Dramatherapy and Drama-Based Approaches in Post-Stroke Psychosocial Rehabilitation: Current Evidence and Research Gaps

Abstract

Background. Stroke can produce emotional, communicative, interpersonal, and identity-related difficulties that are not fully addressed by impairment-focused rehabilitation. Dramatherapy and drama-based approaches may offer embodied, symbolic, and socially meaningful ways of supporting psychosocial adjustment, particularly for people with aphasia.

Aim. To examine current evidence on dramatherapy and related drama-based approaches in post-stroke psychosocial rehabilitation and to identify major research gaps.

Methods. PubMed and Google Scholar were searched in July 2026 for publications issued between July 2021 and July 2026. Search terms combined stroke-related expressions with dramatherapy, drama therapy, therapeutic theatre, participatory theatre, performance-based intervention, role-play, storytelling, and expressive arts. Peer-reviewed studies describing drama-, theatre-, or performance-based interventions for adults after stroke were prioritised. Earlier influential publications were used outside the main evidence synthesis as historical context. Because study designs, intervention content, and outcomes were heterogeneous, findings were synthesised narratively.

Results. The evidence base was small and consisted mainly of qualitative studies, pilot programmes, and exploratory interventions. Identified approaches included individual drama therapy for post-stroke depression, participatory play-making and therapeutic theatre for people with aphasia, and performance-based rehabilitation workshops. Reported outcomes concerned emotional expression, communication confidence, identity, interpersonal connection, and social participation. Samples were small, comparison groups were absent, terminology was inconsistent, and drama was often combined with other rehabilitation activities.

Conclusions. Dramatherapy may be a relevant adjunct to multidisciplinary post-stroke rehabilitation. Evidence does not establish clinical effectiveness or superiority over established psychological or speech-language interventions. Clearly defined protocols, appropriate comparators, validated psychosocial and communication outcomes, and longer follow-up are required.

Keywords: dramatherapy; drama therapy; therapeutic theatre; stroke; psychosocial rehabilitation; aphasia; post-stroke depression

UDC 615.851.8:616.831-005.1

Introduction

Stroke is a major cause of long-term disability, with consequences that extend beyond motor, language, and cognitive impairments. Survivors may experience depression, anxiety, reduced confidence, altered family and social roles, and difficulty returning to meaningful activities. These difficulties can persist after the acute phase of rehabilitation and shape how recovery and life after stroke are understood (Lo et al., 2023).

Functional improvement does not necessarily restore a person’s previous sense of self. Recovery may involve gradual reconnection with the body, other people, and the surrounding world. Long-term participation is influenced by confidence, social support, environmental opportunities, and access to activities that remain personally meaningful (Elloker & Rhoda, 2018; Lo et al., 2023; Norlander et al., 2021). Psychosocial rehabilitation therefore needs to address identity, emotional adjustment, relationships, and social participation alongside physical and cognitive recovery.

Creative arts therapies are used in stroke rehabilitation to address emotional, social, and functional needs. They include visual art, music, dance and movement, drama, and creative writing, although their methods, professional frameworks, and therapeutic aims differ. Existing reviews report possible benefits for psychological well-being, social engagement, and functional recovery. However, the studies are heterogeneous and focus mainly on music, visual arts, and creative activities delivered within occupational therapy (Liu et al., 2024; Lo et al., 2018).

Dramatherapy and related drama-based approaches use dramatic action rather than discussion alone. Depending on the programme, they may involve role-play, storytelling, improvisation, movement, voice, metaphor, enactment, or the creation of a shared performance. These methods may be relevant after stroke because they integrate emotional expression, bodily action, communication, and interaction with others. A fictional role or imagined situation may also provide some distance from experiences of loss, dependency, fear, or changed identity.

This potential may be particularly important for people living with aphasia. Communication difficulties can restrict access to verbally oriented psychological support and may contribute to reduced confidence and social participation. Drama-based work can use gesture, facial expression, movement, rhythm, objects, and shared action, allowing participants to communicate through several channels. A preliminary qualitative study has explored individual drama therapy for people with post-stroke depression, suggesting possible opportunities for emotional expression through projective and dramatic techniques (Hwang et al., 2022).

Terminology is a central difficulty. Relevant publications may use the terms dramatherapy, drama therapy, therapeutic theatre, applied theatre, performance arts, psychodrama, storytelling, or multimodal expressive arts. Searching only one label may overlook relevant work, while including every creative or theatrical activity may exaggerate the evidence base. Not every theatre programme is a therapeutic intervention, and the contribution of drama cannot be isolated when it is combined with speech-language therapy, music, movement, education, or community participation.

Broader reviews confirm that drama remains underrepresented in stroke rehabilitation research. In their qualitative systematic review, Lo et al. (2018) identified studies on music, visual art, dance, and literature, but found no drama-based interventions. Liu et al. (2024) likewise found that research on creative activities after stroke was concentrated mainly in visual arts and occupational activities. A review of therapies targeting confidence after stroke described drama therapy as a non-recurring approach rather than an established intervention field (AlFraih et al., 2024).

This review examines current evidence on dramatherapy and related drama-based approaches in adult post-stroke psychosocial rehabilitation. It focuses on emotional adjustment, confidence, communication, identity, social participation, and quality of life. It also considers how interventions have been defined, which therapeutic mechanisms have been proposed, and which methodological gaps should guide future research.

Search Methodology

This review examined publications on dramatherapy and related drama-based approaches in adults after stroke. PubMed and Google Scholar were searched in July 2026 for literature published between July 2021 and July 2026. Earlier influential publications identified through reference-list searching were excluded from the main evidence synthesis and used only to provide historical and theoretical context.

Search terms combined stroke-related expressions, including stroke, post-stroke, stroke survivor, aphasia, and post-stroke depression, with dramatherapy, drama therapy, therapeutic theatre, psychodrama, applied theatre, performance-based intervention, role-play, storytelling, and expressive arts. Reference lists of relevant reviews and primary studies were screened, and citation and related-article searches were used to identify additional publications.

Eligible publications included peer-reviewed controlled and uncontrolled intervention studies, pilot and feasibility studies, qualitative research, case-based reports, and relevant reviews describing a stroke-specific drama, theatre, or performance component. The review focused on emotional adjustment, depressive symptoms, confidence, self-esteem, self-efficacy, communication, identity, social participation, and quality of life. Studies concerned exclusively with other arts modalities or physical rehabilitation were excluded from the main synthesis unless they directly informed the interpretation of a drama-based intervention.

The evidence was organised according to intervention type and psychosocial outcome. Findings from multimodal programmes were not attributed to drama unless the contribution of the drama component could be distinguished. Because the studies differed substantially in design, intervention content, and outcome measurement, the findings were synthesised narratively, and no meta-analysis was performed.

Evidence Synthesis

Current State of the Evidence

The literature published between July 2021 and July 2026 indicates that dramatherapy and related drama-based approaches remain an emerging area of post-stroke rehabilitation. The identified publications describe individual drama therapy, participatory theatre for people with aphasia, performance-based rehabilitation, and communication interventions that incorporate acting or performance elements. These approaches share an emphasis on embodied expression, role, narrative, voice, and social interaction, but they differ in therapeutic aims, professional leadership, and clinical structure. They should not be treated as one standardised intervention.

The evidence is mainly exploratory. Most publications examine feasibility, participant experience, or possible therapeutic mechanisms rather than comparative effectiveness. Drama is also frequently combined with speech-language therapy, group support, or broader rehabilitation activities, making it difficult to determine whether reported changes are attributable specifically to dramatic methods. A mixed-method review of mind–body and creative arts therapies for people with aphasia similarly found provisional psychosocial benefits but substantial heterogeneity in intervention content, dosage, outcome measurement, and methodological quality (Pieri et al., 2023).

Dramatherapy After Stroke

Direct research on dramatherapy after stroke is particularly limited. Hwang et al. (2022) conducted a preliminary qualitative study with three adults experiencing post-stroke depression. Participants attended twelve individual 90-minute drama therapy sessions, held twice weekly. The intervention used projective and psychodramatic techniques intended to support the recognition, expression, and regulation of emotions.

Interviews, observations, audiovisual records, and materials produced during sessions were used to examine the therapeutic process. Participants were described as becoming more able to identify emotional difficulties, express stroke-related experiences, and consider alternative responses to everyday problems (Hwang et al., 2022). The intervention appeared to offer a structured setting in which difficult emotions could be approached indirectly through role, image, projection, and dramatic action.

The study is important because it explicitly identifies the intervention as drama therapy in a post-stroke population. Nevertheless, its sample was extremely small, no comparison group was used, and the findings depended on qualitative interpretation. It therefore supports feasibility and possible therapeutic relevance rather than effectiveness. No standardised post-stroke dramatherapy protocol or sufficiently powered controlled trial of standalone dramatherapy was identified.

Therapeutic Theatre and Aphasia

Most recent drama-related research concerns people living with aphasia. Aphasia affects communication but may also influence relationships, confidence, social participation, emotional well-being, and the expression of personal identity. Therapeutic theatre addresses these wider consequences by placing communication within a shared creative process.

Den Ouden and Duffy (2024) examined participatory play-making with three people with aphasia. Participants attended weekly sessions over 16 weeks and collaboratively created a play based on their experiences. The process involved developing material, rehearsing scenes, negotiating representation, and presenting the performance to an audience. Interviews conducted four months later indicated perceived improvements in communicative confidence and functional communication. Participants could communicate through speech, gesture, movement, facial expression, timing, and interaction with other performers.

The study also suggested that participatory theatre may improve other people’s understanding of aphasia. Audience members reportedly gained a better appreciation of everyday communication difficulties. However, the sample was very small, and findings were based mainly on self-report and qualitative analysis. Possible benefits could not be separated from rehearsal, peer support, repeated social interaction, or participation in a meaningful group activity.

Datta et al. (2024) examined community responses to people with aphasia participating in CoActive therapeutic theatre. Audience members, relatives, and friends described increased awareness of aphasia and emphasised confidence, camaraderie, and social connection. This community perspective is relevant because communication disability is shaped not only by language impairment but also by other people’s expectations and communication practices. Public performance can present people with aphasia as actors, collaborators, and communicators rather than solely as patients.

At the same time, Datta et al. (2024) primarily evaluated perceptions of the performance and its social impact. The study did not establish sustained changes in participants’ language ability, depression, quality of life, or social participation. Recent therapeutic theatre research therefore suggests a meaningful context for communication, confidence, and community engagement, but it does not demonstrate greater improvement in language impairment than established speech-language therapy.

Performance-Based Approaches

Performance-based interventions overlap with dramatherapy but should not automatically be classified as dramatherapy. Dramatherapy is generally delivered within a defined therapeutic relationship and informed by a clinical framework. Performance-based rehabilitation may instead emphasise artistic training, bodily expression, collaborative creation, or public participation.

Pradier et al. (2022) described a performing arts workshop for people undergoing post-stroke rehabilitation. Drawing on Odin Teatret and Theatre Anthropology, participants developed sequences of physical and vocal actions through sensory stimulation and connected these actions with images and narrative imagination. The programme positioned participants as active creators and treated the body not only as a site of impairment but also as a source of communication and agency.

The authors proposed that action, sensory stimulation, and narrative imagination could mobilise psychological resources during recovery (Pradier et al., 2022). This may be relevant when stroke has altered movement, voice, bodily confidence, or the person’s relationship with the body. However, controlled outcome data were not provided. The programme is therefore better understood as an exploratory performance-based rehabilitation model rather than as evidence supporting the effectiveness of dramatherapy.

Psychosocial Outcomes and Proposed Therapeutic Mechanisms

Across the recent literature, the main psychosocial outcomes were emotional expression, communication confidence, identity, interpersonal connection, and social participation. These outcomes were usually explored through interviews, observations, focus groups, or small-scale assessments.

Emotional expression was central to Hwang et al. (2022). Projective and psychodramatic methods may allow difficult feelings to be represented through role, action, image, metaphor, or imagined situations rather than direct verbal disclosure alone. This symbolic distance may be useful when experiences are painful, difficult to name, or associated with fear, dependency, shame, or loss. The mechanism is plausible but has not been tested experimentally in a stroke population.

Embodied communication is another possible mechanism. Drama uses gesture, posture, movement, spatial positioning, rhythm, facial expression, and voice. Participants may therefore communicate meaningfully even when fluent speech is limited. Rehearsal can also reduce the pressure of spontaneous conversation by providing structure and a shared task, while still requiring attention, timing, adaptation, and communication with other performers.

Identity may be strengthened when participants take on roles beyond that of a patient, such as actor, author, collaborator, or performer. They may become actors, authors, collaborators, or performers. Public performance can make abilities visible to relatives and community members and may support social recognition. Group-based creative work also requires cooperation, shared attention, mutual support, and responsibility for a common goal, which may strengthen participants’ sense of belonging and reduce social isolation.

These possible mechanisms include emotional projection, embodied expression, role exploration, narrative reconstruction, multimodal communication, rehearsal, peer support, achievement, and public recognition. Existing studies have not determined which components are necessary or whether they produce effects beyond therapist attention, group participation, and repeated social contact.

Limitations of the Evidence and Research Gaps

The evidence remains limited in quantity and methodological strength. No sufficiently powered randomised controlled trial was identified that evaluated a clearly defined, standalone dramatherapy intervention in adults after stroke. Most studies used qualitative, pilot, feasibility, or exploratory designs with very small samples.

The interventions were heterogeneous and included individual drama therapy, participatory play-making, therapeutic theatre, and performing arts workshops. They differed in theoretical orientation, session intensity, setting, facilitator qualifications, and intended outcomes. In some programmes, drama was combined with language therapy or other rehabilitation components, preventing the isolation of its specific contribution.

Terminology also remains inconsistent. Dramatherapy, drama therapy, therapeutic theatre, participatory theatre, and performance-based rehabilitation may describe interventions with different aims and methods. Future studies should report the theoretical basis, facilitator qualifications, core dramatic techniques, session structure, duration, communication adaptations, and intended outcomes.

Outcome measurement relied heavily on interviews, observations, and participant perceptions. These methods are valuable for understanding meaning and experience but are vulnerable to expectancy effects and positive response bias. Future research should combine qualitative methods with validated measures of depression, anxiety, confidence, functional communication, social participation, and quality of life. Follow-up is also required to determine whether changes persist after the intervention ends.

Accessibility requires attention. Fatigue, mobility limitations, cognitive or sensory difficulties, aphasia severity, and emotional vulnerability may affect participation. Studies should describe how consent, communication, movement, rehearsal, and public performance were adapted.

The SHAPER–Stroke Odysseys protocol reflects growing interest in the formal evaluation of community-based performance arts after stroke, although it does not yet provide evidence of clinical outcomes (Estevao et al., 2022). A recent systematic review and meta-analysis protocol reflects growing research interest in creative arts therapies after stroke, but it does not provide evidence of effectiveness (Arora et al., 2026).

Initial feasibility work should be followed by controlled mixed-method studies comparing dramatherapy plus usual rehabilitation with usual rehabilitation alone or an active group intervention of similar duration and social intensity.

Discussion

From a psychosomatic perspective, dramatherapy is relevant because it may address bodily experience, emotional meaning, communication, and social relationships within one therapeutic process. Stroke can alter movement, voice, facial expression, independence, and continuity of identity. These consequences are not experienced as separate physical and psychological problems; they interact in everyday communication, self-perception, relationships, and participation. Drama-based work may create a setting in which bodily action is approached not only as impaired performance but also as a means of expression, connection, and creative agency.

A central interpretive issue is the relationship between drama-based interventions and established aphasia rehabilitation. Speech-language therapy remains the principal evidence-based treatment for post-stroke aphasia and is supported by clinical trials, evidence syntheses, and professional guidelines (Brady et al., 2021, 2025; Fridriksson & Hillis, 2021; Rose et al., 2022). No study identified in this review directly compared dramatherapy or therapeutic theatre with adequately delivered speech-language therapy. Drama-based work should therefore not be presented as an alternative treatment for language impairment.

Its potential contribution appears to concern aspects of communication that are not fully represented by impairment-based tests. A person may show little change in naming accuracy while becoming more willing to initiate interaction, communicate within a group, use gesture, take interpersonal risks, or participate in community activities. Functional communication and discourse should be regarded as important outcomes in their own right, not merely as consequences of improved performance on isolated language tasks (Armstrong & Hersh, 2024).

People with aphasia have identified successful communication experiences, opportunities for practice, individual strategies, peer interaction, and supportive communication partners as important contributors to confidence (Howe et al., 2023). Drama-based programmes contain several of these elements. Rehearsal provides repeated practice, the group offers social support, and a shared scene gives communication an immediate interpersonal purpose. However, it remains unclear whether the reported gains in confidence and participation translate into measurable improvements in spoken discourse.

The embodied nature of drama may be particularly relevant for survivors whose spoken communication is restricted. Meaning can be distributed across voice, posture, movement, facial expression, rhythm, spatial position, gesture, objects, and interaction with others. This multimodal structure may allow participants to experience communicative success without depending entirely on fluent speech. It may also reduce the sense that communication is being evaluated primarily in terms of error.

Embodied and symbolic expression may support psychological work when direct verbal reflection is difficult. Through role, image, metaphor, and imagined situations, participants may approach experiences of loss, dependency, fear, shame, or frustration with some psychological distance. In Hwang et al. (2022), these processes were described in relation to post-stroke depression, although the small qualitative design does not allow conclusions about clinical effectiveness.

Identity is another important theme. Stroke may interrupt occupational, family, and social roles and create a division between life before and after the event. Rehabilitation can unintentionally reinforce an identity centred on impairment because the person is repeatedly assessed according to lost functions. Drama offers alternative positions, including actor, author, collaborator, storyteller, or performer.

Participatory play-making may support agency because participants do not simply describe their experiences to a therapist. They decide how experiences will be represented, negotiate meaning with others, rehearse the material, and communicate it to an audience. Den Ouden and Duffy (2024) illustrate how lived experiences of aphasia can become material for a collectively created performance. Osa García et al. (2021) similarly emphasised approaching people with aphasia as artists using different expressive tools rather than only as patients with impaired language.

Public performance adds a community dimension that is uncommon in individual rehabilitation. Participants become visible to relatives, professionals, and audiences in roles other than patient. Datta et al. (2024) reported that audiences and people close to performers associated CoActive therapeutic theatre with greater awareness of aphasia, confidence, camaraderie, and social connection. This is relevant because disability is influenced not only by the individual’s impairment but also by how other people respond and communicate. Nevertheless, audience awareness should not substitute for direct assessment of participant outcomes.

Adjacent creative interventions support the broader plausibility of meaningful group communication without providing direct evidence for dramatherapy. Collaborative storytelling has been associated with preliminary improvements in communication and participation in everyday life among people with aphasia (Mohapatra & Mohan, 2023). Such findings suggest that shared creative projects can support participation, but they cannot be attributed to drama when role, enactment, and embodied performance are not central components.

Earlier publications outside the primary search period provide historical and clinical context. Cherney et al. (2011) described an 18-week drama class in which people with chronic aphasia collaboratively developed and performed a play, with patient-reported changes in communication and mood. Other therapeutic theatre programmes described perceived gains in relationships, self-belief, communication, and self-esteem, while case-based dramatherapy highlighted symbolic and non-verbal communication with a stroke survivor (Côté et al., 2011; Sweet, 2019; Wood et al., 2020). These studies helped establish the clinical rationale for recent work, although their small samples and descriptive designs limited the strength of the evidence.

Terminological inconsistency remains a major barrier. Dramatherapy, drama therapy, therapeutic theatre, participatory theatre, and performance-based rehabilitation may involve different theoretical frameworks, professional responsibilities, and goals. Future publications should specify facilitator qualifications, core dramatic techniques, use of role and improvisation, session intensity, communication adaptations, relationship to other rehabilitation services, and whether public performance is included.

Dramatherapy should be examined within an interdisciplinary rehabilitation framework. Its potential role is not to replace speech-language therapy, neuropsychological care, psychotherapy, occupational therapy, or physical rehabilitation, but to provide an additional setting in which emotional adjustment, bodily experience, communication, identity, and social participation can be addressed together. Collaboration among dramatherapists, psychologists, speech-language therapists, occupational therapists, rehabilitation physicians, and family members may help connect dramatic activities with wider rehabilitation goals.

Future evaluations should use clearly defined, reproducible protocols and accessible mixed-method designs. Standardised measures should assess emotional symptoms, functional communication, confidence, participation, and quality of life, while qualitative interviews can examine embodiment, role, identity, relationships, and social recognition. Studies should report feasibility, attendance, withdrawal, intervention fidelity, facilitator training, adaptations, adverse experiences, and follow-up beyond the period of rehearsal and group contact.

Conclusions

Dramatherapy and related drama-based approaches are promising but insufficiently studied components of post-stroke psychosocial rehabilitation. Current publications suggest possible value for emotional expression, communication confidence, identity reconstruction, interpersonal connection, and social participation. These approaches may be particularly relevant for people with aphasia because meaning can be expressed through role, movement, gesture, voice, imagery, and shared creative action rather than fluent speech alone.

The main limitations of the evidence base are small sample sizes, heterogeneous interventions, and inconsistent terminology. Most studies used qualitative or uncontrolled designs, and drama-based methods were often combined with other rehabilitation activities. The specific effects of dramatherapy cannot yet be separated from therapist attention, peer support, repeated communication practice, and meaningful group participation. Evidence is also insufficient to determine effects on language impairment or discourse.

Dramatherapy should therefore be considered a possible adjunct to established psychological, speech-language, and multidisciplinary rehabilitation rather than a replacement. Future studies need clearly defined stroke-specific protocols, accessible mixed-methods designs, appropriate comparison groups, validated psychosocial and communication measures, assessment of intervention fidelity, and longer follow-up periods.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Funding

The authors received no specific funding for this work.