Is Psychodrama an Effective Method to Intervene High School Students’ Social Anxiety?

: In today's world, 75% of people with social anxiety manifest symptoms as teenagers, but the vast majority of them do not identify or take the problem seriously. In this study, researcher will explore whether psychodrama therapy, a more achievable and attractive to high school students, can alleviate social anxiety through 20 high school students from the International Department of Haidian Foreign Language Experimental School. The experiment consisted of one ice-breaking activity and five formal activities, and the results were quantified by the Comprehensive Interpersonal Relationship Diagnostic Scale. The results of the experiment show that psychodrama therapy has a significant effect in relieving social anxiety of high school students. The findings from this paper will be used in future schools to prevent and alleviate students' social anxiety through the use of psychodrama.


Introduction
Social anxiety is one of the most common categories of anxiety in the population, especially among adolescents. According to World Mental Health Survey Initiative's cross tabulation study which include 28 community surveys with 142,405 respondents in 2017, people who have 30-day, 12-month, and lifetime social anxiety are 1.3%, 2.4%, and 4.0% globally [1]. Specifically, in ADAA's research, 7% of American adults suffer from social anxiety disorder, and more than 75% experience their first symptoms in childhood or early adolescence [2].
Social anxiety has often been underrated and ignored because some of its early symptoms, such as sweaty palms and rapid heartbeat during public speaking or when spending time with others, are seen as perfectly normal conditions. In fact, social anxiety affects us in one way or another. If we do not pay enough attention to it, it can deteriorate into a mental illness, which is known as social anxiety disorder, in serious cases.
Among the approaches to alleviating social anxiety that have proven effective and are commonly used in society is the use of Cognitive Behavioral Therapy, which generally focuses on identifying, challenging, and changing underlying irrational beliefs and exposing people to social situations. Also, the method of taking medicine, including SSRIs, benzodiazepines, and beta blocks, is also has been verified to be effective [3]. However, taking these drugs may also bring side effects such as loss of appetite, dizziness, feeling sick, and tremors [4]. In fact, psychodrama does not require the high cost of doctors and equipment, strict restriction of venue. Also, the theatrical format is relatively more interesting and acceptable for adolescents. Whereas, there are only few prior studies has verified the feasibility and validity of psychodrama's effectiveness on intervening high school students' social anxiety. Therefore, it is significant to study whether psychodrama, one of the most achievable and appealing psychotherapy to teenagers, could ease the common problem for great numbers of high school student-social anxiety.
If the conclusion drawn in this paper is that psychodrama therapy is effective in alleviating social anxiety in high school students, then this result can be used in future schools to prevent and alleviate students' social anxiety, which does not has no significant side effects, and has low requirements for space and equipment, affordable costs, and attractive to students.

Definition of Psychodrama
Psychodrama is a form of drama, also a type of psychotherapy, in which the participants act out their thoughts and feelings through scenes from their past, present, and future lives. In this process, the members of the group experience or re-experience their thoughts, emotions, dreams, and relationships at a particular situation through their own spontaneity and creativity [5].

History and Development of Psychodrama
Psychodrama was invented in the early 20th century by the Viennese psychiatrist Jacob Moreno. His approach stemmed not only from his emphasis on group therapy, but also from his shared interest in Socratic philosophy, Freud's psychoanalytic theory, Marx's reformed influence-object relations theory role theory, and group dynamics theory [6]. Subsequently, Moreno organized the first conference on psychodrama in 1921. After a decade, he established a theater for psychodrama in his own hospital, Beacon Hospital, and practiced psychodrama as a psychotherapy. In 1942, he founded the American Society of Group Psychotherapy and Psychodrama. Other pioneers are also particularly important in the development of psychodrama. For instance, Zerka, who is Moreno's wife, published a great number of academic papers about psychodrama, Eya Fechnin Branham is a trainer in the Southwest, Anne Ancelin Schutzenberger spread psychodrama to France and throughout Europe, and Marcia Karp who initiated and popularized psychodrama in the Great Britain [7].
In the 1990s, psychodrama spread from the West to mainland China. The development of psychodrama in China can be divided into four critical periods: the pre-contact period, the preparatory period, the flourishing period, and the new development period. According to the theoretical classification, three main approaches of psychodrama in mainland China are Gong Shu's Yishu psychodrama, Katherine Hudgens' therapeutic spiral model, and the campus psychodrama developed originally by Chinese psychologists, which has been widely used in mainland China and discussed in this paper [8].

Basic Elements and Phases of Psychodrama
In psychodrama, there are five crucial elements in each play: protagonist, director, auxiliaries, audience, and stage. Most of the time, the protagonist is the character of "I", who plays the role of the center of the conflict or the storyteller. They may be a child who is deeply involved in a parent-child relationship, a spouse in a relationship, a teacher in a teacher-student relationship, etc. The director is generally the designer of the psychodrama, the person who helps the protagonist explore the issues, and the one who controls the pace of the activity. In a group therapy, they can pause the psychodrama and guide the group to think differently, identify problems, and solve them from the plot. The auxiliary are other important characters in the story besides the protagonist, who may play the role of the main character's source of stress and those who are having conflicts with the protagonist. For example, if the main character is the wife who struggle with marital conflict, the auxiliary may be her husband. In a psychodrama event, the audience's role is not only to watch, but more importantly to give feedback and discuss the conflict based on their perception of the drama. Stage, quite simply, is a place where psychological drama is staged, a place that sometimes has props, sound effects and lighting, but also sometimes does not have these [9]. Three phases of psychodrama are the warm-up phase, the action phase, and the sharing phase. The purpose of warm-up phase is to build up the senses of familiarity, trust, group belongingness, and security among the members of the psychodrama group. Making their relationship become less awkward can provide them with a more immersive and harmonious psychodrama environment to achieve better results. At this stage, people generally get familiar with other members by introducing their roles. In action phase, actors could act stories in their lives through the instruction of director. Meanwhile, actors' roles might be switched in order to understand other's situations. In the sharing phase, the director usually organizes a group discussion where the audience could share what they observed and thought after watching the main characters' behavior and language. At this stage, the feedback from the group may provide characters with insight so that they are able to better understand and deal with the issue or emotion they struggle with [10].

Basic Technics in Psychodrama
One of the most frequently used technique in psychodrama is mirroring, which means the protagonist switches his or her perspective to a bystander and auxiliary re-enacts the protagonist's story [11]. This allows the protagonist to keep distance from his or her emotions of the original story and stand in a more objective perspective to reconsider the issue [12].
Soliloquy is another commonly used technique. The protagonist always expresses their inner thought and real feeling to help audience receive more insight and help themselves to catharsis [13].
Also, doubling is a practical method. A group member adopts the protagonist's behavior and actions and expresses any emotions or thoughts that the member believes the protagonist has. This technique is a constructive way to build empathy for the protagonist and established a link between protagonist' inner world and the reality [14].
In addition, the technique of role revealing is just as important as the others. Instead of playing "himself" or "herself", the protagonist will play the role of an important person in his or her life. This can help the protagonist understand the situation and thoughts of others in this conflict and enhance the protagonist's empathy [13].

Functions of Psychodrama
Psychodrama provides participants an opportunity and platform to change their cognition from experiencing emotions or behavioral reactions. By creating specific situations similar with the psychological life of people in the psychological drama, psychological problems can be presented one by one as the drama develops. Due to the infection of vivid scenes in the drama, people in the drama can easily get rid of impedance and naturally show various expressions and behaviors, appearing various behavioral reactions such as laughter, irritation, and anxiety. Because of these characteristics and uniqueness, psychodrama can also be used in combination with other psychotherapies such as psychoanalysis, behavior therapy, play therapy, hypnotherapy, family therapy, group therapy, and Gestalt therapy [9]. Consequently, according to research, psychodrama therapy may increase competence and selfefficacy. Also, it may contribute to better understanding and resolution of trauma [15]. Besides, in a study that conducted with 196 psychodrama group meetings of patients diagnosed with eating disorders over a period of 7 years, psychodrama is tested to be valid in intervene eating disorder [16].

Definition of Social Anxiety
Social anxiety always be displayed from people's negative reaction toward the task of interacting with people, present in social situation, strong avoidance tendencies to interpersonal communication, and fear to be judged or evaluated negatively. In general, people's social anxiety emerges when people interacting with strangers, working in company, studying in school, attending social greeting, and starting conversation [17].

Causes of Adolescents' Social Anxiety
The causes of social anxiety in adolescents are numerous and complicated.
One factor that is generally agreed upon by the public is that parenting style plays a crucial role in the contribution of teenagers' social anxiety. In accordance with Polaris Teen Center, for parents who are overprotecting their children, their children might lose the opportunity to experience and practice their capability of interpersonal communication. Also, they may transfer information of the society is dangerous and other's opinion is extremely important implicitly and explicitly to their children, which could also be observed and adopted by their children [18]. Besides, research carried out by the University of Cambridge illustrates a strong correlation between genetic factor and possibility (51%) of having social anxiety through the study of identical twins [19].
In addition, in 2018, a study conducted in secondary school in Lithuania that included 1,722 participants showed that the more severe physical problems such as headaches, stomach pain, and abdominal pain in adolescents, the higher the social anxiety score they have. Specifically, females with stomach or abdominal pain were twice as likely as others to have social anxiety. Meanwhile, males who presented with back pain also had a double chance to score higher on social anxiety scale [20].
Furthermore, social and cultural factors are also closely related to social anxiety. People's social anxiety is often associated with experiencing, observing, or hearing about others' negative experiences in society causing. Also, social anxiety may be caused by bullying, rejection, or neglect. In a study, experimenters found that popularity in school was negatively associated with social anxiety, and children who were neglected by their peers showed higher level of social anxiety than other children [21].

Consequences of Social Anxiety
Social anxiety can wreak havoc on the lives of adolescents who suffer from it. Many adolescents' academic achievement receives a serious impact due to social anxiety that evolves into social anxiety disorder. The possible reason for this phenomenon might be that students who suffer from social phobia may not only sweating, shaking, blushing, and stammering when they are speaking publicly and communicating with people, but also experience hardship while they are dealing with the complicated social network [22].
Social anxiety disorder in adolescence or young adulthood is a significant predictor of future depressive disorders [1]. Besides, according to Anxiety and Depression Association of America has also verified that people who suffer from social anxiety have a higher risk of alcohol abuse, and even suicidal tendencies than people who suffer from other categories of anxiety. They also have the potential to disrupt family life, lower self-esteem and limit productivity. Because they do not derive positive emotional value from interpersonal interactions, they may even be harmed [2]. Moreover, according to research conducted by researchers in Ohio State University, people who suffer from social anxiety are more likely to become the victims of bullying [23].

The Hypothesis
The hypothesis of this experiment is that the psychodrama is an effective method to reduce the social anxiety level of high school students through the activities with the themes of parent-child relationship, friendship, etc.

Research Design
First, the researcher will distribute the Interpersonal Anxiety Scale in a high school, from which students with interpersonal anxiety will be selected. Then, the researcher will ask them if they want to participate in this trial. If they do, the researcher will interview them about the specific category and situation of interpersonal anxiety and design an experiment based on this information. After five psychodrama activities, the experimenter will distribute the same interpersonal anxiety scale again. Finally, the initial and final data will be used as a basis for exploring the effectiveness of psychodrama therapy in alleviating social anxiety.

Participants
This experiment included 20 subjects (16 females and 4 males), whose ages ranged from 14 to 16 years old. They were all from five classes in the 9th and 10th grades of the International Department of Haidian Foreign Language Experimental School, and all were Chinese who grew up in Beijing. Subjects were selected through their scores on Comprehensive Interpersonal Relationship Diagnostic Scale carried out by Richang Zheng. The internal consistency coefficient, a measurement of reliability of the scale that test similarity of the numbers, or scores produced by each measurement in a repeated trails when other conditions and factors are held constant, of the scale is 0.89 which is highly reliable [24]. The construct validity of this scale is 0.67, which means it has a relatively accuracy in the measurement of subjects' level of social anxiety [25]. The researcher distributed Comprehensive Interpersonal Relationship Diagnostic Scale to 146 students in the freshmen and sophomore classes of Haidian Foreign Language Experimental School and collect them. Students who scored greater than or equal to 9 were considered to have some social anxiety, and the researcher selected those among them who were willing to participate in the activity to be the subjects.
All subjects signed an informed consent form for voluntary participation in the experiment and agreed not to ridicule others, not to reveal their privacy, and to voluntarily share their stories and opinions during the activity.

Experiment Design
The research design of this study was experimental as it verified that is psychodrama a effective way in intervening social anxiety of high school students. The independent variable is present of 5 period of psychodrama, and the change in subjects' levels of social anxiety is the dependent variable. The researcher will measure subjects' levels of social anxiety through the scale before and after the activities of psychodrama are held.

Material
In the study, the technics and instruction the researcher used in the activities are adopted from Huijuyuxin written by Hangzhou Dianzi University.

Procedures
The researcher set the themes of the five formal activities based on their interviews: parent-child relationship, classmate relationship, friend relationship, stranger relationship, and roommate relationship, shown in Figure 1.
The first period of activity is divided into four main sections: Icebreaker, Introduction to Psychodrama, Psychodrama Demonstration and Activity Rules Reaffirmation. In the first part, we divided the 22 subjects into two groups. We sat in two circles and played "one in four", a game in which we told four things about ourselves, three of which were true and one was false, and everyone guessed. Everyone became familiar with each other by introducing their names, classes, hobbies, and personal information. Next, the experimenter gave a demonstration of a psychodrama on the theme of family conflict, and used it to show the basic components, phrases, and techniques of psychodrama. Finally, the experimenter showed the subjects the plan for the rest of the experiment and reiterated the focus of the code that calls for mutual respect, self-openness, and active participation.
In the first formal psychodrama activity, the experimenter chose the parent-child relationship as the theme since it is one of the most common sources of interpersonal anxiety mentioned in the interviews. Student G volunteered to share an experience of an argument she had with her mother. The main plot of the story was that G's mother promised to enroll G in the equestrian program for her, but later backtracked and transferred money to G to solve the problem. As a result, G felt very angry and upset and had a heated argument with her mother. We asked student G to play herself and student H to play her mother to restore the situation, so that they could think differently and understand each other. In the end, we gave the solution that we should actively express our thoughts with our mother and communication is the best way to solve the problem.
In the second activity, we addressed the social anxiety that comes with peer relationships. Student X was an assistant who helped the teacher grade the papers, and his classmate asked x to help him grade the papers a little higher. However, X didn't do it because he didn't think it was a right action. His classmate blamed X for getting a very poor grade on the test, and X felt that his relationship with his classmate had become so awkward that he was afraid to return to class. After restoring the incident, we discussed and concluded that X should face the incident bravely because it was not his fault and explained clearly to his classmates that he definitely did not have a bad opinion of him, but he just thought he should follow the rules. If his classmate recognized the unreasonableness of his behavior, they could get back together, and if his classmate did not, X should reevaluate their relationship.
In the third activity, we focused on the issue of friendship that often arises in high school. W and her friend had a fight over a trivial matter, and the roommate got angry and told the teacher that W had violated the rules by bringing her Mobil phone to school, so the teacher punished W. W was very angry because she felt betrayed by her friend and felt pressure to face her friend in the school. After role-playing between W, the friend she was in conflict with, the other friend, and the teacher, we concluded that W should follow the rules and not bring her cell phone to campus, but she could talk to her friend about mutual trust.
In the fourth activity, we performed a script based on the experience of C's transfer to a new class. Standing in the perspective of both the transfer student and the students in the original class. We summarized some ways to reduce social anxiety, such as generously introducing ourselves, waiting for the more cheerful students in the original class to initiate a conversation and then responding enthusiastically, and choosing a topic that both sides understand to communicate, etc.
In the fifth activity, we addressed the conflicts that can easily arise in boarding schools. Students W, X, Q and Y talked about the conflicts and pressures they face in the dormitory with very different living habits. Finally, after discussion, we came up with the idea of holding a dormitory meeting and being frank with everyone about their ideas, making dormitory rules, following it and understanding each other with patient. Last, the researcher asks all subjects to finish the scale again in order to investigate the effectiveness of psychodrama therapy.

Results
The data analysis for this experiment uses the Two sample t test through GraphPad Prism 9.
After calculation, the p-value of this statement is 0.000197 which is lower than 0.05 and the results did not differ significantly by gender, as shown in Figure 2. Therefore, we could conclude that the result of the reducing social anxiety levels of high school students is not happened by chance variation, and psychodrama is an effective way that could be used into intervene social anxiety of high school student.

Conclusion
In conclusion, the researchers design the study to discuss whether psychodrama can intervene social anxiety among high school students in Haidian International school. The objective is to discover a possible method to cope with anxiety that caused by interpersonal communication for high school students. As the result, this experiment demonstrates that psychodrama therapy is an effective way to alleviate social anxiety in high school students. Considering different variables that may affect the result, researchers conduct following limitations. To begin with, this study was not conducted using random sampling and random assignment. Since the experimenter had the intention to help students with social anxiety in addition to exploring whether psychodrama can alleviate social anxiety, and also wanted to help students with social anxiety. At the same time, because the activity required taking the students' break time, their consent had to be obtained. Therefore, only subjects who had some degree of social anxiety and were willing to participate in the activity were selected for this experiment. This may bring the result of the experiment not being a good inference about the whole population. Besides, because the experimenter was a high school student and each activity of the psychodrama required the experimenter's presence as the "director", the sample size of this experiment was relatively small and only contains the students of Haidian Foreign Language Academy.
Moreover, the results of the experiment are likely to be influenced by the participation of the experimental subjects. In each activity, even though the experimenter made the main character and supporting actors change for each activity as much as possible and involved everyone in the discussion, there were still two subjects who did not actively participate in the activity. The social anxiety level of both remained the same (at 12), while the other one decreased by only 1 (from 12 to 11). At the same time, there was a significant effect for two subjects who actively participated in every activity, they reduced their scores by 7 and 6, respectively. Thus, the motivation of the subjects to participate in the activity can influence the experimental results to some extent.
Furthermore, this experiment recruited subjects at the beginning of the school year, and many subjects who had just entered high school may have shown high levels of social anxiety because they did not adapt to the new school environment, including conflicts with parents over class selection, the need to fit in with new roommates in the new dormitory, and making new friends. and by the end of this experiment students had already lived in school for three months, so we do not rule out the possibility that their social anxiety level was reduced because they had adapted to life here and their status had gradually stabilized.
In future research, the researcher will expand the scope of the search for subjects and increase the number of subjects, so that the subjects are not limited to high school students in Haidian Foreign Language Experimental School, but also include students from all age groups and regions. In addition, the experimenter also plans to conduct activities for all people (not just those with social anxiety problems). Thus, the experimenter will get more accurate results and can generalize the results of the larger populations.
Finally, it is hoped that more people will take social anxiety seriously, as it can potentially threaten the mental health of many people. It is also hoped that psychodrama therapy can be better understood and practiced by more people, as it is not only an effective method for preventing and treating psychological problems, but also an interesting therapy that can be successfully accepted by students.