Dramatherapy for Psychological and Social Well-Being in Obesity and Bariatric Care

Obesity is a major public health concern worldwide and represents a particularlyimportant challenge in France and in the Hauts‐de‐France region, where prevalence ratesexceed 20% of the adult population. Obesity is associated with increased morbidity andmortality, including cardiovascular diseases, type 2 diabetes, respiratory disorders,musculoskeletal conditions, and psychological distress. In this context, bariatricsurgery has become an increasingly common therapeutic option for patients with severeobesity and is currently integrated into multidisciplinary care pathways includingmedical follow‐up, nutritional counseling, psychological support, and adapted physicalactivity (APA).Despite the recognized effectiveness of bariatric surgery and APA programs, many patientscontinue to experience difficulties related to body image, emotional regulation,self‐esteem, problematic eating behaviors, and long‐term adherence to lifestyle changes.These psychosocial dimensions may negatively affect the sustainability of treatmentbenefits and contribute to weight regain or reduced quality of life over time.International literature therefore emphasizes the importance of comprehensiveinterventions integrating psychological and psychosocial support alongside standardmedical and nutritional care.Adapted physical activity is recognized as an essential component of obesity andbariatric care. APA contributes to improvements in physical condition, body composition,psychological well‐being, and quality of life. However, long‐term adherence to physicalactivity programs remains challenging for many patients, particularly because of stigma,altered body perception, anxiety related to movement, and low self‐confidence.Dramatherapy (DT) is a creative therapeutic approach using theatrical tools such as roleplay, improvisation, embodiment, storytelling, symbolic expression, and group interactionto facilitate emotional expression, body awareness, psychosocial adjustment, and identityreconstruction. Although dramatherapy and related creative arts therapies have shownpromising effects in mental health and psychosocial rehabilitation, their integrationinto obesity and bariatric care pathways remains largely underexplored. To date, norandomized controlled trial has systematically evaluated the effects of combiningdramatherapy with adapted physical activity in patients with obesity enrolled in medicalor bariatric care pathways.The present study is a monocentric randomized controlled trial conducted at the Institutde l'Obésité of Clinique ELSAN Saint‐Omer (France), in collaboration with the URePSSSresearch laboratory (ULR 7369, Université du Littoral Côte d'Opale). The study aims toevaluate the effects of adding dramatherapy to a standardized APA program in adultpatients with obesity participating in either a medical obesity care pathway or abariatric surgery pathway.Participants will be recruited during routine consultations within the obesity careprogram. Eligible participants are adults aged 18 years or older with: ‐ BMI ≥ 40 kg/m²; ‐ or BMI ≥ 35 kg/m² with obesity‐related comorbidities; ‐ or BMI ≥ 30 kg/m² associated with eating disorders or problematic eating behaviors.Participants must be enrolled in a medical or bariatric care pathway including APA, beable to participate in the study procedures, and provide written informed consent.Exclusion criteria include major medical contraindications to APA or group participation,severe unstable psychiatric disorders, severe cognitive impairment, unstable medicaltreatment significantly affecting weight or mental health, inability to comply withfollow‐up procedures, or inability to provide informed consent.The study follows a randomized controlled design with two parallel groups: 1. Standardized adapted physical activity alone (control group); 2. Standardized adapted physical activity combined with dramatherapy (experimentalgroup).Randomization will be stratified according to care pathway type (medical versusbariatric). The study uses a two‐stage randomized consent design inspired by Zelenmethodology. Participants initially consent to participation and randomization, while asecond specific consent is requested only from patients allocated to the additionaldramatherapy intervention.The APA program consists of 12 supervised sessions over 6 weeks, delivered by qualifiedAPA professionals. Sessions include cardiovascular exercises, muscle strengthening, andprogressive movement activities adapted to the physical capacities of patients withobesity.The dramatherapy intervention is delivered by a qualified and experienced dramatherapist.It consists of six weekly group sessions lasting approximately 90 minutes each. Theintervention uses theatrical expression, role play, improvisation, breathing exercises,body‐oriented activities, symbolic work, and collective interaction to improve bodyawareness, emotional regulation, self‐esteem, social interaction, and engagement in care.For patients enrolled in bariatric pathways, dramatherapy may be delivered duringpre‐operative and/or post‐operative phases depending on the timing of inclusion.The primary objective is to evaluate the effect of adding dramatherapy to APA on qualityof life at the end of care compared with APA alone. Quality of life will be assessedusing the French version of the EQVOD questionnaire.Secondary objectives include evaluating: ‐ eating behaviors and problematic eating regulation using the TFEQ‐R18 and SCOFFquestionnaires; ‐ body image and body‐related quality of life using the BIQLI; ‐ self‐efficacy using the General Self‐Efficacy Scale (GSES); ‐ anxiety and depressive symptoms using the Beck Depression Inventory‐II (BDI‐II); ‐ adherence and participation in APA programs; ‐ anthropometric outcomes including body mass index, abdominal circumference, and bodycomposition.Assessments will be performed at several time points: ‐ baseline/pre‐care assessment; ‐ beginning of care; ‐ end of care; ‐ 6‐month follow‐up; ‐ 12‐month follow‐up.The study also includes a complementary qualitative and ethnographic component intendedto enrich interpretation of quantitative findings and explore the subjective experienceof participants. Semi‐structured interviews, participant observation, body mappingtechniques, and identity boxes will be used to investigate body perception, emotionalexperiences, psychosocial trajectories, relationship to food and movement, andperceptions of dramatherapy and obesity care pathways.Quantitative analyses will include descriptive statistics, repeated‐measures analyses,mixed linear models, subgroup analyses, and exploratory multivariate analyses.Qualitative data will be analyzed using thematic content analysis and triangulated withquantitative findings within a mixed‐methods framework.The target sample size is 250 participants. This sample size was determined to ensureadequate statistical power for the primary outcome analysis while accounting forpotential attrition during long‐term follow‐up.The expected duration of inclusion is approximately 1 year and 6 weeks. Individualparticipation lasts 6 weeks for the intervention phase, with follow‐up assessmentsextending to 12 months. The total duration of the research project is estimated at 36months.This study aims to provide new evidence regarding the integration of creative therapeuticapproaches into obesity and bariatric care pathways and to evaluate whether combiningdramatherapy with adapted physical activity may improve psychological well‐being,body‐related outcomes, adherence to care, and quality of life in patients with obesity.