Abstract
Many health researchers have started to see the benefits of partnering with playwrights to use theater as a tool to analyze and present complex findings. Such projects about mental health, however, remain few and far between and are especially fraught. This article argues that research-based theater can be an ideal tool for exploring and sharing counter-hegemonic “mad stories”—especially if the plays created can help interrupt, among other things, problematic biomedical narratives about individualized approaches to supporting those who are suffering. This article also incorporates excerpts from the script the author wrote as part of her doctoral thesis project about military trauma to highlight how, guided by mad theory and mad aesthetics, she has creatively woven some of the weightiest ethical conundrums encountered during the research and development process into the play itself, so that, their nuance and magnitude become a critical component of the story being presented.
The above is an excerpt from a play I wrote—titled “The Space in Between”: A research-based play about military trauma, moral injury, and transition—for my doctoral dissertation project. This short scene is based on a real-life conversation that took place between myself and Dr Bonnie Burstow who served as my doctoral supervisor until her death in January 2020. It also represents only one of several thorny ethical issues I encountered while engaging in this project for which I employed a mad studies framework while working closely with nine veterans of the Canadian Armed Forces to transform their narratives about military trauma, moral injury, and the transition from military to civilian life into a piece of research-based theater. This example also represents one of several ways I incorporated these ethical conundrums into the play itself.
I knew going into this project working with (what Research Ethics Boards refer to as) “vulnerable” participants about sensitive subject matter, that professional and institutional ethical challenges were likely to arise during the research and development stages. However other “every day” ethical gray zones—such as the example referenced in the scene above, took me by surprise and visit me still.
The research upon which this play is based was guided by the question: “what is military trauma, really?” and explored aspects of military trauma that fall outside the realm of psychiatry and the diagnostic category Post-Traumatic Stress Disorder (PTSD). The primary underlying assumption behind this question and the project itself is that biomedical, individualized psychiatric approaches to framing and “treating” military trauma fall-short. I sought instead to frame military trauma as a phenomenon rather than a mental illness and wondered what complex (gendered, philosophical, moral) aspects of it might come to light if it were to be explored through art and in community. Through the use of research-based theater and a particular “mad aesthetic,” my work moves beyond critiques of hegemonic approaches to framing military trauma and offers a creative and consciousness-raising alternative to helping suffering veterans.
In recent years, many health researchers have started to see the value in partnering with artists and playwrights to use theater as a tool to analyze and present research findings, and have embraced research-based theater as a unique way to engage audience members emotionally and intellectually so as to leave them grappling with difficult questions instead of placated by tidy resolutions (Boydell et al., 2012; Fraser & Al Sayah, 2011; Gray & Kontos, 2015; Kontos & Naglie, 2006; Rossiter, 2012; Rossiter et al., 2008). Research-based theater projects about mental health, however, remain few and far between and are distinctly fraught. In this article I will argue that research-based theater is an especially fitting medium for analyzing, representing and sharing “mad” stories. I will incorporate excerpts from The Space in Between to highlight how I have been guided by mad theory to creatively weave some of the weightiest ethical conundrums encountered during the research and development phases of the project into the play itself so that their nuance and magnitude become a key component of the story being presented.
Specifically, this article explores the following question: Is the artist-researcher’s ethical obligation to the critical data being uncovered and represented less or more important than their ethical obligation to “vulnerable” participants? When it comes to the mental health system, might the presentation of such critiques be part of the researcher-playwright’s ethical obligation to vulnerable participants? Put otherwise, is it ethical for a play to raise the very real problems with the psychiatric system in an era where no/few viable alternatives exist? If so, how might a mad studies framework and mad aesthetic in theatre assist in this process?
Given that this play has not yet been produced, this article focuses on ethical issues surrounding the interview and playwriting process. Specifically, I offer suggestions on (a) crafting interview questions (designed to lead to play-creation) that are critical in nature but not alienating for participants who may be attached to/grateful for the psychiatric diagnoses and related treatment they have received and (b) How mad theory and a mad aesthetic can help research-based plays about “mental illness” transcend “personal experiences of madness . . . into a critique of systems, institutions, and dominant practices and beliefs” (Reid, 2019, p. 64) so that we can move beyond ideas of individual pathology and explore community-based approaches to helping those who are struggling.
Ethical Tensions: Project Design
In recent years, there has been a trend, generally perceived as positive, to “de-stigmatize” PTSD among military personnel, and to increase access to and funding for psychiatric treatment for service members and veterans so diagnosed. These individuals are encouraged to embrace their “disorder” and, as a result, PTSD has appeared in the public imagination in new and important ways (Spring, 2017). While there may be tangible benefits for military personnel and veterans who attach themselves to the diagnosis (financial support from government to access treatment and/or to cover basic living expenses, for example), significant emerging literature problematizes both the notion of PTSD and the resulting treatment approaches it engenders (Burstow, 2005; Hoge, 2010; Shay, 1994, 2014). Though space constraints prohibit me from exploring these critiques in detail, there are 3 main issues: (a) PTSD is a wide-ranging diagnosis that is typically applied to victims of trauma, and it fails to take into account the fact that military personnel are often both victims and perpetrators of violence (Balfour, 2009a; Nazarov et al., 2015; Shay, 1994, 2014). (b) It is profoundly paradoxical to pathologize an individual’s “normal” human reactions to military training and the horrors of war. For example, certain diagnostic criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM), such as “hyperarousal” are actually linked to key combat survival skills and it is understandable that such behaviors should persist into civilian life (Hoge, 2010). (c) Diagnosing soldiers as “mentally ill” risks further isolating them from civilian society. It can stoke feelings of fear in the public imagination and uphold long-standing, superficial, and destructive stereotypes of the hard-hearted or volatile veteran (Caplan, 2016). This leads us to a profound paradox: the increased media and public health attention that has been paid to military related PTSD in recent years has both shone a spotlight on the fact that many service members and veterans are struggling and may need support (a positive step), but, it has also occluded and simplified the true nature and nuances of this trauma.
While it is becoming increasingly clear that current models for framing and treating military PTSD are largely inadequate and that there is a need for more creative approaches to helping veterans connect with friends, family, and civilian society, there remains a gap in the literature and in research on how to move military trauma out of the realm of psychiatry and into an adult education and community-oriented framework (Hoge, 2010; Nazarov et al., 2015; Shay, 2014). My doctoral project sought to address this gap using phenomenological narrative interviews and, ultimately, a research-based play guided by mad-informed storytelling and aesthetics.
Norman Denzin (2003), one of the first prominent qualitative research specialists to champion research-based theater as a promising methodology that can also inspire critical education, claims that it has the ability to “intervene and interrupt” and that . . . such interruptions are meant to unsettle and challenge taken-for-granted assumptions concerning problematic issues in public life. They create a space for dialogue and questions, giving voice to positions previously silenced or ignored. (p. 11)
While this sort of “interruption” was indeed what I was seeking with this project, I was also well aware that many veteran interview participants would likely take comfort in/ be attached to/ would have found important community as a result of their PTSD diagnoses and so during the interview process, I wanted to be sure to honor these perspectives while also exploring more critical approaches and encouraging discussions that went beyond questions of “brain chemistry” and psychiatric symptom checklists. While mad theory certainly makes space for those who both hold fast to and reject psychiatric labels, I wondered: would it be ethical of me, on my consciousness-raising crusade, to encourage “vulnerable” participants to question the conclusions drawn up by professionals charged with their care? To call attention to the potential harm the only real support available to them might be causing?
Interviews
Taking these ethical concerns into account, I proceeded with caution when crafting and asking interview questions. All veterans I interviewed considered themselves traumatized by their military service in some way, and the vast majority had received a diagnosis of PTSD. But rather than outright explore their experience with the psychiatric system, I opted instead to embed my critique in open-ended exploratory questions which would at once allow for different discussions about military trauma than those that would occur in clinical setting, and also inspire the play creation process. As the following examples demonstrate, I opted during interviews to focus on the embodied experience/phenomenon of trauma. A few of the questions that generated some of the most compelling conversations and lent themselves particularly well to theatrical representation were:
- What was the experience of basic training?
- Is there any music you associate with your deployment(s) to Afghanistan? Why?
- Where in your body do you feel trauma most?
- What was the experience of calling home from Afghanistan?
- What is your strongest memory from the military?
- What did Afghanistan smell like? Sound like? Taste like?
- What sort of feelings do you associate with your deployment to Afghanistan?
Participant responses to such questions often moved me deeply and were at once literal and poetic. As the below excerpt from a short scene in the play illustrates, various participants would sometimes interpret a question (about “feeling,” say) in different ways. I believe that these responses—whether sensory or sentimental, reflected the magic realist “essence” of what I was asking, of the phenomenon itself more “authentically” than if my questions had been overtly critical in nature.
Mad Praxis
I have referred in this article to both mad theory/ studies and mad aesthetics, and before moving forward to speak in detail about the latter, some background on mad theory, studies, and activism is likely needed. “Mad” theory and activism linguistically, practically and symbolically represent a critical alternative to biomedical approaches to “naming and responding to emotional, spiritual, and neuro-diversity” as “mental illness” or “disorders” (Menzies et al., 2014, p. 10). Mad studies is an emergent field, and mad scholars often point out that it owes a debt to other academic disciplines that paved the way: including disability studies, feminism, critical race theory, queer theory, gender studies, and post-colonial theory (Gorman & LeFrançios, 2017; LeFrancois et al., 2014). In underscoring the misogynist, ableist (and also colonial, racist, homophobic, and classist) foundations of psychiatry, Mad studies is intrinsically linked to other human rights-based movements as it seeks to explore “the agency and oppression of mad subjects” (Menzies et al., 2014, p. 1) and highlight how the very constitution of sanity and “mental illness” is still “anchored in the bedrock of (heterosexual, white) male normativity” (Chesler, 1972; Menzies et al., 2014, p. 6; Smith & David, 1975). While the mad movement has existed in different forms for generations, it has only recently appeared as an academic discipline—Mad Studies (Gorman & LeFrançios, 2017; LeFrancois et al., 2014; Reville, 2014). What is now referred to as “mad theory” developed alongside, or as part of, mad studies (Gorman & LeFrançios, 2017). Taking the stance that the medical model is not only biologically reductionist but also favors capitalist ideals of conformity and productivity over exploring more community-based approaches to helping those in distress, mad studies takes a more “holistic” approach “where people are not reduced to symptoms but understood within the social and economic context of the society in which they live” (Menzies et al., 2014, p. 2).
Central to mad praxis, and in stark contrast to hegemonic biomedical approaches to conceptualizing “mental illness,” is storytelling from the perspective of those (consumers/survivors/ex-patients) who have experienced the psychiatric system (Costa et al., 2012; Poole & Ward, 2014). Storytelling has long been used as an effective tool in countless political and civil rights movements in recent decades. When it comes to mad studies, storytelling is especially important as those who have borne the brunt of imperfect systems have often been politically and/or chemically silenced and have struggled historically to have their voices and perspectives heard.
In their foundational piece about “mad grief,” Poole and Ward (2014) remind us that storytelling can serve as an act of both healing and resistance. Others from within the movement also emphasize the power and importance of storytelling but caution that many of these narratives are now at risk of being absorbed into and appropriated by larger mental health systems and having their structures re-framed to emphasize “recovery” or “resilience” instead of “resistance” in order to help garner support (and funding) from government or other authority figures (Costa et al., 2012). Tidy recovery narratives that focus on an individual’s triumph over darkness via “professional help” may be an effective way of building an organizational “brand” (Costa et al., 2012). Such stories are not, however, actually reflective of the experiences of most people who have “problems in living” and they rarely address the wider socio-cultural, economic and political issues also at play (Burstow, 2014, p. 83). In their article about “recovering” mad stories, Costa et al. (2012) suggest that when telling mad stories, one should consciously avoid what they have termed “patient porn” (p. 86). Their definition, in part, reads: “By pornographic we mean that, while some people reveal their most intimate personal details, others achieve relief through passive watching” (p. 86)
Ethical Tensions: Storytelling/ Playwriting Process
While transforming interview narratives into the play, I was left with another ethical conundrum. I wanted to include the highly moving, complex emotional aspects of “untidy” participant stories to communicate aspects of the phenomenon of military trauma as authentically as possible and in ways we do not see in media or pop culture de-stigmatization campaigns, but at the same time also wanted to ensure participants’ identities and intimate details of their lives would be protected. Though the play I have written is based on real-life veteran stories, instead of having each character be representative of a sole interview participant, I opted, rather, to create “composite” characters. That is to say, I made the decision that each character in the play would actually be composed of numerous similar stories offered up by interview participants. I adopted this approach in order to move away from the naturalistic/ documentary style tradition in research-based theater (and its positivist associations) from which many are increasingly eager to stray, but also to protect participants from feeling as though the intimate details of their personal lives were on display for all to witness/consume (for a more complete overview, see Spring, 2021). The vulnerable and messy aspects of the stories veterans so trusted me with are not merely commodities to stimulate big feelings amongst audience members.
When writing the play, I was also deeply inspired by visual artists (such as Frida Kahlo, Betty Goodwin, Alex Colville, Henry Moore) whose work deals with intense personal trauma in a magic realist, expressionist, or abstract sense so as to “make strange” and gain distance from the story being told (Kumagai & Wear, 2014, p. 873). This magic-realist approach not only engages viewers on a deep visceral level, but also transcends the empirical world as we know it and has the ability to lead to “disorienting dilemmas” so often associated with transformative learning and adult education (Mezirow, 2012). In the play, I also frequently make use of various Brechtian theatrical devices to help “jolt” audiences out of the action of a scene, or to keep them from relating too strongly with any given character so that they are able to maintain a critical distance from the story being told. For example, in many scenes, I have not named characters by their actual names, but instead by their social role. (In the excerpt shared below, the characters are simply called VETERAN and WOMAN) and the VETERAN character here is an amalgamation of several interview participants. The excerpt from the scene below, I believe, illustrates how a playwright can both incorporate aspects of “authentic” and deeply moving narratives, while also protecting participant identities and personal stories. This scene also makes use of (a higher-tech version of) Brechtian “placards.” Inspired by mad approaches to storytelling, scenes such as the following seek to show “wellness” as a messy continuum instead of a clear path from “illness” to “recovery.” This scene and others also serve carefully designed pedagogic objectives—asking those in attendance “really good questions” rather than providing “right answers” (Snyder-Young, 2010, p. 891).
This scene then continues in this vein. The well-meaning WOMAN continues to engage VETERAN in conversation about topics he has difficulty relating to. The words projected on to his body are from the symptom checklist for PTSD outlined in the Diagnostic and Statistical Manual. They are incorporated here in order to “jolt” audience members out of the action of the scene into a place of critical reflection. (Is VETERAN “mentally ill” because he feels “isolated” in moments like this? Surely we can all relate to feeling stuck and lonely in similar conversations at parties. Is it normal/understandable that certain sounds in the here/now transport VETERAN back to a different there/ then time and place? Certainly, these memories would still be present in his mind/body after years of military training and deployment . . .). Similarly, VETERAN’s reliance on his tractor headphones might be viewed either as maladaptive behavior or a successful (if slightly bizarre and endearing) coping strategy. Should his use of them be pathologized or commended as a creative solution?
Mad Aesthetics
Studio artist, activist and mad-identified scholar Dr Jenna Reid (2019) has reflected and written a great deal about what a “mad aesthetic” might entail in the visual arts, and her theorizing has been hugely influential on my own as I attempted to apply her suggestions to the creation of this research-based play. Acknowledging that mad movement organizing itself is fraught and that the biomedical model is so dominant and pervasive, it can be challenging to view art about madness outside of this context, Reid has nonetheless sought to define certain traits of a “mad aesthetic.” One trait is that it ought to be created “within and alongside the mad movement” (p. 107) and that it need not have a “curative or healing imperative” (p. 119). She also highlights the importance of transcending “personal experiences of madness . . . into a critique of systems, institutions, and dominant practices and beliefs” (p. 64). Though personal stories may not be “inherently political” if they stress the “social context” of suffering instead of individual pathologization, they can help avoid the voyeurism and co-opting of narratives so often associated with mad storytelling as discussed previously (Reid, 2019, p. 59). Ethically speaking, this seems a good path forward too as even those who have found the psychiatric system and related diagnoses helpful will likely be keen to improve existing systems and to see their suffering in a broader context so that they feel less alone with it today and across time.
In The Space in Between several scenes deliberately explore how social forces/ systems might cause/ exacerbate trauma. For example, I target the patriarchal underpinnings of military and psychiatric institutions, classic Hollywood war hero narratives, and hetero-national ideals of recovery. One scene (excerpts included below) illustrates this particularly well.
This moment begins ordinarily enough (I myself have witnessed several such “Veteran’s Salutes” at Blue Jays games) as the crowd stands to honor and clap for LCOL BRAND. However, when it is time for him to be escorted off the field so that the game can continue, he stays put instead, and the rest of the scene transcends the “familiar.” Members of the crowd turn on LCOL BRAND and begin lobbing questions his way they would likely never dare ask I reality. Such as:
Things continue like this and the crowd starts to boo BRAND. They continue to provoke him and he, clearly shaken, attempts to respond as honestly as possible. We almost get the sense, that—even though this is tremendously difficult for him, he is relieved in a way to be admitting that the hero narrative the crowd seems to subscribe to falls short. Later in the same scene:
The voices then expand beyond the stadium walls and LCOL BRAND, still center-field, is suddenly bombarded by advertising directed at veteran “heroes.” The scene culminates in the following voiceover announcement:
Closing Thoughts
I opened this article with an excerpt from a scene between me and my first doctoral supervisor, Dr. Bonnie Burstow. Burstow was a true radical and her life’s work was vehemently anti-psychiatry in nature. She also strongly believed that the arts hold unique potential when it comes to challenging the status quo in general and hegemonic ideas about “mental illness” in particular.
Theatre, for her, was one way of moving these discussions into community.
In the concluding chapter to her book Psychiatry and the Business of Madness, Burstow (2014) envisions a world she would like to see. In the “commons” that she summons, there is no longer a need for psychiatry nor mental health “professionals” at all as people would accept and support one another in community. Behaviors that are unusual would no longer be pathologized. Instead, she says: “it would be understood that people have different ways of coping, and so with few exceptions, as long as others are not intruded on, actions associated with these would be respected . . .” (p. 236). While I find this idea compelling, years of listening to veteran stories and observing veteran family dynamics has revealed to me that recognizing when one is being “intruded on” is not always straightforward. The first scene I included in this article serves as an example of this. During the first phase of this project, I had been excited by the fact that I “succeeded” in my goal getting this particular veteran to open up to me during our interview. He had even commented on how much more meaningful our one conversation had been than those held weekly with his psychiatrist. I had a brief glimpse, I think, into what the “commons” Burstow envisioned might look like, if only we could make time and hold space for one another without the intrusion of “professional credentials.” Moments later, of course, I realized this was much harder than I initially envisioned when my boundaries were indeed intruded upon. Guided by a mad studies approach that embraces untidy narratives, I opted to be upfront about these thorny ethical questions in the play itself. There is no doubt in my mind that other dynamic ethical questions will arise as the play moves into production. For one, given that it is considered best practice (and often mandated by Research Ethics Boards) to provide audience members with mental health resources or on-site professionals in case a performance “triggers” difficult memories/feelings, where is an artist-researcher to refer participants if their work actively challenges the effectiveness and integrity of these approaches to helping?
To return to my previous question about the project design and creative writing process: is it ethical for a play to raise the very real problems with the psychiatric system in an era where no/few viable alternatives exist for those who are suffering? I have outlined above why I believe it is not only ethical, but vital to do so as hegemonic biomedical narratives often cause and exacerbate harm and deprive broader society from accessing these stories. I have also highlighted some important lessons I have learned on this journey, and offered up suggestions as to how one might engage with mad praxis in order to craft interview questions that help participants frame their experience as embodied phenomenon instead of mental illness. Such questions and ensuing responses also lend themselves well to a mad approach to storytelling that can, at once, move audiences deeply while representing aesthetically the cultural/ institutional causes of “madness,” while also protecting participant identities and serving critical pedagogic objectives.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: A Social Sciences and Humanities Research Council Doctoral Fellowship to conduct the research that lead to the authorship, and/or publication of this article.
