Not being able to recognize a person’s face is a highly debilitating condition from which people with developmental prosopagnosia (DP) suffer their entire life. Here we describe the case of J, a 30 year old woman who reports being unable to recognize her parents, her husband, or herself in the mirror.We set out to assess the severity of J’s prosopagnosia using tests with unfamiliar as well as familiar faces and investigated whether impaired configural processing explains her deficit. To assess the specificity of the impairment, we tested J’s performance when evaluating emotions, intentions, and the attractiveness and likability of faces. Detailed testing revealed typical brain activity patterns for faces and normal object recognition skills, and no evidence of any brain injury. However, compared to a group of matched controls, J showed severe deficits in learning new faces, and in recognizing familiar faces when only inner features were available. Her recognition of uncropped faces with blurred features was within the normal range, indicating preserved configural processing when peripheral features are available. J was also unimpaired when evaluating intentions and emotions in faces. In line with healthy controls, J rated more average faces as more attractive. However, she was the only one to rate them as less likable, indicating a preference for more distinctive and easier to recognize faces.Taken together, the results illustrate both the severity and the specificity of DP in a single case. While DP is a heterogeneous disorder, an inability to integrate the inner features of the face into a whole might be the best explanation for the difficulties many individuals with prosopagnosia experience. J is a 30 year old woman who approached our research department and asked to be examined for possible prosopagnosia. According to her self-report, J has a lifelong inability to recognize the identity of others from their faces. This includes an inability to recognize her parents, her husband, and (under certain conditions) herself in the mirror.“It simply never occurred to me that one could recognize people only by their face”, J told us. A few years ago she was watching a TV talk show, in which one of the guests was interviewed about his prosopagnosia. J describes this moment as the one in which she immediately knew that she must have the same condition.The first case of prosopagnosia present from early childhood, now called developmental prosopagnosia (DP), was described by McConachie in 1976 , 3, McCoBecause a researcher on the show was looking for participants to enroll in a study concerned with hereditary forms of prosopagnosia cf. , 11), J , J 11]),However, some hallmarks of DP have been agreed upon in the research literature: The main deficit is an inability to recognize individuals by their faces, but preserved ability to recognize them by non-face information such as voice, gait or clothes . The onsRegarding the age of onset, J reports that she cannot remember a time when she was able to recognize people by their faces and recalls conspicuous behavior she showed as far back as grade school. Back then, she would spend most of her time in the schoolyard with her best friend, who would constantly have to tell her the names of classmates they passed on the schoolyard, and point out people they knew. J told us that back then she did not suspect she was somehow impaired, but rather thought that her friend was simply exceptionally good at recognizing people. Also, it was not obvious to J what information her friend was using to recognize people. It did not occur to her that it was their faces which gave away other people’s identities.Previous to visiting our lab, J had two clinical MRIs which were diagnosed as asymptomatic. This diagnosis was confirmed by our own MRIs, which do not show any abnormalities on a macroanatomical scale, including the fusiform gyri Fig. a. Areas To characterize both the specificity and the severity of J’s self-reported difficulties with faces, we asked her to perform a number of different tests. These were designed to delineate deficits restricted to recognizing the identity of faces from more global deficits in processing non-identity information in faces and other objects. Furthermore, tests with different degrees of difficulty were used and J’s performance was compared relative to matched healthy controls or to normative data, whenever feasible. Finally, to better understand the possible cognitive mechanisms which underlie DP, we designed experiments which allowed us to evaluate how successfully J uses different face processing strategies, such as configural processing , where iWhenever there is a person, instead of the face there is just a placeholder of some kind”. When reading fiction, J claims that she always imagines the actions of the people described from a first-person perspective, which obviates imagining what the person performing that action might look like. Deficits in imagery for faces have also been found in some previous studies on DP [DP is a condition of varying specificity and particularly the early cases were impaired in more general object recognition as well , 4. Latees on DP , 33.“wrong” (i.e. left) hand when initiating a movement and then has to correct herself and switch hands. In patients with damage to the fusiform gyrus, similar problems with body perception have been reported [Furthermore, J complained to us about problems with body perception, specifically correctly identifying her left and right hand. While J is unequivocally right handed according to the Edinburgh handedness questionnaire , she clareported . Accordireported  was two reported ) was pooIf you have a job where you sit in your office and people come to you at previously appointed times, it is easy. But if you have to actively approach people, go to their offices, or make small talk in the hallway, you can’t do it if you don’t know who is who”. Her inability to recognize customers and colleagues therefore had many repercussions, even leading to the loss of some jobs.J reports that her condition is especially impairing when she has to learn new faces, as was the case when she held a job in sales and distribution: “elongated chin”, “fair eyes”, “chubby cheeks”).To test J’s ability to learn and recognize new faces, we used the Cambridge Face Memory Test , which In the next two parts of the CFMT, six faces are presented simultaneously for 20 s to study and then have to be recognized in subsequent arrangements of 3 faces, of which one is from the learned set. This task is either performed under normal viewing conditions (part 2) or under conditions where faces are strongly degraded by noise (part 3). In both of these tasks, J performed at chance level , we decided against adding a dedicated face matching task like the Cambridge Face Perception Test . InsteadI cannot remember what I look like”, she told us.While remembering faces seen only on one occasion is a difficult task per se, people with DP are also unable to recognize individuals they have known for years , 24, 40.Despite being unable to recognize her husband or herself, J claims that there are a number of famous people she can recognize by their faces with high certainty. Studies in which participants with DP were asked to recognize famous faces have shown that they are significantly worse than controls in these tasks. However, their absolute scores are surprisingly high, as they usually can still identify around 30–40% of the faces correctly , 41. OneTo test J’s ability to recognize famous faces and directly address the role of exposure, we asked her to provide us with a list of people she thinks she can recognize from looking at their face alone. The list J provided consisted of 14 celebrities, including Angela Merkel, Barack Obama, some  actors from the shows “How I Met Your Mother”, “House” and “Law and Order”, as well as some other politicians and actors. In our final experiment, there were 42 famous people (5 images per person), including the ones from J’s list, actors on the same shows who were not on the list, and other famous people , J said that he is easy to recognize due to his “freckles”, a subtle feature which most observers (including the authors) probably do not notice but which prove useful for observers who heavily rely on recognizing individuals by single features.To get a better understanding of how J performed that task, we later asked her to try and verbalize what makes recognizing certain faces easy. Regarding Ms. Merkel (4/5 correct namings), J pointed out that Ms. Merkel seems to have a “the interplay of different face parts” when confronted with blurred images. While intact configural processing in DP has been reported before [one face at a time” strategy might also allow for good performance in certain experimental settings, like the present task.To better understand how J uses the features of the face compared to their configuration , we modd before , 44, it I can recognize if someone recognizes me; and then I act accordingly”. She also judges her skills to tell if her interaction partner is lying, agitated or uncomfortable as very high: “I think I have a very keen understanding of social signals. The way the eyes of a person change when they are uncomfortable, small pauses they make in their speech and certain subtle facial expressions”. In order to objectively assess her ability to derive social cues from faces, we used the “Reading the mind in the eyes” test, which measures the ability to imagine the mental states of others [Another aspect of face processing that is usually unimpaired in people with DP is the recognition of emotions, intentions or other social information, such as trustworthiness , 46. Desf others . In the f others .To further test J’s ability to identify facial expressions of emotion, we used a 7-way forced-choice basic expression recognition task, with happy, sad, angry, fearful, disgusted, surprised and neutral faces. Here, J scored 88% correct and was the second-best participant in our sample Fig. . This isIn addition to identifying intentions and emotions, J is also convinced that she can reliably judge the attractiveness of faces, and a number of episodes from her life seem to corroborate this impression.In one episode, J recalled being at a discotheque with a female friend. She saw a man she found handsome, had a drink with him and they talked for some amount of time. The other day, she was at a café with the same friend, as a man walked by. She remarked to her friend that he also looks quite handsome, to which her friend replied that this was the same man she had drinks with the night before. The same thing happened a third time, only a few days afterwards, with the same man, in pretty much the same way. This provides anecdotal evidence that J’s judgments of attractiveness are consistent across time.“odd” faces and takes an immediate liking to anyone with some idiosyncratic features in their face. She finds people with green eyes or thick eyebrows immediately likable, predominantly because they are easier to identify and consequently interaction with them is considerably less stressful. “I like red hair a lot and take an immediate liking to anyone who has it”, J told us. Similarly, other cases of DP described in the literature have remarked that they focus on the “worst features” of each acquaintance’s face to remember them, keep company with “physically distinctive” people and claim that forgetting someone’s face should be regarded a compliment, because good looks are not memorable [J also reported that she likes emorable .Increasing the averageness of a face normally increases its perceived attractiveness ) while mWe have presented the case of J, a 30-year old woman suffering from DP, a lifelong face recognition deficit. J presents with a pure form of DP, showing strongly impaired recognition of identity for both unfamiliar and familiar faces, but no difficulties recognizing expressions, intentions or attractiveness from faces . Also, participants who know only a few famous people are more likely to be outliers, as knowing 40 people and scoring all correct or all incorrect is much less likely than knowing only 4 people and scoring all correct or incorrect. Hence, using faces that are completely new to all participants, as is in the CFMT, might make results more straightforward to interpret and compare.Regarding explanatory mechanisms for J’s deficits in unfamiliar and familiar face recognition, we expected that impaired configural processing might offer the best explanation. However, the present study as well as some previous work in the literature has found largely intact configural processing in DP , 44; butone face at a time”. This might indicate that tasks which more closely emulate situations in everyday life need to be developed. For example, the effect of using more complex visual stimuli with distracting or misleading peripheral information could be explored. This might allow a better understanding of the challenges individuals with DP face in their daily life.Given that under favorable circumstances a person with DP can recognize faces quite well, the results raise the question of why these abilities do not translate into everyday life. Among the most discriminative symptoms of DP are face recognition problems in “crowded places or out-of context encounters” . J also That a better emulation of real-life experience in the lab is possible is shown by our investigation of perceived attractiveness and likability of faces. Here, the subjective experience of preferring distinctive faces, and lab results indicating typical attractiveness ratings, could be reconciled. The results have shown that while a person with DP might not have an altered sense of what makes a face attractive, they might take a stronger liking to more distinct faces. This subtle dissociation was absent in the non-DP persons we tested.In summary, we present a pure case of DP, in which deficits are restricted to an impairment in recognizing people’s identities from their faces. By carefully delineating the deficit using experimental methods as well as detailed reports of J’s subjective experience, we show that neither lack of familiarity nor impaired configural processing in general can explain the deficits. J’s difficulties show most strongly when only the inner features of the face are visible and no single feature is specific for a given face. This suggests the conclusion that an inability specific to integrating the inner features of the face into a whole, might be the best explanation for the difficulties this and other individuals with DP frequently experience.To screen for visual agnosia, we used a set of full-color photos of 12 objects, cut-out along their contours. The images consisted of living objects such as animals, fruits or vegetables and of non-living objects such as tools, clothes or furniture. The screening consisted of 8 free-naming trials where a single image was shown and had to be named, and of four forced-choice identification trials, where an object was named and had to be selected from a configuration of four objects.www.freesurfer.net; [All MRI data were collected using a 3 T Siemens Trio scanner. A high-resolution T1-weighted structural image was acquired with 0.75 × 0.75 in-plane resolution and 0.8 slice thickness  using a 32-channel head coil. Task-based fMRI data were collected using a high-resolution EPI sequence with 2x2mm in-place resolution and 2 mm slice thickness . Slices covered the whole temporal lobe but omitted most of the rest of the brain. The first 3 volumes of each fMRI run were removed to allow for signal stabilization. Stimuli were presented using PsychoPy2  and backfer.net; ). Structn = 174 adult participants  were taken from [Body perception and mental rotation of bodies were tested using the The Bergen Right-Left Discrimination Test . The teken from . For then = 129 adults, with mean 76 and standard deviation 18 were taken from the test manual [Visuo-spatial abilities were tested using the visuo-spatial tasks from the LPS-2 , which ct manual .To evaluate the memory for unfamiliar faces, we used the CFMT. The test consists of three parts, (i) learning one face, (ii) learning six faces (iii) learning six faces degraded by noise . The conTo evaluate the recognition of known faces, we used an in-house constructed famous faces test. We asked J to provide us with a list of celebrities she thinks she can reliably recognize when she sees them on television or in newspapers, of which she could name 14 . The use of spatial filters to induce featural and configural processing strategies for faces has been demonstrated before . In the In the test, participants see the eye region of a single face and have to select one of four terms that best describes the mental state expressed by that face. A total score of 36 can be reached. To compute percentile scores, we used a normative sample of 50 female student controls from a previous study . This grTo test participants’ performance in recognizing facial expressions we used a 7-way forced-choice decision task with happy, sad, angry, fearful, disgusted, surprised and neutral faces. The face stimuli were taken from the NimStim database  and eachfaceresearch.org [To investigate the judgment of attractiveness and likability of faces depending on their averageness, we used an in-house generated task, using faces from arch.org . Face stThe experimental setup was as follows: Two faces from the same average sequence were presented side-by-side  and the participant was asked to judge which face looks more attractive . This was repeated for every combination of pairs and all 16 identities, giving rise to 160 trials per block. Whether the experiment started with the attractiveness or the likability decisions was randomized. 46 female controls  were used as a control group and tested online using a browser-based presentation tool.p-values were computed based on the t-value and the n-1 degrees of freedom (n being the size of the control sample). All computations were implemented using in-house software written in Python 2.7. A heatmap visualizing the differences of J’s z-scores in all major tasks was created using Seaborn (seaborn.pydata.org).For each test, the percent of correct responses was computed as the ratio of J’s score relative to the maximal achievable score. J’s z-score for each test was computed based on the control sample’s distribution of scores, which was transformed to have zero mean and unit variance. The z-scores were converted into percentile scores using a cumulative distribution function. Inferential statistics were computed using the t-test method developed by Crawford and Howell, as described in . Two-sid


A mixed methods experimental design employing an explanatory sequential approach to data collection was implemented. A total sample of 33 abused women  was involved in studying the impact of a psychodrama intervention combined with an ecological intervention. Spontaneity and wellbeing, considered in this study as dimensions of empowerment, were measured. Phenomenological interviews were conducted with 7 women 3 months after the psychodrama intervention ended, and with 6 women 5 years later. Data was analyzed using the Interpretative Phenomenological Analysis method. The matrix of themes that emerged reflects four overarching themes: the victim, the group experience, the process of change, and the corollary of change. Benefits perceived by the women include trust, hope, increased self-esteem, empowering, and courage to make decisions and changes. Findings describe three paths of change for women who participated in an empowering-oriented psychodrama intervention program: the Proactive – Resilient type, the Active – Resistant type, and the Repetitive – Non-Resilient type. Role-reconstruction and the interruption of trans-generational victim pattern were clear for the proactive type and possible for the active type, while the repetitive type showed minor changes but remained stuck in the victim pattern. As no claims to generalizability can be made, further research is needed to verify the proposed typology on larger samples. Psychodrama, as an action method, can empower abused women and has the potential to stimulate action in women’s lives and initiate adaptive coping strategies leading to resilience. The study ends with several suggestions for assisted resilience specialists.This paper discusses how psychodrama methods and techniques can empower abused women and stimulate changes in their victim role. Through an in-depth exploration, we sought to gain an insider’s perspective of the experiences of change and perceived outcomes for abused women, which could contribute to optimizing gender violence intervention. Theoretically, the study is grounded in the female co-responsibility and  Domestic violence is a complex phenomenon which cuts across all social classes, countries and periods of human history. It is one of the most widespread forms of violence among people, and it affects women in particular. If fundamental changes are to take place in women’s condition, they themselves must take an active role . The EurSeveral Romanian studies have drawn attention to the country’s high tolerance of domestic violence in all its forms . The mosAny social program that hopes to change the current situation must first change the cultural premises and associated stereotypes, since culture is often responsible for the way women and the issue of violence against them are viewed and addressed. We believe that domestic violence occurs as a result of the backlash that seeks to maintain and/or restore the traditional separation between natural and social tasks.One of the world-wide effects of this backlash has been to reinforce sex and maternal roles, which weigh more heavily on Eastern Europe women than in the past . The mosAgainst this backdrop, the Empower Daphne Project  and consisted of an experimental design  that investigated the impact of psychodrama group intervention on spontaneity and wellbeing.The quantitative component was part of the Empower Daphne Project , and again 5 years later . The Interpretative Phenomenological Analysis Method (IPA)  was chosA convenience sample was used.Access was granted through a voluntary organization, Home of Hope, which was a partner of the Romanian Association of Classical Psychodrama (ARPsiC) in the Empower Daphne Project. Home of Hope supports abused women through a project entitled “Preventing and Combating Domestic Violence” which uses the ecological intervention framework .The 2011–2012 Empower Daphne Project was carried out in accordance with the guidelines of the University of Padova Scientific and Ethics Committee.n = 20 women were included in the control group and n = 16 in the experimental group. One woman withdrew from the experimental group during the intervention. During data analysis, two participants from the control group were excluded because of incomplete data.The sample included a selection of women who were Home of Hope clients during July – November 2011. They were informed regarding the project and the voluntary nature of their participation and were given the choice of participating in either the experimental group or the control group. Informed consent was given in writing. The specialists from Home of Hope acted as contact persons for any questions regarding the study. Upon their voluntary decision, N = 33 abused women, n = 15 in the experimental group  and n = 18 in the control group . The age range was 19 – 62 years for the total sample , 19 – 45 years  for the experimental group, and 21 – 62 years  for the control group. All women had experiences of abuse. Except for two students, all participants had one to five children.The total sample thus consisted of n = 8), consisting of women living at home, and PG2 (n = 7) consisting of women living in a shelter for victims of abuse. The women in PG1 were followed up longitudinally. The sample profile is described in Table 1. Pseudonyms are used to maintain anonymity.The experimental group was divided into two psychodrama groups: PG1 , the Revised Spontaneity Assessment Inventory (SAI-R) and the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM). Qualitative data was collected using a semi-structured phenomenological interview.The research phases and data collection are described in Revised Spontaneity Assessment Inventory (SAI-R)   is a queClinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) (The CORE-OM)  is routiBoth SAI-R and CORE-OM were used to evaluate the clinical efficiency of the interventions and were cross-culturally validated in the Empower Daphne Project .An interview schedule was formulated and applied in a flexible manner, using a phenomenological approach . InterviThe dimensions of the interview are:1.Psychodrama group experience2.Perceived impact of psychodrama techniques and activities3.Perception of change4.Perception of self5.Messages for other victims of gender violenceIn addition to these common dimensions, the 3-month follow-up (T2) included the individual and trans-generational history of abuse, while the 5-year follow-up (T3) explored significant experiences/events during this period.Psychodrama was used as part of a psycho-social intervention program aiming to empower abused women. Before the group started, the psychodramatist had one individual session with each member to prepare the women for the group and build therapeutic alliances. The psychodrama intervention program consisted of a total of 25 2-h sessions, provided on a weekly basis. When the project ended, Home of Hope offered follow-up after-care for those who still needed support. The group psychodramatist had 10 years of experience in using psychodrama and was supervised by the national Empower Daphne project coordinator/psychodrama trainer and supervisor to ensure treatment integrity and fidelity.Table 2, where they are grouped according to an adaptation of Tuckman’s group development stages  were calculated. The non-parametric Wilcoxon signed rank test was used to compare mean ranks between pre- and post-test within the experimental group. Analysis of covariance (ANCOVA) was used to compare the experimental and control groups, while statistically controlling for the effects of the differences at pre-test.Qualitative analysis was based on a total of 13 verbatim transcripts . Each transcript was analyzed until an IPA matrix of themes emerged; common themes and discrepancies were searched for until a group matrix for T2 and one for T3 were generated. These two matrices were analyzed for consensual themes and one IPA matrix emerged, capturing the experiences of women longitudinally , for both SAI-R  and CORE-OM . Reliabilities calculated for independent samples, pre-test and post-test are also good and very good as detailed below:The reliabilities of the questionnaires  were excellent for the total sample (1.N = 15): SAI-R  and CORE-OM Experimental group (2.N = 18): SAI-R  and CORE-OM Control group  between pre- and post-test. For CORE-OM, the results for the Problems scale are statistically significant, indicating a decrease in experienced problems or symptoms; the mean score and standard deviation at pre-test were T0: M = 19.47, SD = 8.73, while at post-test T1: M = 14.05, SD = 9.20. Results for the Non-Risks items are marginally significant (p = 0.06), showing a tendency to decrease self-risk behaviors: the mean score and standard deviation at pre-test were T0: M = 50.03, SD = 11.48, while at post-test T1: M = 44.35, SD = 10.99. The total CORE-OM score is also marginally significant (p = 0.06), pointing to an improvement in wellbeing. Hence, the mean score and standard deviation at pre-test were T0: M = 51.68, SD = 13.03, while at post-test T1: M = 45.67, SD = 13.15 (Table 3).Furthermore, we analyzed the experimental group using the non-parametric Wilcoxon signed rank test. Results illustrated in Table 5 do not identify statistically significant differences between the experimental and control groups, as the control group also showed improvements between pre and post-test.Analysis of covariance (ANCOVA) was used to compare the experimental and control groups, while statistically controlling for the effects of the differences at pre-test. Results presented in To conclude, the results show that it seems possible that psychodrama contributed to a positive trend of improving wellbeing, especially in terms of problems and risks. As regards spontaneity, the experimental group showed no statistically significant improvement compared to the control group.However, while questionnaires were able to identify only minor differences between the improvements shown by women participating in the psychodrama program and those who only received ecological intervention, the observations and comments of the two psychodramatists indicated more complex changes. Further analysis was thus carried out based on phenomenological interviews.This study does not claim to be representative; the main objective is to explore the processes in depth and create meaning. It centers on “giving voice” and “making sense” of women’s experiences, perceptions and views , thus gaTable 6).The matrix of themes that grounded the results is presented below .Many of them lived in terror: “that fear…that he would do it, that he would come and kill me...” . Silence, putting up with humiliation, terror, being careful not to provoke the perpetrator were all part of their survival strategies: “… I was silent and that bothered him more and he had all kinds of outbursts and I started being afraid that my life and my children’s were threatened...” .The difficulty of ending an abusive relationship is common to all participants. The reasons invoked by most of them are the lack of financial independence, no place to go, no job, family pressure  and sometimes poor health: “…if only I had a job, or my health was better, I would have done otherwise...” confesses Maria. They all “gave another chance” to the abusive husband: “…I always gave him another chance. I thought he would change” .With one exception (Mona), all participants in the study found themselves to be the third generation of victims of violence. Although they faced extreme violence, the great majority of participants’ grandmothers and mothers stayed in an abusive relationship. In trying to find an explanation, all participants invoke the same reasons: social pressure , faith (religion), and motherhood. For example, one of the participants says: “poor dear... (Grandma) lived in a society in which nobody listened to you if you told them what you had to suffer as a woman; they would listen to the man…” . One generation later: “…she (mother) would have thought of divorcing, but at that time, Ceauşescu’s time, there was the shame of divorcing... kids without a father!” recalls Erna, 2017.Ina explains her grandmother’s and mother’s decision to stay in the abusive relationship by invoking the religion, customs and mentality of those times: “their elders taught (grandma and mother) that the moment you marry someone and take the oath before the holy shrine, before God that you are going to be together, you are not allowed to leave as you are going to upset God... and she swore she would stay with him (grandpa) until death did them part, and she stayed, plus she had the children” .Maria’s account is illustrative of how the victim model was transmitted from generation to generation: “She (grandma) was a fighter, there was no divorce or separation at the time […]. And then mother handed it down to me, this model of misplaced obedience. Yes, obedience, shut up and let it be and swallow it, a model mother took up somehow and handed it down to me... I used to live with this model, I took it with me in my marriage and... my daughters saw it for a while...” .All women stated that they had difficulty in asking for and receiving help.The good relationship built up with the specialists  during the ecological intervention carried considerable weight in their decision to participate in the group.Group participation was initially accompanied by fear, anxiety, shame, holding back. Maria’s account illustrates the struggle with shame all the participants experienced in their lives: “Yes, I was ashamed of the situation I ended up in, what I knew about life, what I wanted my marriage to be like and where I was at the time… I was ashamed of those around me, of myself, of the choices I had made, of my family, my daughters, my mother and my brothers.” . For most of them, joining the group initially meant “to complain, to display all your problems”  and accepting the fact that they cannot manage for themselves: “…I think I was simply ashamed to admit that I was in trouble, I thought that meant I was incapable .The abuse experience led to mistrust the idea that someone might help them: “… if the man closest to you, the man you loved and offered the best you had could act like that, why would some strangers treat you better?” .The conviction that they cannot be helped, that only they can help “by themselves” was unanimously shared: “Before I came to the group, I absolutely refused to believe that anyone else could help me… I have to help myself...” .Fear, mistrust, shame were overcome only with the help of the group psychotherapist. The first meeting was perceived with considerable anxiety. All participants described the psychotherapist’s attitude as unobtrusive, affectionate, delicate and mindful; that was the only thing that engendered trust from the very beginning. Erna reports: “She treated me, us, the girls, in a very delicate way, and that brought me pleasure and a feeling of trust, belonging and self-value” .Maria described the psychotherapists’ attitude with a metaphor: “…step by step, slowly, Ema (the psychotherapist) came closer to us in steps of smoke” .Understanding, encouraging, and appreciating women’s efforts to participate in the group was a major part of the decision not to abandon the intervention program.For most of the women, the relation with the psychotherapist was the first model of another type of relationship which generated a new experience.For some women, the therapeutic relationship was the first experience of being accepted, valued and loved, which brought the light of hope into their life and motivated them to change: “and if Ema treated us with respect, dignity and patience – after all, this means love for the other – and I thought that if she (the therapist) wants to help me, a person I’d never met before, if God loves me, if the girls (the other participants in the group) agree to interchange […] that means that self-love exists and I have to find it and build it for me .The feelings and emotions engendered by the psychodrama techniques were powerful and diverse: both positive and negative, and experienced, more than a few times, as strange and odd.Ludic, psychomotor activation and mental imagery activities were perceived by the great majority of the participants as an antidote for anxiety and a way to facilitate self-confession: “…the initial relaxation games […] Yes, we were relieved and somehow we were able to open up more easily” . The connection with the present, with the “here and now” was another perceived effect of these activities, claims Ina: “there were little games and we focused effectively upon what happened here, and then negative outer things were left out there that moment...” . Moreover, they were among the first activities that allowed participants to access positive emotions: “an island of positive emotions, in a sea of negative emotions” .The Mirror, another technique perceived as being helpful and having an impact, stirred powerful positive emotions and new experiences. “…and I received so much... it helped me remember who I can be” .role-play and role-reversal. For most participants, role-play is a chance to work on resistances, thus making action and interaction possible: “…that role-play, the interplay with the others… whether you want it or not, you interact, you cannot avoid it…” . Other times, it enabled them to build new experiences, which generated contents and new positive emotions. “The great benefit here is the fact that it helped me understand and to keep the hope alive that not all men are like that, that somewhere there is a good man....” .The activities that are most frequently cited as having the largest impact, both in 2012 and 2017, are The most difficult and disturbing experiences were engendered by role-reversal. “Inversions, well, disturbed me and moved me a great deal, but they helped me for the future, for the years to come, to understand her (the mother) and become closer” .All women experienced the role of protagonist, that of auxiliary ego and the witness. The experience is described in terms such as “odd,” difficult, and engendering strong negative emotions. The women’s defenses and resistances were severely tested. Maria reports: “Emotions were very strong, sometimes I felt like quitting, although the voice of reason said that it was ok and there was a struggle between reason and sensibility, I was telling myself I’m not going there anymore, I can’t take any more of that pain...yet I continued to go, I came” . Another participant says: “It seemed weird to me the moment where my group colleague was, say, my mother or my daughter or my friend or my husband, the impact was large. There were moments when I cried, those when my hair stood on end, moments of very, very strong feelings” .After 5 years, most of the participants appreciate that the most impactful and beneficial experiences are still those engendered by role-reversals and role-playing. For many of them, those experiences led to an increase in emphatic capacity, to improving the ability to identify and express one’s own emotions and thoughts, to a change of perspective: “…they were some of the toughest moments (the inversions with mother), it’s hard to be in the other’s shoes and...Yet this is how I started to understand and later to accept!”.Concretization was perceived as being of great help in understanding the psychic and social realities participants were facing. The great majority recalled the activity in which the therapist concretized the cycle of violence. “The very moment I saw that circle enacted, the way violence kept repeating, I really understood what was happening to me” reports Diana (2012).future projection helped them experience their inner power: “I envisioned for myself the professional role I was going to have 5 years later. That was tough, but I managed to feel confident, capable and fulfilled,” says Mona (2012).A few participants told us about the way the activities using catharsis. If experienced, catharsis meant releasing and relief: “I felt liberated and so light” (Mona). Observing it as a witness led to fear and also to identification and a raw model of courage. As Maria describes: “…she had such a reaction... she got down on her belly and burst out sobbing. I got so shaken... I was also scared... how can I put it... that shook me deeply and eventually I was happy she could do that, and I couldn’t... because of so much that was shut up and restrained, I couldn’t manifest like that, although I was doing it in my heart” .Intense experiences sometimes led to how changes occurred in their lives, starting from the group experience.This theme offers an insider’s perspective of the process of change, as it was felt, experienced and explained by the study participants. It represents “the participants’ voice” which answers the question of Once they were “taken into care” by the therapist and as the group was organizing and becoming cohesive, and while they experienced trust, safety, respect and revaluation, women built a base for change.Breaking of silence presupposes overcoming shame and the courage to talk. “And when I saw the others in the group I thought ‘Oh, God’ how many women I see suffering and I thought: away with the shame, it’s no use, it just makes me sink more, I went deeper from where I wanted to get out, and acceptance intervened in time” . For all participants, telling their story of a life filled with violence not only means beating the shame, but is also a great act of courage and power. Those who succeeded became raw models for the others: “Their power (the colleagues’) helped me open up too…” .Breaking silence provides a feeling of releasing the pain, of relief. All participants had moments of releasing the negative emotions accumulated over time. “I remember that once I cried here, I also cried at home and all that crying made me feel good, all that pain... it takes out all the pain and I felt lighter the next day, stronger the third day, like when you get out of the morass and take a shower. Yes, that smell of mud doesn’t go away that easily and I felt lighter…” .Though participants became aware of the pattern conveyed during their childhood, the level of understanding and acceptance differs. One participant says: “I’ve got the awareness that this issue of self-mistrust and lack of forgiveness for myself actually came from my childhood... I don’t know and I didn’t even spend time thinking whether that caused my marriage failure... because... that would hurt a lot . Another was able to go deeper: “...and I realized while I was coming here (to the group) that I have to clean up inside myself so that things fall in place around me”. She goes on to say: “I understood and also accepted… that problems come from my childhood, from a bad family model, from a model of wife and mother which was handed down to me as being very important, it was the best my mother could do, what can I say...” .Sharing life stories enabled participants to identify and compare themselves with the other women. In most cases, this comparison led to the conclusion “I’m not the only one having problems”  and “my problems are not even as big as the others”’ . Those findings, and also the activities designed to activate inner resources and re-build self-image, engendered feelings of trust, hope, power and determination to make changes and go further: “…They would fill me with optimism, I mean look at them with their tough problems and they continue to fight, and they have such drive, they don’t let themselves be dragged down...” .Courage, as an inner resource activated by the group experience, figures in all participants’ remarks. “I had no idea of this courage inside myself […]When I came here I realized that was courage, I defined that myself, ultimately that is courage, no matter what...” . Courage and power occur together in all participants’ accounts.For the great majority, one of the greatest benefits of participation in the group proved to be power. Initially, the power to hold on, as in Erna’s case : “… it was like a rescue, as if I was receiving power, no matter what the theme of the session.” It was the power to fight and finally solve things and change. More participants understood that “if you have a problem, don’t hide it under the carpet, because it will come after you eventually, as it is not solved” . The power they have achieved allowed many participants to face reality, no matter how painful that would be, to accept and assume pro-active behavior: “I realized I wasn’t the only one who has problems, that others have problems too, but only facing the situations will help you make some changes in your life” . In other cases, the benefit came from the newly found capacity, practiced within the group, to see the situation from another perspective, which gives space for hope and trust that there are solutions: “Yes, and I saw it differently (the situation), not necessarily better, but as I could detach myself from it, it wasn’t mine anymore and thus I could see the solution.” .With one single exception, all participants who are mothers speak about changes in the relationship with their children. If the role of being a mother previously made them stay in the abusive relationship, a decision heavily influenced by the fear that they would not be able to raise the children on their own, this role later gave them power, strength and motivation to fight and change the way they related to their children. This was especially true after they became aware that the victim role had been handed down to them transgenerationally: “I realized that I gave my children a poor model of what it means to be a woman, wife, mother, as I took it from my mother or from generation to generation and I went into it in the wrong way, and I had to make a change… (Maria). Most of them initiated the change since the group intervention: “I started with my daughter… by beginning with small moments, with reverberations until you arrive at important life events, I applied these...” (Maria).In most cases, not only did the participants stop transmitting the victim model, but they also started to build and convey another model started to be built and delivered, one based on understanding, communication and expressed love, self-confidence and respect. Maria says: “I saw that if I love myself and respect my moment, the child will also respect that, and I felt good, she felt good, I had my moment, it was perfect both for me and for her” . Personal change generated changes in the way they related to their own children: “I feel the change in that I don’t want to be like her (mother), and […] my principle is to be closer to the children, to show them love, as this is what I missed” . Improved communication with self and others is also reflected in the quality of the relationship with the children: “This is what the group mostly taught me… to stop hiding. […] and now I try to talk as much as I can with him and with myself” .In one case, the relationship with the child stayed on the same coordinates after 5 years. In 2012, Mioara said: “I wished she (mother) could have understood this need to not live with an alcoholic father… but […] I am living the same issue in turn, I also have a girl, I am supposed to take care of her and her needs.” Five years later, she reports how she reproduces the model in which she was raised herself: “anyway I always had this aggressiveness, often uncontrolled, I beat her when it was hard for me…after that I felt sorry.”Most of the participants also made changes in the mother-daughter relationship. Most of the women in the group claim that the intervention helped them understand their mothers better. They understand their mothers were victims themselves: “…she also inherited it from grandmother (the role of victim) … that’s what she saw at home (violence).” In this way, they gave meaning to their mothers’ powerlessness to get out of the abusive relationship, and to protect them from experiencing the abuse. What helped most of them was: “To have the opportunity to speak to her (during the group activities), as I’ve never talked with my mother about certain aspects and pain, hers and mine...” (Mona). Another woman said: “I was able to put these issues (on the scene) so as not to bother me anymore” , and after 5 years she says she feels “this reconciliation… she has been trying to understand her and come to grips with what the situations were then” .Maria’s account describes the process of restructuring the relationship with her mother: “I managed 1 year after the group ended, by repeated trials... we both cried, we also fought… but the result was that I managed to talk to her and really discuss things”. The process was difficult, but “I was left with that (from the group), if it was hard for me to play her role for several minutes, she is the one who lives it, I wonder how she feels, how are things for her? And that helped me to keep going.” Nowadays, “it is not a very close relationship, yet we are not as far from one another as we were...it is a decent relationship, marked by peace, calm, and respect and... it’s a great achievement for me...” .In a single case, both women, mother and daughter, find themselves in the same vicious circle: “She still judges me for not being able to choose well. And I wonder who generated this entire situation? Isn’t that my mother? Somewhere, she was always wrong. Tolerance for alcohol; this is the mistake… and it is also mine. I took it over” .Participants progressed in different ways over the 5 years. To some, progress meant experiencing relations in which they faced the old patterns. Talking about the moment she made the decision and had the power to break out of the addictive relationship, Ina refers to the group experience: “I think that the moment people talk, as happened in the group, the brain registers it anyway, it keeps the information there and shows it when needed and then you react to this kind of thinking…” and she continues “… the moment he was aggressive to me, something broke inside” and “I could see my past, I could see my father or my grandfather in the past and what they did when they were drunk and I said NO” […] At present, her decision is to become independent and enter a relationship which is free from the past conditioning. “This is how I see things, it is good to go out with people you resonate with, yet don’t try to save them, I think I practically tried to save this guy (the lover), because I may have wanted to save my father, and I couldn’t…and there’s nothing there to save, if he doesn’t want to save himself, going there and trying is pointless…” .Maria, after a period of time spent by herself, had an 8-month relationship. “I’ve seen what it means to be loved, to be given things, to receive and not only to give, to be respected, I saw the effects of saying no, of setting limits, I saw that if I set some limits, he respects that, he doesn’t mind and even if he does mind he makes an effort to understand… I saw what it means to be treated with dignity” .During those 5 years, the other three participants made smaller changes in this role: Mona gave up a relation that did not fulfill her, Erna, although in a new relationship, feels that “he is a good man… yet I don’t know why I can’t be more involved,” and Paula, the only one who stayed with her husband, says after 5 years: “he’s better, I understand him better… I’m calmer… he still upsets me.” Yet Mioara, although she managed to leave her alcoholic and violent husband – “I told him it was over. I could make that difference” – entered another relationship, again with an abusive man who is also an alcohol addict: “I am aware of the fact that I slipped into the old pattern again and I ended up, maybe without realizing it, by taking back that door mat” .where the participants arrived 5 years after the group work ended and what significance they assign to the group psychodrama intervention.This theme describes During the 5-year period, all the participants faced having to make important decisions. For most of them, the first and most important decision was to stop being a victim; it was a decision they had made 5 years ago, during the group intervention. As Maria (2017) asserts, “I won’t be a Cinderella again! Because a woman, I’ve learned, wasn’t born to be a Cinderella. She was born to be respectable, to be loved, to love, to stand up, to live with dignity, not covered in ashes.”Some of the women decided to separate from the abusing partner, others decided to try a new relationship, yet others decided to re-evaluate their social relations and to enjoy having new people around. For two of the participants, the social network is being re-structured after 5 years. While Ina considers that changing her social network is a consequence of growing up: “…I think it is normal, in one’s thirties to have other interests and another circle of friends” , to Maria, the whole restructuring of the social network was a part of the long and difficult process of change: “After the experience I had (of victimhood) and all that I’ve learned in this group, I decided to leave everything behind me, to clean up my life, to get rid of toxic people, false friends and... to start a new life.”They all report that their decisions in the professional sphere led to better jobs. For some participants, success in their career became one of their greatest achievements as well as one of their greatest resources . Mona claims: “I’ve learned to have courage to want more; because I am competent. I am now just where I wanted to be (a psychologist)” . For Mioara, the job is the same challenge as it was 5 years earlier: she can’t stay longer in one place, so she leaves.Participants had to make important decisions concerning where they live. Some of them changed their living place: Maria made a radical decision and moved to the countryside, 80 km away from her old home, starting a new life, while Mona started building her own business.For two of the participants, the group experience meant the beginning of a transformation they perceive as fundamental. In 2012, Ina found herself in an addictive relationship with a man whom she also worked with, and she feared being on her own, while in 2017 she claims: “…I want to say that I have a completely different life right now […] I’m organizing things on my own, I’m not expecting a man’s help, I mean I can do it and I’m not afraid anymore to do it alone.” Her plans for the future are: “Well, I even have starting my own business in mind.” Maria defines herself by the progress she made: “…starting from here, from the group, I raised myself and the rest came… like with dominoes: dignity, then power, then I found out what it means to be respected by those around me, because when I respect myself and feel worthy of love, I really am loved and respected […] I am aware now that I am a valuable woman.” And she continues: “yes, I am a happy woman…it’s not about an ideal happiness, it’s about living your daily life beautifully” .For three other women, those 5 years, despite certain difficulties, also meant development, growth. While before the group intervention, Paula described herself as being: “...kind of introverted, I used to torment myself inside… and I revolted,” afterward she says: “now I’ve learned to be myself first of all, so that they may also see me as I am […] more communicative and I can say what I feel…”. Mona also talks about trust, authenticity and the courage to make decisions and accept the results: “I started to grow even then (during the group period). Now I have trust and courage and power to do things.”Erna (2012) described herself as: “generally pessimistic, disappointed in myself because of the failures I’ve had…”. Concerning the group experience, she says: “I think I’ve woken up…it finished too soon for me, I think I would have needed more time...I felt like I climbed up the stairs, even if I immediately add that I haven’t solved everything… yet I feel this growth...”. When referring to the last 5 years, Erna says that: “I could even boast by saying that when I was hopeless or I thought I couldn’t make it anymore or that it was too much and too difficult, I remembered those times (the group) when I had such drive and trust...” .Only one participant reports that after 5 years things are worse than before. “I hurried up toward something else, I walked on the same pattern…and I couldn’t take it anymore... so I went lower... .” She has remained the prisoner of old patterns.When asked to summarize the group psychodrama intervention experience in a few words, all participants, no matter what their journey during the last 5 years was like, talked about getting help and the feeling of not being alone anymore: “It has helped me a lot to understand that I was not the only one who has troubles ”; they also mentioned trust, safety, power and hope.The significance they found in the group psychodrama experience refers to the traces, deep or less so, left in every participant’s life and destiny. To Erna, “it was like a ray of light, I held on to something, I became more aware of certain issues.”For Ina, it was “a part of evolution… of releasing my inner demons.” Maria speaks about the way in which, through the psychodrama experience: “I have built myself, I’ve got rich…, I’ve finally made that jump on the trampoline, I was able to evolve, to get up and see the world…, and it’s so beautiful, seen from above, because if one stays in the dust, they think that’s normal, being in the dust.” Most participants feel something that Erna (2017) best articulates: “I really thank God I’ve got that chance.”Contrary to our expectations, the findings from the questionnaires administered at the end of the psychodrama intervention program show no significant difference between the experimental and the control group as regards spontaneity, and differences that reached only marginal statistical significance for wellbeing.However, the findings show a positive trend of improvement for both samples, indicating that both psychodrama and ecological interventions are able to support abused women in their recovery process. In the psychodrama group, quantitative results show that participants experienced a decrease in symptoms and problems , a reduction in risk behaviors (Non-risk items), and an improvement in wellbeing . Building on this basis, the qualitative findings are meant to offer an insider’s view into the perceived impact of the psychodrama intervention program focusing on empowerment.This study is innovative in the following respects: first, it is a longitudinal long-term follow-up of an intervention designed to offer psycho-social support to victims of gender violence; second, it provides an insider’s view and in-depth analysis of the change process stimulated by an empowering-oriented psychodrama intervention program; third, it proposes a three-path process of change typology.where the women started their recovery (from the victim role), what was helpful , how change occurred and where the participants are now in their lives (5 years from the psychodrama group intervention), as a corollary of change.The findings shed light on With only one exception, all participants have “families haunted by violence” , p. 70 aFor all participants, the idea of participating in a group was accompanied by anxiety, shame and lack of trust. All of them had difficulty receiving help , a commoAll women acknowledged the key role played by the therapeutic alliance in helping them to begin developing a sense of trust and safety. The need for a gentle touch  reportedFor all women, the psychodrama group experience offered a “culture of non-condemnation and non-blame” , p. 6, wThe findings indicate that the psychodrama therapist fulfilled the function of containing double  and mirrSome of the women appreciated the positive impact of the empowering mirror in regaining the feeling of personal value, just as psychodrama literature emphasizes the role of the mirror in activating the observing self , challenThe psychodrama techniques which were appreciated by the participants as having the greatest impact were role reversal and role playing. Role playing, an expression of the holistic person, one of the mechanisms of change , was higRole play leads to the development of autonomy : from beRole reversal was considered by all the abused women to be the most difficult experience. In some cases, it generated an intense emotional catharsis. Women in the psychodrama group experienced both facets of this catharsis, its healing power and potential for re-traumatization, which is acknowledged in the literature on abuse . This riRole reversal was what helped participants gain insights and activated their spontaneity, flexibility and creativity, leading eventually to a perceptive decentering and the possibility of creating new roles. Most of the women gained a significantly better understanding of the other, and a better understanding of themselves. According to The encounter technique allowed the participants to experience the tele in the psychodrama group to train their empathy  and to dTo conclude, we could say that psychodrama, as an action method, has the potential to stimulate action in women’s lives and initiate adaptive coping strategies leading to resilience. This is consistent with Our findings show that the participants’ path after the end of the psychodrama group intervention was neither linear nor quiet. Moreno explains that conserving an old role, such as the victim role, might have inhibited change, but simultaneously provided a sense of stability and security. A warming up phase thus stimulates a spontaneity state (status nascendi), necessary for the development of new, creative solutions (creative phase) . SchachtOn the other hand, Thus, our in-depth analysis of women’s starting points – the victim role, change processes and outcomes over 5 years – indicated that change takes place along three paths, which differ according to the type of change in the victim role and the victim’s resilience. These paths are the basis for our proposed typology:(1)Proactive – Resilient type : shows high resilience, feels inner strength and self-esteem (re)gained, acts based on her own initiative, makes decisions, proposes and makes changes in her own life, has sufficient determination to create favorable contexts and to act toward achieving own goals; over time, she rebuilds her role as a partner, mother and daughter. Self-perception changes significantly, it is reinvented; the reconstruction of identity can be the crowning achievement of this change. Is aware of the victim model and transmission pattern and has the power to put an end to the trans-generational transmission.(2)Active – Resistant type : although this type shows resilience, the strength in fighting the problems of life prevails; the woman comes into contact with her inner strength, improves her self-image, is active, shows improvement in some areas of psychological and social functioning; enacts some changes in her personal life; can enact changes in some roles – as mother and daughter, for instance – and makes adjustments in her role as partner. Has a vacillating evolution with possible stagnation or even relapse. Has some awareness of the victim model and its transmission pattern, may put an end to the trans-generational transmission.(3)Repetitive – Non-resilient type (fr. desilience) (Mioara): no substantial changes in the role of partner, mother, daughter; continues to perceive human relationships in the form of submission and dependency; on a personal level, has feelings of desperation and alienation; has a high risk of seeking refuge in religious cults/groups. Has some awareness of the victim model and transmission pattern but cannot put an end to it and preserves her main role as a victim.If we agree that resilience is a dynamic process , we agreThe typology presented here is based on data from 6 abused women and is valid for this sample. It offers a framework for understanding the change path and can be useful in calibrating intervention services to reflect the characteristics of each type. However, we can make claims to generalizability, and further research is needed to verify this typology.Another limit is the small convenience sample, where participants were assigned to the experimental and control groups on a voluntary basis, rather than randomly. Thus, it is possible that participants volunteering for the experimental group were more resilient and open to change, or in another phase of their healing process. Also, the possibility that several of the reported effects occurred by chance cannot be ruled out.Follow-up was possible for only one of the two psychodrama groups, consisting of women living at home. Exploring the experiences of sheltered women could emphasize different aspects. In addition, women participating in the control group could not be tracked and there are no follow-up data for this group.To conclude, this study does not aim to be representative, as its main objective is to explore processes in-depth and find meanings.The study sought to demonstrate the value of psychodrama in working with abused women and show how methods and techniques can empower them and stimulate changes in their victim role.In working with women victims of abuse, the therapeutic relationship is fundamental to the intervention, and must be built slowly and gently to develop a sense of trust and safety. In addition, the psychodramatist must be aware and careful when assuming the roles of double and mirror for the abused women. The psychodrama psychotherapist has an active and proactive role, avoids a neutral approach and favors a direct, authentic human relationship experience that can be configured as positive. Our findings indicate that the good therapeutic relationship entailed a balanced activation of the three functions named by The most helpful techniques in changing the victim role were role reversal, role playing, empowering mirror and concretization. The women who showed the greatest change after 5 years considered that role reversal was the most impactful experience and helped them initiate the changes they made. On the other hand, all participants perceived role reversal as being the most difficult experience, which draws attention to the risk of re-traumatization. We recommend that it be used carefully, mindful of both its benefits and risks: its ability to activate the spontaneity and creativity needed to create new roles, and the danger that it can re-traumatize.trans-generational transmission; the Repetitive – Non-resilient type, with no substantial changes in roles, remains caught in the victim pattern. As women can navigate from one category to another, services should be calibrated accordingly.We could say that psychodrama, as an action method, has the potential to stimulate action in women’s lives and initiate adaptive coping strategies leading to resilience. We identified three paths or directions of change for women who participated in an empowering-oriented psychodrama intervention program. On the basis of these paths, we propose a typology: the Proactive – Resilient type shows high resilience, significant changes in roles and is capable of ending the trans-generational transmission of the victim role; the Active – Resistant type can enact changes in some roles and may put an end to the Our findings allow us to suggest that specialists and providers of assisted resilience to victims of gender violence can build trust and safety, a nurturing and caring attitude, and activate intra-psychic strengths and empowerment by using role-play in a secure environment to practice new, feared or wished roles. Therapists working with abused women, either in groups or as individuals, can use psychodrama techniques such as empowering mirror, validating mirror, containing double, concretization, role-play and role-reversal.To minimize the risk of re-traumatization, professionals should consider an empowering-oriented psychodrama model in the initial phases of working with abused women, until they are strong enough and prepared for psychodrama therapy. In addition, it is essential that therapists respond to women’s need for safety and comfort through warm-up activities (which reduce anxiety) and sharing, as well as the need for predictability through the session structure and ritual activities.Among its strengths, this study provides an insider’s view into the process of change experienced by women participating in a psychodrama intervention program and proposes a three-path typology of the change process. While no claims to generalizability can be made, future research could verify this typology.trans-generational pattern.Including psychodrama among the psycho-social services offered to abused women can be a valuable contribution, especially as regards empowerment, role-reconstruction and interruption of the The 2011–2012 Empower Daphne Project was carried out in accordance with guidelines of the University of Padova Scientific and Ethics Committee. The protocol was approved by the University of Padova Department of Applied Psychology Scientific and Ethics Committee in 2010. All subjects gave their written consent in accordance with the Declaration of Helsinki.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Achieving a desirable death is an urgent aging-related problem in Japan. However, measures of the quality of death and dying in Japan are lacking. This study aimed to identify components of a desirable death in the residents of Kagawa prefecture, Japan, through focus group interviews.Mage = 50.9, SD = 22.1 years; 43.3% ≥ 65 years; 40.0% unemployed) who had experienced the death of a closely associated person. Participants were grouped into four generations with diverse characteristics . The interview lasted 1–2 h and involved one interviewer, one observer, and one recorder. The interview theme was “What is a desirable death?” Participants were asked “What do you want to achieve before you die?” or “What would a close friend want to experience when death is near?” We then extracted important items related to “desirable death” using serialization and observation records, while also consulting three analysts. The analysis results of the four generations were ultimately integrated into final categories.A group interview was conducted with 30 residents aged 20–80 (The most common experience of a familiar death was that of parents, followed by grandparents. Half of participants had witnessed the death. Through category analysis, eight important categories related to desirable death were ultimately extracted. Nine items were identified as common to all generations. While the elderly generation had wide-ranging opinions, the younger generations’ opinions tended to concentrate on satisfaction with life and family relations.Eight concepts were extracted as important factors of a desirable death from the residents of Kagawa prefecture, Japan. The quality of dying and/or death (QOD) refers to a dying person’s views on what constitutes a “desirable death.” It is important to understand people’s views on what constitute the components of a desirable death. Patrick et al.  reportedThe Economist, a UK-based magazine, announced worldwide rankings in the 2015 Quality of Death Index [Research on QOD began in the USA around 1980 –5 and hath Index , 11 was th Index , 13. TheFocusing on this topic, we recognized the need to develop a scale that could be used to consider QOD when death is approaching. Although it is important for bereaved families to evaluate patients’ QOD, it is also necessary to prepare in advance of them reaching the end of life by knowing the conditions for people to achieve a desirable death.Therefore, as a pilot study, we undertook to extract important elements of desirable death from interview surveys divided by age groups in small-scale community panels.We used a focus group interview to identify the attributes of a desirable death. This is a common data collection technique for exploratory qualitative studies to generate hypotheses and provide rich descriptive information about a phenomenon , 15. ResThe study included men and women aged 20–80 years dwelling in communities in Kagawa from March to February 2017. A group interview was conducted for a total of 30 people divided into four generations: (1) 20–29 years old, (2) 30–39 years old, (3) 40–59 years old, and (4) 65–80 years old. We did not use random sampling as our study focused primarily on obtaining meaningful and broad qualitative information from many cases, rather than sourcing quantitative data from a sample representative of the general population. To obtain deeper and wider information on the subject of “what is a desirable death,” we asked the welfare commissioner and public health nurses in the municipality, who are familiar with the area, to assist with the recruitment, and we gathered local residents of five areas. We recruited participants who were local residents; had diverse backgrounds in terms of age, gender, occupation, residential area, and care environment; were familiar with cases related to the theme; and were able to clearly discuss these cases. Before being interviewed, participants were informed of the contents of the study and provided written consent.The focus group interview guide is shown in Table We asked focus group participants to discuss their experiences with the deaths of family members, friends, or patients and to reflect on what made those deaths good or bad. When necessary, we asked probing questions to clarify a comment or obtain more detail .The following techniques were used to analyze the focus group interviews. Multiple analysts performed the same task, discussed similarities and differences, collaboratively developed the most objective explanations, and reached consensus on the important categories. In the analysis, important items related to a “desirable death” were extracted using serialization of words and observation records while consulting with three analysts, and the important categories were organized. The items and categories extracted from the five groups were ultimately integrated to identify the final categories , 19.The concrete steps of the primary analysis were as follows: prepare a verbatim record of the interview, extract the content related to a “desirable death” interview item, and then summarize and code that content. In addition to the verbatim transcripts generated from the electronic audio records, we considered participants’ response to the sequential observation record, and important items (words) reflecting QOD were extracted while being confirmed by the analysts. The secondary analysis focused on identifying similarities in important items  obtained through the primary analysis and subcategorizing them. These subcategories were further categorized, and important categories were extracted. In the tertiary analysis, important items and important categories of each group were integrated, and common points and differences according to generation were examined . Through these processes, the final important categories were extracted. The analysis was performed by three analysts, who discussed all common points and differences, and decided on important categories through consensus.Informed consent was obtained from the participants. In addition, this study was approved by the Ethics Committee of Kagawa University Faculty of Medicine and Graduate School of Medicine .Mage = 51 years, SD = 22.1 years), 73% were women, 43% were 65 years old or older, and 40% were unemployed. The most frequently mentioned experience of death of a familiar person referred to parents, followed by grandparents. Half of the participants had witnessed the person dying.The characteristics of the study participants are shown in Table Regarding category analysis, 53 important items were extracted via the primary analysis. The secondary analysis produced 19 subcategories. In the tertiary analysis, eight important final categories were extracted ,” “having no regrets,” “not being a burden to family members,” “good relationship with family of nursing care,” “being free from physical distress,” “being free from emotional distress,” “being able to stay at one’s favorite place,” and “family present at the deathbed” Table .In this research, we conducted an interview survey with Japanese residents and extracted factors related to a desirable death. The first major contribution of this study is that it explored the raw opinions of local residents using a focus group interview. This addresses gaps in past research, which primarily used the QODD (which contains questions that are not suitable for Japanese people) and GDI . We found that the contents of the important categories were almost the same as those of previous studies in Japan, but differences were found in the following points. Compared to Miyashita et al.’s  GDI, newThe second major contribution of this study was that by conducting a wide range of interview surveys by age, we were able to clarify the generational factors. Nine items in this study spanned all generations. Miyashita et al.’s  survey oRegarding characteristics related to age, the opinions of the elderly generation were multifaceted and referred to specific diseases, treatment, physical condition, psychological state, family relationship, preparation for death, and physical environment. Participants in their twenties and thirties, on the other hand, focused on psychological conditions such as “satisfaction with life” and “acceptance of death” and family relations such as “how to spend time with family” and “sense of burden of nursing care.”This study has some limitations. First, since a focus group interview was used, the sample size was naturally small. Second, because the study area was limited, we cannot make inferences about regional differences in our results. Given both of these factors, the sample cannot be considered representative of the general Japanese population . TherefoEight concepts were extracted as important factors of a desirable death identified by members of the general Japanese population: (1) preparation for death, (2) satisfaction with life, (3) reliable medical environment, (4) good family relationship, (5) independence for oneself, (6) physical and psychological distress, (7) dying in a favorite place, and (8) attending the deathbed.


However, their meaning and scope as scholarly metrics is still far from being grasped. This research seeks to shift focus from the consideration of social media metrics around science as mere indicators confined to the analysis of the use and visibility of publications on social media to their consideration as metrics of interaction and circulation of scientific knowledge across different communities of attention, and particularly as metrics that can also be used to characterize these communities. Although recent research efforts have proposed tentative typologies of social media users, no study has empirically examined the full range of Twitter user’s behavior within Twitter and disclosed the latent dimensions in which activity on Twitter around science can be classified. To do so, we draw on the overall activity of social media users on Twitter interacting with research objects collected from the Altmetic.com database. Data from over 1.3 million unique users, accounting for over 14 million tweets to scientific publications, is analyzed. Based on an exploratory and confirmatory factor analysis, four latent dimensions are identified: ‘Science Engagement’, ‘Social Media Capital’, ‘Social Media Activity’ and ‘Science Focus’. Evidence on the predominant type of users by each of the four dimensions is provided by means of VOSviewer term maps of Twitter profile descriptions. This research breaks new ground for the systematic analysis and characterization of social media users’ activity around science. Accordingly, an oblimin oblique rotation was performed such that the number of metrics with high loadings was minimized making the factor easily interpretable [For data analysis, the authors used three analytical approaches described below. First, an Exploratory Factor Analysis (EFA) was conducted using Principal Component Analysis (PCA) for factor extraction. EFA aims to study the underlying latent structure of correlations among a set of variables. In this work, EFA allows grouping metrics that measure similar characteristics into dimensions based on the interrelations among them. Seeing that some variables differ in scale, the analysis is run based on the correlation matrix (i.e. standardized covariances). As some metrics, such as those referring to the interaction with scholarly outputs  reflects that there is no one-size-fits-all user’s behavioral pattern. For instance, the ptws to papers is on average 1.62% and on median 0.20% by user, which implies that interacting with scholarly outputs represents, on average, a very small share of a user’s activity on Twitter.tws, otw, tws hash, and ptw). Predictably, the overall activity on Twitter (tweets) is relatively high and positively correlated with the number of followers, and especially, likes given (ρ = 0.684). Likewise, there is high negative correlation between tweets and ptws to papers (ρ = -0.854) and, to a lesser extent, between ptws to papers and likes given (ρ = -0.593), indicating that users who are very active on Twitter do not focus their tweeting activity primarily on sharing scholarly papers. In other words, this suggests that highly active users use this social media platform for a larger number of purposes other than tweeting research objects.The Spearman’s Rho correlations showed in An EFA was applied to disentangle the underlying latent structure on which Twitter users’ metrics revolve. Results are displayed in , which relates to what can be categorized as ‘Science Engagement’ because it reflects to what extent sharing science-related material characterizes users’ Twitter activity. Factor 2 explained 15.7% of the total variance and grouped two indicators , which can be categorized as ‘Social Media Activity’ as it relates to what users share and what they pay attention to. Factor 3 accounted for 10% of the variance and grouped three indicators , which mirror the ‘Social Media Capital’ attained by users. It is worth noting here that listed count also shows an appreciable loading on the ‘Social Media Activity’ dimension. Although the prominent feature of lists is bringing together users with some kind of proximity , this metric also reflects that the more active a user is on Twitter, the more likely it is that they create or join other users’ lists. Apart from this, dimensions are fairly robust since there are no other cross-loadings (e.g. metrics that load ≥ 0.32 on two or more factors) [average title length, share of tweets to papers, avg days to tweet pub), which reflect what can be categorized as ‘Science Focus’.Factor 1 accounted for 27.4% of the variance comprising four Twitter metrics factors) . Lastly,tws, p tw, ptws to papers).Furthermore, correlations between the four dimensions are also shown in the bottom of To assess the validity of the four latent dimensions found through EFA, a CFA was performed. CFA tests if the hypothesized model is consistent with the actual data. Rather than making a dichotomous decision on the validity of the model, the CFA is intended to explore if the structure model gives a reasonable fit given the interdependence of several metrics from the number of tweets and the fact that interacting with scholarly outputs accounts for a very small share of users’ behavior on Twitter. Errors were included in the model along with some correlations among them based on large modification indices.χ2 test is significant (p = 0.0008), which would suggest that the model does not fit the data. However, it is well-known that this test is very sensitive to the sample size, and significant results can be found despite actual differences being negligible [Goodness-of-fit indices are provided in gligible . Absolutgligible . These igligible . Hu and gligible  suggest To reveal the predominant type of users using the four latent dimensions, we draw on the user’s profile description. To do so, profile descriptions from 200,000 random Twitter accounts  and factor scores for each dimension were used. Terms in the VOSviewer maps are placed in such a way that the distance between any pair of terms reflects their similarity in terms of co-occurrence. In other words, the proximity between terms indicates that the profiles are characterized by the same terms and represent a particular community of tweeters. The size of the nodes reflects the frequency of words and the thickness of the edges relate to how often the words appear together. A threshold of 200 occurrences was set for the terms, resulting in a total of 211 terms. For the sake of visualization, those terms accounting for over 60% of the occurrences were finally retained . personal description).Cluster 1 (red cluster) is formed by words such as ‘mother’, ‘lover’, ‘love’, ‘life’, ‘fan’, ‘husband’ or ‘soul,’ which reveal tweeters who set forth their private and personal life in their profile (opinions and own position).Cluster 2 (yellow cluster) is comprised by terms that underline the expression of a user’s own opinions and views. Few words concentrate most of occurrences: ‘view’, ‘opinion’, ‘tweet’, ‘endorsement’ and ‘mine’ (academic role).Cluster 3 (green cluster) includes words that belong to the academic and scientific community: ‘university’, ‘department’, ‘researcher’, ‘development’, ‘director’, ‘lecturer’ or ‘PhD student’ (business and practice role).Cluster 4 (blue cluster) is formed by words that refer to the professional role of tweeters, but in this case seems to be more connected with firms and professional practice. It includes words such as ‘organization’, ‘business’, ‘community’, ‘practice’, ‘service’, ‘client’ or ‘solution’  stand out in the ‘Science Focus’ and ‘Science Engagement’ dimensions. In the latter dimension, users that describe themselves as opinion holders (Cluster 2) also show high values and greater ‘Social Media Activity'. This is consistent for both groups with what would be expected from the claims of their profiles. On the other hand, users who refer to their personal and private life (Cluster 1) in their description are unmistakably characterized by their high ‘Social Media Activity’. However, those who allude to their business and professional practice (Cluster 4) demonstrate the most heterogeneous behavioural pattern, even though they relatively stand out for their ‘Social Media Capital’ and ‘Science Focus'.social media studies of science  [The findings presented in this research are framed around the idea of developing a second generation of social media metrics, focused on characterizing the different social media communities of attention around science and their activities and interactions around scientific results. This work contributes to pave the way for reconciling ‘altmetric’ and bibliometric approaches in what can be seen as a broader perspective of objects) , 16. Somobjects)  by studyobjects) , which mobjects) . These dfour dimensions of Twitter metrics around science. These four dimensions of secondary Twitter metrics cover the frequency of tweeting, both regarding the general activity of users in the social media realm  and their specific activity around science (‘Science Focus’ and ‘Science Engagement’). Regarding the latter, whereas ‘Science Engagement’ may be understood as the quantitative side of engagement by users in science, ‘Science Focus’ provides a much more nuanced insight that mirrors the overall tweeters involvement in science related issues. Finally, the number of followers, followees, and lists  can be seen through the lens of social capital theory [The large-scale analysis of tweeters interacting with scholarly outputs has disclosed l theory , 46, as l theory  (p. 250)personal description); tweeters who describe themselves as opinion holders and show a certain degree of engagement and activity (opinions and own position); tweeters who belong to the academic realm and are notable for their high science focus and engagement (academic role); and tweeters who refer to their professional role and show a more balanced pattern of use and relatively high social media capital (business and practice dimension).On the other hand, term maps based on users’ profile descriptions and the factor scores have enabled the authors to outline the type of users that stand out in each dimension. Four separated clusters of users’ terms have been found, which are aligned with previous results studying scholarly tweeters’ descriptions : Tweeterbottom-up perspective. For instance, one might be interested in identifying potential opinion leaders acting as influencers or science brokers . These could be operationalized as tweeters with at least medium levels of ‘Science Focus’ and well-established ‘Social Media Capital’. Science brokers would expect to devote a significant proportion of their tweeting activity to research objects, reducing the time between the publication of the paper and the first tweets, and share research articles with interesting findings. Here, there is also room for expanding the outreach of users, for instance, by distinguishing between local and global science brokers by utilizing followers’ time zone information as previously suggested by Kwak et al. [Revealing the four dimensions of secondary Twitter metrics as described in this paper allows tracing the communities of users around science within the complete Twittersphere. Given the great variety of patterns and behaviors of Twitter users’ activities, the authors did not consider clustering users according to the overall range of activities and interactions as a feasible and grounded approach in the quest for a unified range of typologies. Rather, the identification of communities of users around science based on the four dimensions of metrics depicted here can be approached from a k et al. .Profile descriptions are also an appealing source for outlining the potential communities of users by providing hints on the background and professional activity of users. In this research, the authors have drawn on this information to complement our main empirical findings, rather than to rely primarily on the self-presentation users have chosen to provide online. Given the general scope of Twitter and the array of impressions that one user may give on Twitter, a professional role does not necessarily have to be the primary one given in the social media realm. In fact, even when a user believes they are tweeting in a professional manner, readers of their tweets may not agree . Expandifour dimensions of metrics around science presented here may support other approaches for exploring the traces of societal impact of research, such as focusing on the engagement among researchers through case studies [The step towards the second generation of social media metrics fits within the paradigm change that is taking place in the larger scientometric community; impact can no longer be measured solely in scientific terms (e.g. citations), but must include other factors including societal, environmental, political, health, and economic impact , 53. The studies . In facttertiary forms of altmetrics; which, conceptually speaking, would refer to the combination of both primary and secondary social media metrics . A potential example of this third generation of social media metrics would be the number (or share) of tweets of a publication that come only from tweeters with high social media capital. In this example, the primary metric is the number of tweets of the publication, and the secondary metric is the number of followers used to characterize the social media capital of the tweeters.Moreover, further conceptual discussions would also suggest the existence of In any case, there is still a long way ahead for the potential use of social media metrics as supporting tools in research evaluation contexts. The need for a sound definition of altmetrics based on the understanding of the processes leading to societal impact remains a crucial goal , 53, 54.This research has some limitations which suggest avenues for future research. First, the metrics interrelated structure and, especially, the typology of users around science may differ across geographical areas, languages, and for particular kind of users (e.g. verified profiles). Second, the dataset comprises Twitter users which have posted at least one ‘tweet’ mentioning a scholarly output from August 2011. To avoid a bias representation of their Twitter activity, users with previous activity were excluded from the study. These early adopter users may perform differently on Twitter. Third, given the current emerging state of the second generation of social media metrics, new indicators are needed to expand the potential of these metrics as traces of societal impact such as those referring to the actual discussion generated on the Twitter community around scholarly outputs . Therefore, upcoming research dealing with the second generation of Twitter metrics should cross-validate the underlying structure on another sample and explore if the four dimensions of Twitter metrics around science remain stable when other metrics, languages, datasets, and geographical areas are considered.