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Abstract

The global rise in the older adults’ population underscores the urgency of addressing mental health issues among older LGBT adults. Older gay men, navigating the intersection of ageism and homophobia, often confront complex stigma affecting their well-being. In Italy, where research on older LGBT adults is very limited, investigation of this issue is crucial. The overarching purpose of this qualitative research project is to explore the life stories of older gay men in Italy and examine their response to a group tele-drama intervention tailored to their unique psychosocial needs. Narrative interviews will be conducted with older gay men in Italy, and the resulting data will be subjected to narrative analysis principles. Volunteers or social workers who work with older gay men will also be interviewed and the data will be analyzed according to thematic analysis, followed by a triangulation of the two datasets. Building on these findings and relevant literature, a group tele-drama intervention will be adapted for older gay men. Video-recorded intervention sessions will be analyzed using the 6-Key model of drama therapy assessment. Post-intervention, participants will undergo Client Change Interviews, with the data thematically analyzed. Ensuring the qualitative rigor of the study will involve triangulation, reflexive journaling, and member checking. The three-year data collection period will span from 2023 to 2025. The findings of this study will shed light on the life stories of older gay men in Italy and the design and contribution of a tele-drama-based therapy program that can help them cope with challenges associated with the intersectionality of ageism and homophobia.

Keywords

older gay men psychodrama drama therapy tele-drama-based-therapy group intervention

Background

Older LGBT Adults

The global population is undergoing a swift aging process. Projections indicate that by 2050, approximately two billion individuals will be 60 or older (Organization, 2015). In the US, the population of LGBT aged 50 and above is expected to increase from three million to seven million by 2030 (Sage, 2021). Given this increase, the American Psychological Association (APA) has emphasized the need for more research on older LGBT adults (American Psychological Association, 2021). Engaging with the older LGBT population is challenging due to their frequent concealment of their sexual orientation as a protective measure stemming from historical discrimination (Knauer, 2010). Numerous studies have shown that the LGBT population faces identity and relationship issues due to social restrictions on self-expression (Pelton-Sweet & Sherry, 2008). Stigma and marginalization have been persistent throughout their lives, and manifest as structural, public, and self-stigma (Liu et al., 2011; Yip & Chan, 2021). Structural stigma arises from sociopolitical forces that limit opportunities through institutional policies (On the stigma of mental illness: Practical strategies for research and social change, 2005). Public stigma involves negative attitudes and discrimination from the general population (Corrigan, 2000). Self-stigma arises from internalized negative beliefs that can impact mental health (Corrigan et al., 2016; Yip & Chan, 2021). This makes it imperative to develop interventions for older gay men.

Older Gay Men

The lives of today’s older gay men have been shaped by adverse historical and social contexts, where homosexuality was considered a mental illness and criminalized, leading to persecution and discrimination (Haber, 2009). The AIDS pandemic exacerbated these conditions, fostering isolation and concealment (Choi & Meyer, 2016; Dickinson et al., 2012; Muraco & Fredriksen-Goldsen, 2016), thus potentially leading to increased minority stress and negative health outcomes (Frost et al., 2015; Shenkman et al., 2022). There is little research on the needs and challenges of older gay men, although they face unique aging experiences at the intersection of ageism and homophobia (Knauer, 2010). These men endure age-related stigma, as well as stigma associated with their gay identity that impact their well-being (De Vries & Croghan, 2014; Lyons et al., 2013; Pereira, 2022). Studies suggest that the needs and concerns of older gay men can be divided into seven domains of major discrimination: medical/healthcare, mental health, social networks, family, spiritual, housing, and legal rights (Orel, 2004, 2014). In terms of healthcare, the historical impact of the AIDS epidemic and ongoing stigma have significantly shaped the health expectations of older gay men (Catalan et al., 2020; Rosenfeld et al., 2012). These individuals face various barriers to care, which can result in poorer health outcomes compared to their heterosexual counterparts (Fredriksen-Goldsen et al., 2013; Kia et al., 2022). Stigmatization within healthcare settings is likely to discourage older gay men from seeking assistance when needed (Brotman et al., 2003; Robinson, 2016), while internalized homophobia poses substantial mental health risks (Pereira, 2022; Wight et al., 2012). Older gay men frequently experience loneliness and isolation due to ageism, which is prevalent within the LGBT community and is based on youthful social stereotypes (Carnaghi et al., 2022; Sage, 2021). The absence of adequate family support often drives older gay men to create chosen families as an alternative (Van Wagenen et al., 2013). Further, religious isolation stemming from discrimination can impact their faith experiences (Orel, 2004). Housing preferences, legal rights, and relationships also play crucial roles. Many older gay men would prefer to ‘age in place’ at home, but may encounter discrimination when seeking housing options (Orel, 2004). Legal challenges and societal hostility have substantial effects on their quality of life and interpersonal relationships (Grabovac et al., 2019; Shenkman et al., 2022). Thus, in-depth research on this population is crucial to effectively address their specific needs and challenges (Eppler-Hattab, 2023; Gonçalves et al., 2020).

The Italian Context

Italy has a large aging population, but no data have been collected to date on older LGBT adults by the official Italian Institute of Statistics (ISTAT, 2021). Recent studies have documented the prevalence of homophobic attitudes in Italy, which have been exacerbated by the current conservative political climate that hampers LGBT rights (Donà, 2021; European Commission, 2019). Recent government measures voted by the Fratelli d’Italia party have further curtailed LGBT rights (Broder, 2023; Giuffrida, 2022. https://www.theguardian.com/world/2022/oct/24/fears-lgbtq-rights-italy-giorgia-melonidata). The influence of the Catholic Church and traditional family values also contributes to this discriminatory environment (Callahan & Loscocco, 2023).

Drama-Based Therapies and Their Use with Older Adults and LGBT People

Psychodrama and drama therapy are part of the creative arts therapies (CATs), an umbrella term that covers art therapy, dance/movement therapy, music therapy, and poetry/bibliotherapy (De Witte et al., 2021). In psychodrama, as developed by J. L. Moreno in the 1920s, guided role-play and specific techniques are used to explore clients’ personal and interpersonal issues (Moreno, 1946). According to Moreno, the goal of psychodrama is to enhance spontaneity and creativity to generate adaptive responses to previous or changing situations (Moreno, 1946; Orkibi & Feniger-Schaal, 2019). Relatedly, drama therapy, rooted in theater practices, employs drama processes to achieve therapeutic goals (North American Drama Therapy Association, 2005) by fostering embodiment, projection, role-play, and improvisation (Orkibi et al., 2023). Both approaches aim to address psychological concerns and enhance well-being. The two drama therapy approaches implemented in the current study will consist of narradrama and therapeutic playback theater. Narradrama combines narrative therapy principles with drama therapy, and aims to encourage the reconstruction of problem-saturated stories (Dunne, 2003), whereas therapeutic playback theater involves improvisation based on personal stories (Kowalsky et al., 2022). Here, the intervention will combine psychodrama and therapeutic playback techniques with life review (Keisari et al., 2020, 2022). Life review is an approach where clients reflect on the significant events and experiences of their lives to promote resolution of past conflicts, and a sense of meaning and coherence through the integration of both positive and negative events (Kenyon et al., 2010; Westerhof & Bohlmeijer, 2014).

Although there is less research on psychodrama and drama therapy than on other forms of psychotherapy, studies suggest it has may have benefits for mental health (Orkibi et al., 2023; Orkibi & Feniger-Schaal, 2019). Specifically, in older adults, psychodrama fosters social interaction and counters social isolation (Carman & Nordin, 1984) and helps address loss-related issues, promotes memory recollection and emotional resolution (Carman & Nordin, 1984; Pitt, 1982). Similarly, drama therapy enables positive identity formation through role exploration (Keisari et al., 2018) and can benefit high-functioning older adults as well as those facing physical, emotional, and cognitive challenges (Dassa & Harel, 2019; Dunphy et al., 2019; Keisari & Palgi, 2017; Sandel & Johnson, 2014). Drama therapy’s contributions include enhanced positive mental health indices, improved social engagement, and coping with aging-related changes (Keisari et al., 2018, 2022; Mechaeil et al., 2009). In particular, therapeutic playback theater in drama therapy aids in resolving unfinished business, coping with loss, and preparing for end-of-life (Harel & Keisari, 2021; Keisari et al., 2020).

Although there is scant research on psychodrama for gay men, data suggest that psychodrama can help facilitate the resolution of personal and interpersonal conflicts (Gershoni, 2003; Zakabi, 2014). Group psychodrama can help “coming out” and integrating a positive gay identity, countering depression and isolation (Gershoni, 2003; Zakabi, 2014). Research on drama therapy reports similar benefits for LGBT individuals, in that it can address their psychological needs, enhance confidence, and promote family conflict resolution (Beauregard, 2019; Beauregard et al., 2016; Lunardi, 2019). Combined with narrative therapy, drama therapy contributes to LGBT individuals’ mental health (Wilson, 2011). The contributions of psychodrama and drama therapy can thus meet the needs of older gay men by helping them overcome the negative effects of discrimination and stigma on their mental health and by promoting positive self-definition.

Tele-Drama-Based Therapy

Prior to the COVID-19 pandemic, there was little research on tele-CATs (Feniger-Schaal et al., 2022). The pandemic compelled mental health professionals to adopt alternative approaches such as tele-therapy, due to restrictions on face to face gatherings and increased psychological distress (Humer et al., 2020). Research points to the positive outcomes of tele-therapy, and suggests it is on a par with in-person therapy (Andersson, 2016; Berryhill et al., 2019; Hilty et al., 2013), despite the concerns related to maintaining the therapeutic alliance and diagnosing remotely (Connolly et al., 2020). Tele-psychodrama also emerged as a response to the pandemic. This involved readapting psychodramatic techniques to the online setting; in particular, role reversal and doubles only used the cameras of the protagonist and his/her alter ego/double on in the scene, whereas soliloquy only used the protagonist’s camera on in the scene (Biancalani et al., 2021, 2022). Recent studies show that the benefits included treatment continuity, the promotion of self-awareness, and the maintenance of group relationships (Biancalani et al., 2022), whereas the limitations comprised the lack of physical contact, emotional expression difficulties, technical issues, and distractions (Biancalani et al., 2021, 2022). As is the case for psychodrama, drama therapy has also transitioned online, generating positive transformations and connections, particularly in older adults. It was shown to foster self-expression, creative engagement, and coping skills (Harel & Keisari, 2023; Kordova & Keisari, 2020). Research indicates that tele-psychodrama and tele-drama therapy support clients’ psychological well-being (Biancalani et al., 2021, 2022; Cortes & Vidal, 2021; Harel & Keisari, 2023; Kordova & Keisari, 2020; Pereira Vidal & Castro, 2020).

Research Questions

The following research questions will be probed: (1) Before the intervention: What are the life stories of older gay men in Italy (encompassing aspects such as their upbringing, coming out as gay if applicable, social and romantic relationships, experiences with stigma and discrimination, as well as their psychosocial needs and difficulties)? (2) During the intervention: How do the participants depict their narratives through the drama work? (3) Post-intervention: How do the participants perceive the contribution of the intervention, including identifying helpful and hindering factors?

Method

This qualitative study will adopt a narrative approach, by considering narrative as a paradigm that underscores the significance of stories in human life (Spector-Mersel & Ben-Asher, 2022). Narratives play a vital role in constructing identity and shaping people’s understanding of both themselves and the world around them (Spector-Mersel, 2011; Spector-Mersel & Ben-Asher, 2022). Narrative research delves into life stories within their contextual framework (Zilber et al., 2008) by examining aspects such as content, narration style, and intended audience (Riessman, 2012). Participants are invited to share their stories without interruption, thus facilitating a comprehensive exploration of their experiences (Riessman, 2012). Through narratives, individuals’ intentions, motivations, emotions, and decisions are unveiled (Meraz et al., 2019). This approach is particularly pertinent to understanding disruptive events, social movements, and the narratives of marginalized groups (Riessman, 2012). Narratives themselves serve as fundamental data, enabling an in-depth exploration of human experiences (Butina, 2015).

Sampling and Recruitment

The sample will consist of older gay men from across Italy with the following inclusion criteria: (a) aged 60 and over, (b) self-identified as gay men, (c) ability to use online video conferencing platforms, (d) participant self-report indicating that they can understand and follow instructions, and (e) the absence of a clinical diagnosis of major psychiatric disorders or alcohol/drug misuse. Inclusion criteria for the volunteers/social workers will be to have worked with older gay men for at least one year. Older gay men and volunteers/social workers will be recruited by convenience sampling through the main Italian LGBT + organizations (e.g., Arcigay) who will ask potential participants to contact the researcher by email or phone. In parallel, snowball sampling will be used, by asking the people contacted through convenience sampling or other people close to the PhD candidate to forward the call for participants. Snowball sampling is typically used to recruit populations that are difficult to reach (Parker et al., 2019), which is the case for older gay men and the volunteers/social workers who work with them (Fredriksen-Goldsen & Kim, 2017). Older gay men and volunteers/social workers will be recruited until saturation is reached; that is, the point at which new data cease to provide additional insights or yield new themes, leading to informational redundancy (Guest et al., 2006).

Procedure

The procedure involves three distinct phases. Phase 1, will entail conducting narrative interviews (see interview guide in Appendix A) with 10–15 older gay men by the first author to explore their life stories. In addition, data from volunteers and social workers, who work with this population will be gathered through semi-structured interviews (see Appendix B) and triangulated with the narrative interviews with the older gay men, in order to strengthen the trustworthiness of the findings. Then, based on the data collected and the literature, an intervention protocol will be written that integrates psychodrama and drama therapy (Dunne, 2003; Kowalsky et al., 2022; Moreno, 1946) with life review techniques (Westerhof & Slatman, 2019). The tele-drama-based intervention will be based on a similar intervention that was found to be effective with older adults both online (Harel & Keisari, 2023) and in person (Keisari et al., 2020, 2022). The intervention gives individuals the opportunity to share their own story using dramatization, and then to witness, listen to and validate others’ stories. This will reveal patterns in the dominant narratives of older gay men in Italy (White & Epston, 1990), while focusing on their strengths and resilience in past and future life events. The first author will co-facilitate the intervention with an Italian clinical psychologist (a heterosexual female) who is also a senior psychodrama therapist and trainer. In Phase 2, before the intervention, both therapists will conduct a 30-min online intake session with each individual participant on Zoom to introduce themselves and the intervention. The tele-drama-based intervention will be delivered each week for 75min for 8 weeks, in a group format of four to six participants. The intervention will be delivered in Italian and video-recorded. The two group therapists will meet for weekly clinical supervision and will also receive research supervision by the research supervisors (second and third authors) to ensure treatment fidelity. Phase 3, will take place after the intervention, where both therapists will conduct a 60-min individual interviews with each participant using the Client Change Interview (Elliott, 2008). Client Change Interview aims to gain insights into clients’ understanding of what changed as a result of the treatment process and how those changes occurred, including the factors that interfered with that process (Elliott, 2011).

The Intervention

The intervention protocol will be developed for this study based on an existing program for older adults (Keisari et al., 2022). It will combine elements of life-review therapy, improvisation, and group interaction to help participants explore their life stories, integrate them into a cohesive narrative, and foster a sense of continuity and purpose in their lives. The protocol is structured into five stages, each with a distinct purpose. The first stage involves introducing participants to the basic notions of drama-based therapies in online settings, where stories are not just told but acted out on stage together as a group. In the second stage, participants explore and write their most significant and self-defining memories (termed ‘life-crossroads’), which will be the only session that includes writing and non-improvised storytelling. The third stage centers on a life review performed online, with the group working together to integrate dramatic elements from various life-crossroads stories to create a unified life review. The fourth stage focuses on future life-crossroads, to reinforce participants’ sense of continuity and life purpose. The fifth and final stage is dedicated to a farewell. The general structure of each session comprises a warm-up phase, an action phase, where participants share their life-crossroads stories and engage in theatrical improvisation based on these stories, and a sharing phase, where participants respond to the stories and improvisations from their own subjective perspective by sharing related personal stories.

Data Analysis

The qualitative data collected from the interviews and the sessions of the intervention will be recorded and transcribed. During Phase 1, Riessman’s analysis of personal narratives (Riessman, 2012) will be applied to the data collected from the narrative interviews of the older gay men to understand their life stories. We will apply multiple methods for systematic data evaluation: thematic, structural, and performance analyses (Meraz et al., 2019). Thematic analysis interprets meanings, structural analysis delves into story construction and narrative devices, and performance analysis examines how stories are conveyed to the interviewer (Riessman, 2012). The data collected from the interviews with volunteers/social workers will be analyzed based on thematic analysis. The stages include familiarization with the data, coding, generating initial themes, reviewing themes, defining and naming themes, and writing up the report (Braun & Clarke, 2006). These findings will be integrated into the thematic part of the narrative analysis to construct an integrative view. During Phase 2, the video recorded data of the intervention will be analyzed using the 6-Key model (Pendzik, 2012), a qualitative assessment approach based on the concept of dramatic reality (see Appendix C). This model encompasses six core aspects: passages, quality, characters and roles, content, response of the client to the drama work, and meta-reality. Through these lenses, we will explore how the participants depict their narratives through the drama work. In the Phase 3, the data collected from the Client Change Interview with older gay men will be analyzed through thematic analysis (Braun & Clarke, 2006).

Ethics and Dissemination

Approval from the Ethics Committee for Human Research at the Faculty of Social Welfare and Health Sciences at the University of Haifa was obtained (approval #332/29). Each participant will be asked to provide their informed consent to participate in the study at the start of the recorded interview, in Phase 1, and will be guaranteed confidentiality and anonymity. Throughout the study, the chart of values of the Italian Association of Morenian Psychodramatists (Italian Association of Morenian Psychodramatists [AIPsiM], 2021) will be adhered to. The findings will be disseminated in academic articles in English as part of a doctoral dissertation.

Rigor

To ensure the qualitative rigor of the study, several strategies will be implemented. In Phase 1, the participants’ data will be integrated with the data collected from volunteers/social workers who work with older gay men in Italy. In Phase 2, the research team (i.e., the three authors and the therapist) will convene regularly to discuss intervention implementation and the research process. In addition, during the intervention, the two group therapists will meet for a weekly clinical supervision session to guarantee adequate psychological support for each of the participants. In addition, during the intervention, the recordings of the sessions will be examined against the protocol to insure treatment fidelity (Hildebrand et al., 2012). Reflexivity, involving self-awareness and critical reflection on personal biases and assumptions that may impact the research, will be maintained through a reflexivity journal documenting the researcher’s thoughts, emotions, and actions (Birks et al., 2008). In Phase 3, an audit procedure will be conducted by an impartial Italian psychologist colleague to verify analysis accuracy against the raw data in Italy. Finally, to facilitate a member-checking procedure (i.e., respondent validation), a summary of the findings will be shared with the participants via email to gather feedback and enhance the credibility of the researcher’s interpretations (Birt et al., 2016).

Discussion

This intervention will shed light on the issues faced by older gay men. Providing them with adequate psychological support for their needs is crucial, especially in Italy where this population has rarely been studied (Ross, 2012). As is the case in other countries, it is likely that older gay men in Italy have suffered the effects of stigma in the seven domains of greatest discrimination (Orel, 2004, 2014), as well as ageism (Carnaghi et al., 2022). This discrimination can impact their psychological health and influence their conduct in daily life (American Psychological Association, 2021; Orel, 2004; Sage, 2021). To date, there are no studies exploring the life narratives of older gay men in Italy in terms of their life stories and psychosocial needs, difficulties, and resources. Thus, little is known about their psychosocial needs, making it difficult for decision makers to devise policies providing adequate assistance services that can respond to them.

Studies have reported the positive effects of psychodrama and drama therapy on older adults, and confirmed that it promotes their social engagement, emotional resolution and mental health (Carman & Nordin, 1984; Harel & Keisari, 2021; Keisari et al., 2020; Pitt, 1982). In LGBT people, it promotes the integration of a positive gay identity, enhances confidence, and counters depression and isolation (Beauregard, 2019; Beauregard et al., 2016; Gershoni, 2003; Lunardi, 2019; Zakabi, 2014). However, there are no studies involving a specifically constructed intervention that combines tele-drama-based therapy and life review for older gay men. The findings of the present study will thus provide a better understanding of this population. The goal of this study is to design tele-drama-based therapy that addresses the psychosocial needs of older gay men and help them cope with challenges associated with the intersectionality of ageism and homophobia.

This study will also innovate through its online delivery of the drama-based intervention. This setting makes it possible to reach people who live in different parts of the country or who find it difficult to attend the intervention physically, for example for health reasons. Overall, the creation of tele-drama-based interventions, derived from data collected from the life stories of older gay men will constitute an important first step in providing adequate treatment options for this at-risk population, and contribute to their mental well-being.

Supplemental Material

Supplemental Material - The Life Stories of Older Gay Men in Italy and Their Response to a Tele-Drama-Based Intervention: A Qualitative Study Protocol

Supplemental Material for The Life Stories of Older Gay Men in Italy and Their Response to a Tele-Drama-Based Intervention: A Qualitative Study Protocol by Gianmarco Biancalani, Hod Orkibi, and Shoshi Keisari in International Journal of Qualitative Methods

Footnotes

Author Contributors

All authors contributed equally to the conceptualization and design of this study. GB (MA, PhD candidate, psychologist and psychodramatist in training, male) conducted the literature review that was examined and approved by HO (PhD, researcher, psychodramatist, male) and SK (PhD, researcher, drama therapist, female). All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

ORCID iDs

Gianmarco Biancalani

Hod Orkibi

Supplemental Material

Supplemental material for this article is available online.

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