Role-playing interventions in adult psychotherapy: a systematic review of clinical applications, reported outcomes, and future directions

Background: Role-playing has been employed across diverse psychotherapeutic traditions, yet no comprehensive synthesis has examined contemporary applications with adult populations and analyzed which theoretical orientations have reported beneficial or positive outcomes and under what implementation modalities. Objective: This systematic review with narrative synthesis aimed to summarize empirical evidence (2015-2025) on the use of role-playing in adult psychotherapy, examining implementation patterns (clinical populations, design and duration, descriptions of role-playing procedures), therapeutic outcomes, and emerging trends across theoretical frameworks. Methods: Following PRISMA 2020 guidelines, a systematic search was conducted in PubMed, PsycINFO, Scopus, and Web of Science for empirical studies published between January 2015 and May 2025. Eligible studies included adults (≥18 years) receiving psychotherapeutic interventions that incorporated role-playing or related enactment techniques (e.g., psychodrama, empty-chair technique, behavioral rehearsal), defined as therapeutic interventions in which the therapist assigns and guides the enactment of roles to foster psychological change. Results: Twenty-six studies met the inclusion criteria. Most (≈77-80%) adopted psychodramatic frameworks, primarily in group settings (73%), addressing conditions such as depression, trauma, substance use, chronic illness, dementia, fibromyalgia, infertility, and complicated grief. Across studies, consistent improvements were observed in symptom reduction, emotional regulation, interpersonal functioning, and empowerment, with preliminary evidence for psychophysiological changes (e.g., cortisol reduction, neural connectivity). Role-playing was most frequently conceptualized within psychodramatic or experiential models, but promising integrative applications combined psychodrama with cognitive-behavioral, emotion-focused, and person-centered approaches. Conclusion: Findings from this review suggest promising but preliminary evidence regarding the use of role-playing as a flexible and theoretically versatile intervention that can be adapted across clinical populations and orientations. Considering its reported beneficial effects across diverse clinical contexts, there is substantial potential for other therapeutic approaches to systematically integrate and investigate role-playing within their own theoretical frameworks. Future studies should therefore explore how role-playing can be used in different models of psychotherapy, employ rigorous designs, standardized outcome measures, and longitudinal assessments, and examine both in-session and out-of-session enactments to clarify processes of change and long-term effects.