondary to the hospitalization itself.A concrete example is found in one session in which the participants were asked to write a letter to someone who was significant to them.One of the group members, David, chose to write a letter to himself: "Letter to David: David has no more strength, I've lost all hope, these horrible feelings won't let me be, and every day in this ward is hell for me.I feel I might go insane, I want to go home.Every day my mother fights with me, that I'll agree to stay here longer.In the ward, everything feels sad and gloomy, and I just cross my fingers and hope that I'll have the patience to last until I can be discharged" This expression of distress, the ability to share it with the group while they do the same, is in itself beneficial.David's letter prompted an opportunity to let him experience a new perspective using role-playing, and then to simply echo David's words and feelings using a psychodramatic double: I place a chair across from David, and ask him to sit in it.I ask him how he would respond to himself.He says, "You need to be patient." As he returns to his own seat I ask him if he was persuaded-he says he was not.I offer a double for him-"It's difficult, I don't have the patience."

Patients Supporting One Another
Alongside the manifestations of participants' loneliness and distress, one could also sense the power of the psychodramatic stage and of the group itself to act as a space for self-expression and empathy, mutual support, relatedness, and sharing.The sharing phase in psychodrama is the phase in which the group members share their personal life experiences as they relate to the work of the protagonist.In practice, the psychodrama activity in the inpatients group did not necessarily focus on one protagonist, and there was not always a clear separation between the main activity and the sharing phase.Within the group, the sharing circle was a space where participants could share their feelings, their troubles, and whatever else they were experiencing.
When tremendous distress took center stage during group session, one could often see how the circle of sharing allowed participants to support one another, to offer a kind word, to encourage, and to offer solutions, different perspectives, and productive steps that could be taken: Sara talks about her suicidal thoughts: "I've been here for two months already and nothing is better.I want to die every day, but I promised that as long as I am here, I will not do anything . . .People always tell me I look better, but I don't feel any better".
Hannah shares that she sees Sara's suffering and depression and her wish for Sara is that she will feel better, that it is difficult for her [Hannah] to see Sara this way.She says that Sara is wonderful and she deserves to feel well.
Jacob also speaks about despair, about his depression that arises from the fact that he has destroyed himself and lost everything, on his immense weariness; about the fact that he just wants to hide here from reality and sleep.Ethan speaks about faith and tries to encourage Jacob.This illustrates how group sharing transforms the psychodramatic space into one of mutual support: Hannah tries to support Sara and Ethan encourages Jacob.Later, the group showers Sara and Jacob with another gesture of encouragement and support.It is not always clear whether the distress heard was the personal distress of Sara or Jacob or whether the empowering voices are the private voices of Hannah and Ethan.Sometimes it seems as if all the voices are the voice of the group itself; that each participant manifests distress and need-and at times despair-alongside strength, optimism, and the desire to help.Group sharing created an important space for expressing these voices and enabling them to encounter one another.
Through the sharing circle, the group members supported and empowered each other, as common themes and challenges emerged and served as the framework for a support system, helping alleviate a sense of loneliness within individual situations and struggles.

Universality
This space of empathy, mutual support, and sharing often evoked an experience of universality; a discovery that individuals are not alone in the difficulties and distress they are experiencing: In the psychodramatic vignette Lisa describes the great difficulty she causes her mother because of her illness.[She tells about] the guilt she feels towards her mother.She becomes emotional and cries.
[In the sharing phase] we discuss feelings of guilt surrounding illness, as Lisa has expressed; how it is an experience that other participants share as well.Nastya and Rachel say they also feel guilt towards their families.
. . .At the end of the session Lisa hugs Nastya.She thanks her and says she feels much better now.
In another example, a circle of sharing that evoked an experience of universality occurred right at the beginning of the group session: The group members share how they are doing this morning.Aaron shares that he is confused about his place in the world.When he doesn't observe the commandments of Judaism he feels emptiness, yet when he tries to observe the rituals he becomes unbalanced and triggers manic episodes.Another participant, Abraham tells him that when a person brings oneself closer to religion, at first God gives a push forward, but afterwards one is left [to struggle] with it alone.I ask Abraham if this is something he has personally experienced; he says yes, and adds: "We are souls attached together, souls that speak."

Sharing as a Ritual
Sometimes, when the group space is filled with distress and harsh emotions, the sharing takes on a ritual character.A group exorcism of sorts takes place that is intended to inspire hope and to enable the participants to share their experience of coping with suffering: I take jars of paint that are in the room, and we begin placing them in the center of the circle, each one representing one of the bad feelings that had been expressed: sadness, anxiety, depression, stress, the wish to die, weariness, boredom, confusion, lack of control over one's needs . . . .Afterward, I ask each group member, in turn, to remove a jar of paint from the circle and share what the feeling/the thing is that they would like to expel.The group does this: Each participant takes a jar of paint out of the center of the circle and shares what it represents and what they would like to do with it.We all repeat their words as if they were a mantra: "I wish this weariness would go away", "I wish this sadness would depart".
In another session-the one in which Sara and Jacob shared their distress with the group-the sharing circle at the end of the meeting had a similarly ritual character: We place a circle of hoops in the room, and each hoop represents a feeling that arose during the encounter: sadness, confusion, optimism, depression, partnership, joy, shame, fatigue . . .Each participant chooses a hoop and tells the group what he would like to do with it.
Ethan chooses the hoop labeled "despair," to tell Sara not to lose hope.Jacob chooses (Ethan's) optimism.Abraham chooses faith and optimism.He addresses his words to Sara and Jacob, and talks about God, who, even if it is difficult to understand, always has our interests in mind.
Finally, I take the partnership hoop, and say that I've felt a lot of that partnership within the last hour.
The sharing, which in this case took place via the hoops that represented the feelings that were manifest in the encounter, allowed the participants to give away and take from one another some of their strengths as well as their distress, just like in a "magic shop" in which barter based on altruism and generosity takes place (The Magic Shop: A psychodramatic exercise in which the participants engage in commerce, bartering traits, values, feelings, and more).This example demonstrates the essence of the role of group sharing in the psychiatric inpatients' psychodrama group-distribution of the heavy burden, as well as the resources and strengths of the participants in the group.

Discussion
The research literature based on action research and case studies strive to achieve an integrative understanding of complex phenomena through in-depth, concrete, and uncontrollable encounters with discrete cases, which are often singular occurrences, in their authentic surroundings and within a dynamic, real-life setting [63][64][65][66].One of the significant advantages that action research offers is the deep familiarity of the researcher with their subjects.In this case this familiarity enabled an intimate and unique encounter with psychiatric inpatients' distress and with the role that group sharing plays in dealing with situations of acute mental distress.
Loneliness, shame, and guilt, as well as depression, weariness, and despair were regularly present in the group sessions described in this paper, both as direct, physical, and behavioral manifestations of fatigue, passivity, and distress, and in the stories shared by the participants regarding the experience of coping with their illness and with the difficulties involved in psychiatric hospitalization.These findings complement the picture that has emerged from a number of previous studies regarding the symptoms of depression that arise in patients following a medical diagnosis [76,77], the self-stigma and learned helplessness, loss of self-belief, despair, and loss of will which characterize the experience of coping with mental illness [1,6,7], as well as previous findings that point to the experience of loneliness, the separation from friends and family, loss of independence, and the distress associated with psychiatric hospitalization [8,9].
Alongside the manifestations of inpatients' acute distress throughout the therapeutic process, the study illustrates the role of sharing in the therapy group as scaffolding for self-expression, relatedness, and mutual support among the participants.In this space, the patients could share their distress and feelings with the group, and sense the attentiveness of the other participants, who occasionally offered their responses as well.They could sense the universality of their experiences [22], or the mirror reaction as termed by Foulkes, in which the participants discover that they are not alone in their distress; that their fellow group members cope with similar distress and they share it with the group [18].This phenomenon corresponds with the concept of common humanity (seeing one's experiences as part of the larger human experience, rather than as separating and isolating) in Neff's discussion of the construct of self-compassion [78].This happened not only during the sharing phase at the end of a psychodramatic vignette, when the participants were provided with the opportunity to share personal experiences and issues relevant to the protagonist's work [51], but also at other moments of group sharing that occurred during the sessions.
The practice of group sharing is a therapeutic tool that promotes emotional connection, awareness, and self-expression among the participants; it establishes trust and a sense of closeness among fellow group members [79,80].Sharing is not limited to a specific therapeutic stage and is undertaken in a wide range of group therapies.This practice is simultaneously a means of expression and an establishment of intimacy-both in the personal sense of heightening emotional awareness and in the group sense of strengthening interpersonal connections [49].Sharing plays a distinct and significant role in promoting many of Yalom's therapeutic factors of group psychotherapy: universality; instillation of hope; corrective recapitulation of the primary family group; development of socializing techniques; interpersonal learning; and group cohesiveness [21,22]; all of these are of great significance concerning acute distress, such as in the cases described in this paper.
Moreover, the sharing of emotions in group therapy and its contribution to the establishment of awareness, self-expression, closeness, and trust in the group, all complement the goals that Yalom defines for group psychotherapy within an inpatient setting: encouraging patients to be involved in their treatment and recovery process; demonstrating to the patient that talking about one's problems and sharing can help; identifying problems with the help of the group; alleviating loneliness and bridging barriers between fellow inpatients; providing a tool for patients to help and support one other, which empowers patients-giving them a sense of capability and self-value; and lastly, easing the anxiety that is experienced in psychiatric hospitals by offering a safe and protected space within it [21,22].
The Psychodramatic sharing, which is a distinct stage immediately following the psychodrama work of a protagonist, adds to the above factors and goals.Its cruces include the mobilization of group members in support of the protagonist, the resonance of the psychodrama work's content with the group, and the integration that is made possible as a result.Moreno described the sharing phase as a phase where "strangers" in the group can reveal their emotions and cease to be strangers, can express their love for the protagonist, and allow for their own self-expression [52].At the same time, the protagonist who was detached from the group during the psychodramatic work, undergoes an accelerated reintegration back into the group structure [53].Kellerman [27] emphasizes the existential and universal validity that the group imparts to the protagonist via sharing, and how psychodramatic sharing serves as a means of personal and emotional identification with the protagonist.
In the inpatients' group presented in this paper, the work space was not necessarily subjected to the psychodrama work of a single protagonist.The limitations regarding the short time allotted to each therapy session, the group's open nature, with participants joining and leaving frequently throughout the course of the group [69,70], and the frequent manifestations of the participants' distress, which in many cases required immediate responses; all of these resulted in the work space being divided multiple times among all of the participants.However, the frequent expressions of distress, emotion, or acute need by group members (sometimes several times in one session) repeatedly led to an unplanned performance by a momentary protagonist who expressed emotion, experience, or any other fervent content to the group that touched the other participants as it related to their own experiences, and they then engaged with the performance via "share-back," to use the term coined by Olsson [81].This is the quintessence of what Moreno described as the fabric of life and the human encounter that comprises the psychodrama group [43,[82][83][84][85].
The sharing in the inpatients' group occasionally occurred spontaneously, at the participants' initiative, but it mostly had a structured and distinct space-a sharing circle-whether it occurred as part of the "group pulse-check" at the start of the sessions in which the participants shared with the group how they were (and where sharing was mainly related to experiences of being admitted to hospital or life within it) or part of structured sharing toward the end of the sessions.This built-in space for sharing at the end of the sessions did not consistently meet all of the criteria of a sharing phase that occurs after the protagonist's work in classical psychodrama.Still, it was distinct from the sharing that occurred at the start of the sessions as it was fed by the work that had taken place within the group and tended to be more integrative in how participants' content resonated with each other's and helped form meaningful individual and group experiences from the work that had taken place in the session.The sharing at the end of the sessions enriched the work with partnership, interpersonal affinity, humanity, and hope.In this way, the sharing also served as a space for closure that helped soften the "re-entry" [86] into their lives as inpatients in a psychiatric hospital.

Limitations
The findings of this study may contribute to the understanding of the benefits of psychodrama group therapy in treating acute psychiatric inpatients, but this study is not without limitations.One methodological issue concerns the action research method and the danger of blurring boundaries between researcher and practitioner, and between research and clinical action.As regards the current study it is important to refer to the author's role as practitioner-researcher.While the author's familiarity and deep connection with the participants were invaluable and allowed a better understanding of subtle nuances of the participants' behaviors and emotions, it also required consistent effort to restrain possible negative effects of his engagement as practitioner-researcher.
Secondly, it is important to note that this study is descriptive in nature and based on qualitative research methods that are not intended to provide a precise measurement of the effects of psychodrama therapy or participants' difficulties and needs, nor does it purport to definitively demonstrate a direct causal relationship between these two factors.Thus, another limitation of this study-related to the naturalistic and uncontrolled characteristics of the Single Case Study design and the avoidance of using a control group-is that it cannot point to a one-dimensional causal association between engagement in the performance of sharing within the setting of a therapy group and the reduction of emotional distress among psychiatric inpatients.It is important to note, though, that while such qualitative inquiry does not purport to point to a direct causal relationship between different variables or events, it contributes to the understanding of aspects related to causality through the explaining of participants' values and beliefs, which play a role in understanding behaviors and their consequences, as well as the effect of social and cultural contexts.
In the same way as other cases of clinical single case reports, this study relies on anecdotal data in which clinical judgement and interpretation play a major role, and alternative explanations are available to account for the processes and events described other than those provided here.In order to achieve a more complete picture there is clearly room for further research, including quantitative and experimental controlled studies that can produce reproducible and generalizable results regarding the effects of the therapeutic tool of group sharing.

Conclusions
This study contributes to our understanding of the benefits of psychodrama group therapy for psychiatric inpatients in dealing with situations of acute mental distress.Previous studies point to the experience of loneliness, the separation from friends and family, loss of independence, and the acute distress associated with psychiatric hospitalization.Another strand of research describes the therapeutic benefit of psychodramatic techniques, and its effectiveness in treating particularly difficult populations for whom traditional psychotherapy's usefulness is limited.The findings of this study point to the role of group sharing in allowing the participants in an inpatients' psychodrama group to distribute the burden among their fellow group members along with the resources to cope with it, and in creating an accommodating space of self-expression, mutual support, and relatedness, which offers a relief for the distress of psychiatric inpatients.A recommendation derived from these findings concerns the need for policy-and decision-makers in psychiatric hospi-tals to recognize the value of group work within inpatient settings as a therapeutic resource, and to increase the amount of therapy groups in acute psychiatric wards.
The unique contribution of this study is the close encounter that it provides to practitioners and researchers with the processes that take place within the setting of psychodrama group therapy in a psychiatric inpatient ward, and with the therapeutic dimension of group sharing, which is rarely dealt with by the existing literature.
Funding: The research received no external funding.
Institutional Review Board Statement: Ethical review and approval were waived for this study in accordance with the local legislation and institutional requirements for studies carried out as part of a clinical seminar.Informed consent was obtained from all participants.
Informed Consent Statement: Informed consent was obtained from all participants involved in the study.