1 Introduction

1.1 Trauma in the context of Gaza Strip

Over the past few decades, children in Gaza Strip have experienced many traumatic events including wars, political conflicts and the resulting complex economic and social conditions (Punamäki et al. 2014). As children interact with these events and circumstances, they develop reactions that appear in the short or long term. These reactions include: sadness, anger, fear, nervousness, difficulty in concentrating, change in appetite, difficulty in sleeping, nightmares, avoiding situations that remind them of shock and feeling guilty (Thabet et al. 2008). Studies have shown that exposure to war and violence increases mental health problems in children, including post-traumatic stress disorder, psychological symptoms may decrease over time that violence and threat end (Punamäki et al. 2014). In Gaza Strip, however, it may be different and more complex, as these events are ongoing.

Children in Gaza Strip were subjected to several wars in 2008–2009, 2012 and 2014, resulting in long-term physical and psychological injuries. The negative effects of these wars were exacerbated because of the political, economic, psychological and social spheres. Children suffered, in this complex context, from many difficult events such as loss, threat of life, destruction of the family, and the social networks, which is an important source of growth in the psychological and social child (Diab 2018).

Trauma means a threat to a child’s life and lack of feeling safe. As a consequence of fragility and weakness, children react to trauma with intense terror, which increases the possibility of experiencing psychological difficulties (Diab 2018). There are various factors that play a role in the development of Post-traumatic stress disorder (PTSD) such as: the severity of the trauma, self-perception of psychological trauma, type and extent of trauma, social context, previous experiences of the disease including pre-existing anxiety or depressive disorders (Shrestha et al. 2019). The two main factors in determining the results in the long term are: the amount of pressure or stress experienced by the individual to adapt and respond to the traumatic event, and the availability and quality of social support during the recovery, and recovery period (Greenberg et al. 2015).

Altawil et al. (2008) conducted a study to identify the long-term effects of wars on children in the Gaza Strip, sample of 1137 children aged 10–18 years, were randomly selected from all governorates of Gaza. Results showed that the most prevalent symptoms of PTSD are: cognitive symptoms, of which 25% of children suffered (for example, a child may take a long time to sleep, or cannot stop thinking about the experienced trauma, or may feel everything around not safe); emotional symptoms of which 22% suffered (for example, the child’s feeling that he/she is alone, suffers from nightmares, easily gets tensed, and feels sad and afraid); Social behavioural disorders, of which 22% suffered (for example, aggressive and rude behaviour, rejection of the authority of the teacher or parents, difficulty in enjoying games and hobbies); academic behavioural disorders, of which 17% suffered (for example, difficulty in concentrating in study, academic performance is decreasing, difficulties with attention during school lessons, disruptive behaviour in school); physical symptoms, of which 14% experienced (such as headache and stomach pain).

1.1.1 Psychodrama

Psychodrama is a method of experimental psychotherapy, originated in 1921 by its founder, J.L. Moreno, during which individuals play directed roles, to work on solving their personal problems, and to work on alternatives and solutions through (acting) instead of words merely (Orkibi and Feniger-Schaal 2019).

It is defined as a form of therapeutic art where therapists encourage clients to use their bodies as a way to discover personal facts and recover from painful experiences rather than using traditional verbal sharing (Clark and Davis-Gage 2010) It is also a therapeutic technique that can be used for group role play and spontaneous acting to gain insight into the lives of individuals (Akinsola and Udoka 2013).

Spontaneity and creativity are among the most important theoretical concepts on which psychodrama is based on as a treatment method. Moreno the father of psychodrama considered creativity necessary to adapt to life changes and deal with unexpected challenges. This idea coincides with contemporary views of creativity as an important factor for adaptation (Orkibi and Feniger-Schaal 2019).

Psychodrama involves recreating real-life situations and presenting them today, as individuals have the opportunity to assess their behaviour, and to understand their position more deeply. Coleman emphasized that psychodrama is effective for treating mental disorders such as sadness, loss, depression and anxiety. Pramann also stressed that psychodrama can be used to treat symptoms of PTSD and to enhance a sense of control, inclusion, and settlement (as cited in iAkinsola and Udoka 2013).

1.2 Psychodrama role in the treatment of trauma

Psychodrama is a unique method among other treatments, in which it interpreted through body movement, by reactivating physical experiences that are brought from the past to here and now, allowing the client to process memories with the guidance of the therapist, and perhaps with the help of group members who suffer from similar trauma.

Survivors of trauma found that group therapy by psychodrama is useful, where they feel supported through communication with the group. Psychodrama is especially suitable for clients with trauma because painful memories are stored at the sensory level. Trauma is not only a product of the inability of the mind to deal effectively, it is a phenomenon of “physical mind”. Remembering trauma is not limited to cognitive perceptions, but also includes body memories and sensory reactions such as rapid breathing and sweating. Sensory reactions are part of responses to attack, escape, or freeze. Additionally, given the impact of trauma on thought processes, the client’s cognitive memories are often distorted and lack clarity.

The fact that perception trauma is linked to the body and mind, it means that a good treatment plan should be aimed at the body and mind together, in many cases, the body needs to lead the mind to the truth, the body needs to speak your voice, to show rather than say (Clark and Davis-Gage 2010).

2 Aim of the study

This study aims to explore psychological needs of a traumatized child from Gaza, through analysing her roles in fifteen sessions using therapeutic psychodrama.

3 Methodology

This study uses descriptive analytical approach of a qualitative research, as it relies on a case study of a female child getting treatment while being involved in psychodrama group psychotherapy. The case study is an in-depth investigation of this single child.

3.1 Study tools

3.1.1 Roles tree

This tool aims to analyse the child’s roles during the psychodrama sessions, in order to understand the child’s psychological needs.

The roles tree contains the roots that reflect the girl’s current history, and the leg that demonstrates the capabilities and skills the child has, as well as the things and people who support. The branches reflect the symbolic way of expressing the child’s psychological needs through her roles.

The storm, which symbolizes the traumatic event, and the green leaves of the tree that explain the protective factors for the child. Also, there is a star on the tree that indicates the good qualities that distinguishes the child.

3.1.2 Observation card

This tool aims to measure and monitor the changes that the mother notices on the child’s behaviour and mood. The therapist gets feedback about the card every two weeks.

The observation card contains two parts. The first part aims to track changes in behaviour and feelings such as isolation, aggressiveness, ease of crying, lack of enjoyment of daily activities, lack of focus on homework are followed during the treatment period. Where in the mood, feelings of anxiety, fear, anger, frustration, and sadness are followed. The second part of the card: It contains the mother’s observation of the child’s behaviour in everyday situations, where the focus is on the relationship and attachment between the child and the mother, not just a description of the note. In this part, the mother clarifies what she notices, and how she reacted. She also documents what she thinks after the situation is over, and if there is a better way to respond. At the end, the mother writes how she can interact with her daughter in the future.

3.1.3 Interview

The interview aims to understand the child’s behaviour and mood during the treatment period, as well as to know the extent of the girl’s satisfaction with the psychodrama. During the study period, four in-depth individual interviews were conducted, three interviews with the mother and one with the child. Each interview duration was 30–40 min.

4 About the child Sama

4.1 Child and family psychological status

Sama (pseudonym name of the child) is eight years old, in the third grade of primary school. She lives with a family of 16 individuals, where she is next-to-last member in the family. The father and mother have low education, without work, and the father is married to two wives. Each wife and her children live in one house and are separated by a wall.

Sama lives poverty and deprivation in her family, as well as being subjected to psychological abuse and neglect by the father. The mother blames herself saying, “All what my daughter needs is attention and I am not even able to provide it to her, because I live in a lot of pressure”. The mother also reported that her child is shy and does not interact with others, as well as crying constantly. The mother began to feel the seriousness of the symptoms when the school counsellor called her and complained that her child never spoke at the school, and she had no friends. Here, the mother explained that a major change happened to her child after watching the older brother flooded with his blood in his attempt to commit suicide, in the presence of the ambulance and police officer. The mother said, “At that time we were all busy with the event, but I remember when I saw her sitting in the corner of the room scared and she suffered from urinary incontinence. Sama was afraid and I tried to calm her down. After the event, I did not realize that it continued with her”.

4.2 Traumatic events in Sama’s life

When Sama was four years old, her grandmother, from the mother’s side, died. Sama was attached to her a lot because she was the most caring and supportive person for her. This was a sad and painful event for her. At the age of five, Sama saw fights between her mother and the stepmother, using sharp tools where her brothers joined the fight and things got worse and the mother was severely injured in her hand. At the age of seven, Sama witnessed the accident of her older brother’s suicide, the police’s presence at home and the arrest of the older brother who was involved in financial problems. During these events the Sama is subjected to constant neglect from the family, and she was also subjected to repeated psychological abuse from the father.

4.3 Significant negative and positive psychological symptoms developed by Sama

  • Avoidance: Sama avoids going to the place where the older brother committed suicide. Moreover, she is afraid of anything associated with the police.

  • Easily aroused all the time as Sama starts crying for the simplest things.

  • Inability of verbal expression, most of the time Sama is silent, does not talk to others.

  • Dysfunctional social relations with peers at school in addition to low academic achivement level.

  • Disturbing dreams that nearly repeated once every two weeks.

  • Being tolerant, kind and gentle.

5 The integration of the Sama with a psychodrama group psychotherapy

Sama was a part of psychodrama group therapy consisting of eight children exposed to traumatic events, aged (8–10) years old. The group consists of four males and four female. Sama attended all the sessions. The main implemented psychodrama techniques were doubling, mirroring, soliloquy and role reversal.

6 Results

By analysing the roles tree, it was found that the Sama played several roles as follows: the spectator on the circus of animals, the tiger cub, the actress in a play, the drummer, the fierce fighter, the mother assistant, the cook, the sheep mother, the strong big lion, an officer, the sheikh who chants Takbeerat of Eid, and a lawyer.

6.1 Sama’s interaction with her roles during the psychodrama sessions

Sama interacted with her roles during the following scenarios:

6.1.1 The spectators on the circus of animals

Sama chose to play the spectator role on the circus and chose to be kind to encourage the animals that perform the show and provide them with delicious food. During the interaction, Sama expressed that the evil clown (one of the children) and the cruel trainer (the therapist) spoiled the show and that she was planning to imprison them and said, “I want to lock them away from the circus”.

6.1.2 The tiger cub with its father

During the story, a group of tigers wanted to cross the sea and suddenly fell into a trap that the hunters had prepared for them, during which the rescuer helped them to survive. Sama reacted with fear and accompanied the big tiger and walked behind it and asked it for protection. The therapist was playing the role of the food servant, and she tried to calm the tigers. She said that the rescuer (one of the children) is strong and able to help them and has previously saved a group of lions. This is to support them and help them feel safe.

6.1.3 The actress in a play

In this story, the children were divided into two sections: spectators and actors. When the play started, the spectators began throwing paper at the actors because they were not satisfied with their performance. Here, Sama suggested that the role be re-trained in order to obtain the audience’s satisfaction. And indeed that was done, but the spectators did not like the role as well. Here, Sama responded to the public’s dissatisfaction by re-representing parts of the traumatic event, wounding herself and said: “We want one who hangs himself and one who throws himself from above”.

When the acting was stopped and the children were asked about the end, the child said, “Now, we want all the party fighting and the place to explode”.

At the end of the session, the therapist played the role of a journalist. She asked the children, at the venue of the play, that everyone in the city wondered why the concert was ended in this way? The play was beautiful, even if audience did not like it. Many who watched it on TV liked it. Why did the party end with a fight? a child from the audience said that there are other things they did not like, not just the play. One of them said; “I went to the bathroom, I did not find the chair that I was sitting on when I returned back, and that disturbed me”.

6.1.4 The drummer

In this scene, the children planned to hold a royal party in the castle, and this ceremony needs a distinguished and trained band. Sama chose to play the role of the drummer. She was very happy with her role and most of the children played their roles, played musical instruments and there was no conflict between the group of children in this scene.

6.1.5 The fierce fighter

The children in this session were divided into two groups. One of them played the role of soldiers defending their country. The other played the role of fierce fighters. The girl played the role of a strong fighter within the group of fierce fighters, where the girl with the fighters destroyed and bombed the soldiers ’place. The fierce fighters owned the tanks Bombs and warplanes. The girl played her role with full force and violence, throwing bombs and missiles at the soldiers and destroying their places, and the girl interacted fully during the session.

6.1.6 The sheep mother

Sama played the role of the mother of the sheep. When she learned the fox’s plan (the therapist) to attack the sheep, she said: “I want to defend and protect my children”. The giraffe (one of the children) saw the fox from a distance, and warned the mother of the sheep against the fox as it is nearing to the place. Sama said that she will not allow the fox to harm her sheep and closed the doors well. When the fox approached, she thought of a clever plan where she and her sheep fought against the fox, and she cried with the loudest voice. Then all the animals came and besieged the fox and decided to lock him.

6.1.7 The strong lion

Sama chose to play the role of a huge strong lion and with her in this scenario was a group of lions. The second group played the role of pilots. While playing with toys the plane landed near the lions. The lions could not understand the pilots so they attacked the pilots and the children clashed together. Here, the captain ordered (The therapist) the pilots to return to the plane to take off from the place in order to talk and understand each other, the pilots and lions. They would talk at a high distance that does not allow the lions to attack them, but allows communication and hear each other. They reached a compromise where the lions own the forest, and the pilots possess planes and weapons that protect the animal in the woods. In the end, the pilots found a place in the forest to land, and the child (the huge strong lion) welcomed them with an agreement to respect the laws of the forest and not to harm the other, and each party committed to provide protection and possible assistance to the other party if needed.

6.1.8 The mother’s assistant

In this quiet session, Sama chose the role of the mother assistant. The children played the role of the city of dreams and every child chose to fulfill a dream for them through their role. The child chose to live in a dream house full of toys and to have her own room and a beautiful bed, also to help the mother in arranging and decorating the house.

6.1.9 The police officer

The group split into two groups. A group lives in a castle with a precious necklace, and a group of thieves. Sama played the role of the police officer. The people living in the castle called the officer to report that the precious necklace has been stolen. Sama sent the police to search for the thief and found the gang of thieves and arrested them. Here, the officer began confronting them strongly, and asked them how they dared to steal the castle. And in turn, the children who played the gang, they said that they are not thieves but want to test the police strength and their ability to maintain security in their town. But she did not forgive them, rather she put them under probation period under police supervision to follow them and follow their behavior.

6.1.10 The Sheikh who chants TakbeeratFootnote 1 of Eid

During this scene, which actually coincided with the period of Eid Al-Adha, the children played the celebrations atmosphere of Eid. Sama chose the role of the Sheikh who chants the Takbeerat in the mosque. Sama chanted loudly, and she repeated these Takbeerat, which needed a loud voice and a certain rhythm.

6.1.11 The role of the lawyer

The children were divided into two groups, a group played the role of the oppressed, and a group played the role of the aggressors, where the girl played the role of a lawyer. Sama expressed with all her strength and courage with a loud voice in front of the judge about the injustice suffered by the oppressed people and how the aggressors stole their possessions, deceived them, imprisoned their children, and screamed at the loudest voice at the aggressors. She stated: “you said that you will return their daughter, but you killed her. What you did, is cruelty”.

6.2 The child expression of her psychological needs during role-playing

The child has expressed her psychological needs clearly during the role playing in three stages as follows:

The first stage: the need to feel safe

The girl clearly expressed this need to feel safe during the first two role-plays of the child. Her choice of the role of the good spectator on the circus in the first round, in an attempt to stay away from any harm and avoid any potential threat. When the threat, which was represented by the role of cruel trainer (the therapist) to reflect the role of the battered father, the child embodied her real situation through interaction with the role that she planned to avoid and remove the threat away from her. As she played the role of spectator, she did not choose to confront it, but rather preferred to avoid it, in an attempt to protect herself. In the second round of this stage, the child chose the role of the little tiger who has a father, as the father represents a security reference for the child. When she was concerned, she asked protection from the father (the big tiger) by walking near him in an attempt to express her need to feel safe.

Between the first and second stage, the therapist noted that the girl embodied two roles that were directly related to the traumatic events that the child was exposed to, as follows: In the third role of the girl, she played the role of the actress in a play. When she was frustrated by the dissatisfaction of the audience about the presented play, she responded by returning parts of the traumatic events. This is a type of traumatic play in which the child repeats parts of the traumatic event, in an attempt to reaching the meaning of this event and find a way to solve the conflict. Here, the therapist showed sympathy, understanding and support for the child through her role, as it seemed that the child was in need of expressing the conflict within. After expressing this conflict and ending the scene with the children, the therapist provided support and assistance by playing the role of the journalist, as mentioned in the scenario above.

Then the child played the role of a drummer in a distinctive royal ceremony and the children played musical instruments. In this session, it seemed that children and therapists avoided any conflict subconsciously, where the session that preceded it was stressful for everyone. The child used the drum and continued to play on it with a great rhythm as if the drum was the child’s voice expressing conflict. Then she played the role of the fierce fighter, where she expressed her anger greatly during the role. The therapist observed that in many sessions, the group was divided into two parts, which shows the nature of the interaction of the traumatized children who are usually considered victims of others who abuse them.

Second stage: the need for a sense of care, love and belonging

The child here started playing the roles that provide her with assistance and care. This indicates the child’s need for care, love and affiliation from the family, peers and others. The child played the role of the mother of the sheep that provides care and love to her children. She called the animals of the forest to protect them which indicates her need to belong to those around her, where she felt strength when she formed a supportive network of animals to protect her sheep. Then, when she played the strong and powerful role of the lion and expressed her love for the pilots and her desire to contain them, while setting laws for everyone to respect, this indicates the child’s need to organize relationships and feelings between family members according to clear and understandable criteria for everyone. And this confirmed her second role, which was her help to the mother in a beautiful house full of toys. She arranges and cleans it, as if it reflects that the house that she needs is the house that offers her love and belonging. Moreover, this house is organized and arranged in a psychological concept, that is, away from the chaos of relationships and feelings that prevail in her house on the ground.

Third stage: the need for a sense of psychological independence and efficiency

During this stage, the child began to act in creative way by incorporate feelings of strength and independence, as she started to play independent and not subordinate roles. She chose three strong and influential roles. She chose the role of the officer, in which she faced the gang of thieves and made a firm decision with them. Then, she played the role of Sheikh of the mosque, who chanted in Muslims Eid, where in Islamic culture it is known that this role is for men. And the fact that the girl took this role, she regained her self-confidence and began to feel her strength. The child impressed everyone when she played the role of a lawyer and defended with the loudest voice in the face of injustice and faced the aggressors that they should feel the shame of what they did. She expressed here that the aggressor is the one to feel shame, and the victim stand in the face of the aggressor, where the healing and recovery from trauma was evidenced during this stage.

6.3 Observation card results

During the treatment period, which lasted 15 sessions, feedback was obtained from the mother through three stages, namely: before the intervention, then after 8 sessions, then one month after the sessions ended. The results of the mother observing the behavior and feelings of her child are as follows:

The mother expressed that her daughter significantly saw improvements in her child mood, and began to notice this improvement after the fourth session. With regard to the improvement of the behavior of her child, the mother, and those around her, began noticing that after the sixth session. The improvement was obvious. The rate of improvement of psychological symptoms that resulted during the three stages, is illustrated in the Fig. 1.

Fig. 1
figure 1

Observation card results. a Mood symptoms, b Behavioral symptoms

Full size image

Regarding the mother’s observation of her child’s daily situations, the mother explained that this tool was very important for her, as she stated, “out of all this pressures I live in, I never thought that I would be aware of my daughter, this is the first time to care, notice and understand my daughter”.

She also expressed that this tool strengthened her relationship with her child. She stated that she started to care about the ways to respond to her daughter’s behavior. The response may not be immediate as she thought, since some situations require multiple and continuous responses for a longer periods of time.

One of the situations that the mother recorded in the the observation card after the sessions ended, was about her daughter starting to talk with family members more than she used to do. The mother pointed that she sat with her child and asking her, “Sama, I see you have started to speak too much”. The girl replied to her, “Because I want to become a lawyer, I will help my brother to get out of prison and defend him”. The mother wrote on the card: “In the future, I want to stay close to my daughter, support her, and increase her self-confidence to become a great person, and achieve her dream”.

6.4 The results of the interviews

Three in-depth individual interviews were carried out with the mother for the purpose of following-up the improvement of the child’s behavior and feelings. The mother reported that her child was improving in an excellent way. In fact she stated that her child returns home very happy and talks about her role during the session. The mother explained that her child became stronger than before. For example, she noticed that her child used to wait for her brother to deliver her to the center to participate in the psychodrama sessions. However throughout the sessions, the mother started to hear her child saying to her brother: “If you are late again, I will go to the center by myself”. Indeed, she attended on her own, while she was afraid to go alone before.

During the interviews, it became clear that the mother needs psychological support to alleviate the psychological pressures she is going through. In addition, she needs psychological education about ways to deal with the child. In some interviews the mother said, “I need to attend these sessions as I feel a great load was removed from my shoulders after each session”.

The mother added that she was pleased that to see that her child aunts started to recognize her improvement in social interaction with relatives. One of them wondered: “What happened with Sama? She is positively different”

Regarding the interview with the Sama to evaluate her satisfaction with the psychodrama sessions, the child explained that she liked acting a lot through animals, and she also said, “I liked more than anything, when I played the mother of sheep, and the role of the lawyer”. The child said that she was comfortable with the group of children and with the two therapists, and she said, “I learned from the sessions, cooperating with my friends and helping them”.

7 Discussion

The family is considered the first supportive environment for the child. When this environment creates the conflict, the matter becomes more complicated and difficult. So, the child begins to direct the conflict and anger towards him/herself because he/she is the weakest link. In such circumstances where the child faces a threat, with limited resources to face it, trauma may appear.

But despite the difficult and complicated circumstances, the psychodrama sessions were able to help the child to improve psychologically in addition to impact her life. The sessions helped her in changing her awareness of reality, which reflected on the child feeling able to make an influence. The child started to build her self-confidence, feel competent, being able to control her reality, face it, and not give in.

The child also dealt with trauma by embodying and extracting herself from the within conflicts. A clear development occurred throughout her psychodrama roles. The child began to see herself differently once she extracted herself form what is hidden inside her for long periods of time, as she was not given any opportunity to do so.

It is of great consequence to focus on the role of the mother or the caregiver during the psychodrama sessions, and pay attention to strengthening the relationship between the child and the mother because of its positive impact on the child. Moreover, it is important to activate social support networks that form a source of psychological and social development for the child. Evidence is growing that good social relationships help protect the mental health of children in threatened conditions (Diab et al. 2014).

Literature in the field is limited with regard to analyzing psychodrama roles to understand psychological needs for traumatized children. Most of the reviewed literature relied on psychodrama as a psychological intervention method where the focus is on adults. Very few studies tackled children (Orkibi and Feniger-Schaal 2019). This highlights the need for more research in the field of child psychodrama.

The researches emphasizes the importance, according to therapists, to understand the psychological needs of children through their clinical work. A number of tools can be developed that focus on exploring the psychological needs of children during their play at the therapeutic sessions. It is preferred, that the results be supported through the perspective of care-givers and teachers as they can provide better and more comprehensive understanding of the psychological needs of children in multi-contexts, where the child lives like at home and at school. The significance importance of understanding the children’s needs is that it would help therapists to develop creative tools and sessions to address children’s psychological needs. This would help us convey this understanding to caregivers and teachers so they can deal with children in better way.

8 Conclusion

The study showed the importance of analyzing children’s roles during psychodrama sessions because it benefits therapists to gain a better understanding of children’s psychological needs and develop their abilities. The study also demonstrated the importance of the role of the mother or the caregiver with the child. Supporting and strengthening the relationship between them has a significant role in the sustainability of the positive effect of therapy sessions.