A Psychodrama Intervention to Loneliness Due to COVID-19

Loneliness as a psychological state is affective and cognitive discomfort or uneasiness from being or perceiving oneself to be alone or otherwise solitary. Since the beginning of the pandemic, people stayed at home, afraid of contracting COVID-19. As youths followed lectures via the internet for long hours without physical participation, they became more and more withdrawn and socially isolated. This study explores psychodrama as an intervention to reduce loneliness in university students. COVID-19 pandemic durations seemed to be caused loneliness for all people. The short-version of the ULCA loneliness scale was applied to 358 university students. 24 students were selected for the study based on their higher scores on the assessment. These students also accepted that COVID-19 negatively affected their loneliness state. The average age of participants was 21 years old, and no one was younger than 19 years old. Randomly they were divided into two groups as experimental and controlling with equal representation of number. The experimental group joined 15 weeks of psychodrama groups for 90 minutes each week. All sessions were held with via internet video platform meeting program. In psychodrama method of psychotherapy, clients enacted their concerns to achieve new insight about themselves and others. The psychodrama program started with introducing group participants and expression of why they are in the group to each other. The group was guided with an experienced group leader. With the techniques of psychodrama such as warmup, mirror, doubling, and role reversal, participants self-disclosed their current moods. K-square statistical analyses suggested that the group of university students who joined psychodrama overcame their loneliness. Education policy makers should bear in mind that today’s Covid-19 society suffers from psychological treatment deficits in the area of loneliness. Group action methods should be taken immediately. Group guidance, counseling, and drama in education and psychodrama can be useful for students to cope with problems resulting from of COVID-19. Youths truly need to share their suffering with professionals. Preventive guidance activities should be given importance in schools.


Introduction
COVID-19, which originated in China and spread all over the world in a short time, like a nightmare, affected all people negatively. Hundreds of people have died and thousands of people also are suffering from this illness in most miserable health conditions. Coronavirus (CoV), what we used to see around us, it is among the catarrhal-flu factors. The variant that emerged on December 29-31, 2019 and is currently in the pandemic (world epidemic) that we fear will cause CoV type is defined as "Coronavirus disease 2019", i.e., "COVID-19" from the beta-CoV group. All types of it can affect mammals. At the time of publication, COVID-19 proved fatal in 3% of cases worldwide. Health authorities suggested that rapid recognition and isolation of cases be combined with increasing awareness and social, residential quarantine in order to prevent the spread of the virus.
Scientific institutions and health units will end the epidemic with the coordinated work of government agencies (Karcioglu, 2020).
On January 23, 2020 "Lock-down" for the city of Wuhan, quarantine decision was made and implemented. Considering the different clinical prognosis of the disease, the age groups in which it is seen, and it's spread; it can be anticipated that the subject will not be limited to the medical dimension, but may have negative effects in terms of socio-cultural, ethical and moral, legal, education, tourism, economy, agriculture and public health. This article, which is the starting point, includes content that examines and evaluates the negative aspects of the COVID-19 pandemic that affect social life and the ethical plane based on news sources with high accuracy on the internet and scientific literature (Ustun & Ozciftci, 2020).
Terá n-Pé rez et al. (2021) claim that concerning anxiety and depression, both sexes reported high symptoms. These data suggest that stressful conditions related to social isolation and the economic uncertainty caused by the pandemic may induce mental health disturbances, which may become worse with sleep restriction. In a similar study, Citak and Pakdemir (2021), found that a significant number of participants had high anxiety levels. Also, it was determined that individuals' sleeping habits changed, and that they had more difficulty sleeping during the COVID-19 pandemic. The study also found that those individuals having trouble sleeping also had a higher inclination to have generalized anxiety.
As a psychological maladaptation, loneliness is one of today's epidemic diseases. The concept of loneliness defined by dictionaries and the concept of loneliness used in the field of mental health are not exactly the same. Loneliness in the dictionary refers to the situation where nobody is around.
However, the concept of loneliness used in the field of mental health is the inability of a person to feel the feelings of attachment, closeness and belonging to anyone. According to Genctan (1994) there are different kinds of loneliness such as: 1) People who live alone may feel lonely.
2) He/she may become lonely by alienating his/her community group.
3) Loneliness may occur due to exclusion by the environment. loneliness is seen as the lack of a close friend or lover/spouse due to the influence of individualist culture. But in Eastern societies, loneliness is evaluated in the context of a wider network with the effect of social culture. In other words, incomplete relationships with family, relatives or even communities are considered loneliness Genctan (1994).
The reasons that prevent lonely people from establishing relationships have been investigated and, according to research, two main reasons causing loneliness were found. One of them is negative expectations and the other is a lack of social skills (Hawkley, 2019, p. 185). First, look at what is meant when speaking about negative attachments. As lonely people enter a social environment, they think that their experiences here will not go well like others, and they constantly have negative expectations.
These low expectations poison lonely people while trying to establish a friendship or romantic relationship. This poison is reflected in their thoughts and behavior, causing them to behave cold and avoidant. At this stage, people alone should try to overcome their negative thoughts and low expectations and try to replace those thoughts with more functional thoughts (Sahin, 2019).
Let us look now at the deficiencies in social skills, which is another factor. Some situations such as not knowing how to communicate, not knowing how to behave, not being able to use gentle and effective language, not being able to empathize, and not knowing how to continue talking are some of the situations that are seen due to the lack of social skills. Lack of social skills can lead to inability to get out of the loneliness cycle and to be trapped in that cycle. At this stage, in order to overcome loneliness,  (Giacomucci, 2021).

Psychodrama
Psychodrama is an action method of psychotherapy which has a distinctive language and a characteristic structure. Psychodrama interventions are creative, engaging, and interactive for group and individual treatment. Psychodrama is a form of group psychotherapy in which action techniques are used. Group members do not sit in a circle on chairs discussing life and its problems. Life is brought into the room and enacted using group members as the cast of the drama. The process is rich, enlivening and fun. Solutions are found to problems using the creativity and spontaneity of the group (Holmes, 1992).
The aim of psychodrama is to help a person be more constructively spontaneous, be happier and have the strength to design life as she wants it to be. The objectives of insight and cathartic release play their part in unblocking the person's perception and ability to deal with change (Wilkins, 1999).
What this means is that psychodrama, in combination with all the other psychological and social technologies being developed, can facilitate a new, potentially achievable goal: the intentional transformation of consciousness itself. With these considerations in place, let us proceed to an examination of some of the issues in greater detail (Blatner, 2000).
Psychodrama involves the staging of a problem in life as if it were a play, and so certain terms are used which are derived from theatre: protagonist, director, stage, audience, and the like. The protagonist is the person who is the subject of the psycho dramatic enactment and the director is the person who orchestrates the psychodrama to help the protagonist explore a problem. The stage is the area in which the enactment takes place. The audience or the auxiliary egos play the roles the protagonist wants to work on and the audience watches the play.  Table 1 illustrates the techniques in psychodrama that frequently used.

Definition of techniques:
Soliloquy: The protagonist shares with the audience the feelings and thoughts that would normally be kept hidden or suppressed.
Double: When another group member joins the protagonist, taking on their posture and, when it is helpful, speaking for the protagonist, they are said to be a double.
Mirror: A process in which the protagonist's part in the drama is taken by another who then does and says what the protagonist did previously while the latter watches. This "instant replay" allows the protagonist a more objective view of the scene.
Role Reversal: When protagonists take on the role of "the other" in their dramas and the auxiliary plays the protagonist, roles are said to be reversed.
Resistance Interpolation: This intervention describes the process of testing the protagonist's spontaneity, in terms of responding to new situations, by modifying the psychodrama scene. Sculpture: The director asks the protagonist to arrange group members in a symbolic representation of the way he/she perceives an aspect of his/her life or self.
Social atom: An individual's immediate social network. Originally the social network into which a person is born, and which continues to affect them throughout life, but also used to mean those "significant others" surrounding an individual in the present.
Intermediate objects: Objects such as props, fabrics, puppets, cloth dolls and masks have been recognized as catalysts of important non-verbal reactions and at the same time allow a greater distance from the emotionally charged situation.
Games: Dramatic games were referred to in about a quarter of the revised references. The game must go through the same stages of the psychodrama session: warm-up, action and sharing.
Sociometry: An approach to the measurement of interpersonal relationships.
Role play: A group therapy approach in which clients act out their problems to gain new insights and achieve emotional catharsis and was developed by Jacob Moreno who contended that people could gain more from acting out their problems than from talking about them.
Symbolic representation: The process of mentally representing objects and experiences through the use of symbols (including linguistic symbols) Psychodrama utilizes and cultivates imagination, symbolic representation, and also the ability to shift back and forth between the realms of imagination and ordinary reality.
Amplification: Describe a judged tendency of a person to amplify physical symptoms based on psychological factors such as anxiety or depression.
Concretization: Concretization allows protagonists to experience physically what had been experienced psychologically, and the marshaling of the multilevel resources of the body can serve as a vehicle for spontaneity and insight.
Empty chair: (also known as "auxiliary chair") Instead of another person (an auxiliary) playing the complementary figure in a protagonist's enactment, an empty chair represents that position. Sometimes this allows for a more spontaneous expression of aggressive or tender feelings, depending on the makeup of the group or the embarrassment of the protagonist in working with another person (Lippitt, 1958). This is an invaluable technique in a one-to-one therapeutic context and has been incorporated as an integral part of Gestalt therapy.
Spontaneity and creativity are two broad and very important concepts in psychodrama, and those lead to interpersonal and social changes (Giacomucci, 2021).
The aim of this study is to find out effectiveness of psychodrama on loneliness of university students caused by COVID-19. There are many studies relating to COVID-19 and loneliness as mentioned above. None of those studies indicate any remedies to loneliness of university students. So, this study seeks to offer effective remedies.

Participants
The loneliness short version scale was applied to 358 university students whereby 50 students scored high indicating loneliness and were interviewed to determine if the pandemic affected them negatively.
The interviews revealed 24 students accepted that the lockdown affected them badly and feel extremely lonely. The participants were in the age of between 19 and 21. Two groups randomly were assigned as control and experimental. All groups consisted of the same number of participants.

Data Analysis
The Mann-Whitney U test was used in this study to compare differences between two independent groups when the dependent variable is either ordinal or continuous, but not normally distributed (MacFarland & Yates, 2021).

Measure
Loneliness Scale UCLA Loneliness Scale short form was used. The scale, which consists of 20 items, is in the four-point Likert type, and is scored as 1 (not at all appropriate) and 4 (completely appropriate). The lowest score that can be obtained from the scale with 2 reverse coded items (items 3 and 6) is 8 and the highest score is 32. High scores on the scale indicate that the individual has a high level of loneliness. The exploratory factor analysis resulted in a factor and a confirmatory factor. The analysis showed that the model fits well with the original scale and has high validity. The psychometric properties of the scale were analyzed with internal consistency, exploratory and confirmatory factors. The internal consistency coefficient of the scale is .96, and the test-retest reliability coefficient is .94 (Dogan, Cotok, & Tekin, 2011).   Table 3 illustrates U-test result of the loneliness scale according to the group. Mann Whitney U-test results of post-application loneliness scale scores of university students with high loneliness scores who participated in the psychodrama program and those who did not participate in such a program are given in Table 1. Accordingly, at the end of a fifteen-week experimental study, it was found that there was a significant difference between the loneliness scores of the students who participated in the psychodrama program and the students who did not participate in such a program (U=4.50, p<.00).

Findings
When the mean ranks are taken into account, it is understood that students participating in psychodrama have lower loneliness scores than students who do not participate in psychodrama. This finding can be said that the psychodrama program is effective in reducing the loneliness of students who are lonely.

Conclusion and Discussion
COVID-19 has been highly and negatively affecting all over the world. Due to the prohibition on going out, people cannot go to parks, visit family, meet with their friends, and cannot go to places such as restaurants, bars and discos. Young people stated that they had been quite alone for more than a year.
Another fact is that people start to have psychological problems. Especially young people have expressed their loneliness on various platforms.
Psychodrama is an effective method for young people to overcome their loneliness. Techniques such as double, mirror, role reversal and so on can be highly effective for participants of psychodrama (Wilkins, 1999;Blatner, 2000). These interventions create a non-threatening environment for the psychodrama participants (Usakli, 2012).
In conclusion, processes such as psychodrama, group therapy, group counseling are recommended to children, adolescents and adults who are the victims of unwanted psychological situations such as loneliness, anxiety, and decline in well-being due to COVID-19.