Abstract
Healthcare practitioners are often presented with vulnerable encounters where their professional experience is insufficient when dealing with patients who suffer from illnesses such as chronic pain. How can one otherwise understand chronic pain and develop practices whereby medical healthcare practitioners can experience alternative ways of doing their practice? This essay describes how a group of researchers have, over a number of years, developed improvised participatory theatre as a means of engaging healthcare practitioners, patients and other lay people in situations where it is legitimate to reappraise their practice and reunderstand the nature of an illness such as chronic pain. One conclusion was to consider that it is a relational rather than an individual phenomenon that in turn demands alternative practice. Through iterative workshop processes of improvised theatre, participants are encouraged to experience the vulnerable, the unknown, and the need to be alternatively present when dealing with patients whose situation is imbued with suffering.
Introduction
This essay is designed to reflectively and reflexively explore how our practice of using improvised participatory theatre (henceforth ‘improvised theatre’) evolved in the development of various healthcare initiatives. Our interest has been to explore healthcare situations with a view to encouraging change in practice, both our own theatre practice and that of the healthcare practitioners we work with.
We will primarily describe our work with chronic pain and the narratives it engendered. As we traverse our path, we will also introduce snippets from other similar healthcare projects. This work, carried out over the past 5 years, is based on 20 years of similar work that focused on business organisational issues and drew on improvised theatre methods. Our shift to exploring healthcare practice has encouraged us to become more discerning as to what theatre's contribution is to our research and the practice of others.
At a conference, a keynote speaker, Brian Hurwitz (2016), introduced an anecdote from Archie Cochrane's memoir (Cochrane and Bythe, 1989). As a young medical doctor, Cochrane witnessed the death of a Soviet soldier in Germany in 1943. The soldier was in great pain, which Cochrane diagnosed as a lung infection. He felt he was in a hopeless situation, as he had no medicine to cure the infection or the pain. ‘I finally instinctively sat down on the bed and held him in my arms, and the screaming stopped almost at once’. Cochrane concluded that ‘it was not the pleurisy that caused the screaming, but loneliness’.
However, Hurwitz also noted that Cochrane's account of the dying soldier was only made available to the public 40 years later in his memoir where he wrote: ‘I was ashamed of my misdiagnosis and kept the story secret’. In his presentation, Hurwitz argued for the need for healthcare narratives that go further than a detached case description to include the emotions and thoughts a healthcare professional might have when reflecting on the experience of a situation with a patient.
Obviously, Cochrane had the empathy to relate to the patient, yet appeared reluctant to reveal his mistake. By doing so, he reinforced a discourse that shuns expressions of vulnerability, the sharing of mistakes and the incorporation of not-knowing as part of professional medical practice. Shapiro (2008) describes this as the modernist discourse in medicine, which, by reducing illness to its scientific foundation, ostensibly removes moral judgement.
Coulehan (2005) appeals for a ‘narrative based professionalism’ whereby medical practitioners can foster ‘the ability to acknowledge, absorb, interpret, and act on the stories and plights of others’ (Charon, 2001). The importance of patient narratives is described by Frank (1995) in his work on ‘the wounded storyteller’ and by Kleinman (1988) as a means of structuring meaning. Significant work has also been done to introduce alternative educational processes that specifically explore the potential of narrative medicine for medical and other health related students (Arntfield et al., 2013; Charon, 2012; DasGupta and Charon, 2004).
In order to counter the impulse to hide the imperfections of professional healthcare practice, similar to Cochrane's example above, our wish is to encourage people to share their experience by inviting those involved to deliberately explore the dilemmas of their practice. We notice that by engendering narratives of practice by working live with improvised theatre, we are able to engender situations where those involved can actively engage dilemmas of suffering, not knowing what to do, and in particular the challenge of staying present in a shared vulnerability that is engendered between those involved.
Improvised participatory theatre
The first two authors (Larsen and Friis) have worked with private and public sectors, organisational change since 1999 (Friis, 2006; Larsen, 2006, 2008, 2011; Larsen and Friis, 2006, in press). Our work began with Forum Theatre as developed by Boal (1979), where initially a piece of rehearsed theatre is played to an audience. The piece focuses on what Boal called an ‘antiplay’, which shows situations that are recognisable to the audience, yet not acceptable to them. After the rehearsed piece is played, the audience is invited to make suggestions, either by directing the actors or to go on stage themselves to try out their ideas as to how to continue the situation. This is why Boal called the audience spect-actors. Boal developed this method in Brazil during the dictatorship as the ‘theatre of the oppressed’ (1979). We gradually realised that dealing with a notion of oppression was not helpful with regard to the organisational issues we engaged. As a result, our work shifted from the audience as oppressed to that of mutually exploring the problems involved, mostly by exploring tensions and contradictions in the audience.
Over the next few years, our work was influenced by Keith Johnstone and his concepts of theatre improvisation (Johnstone, 1981, 1999), for example, ‘theatre sport’. Actors are given a cue from the audience, which they then use to improvise with on stage. In theatre improvisation, Johnstone understands the emergence of the actor roles as re-acting. Rather than focusing on his or her own role, the actor has to engage the other actors and spontaneously re-act. By doing so, both situation and roles emerge and transform.
Another focus of this work was that of human action as a complex responsive process of relating, developed by Ralph Stacey, Douglas Griffin and Patricia Shaw. First described in 2000 (Stacey et al., 2000), their theories build on those of the pragmatist George Herbert Mead (1934) and Norbert Elias (1956). Where some researchers created loose metaphors for human interaction based on complexity insights from natural science (local interaction creates larger patterns in non-linear interactions), Stacey et al. looked for insights from social psychology and sociology that could serve as analogies for human interaction as complex and relational. They understood communication as transformative and the work of Mead became key in understanding this.
For Mead, the creation of mind, self and society emerges in local, social interaction. This understanding shifts the focus from the individual and his or her relation to an overall situation, to a focus on the processes of relating that Mead calls iterations of gesturing and responding. Instead of understanding communication as sending and receiving messages to convey what is already thought, Mead understood communicative interactions as transformative, as creating and changing mind, self and society in one and the same action. In this gesturing and responding, we re-interpret our own gestures according to the response we get. This perspective is similar to that of Johnstone (1981) who considers the role of the actor in theatre improvisation as emerging in the re-acting towards the other actors (Larsen and Friis, 2006), where the interaction between actors develops the situation at the same time.
The work with theatre influenced the community that explored complex responsive processes of relating. Shaw (2002), for example, developed the concept of organisations as ‘improvisational ensembles’. From the collaboration, the notion of ‘working live’ was introduced (Shaw and Stacey, 2006); although we all improvise in a situation by drawing on known experience, we are not necessarily in control of the interaction.
Following Mead and Johnstone, conversation and bodily communication is a way of gesturing and responding in an ongoing improvisation created from moment to moment. When we improvise, we spontaneously respond to each other's gestures. As such we do not know the full meaning of what we are doing until we have done it. Meaning emerges through the process of having intentions, acting and getting a response. This is a social process where we create meaning together in what we are doing, in the act of doing it.
Mead expressed the individual self as paradoxically social and as emerging in the conversation with others, in what he named the I-me dialectic, the inner conversation where ‘I’ spontaneously responds to ‘me’, which for Mead is the perception of what other people might mean and which he also describes as ‘the generalised other’. For Mead, the inner I-me conversation is a continuation of the conversation with others. Thus, Mead avoids understanding the individual solely as a product of the social or as independent of others (Joas, 1985; Mead, 1934; Stacey et al., 2000).
By combining a complex process of relating research focus (Shaw and Stacey 2006; Stacey, 2001, 2003; Stacey et al., 2000) with our use of improvised theatre methods, we were able to both explore and analyse, principally through collaborative workshops, issues that our research interventions exposed.
Exploring chronic pain
Our initial approach to chronic pain was motivated by a frustration with the question many patients are posed with, namely: ‘How is your pain today on a scale of 1 to 10?’ This decontextualising of experience to a number both irked and alarmed. This led to the question of whether a heightened perception of pain could lead to a more precise articulation that could better serve both patient and health practitioner. We soon discovered that this understanding of chronic pain was naive at best. Through our research, it became clear that for those with a chronic pain issue, the negative consequences of the life-changing situation they are thrown into are significant. Through the work of Lisa Käll et al. (2013) and her notion of pain as an intercorporeal weave that is established among those affected, and the work of Nanna Johannesen (2011) who introduced the notion of the sociality of pain, we became more aware of the relational nature of chronic pain. Johannesen's work also introduced the discursive figure of the Good Chronic Pain Patient, with its emphasis on chronic pain as an individual experience and connotations of self-efficacy, management, coping (Mann et al., 2013) and lonely struggle.
Chronic pain engenders broken life narratives that leave patients, their relations, friends and work colleagues to struggle with issues of shifts in identity and lack of coherence as to where a life narrative might be expected to develop for all concerned. These broken life narratives also perplex professional practitioners who are often at a loss as to how to deal with them, with the result that nuances of suffering are never cared for. The notion of the Good Chronic Pain Patient is averse to disturbances of the controllable, the manageable, the efficient, of which a broken life narrative is a prime example.
Taking this relational aspect into account and wishing to explore narratives that could work with past, present and future life expectations and the relationships involved, we were inspired by Ochs and Capps (1996) who consider the use of narrative as a means of sense-making in which ‘narrative … is a fundamental means of making experience … Narrative activity provides tellers with an opportunity to impose order on otherwise disconnected events and so create continuity between past, present and imagined worlds’ (Ochs and Capps, 1996: 19) where ‘we use narrative as a tool for probing and forging connections between our unstable, situated selves’ (Ochs and Capps, 1996: 29). This led to a series of experiments with patients and health practitioners.
One example is the use of name cards. After completing a local municipality rehabilitation course, two patients were interviewed, and the researcher (third author, Chris Heape) asked the patients to write the names of the people mentioned in the conversation on blank visiting cards. By moving the cards, they described how relationships had changed over the course of their chronic pain situation. One situation stood out: A young woman (32 years) ended her session by aggressively throwing two cards into the corner of the room without looking. When asked who they were, she replied: ‘My parents. They don't give a damn about me. They don't understand or help with my daughter at all’.
Based on these experiments, we were encouraged to further explore this chronic pain field of relationships by drawing on improvised theatre methods.
Working in and from workshop to workshop
Over the next two and a half years, we carried out five theatre workshops, where each workshop further developed our understanding of the almost predatory nature of chronic pain's influence on family and work life, and professional healthcare practice. At each workshop, various groups of participants were asked to engage the actors. An introductory, recognisable scene initiated the process. Gradually, a fuller narrative was co-constructed between the actors and participants in each workshop and from workshop to workshop. Intermediate reflections between the workshops served to get to grips with both the new aspects of the narrative that had emerged and with what we had learnt as researchers. This growing understanding of what we were dealing with was also influenced by reflections on other workshops that addressed similar projects, namely patient falls (Norman et al., 2015), cancer communication and nursing education.
Based on interviews with practitioners and patients, the chronic pain narrative evolved from an initial exploration of a 63-year-old man with chronic back pain, Peter, who lost his job due to his pain. In the first workshop, Peter sits in a café waiting for his wife. A former colleague comes by, and they have an awkward conversation where both pretend to be happy about meeting again, but for the audience it is obvious that Peter is no longer part of his former workplace community. He is now an outsider. The colleague departs, and his wife arrives. Through the acting, we see how she has taken control of what they do and that Peter has allowed her to do so.
In a later workshop where chronic pain patients and healthcare professionals from pain clinics and municipalities take part, we replay the scene. This leads to a suggestion from one of the participants to play a scene where Peter, now a grandfather with two young grandchildren, has a discussion with his daughter. Peter ferries the children home in his car from day-care to his daughter's, even though he is heavily medicated. The focus turns to the daughter. Although she is a single mother and dependent on her father's help, she is still angry that he does not keep his promise of not driving with the kids. How do you deal with such a conversation?
So with participant contributions over time, we have developed a sophisticated narrative that depicts Peter, as both father and grandfather with a daughter and two grandchildren. The range of conflicts also expanded, in as much as Peter's medication affected his relationship with his daughter due to his careless driving habits with her children, to his dysfunctional sexual relations with his wife and the conflict between wife and daughter as to how much they could or could not discuss about the husband's/father's influence on their lives.
What became clear in all five workshops was that chronic pain weaves its way into the very fabric of people's daily lives, both at work and at home, thus influencing the relational.
Conference workshop – Tenerife 2017
The theme of the conference was health and illness narratives. Around 30 conference participants witness a 3-minute scene of strained conversation between Peter and Hannah, his daughter, about Peter picking up the children by car whilst heavily medicated. Little is said, and the issue is left unresolved.
After the scene, the facilitator asks the audience to discuss what they saw. A lively discussion ensues about the implicit nature of the non-verbal interaction, safety when driving the car and can the daughter trust her father with the children when he is medicated. The audience also points to the daughter's anger about how the father, she had known as a strong and loving man, now seems to be almost out of touch. Maybe she unconsciously feels angry with him as she struggles with a sense of loss and betrayal. The audience offers a number of suggestions as to how to move on, one being that the daughter visits the doctor with her father. At some point, one participant remarks how this audience, all with a particular interest in health and illness narratives, tends to suggest medical solutions rather than pursue the relational implications of what they see. This is followed by another person who suggests the real pain is not his physical pain, but the broken relationship with the daughter. As both of these remarks create a strong resonance with the audience, the facilitator suggests exploring how the daughter might describe her dilemma in a conversation with a friend. A woman in the front row offers to act as her friend. They do not otherwise know each other.
There now follows a four-minute scene between the two. Hannah, played by a trained actor, is clearly distressed, yet reluctant to share her situation with her friend. She initiates the conversation by indicating how overwhelmed she is feeling with work. The friend encourages her to ‘tell me more’. Instead of answering, Hannah turns to the audience to ask, ‘What do I say?’
A trained actor can easily come up with answers, but asking the audience for help is one of the techniques an actor can use to ensure they stay in touch with thoughts and feelings in the audience.
The audience suggests to Hannah she should talk about the conflict with her father. One person repeatedly suggests, ‘Just grow up!’ Hannah turns to her friend and weaves suggestions from the audience into the conversation. Finally, in despair, Hannah admits to her friend that, ‘Something is changing. I don't know how to talk to him. To be honest, I don't know’.
Now the person playing the friend turns to the audience and asks for help. The audience laughs, no doubt as she adopts the same technique as Hannah. The facilitator asks what she would do if she really was her good friend. Friend – to the audience: I would be brutally honest. And I would just say, if that was my father and these were my children …
The two resume their conversation. Hannah becomes very emotional, and on the verge of crying and with trembling voice, she says: Work, it's all a hassle. And with him – she lifts her arms up and down dejectedly – I don't know … She sighs.
The person playing the friend turns to the audience, lifts her hand to the side of her mouth as if she is trying to hide a secret from Hannah, laughs a little and whispers loudly: I want to give her a hug.
The friend then turns to Hannah, and they both embrace in a long hug. The response to this genuine expression of compassion is quite palpable and the audience laugh and clap.
Using methods beyond realistic theatre
As we have seen above, improvised theatre plays out small vignettes based on real-life situations after which people are invited to comment on what they have seen, how it relates to their own situation and how they think the piece should proceed. Actors then improvise around the original situation by incorporating the suggestions of those present. Sometimes people from the audience are asked to improvise by taking on the role of the actors to play out their perspective or explore alternatives. This allows actors, audience and researchers to run and re-run situations to explore nuances of relating, of gesture and response and to demonstrate how sense-making and meaning emerge from the moment-to-moment interactions of those involved. The process enables people to see how they are influencing the relating that is going regardless as to whether they adopt an active or passive role.
As we developed the chronic pain theme, we continued with scenes involving Peter. However, we also asked the audience to contribute with their experience and from there improvised similar, yet different situations on stage. Although not a conscious choice, more the intensity of the theme, it seemed natural to continue with the same overall narrative rather than develop alternatives.
Although we usually aim to play realistic, improvised theatre, now and then we draw on alternative ways of working. At a workshop session after the Tenerife conference, the facilitator asks the audience for suggestions as to what the daughter, Hannah, might be thinking. The actress playing Hannah repeats these together with the inherent emotions. By doing so, we avoid only getting a detached, intellectual, analytical response from the audience. One of the thoughts expressed by the audience is that Hannah does not think the doctor is doing enough for her father. Again suggestions from the audience express a wish for the doctor to fix the problem. This leads to a new scene where the father has a consultation with his general practitioner (GP) on stage. Hannah now has the opportunity to be a fly on the wall, a method that allows the audience to simultaneously follow the improvised play and the daughter's reaction. In the consultation, the father tells the doctor how his pain and medicine impairs his sex life with his wife and his worries as to how this might affect their marriage. In the moment, it is obvious to the audience that this is something Peter would never tell his daughter. In the play, after being the fly on the wall, the daughter feels ashamed and realises she cannot allow her anger to influence her cutting her father off from his beloved grandchildren.
In another situation, a suggestion is that each participant writes a short personal postcard to Peter, not from his or her own perspective, but from that of another character in the story. The postcards are then randomly read aloud as a continuous stream and have the air of a recital for different voices. The voices become very emotional and reveal a wealth of perspectives as to how we variously experience the complexity of Peter's chronic pain and the effect it has on those involved. One of the postcards is from the twins to their grandfather asking: ‘Why didn't you come to the kindergarten today? There is something I wanted to show you. Mama says that Susan is going to pick us up next week. Don't you want to play with us anymore?’ Until that moment, nobody had thought of or talked about how the children experienced the conflict between Peter and Hannah.
Chronic pain as a relational phenomenon – contribution from theatre improvisation
As noted above, current attitudes to chronic pain focus on the notion of chronic pain as an individual experience, with its ‘Good Chronic Pain Patient’ (Johannesen, 2011) connotations of self-efficacy, management, coping (Mann et al., 2013) and lonely struggle. This understanding frames chronic pain life, care, practice and rehabilitation in Denmark and abroad. Professional practitioners are in doubt about this approach (Johannesen, 2011; Mik-Meyer and Johansen, 2009) and have conflicting views as to how they could otherwise engage those with chronic pain. Added to this, chronic pain situations can become ‘zones of conflict that lie between different understandings of illness and health, of body and mind, of obligation and rights’ (Johannesen, 2011: 7), and ‘illness, diagnosis and documentation’ (Mik-Meyer and Johansen, 2009).
The general assumption is that a person with chronic pain can reach beyond a ‘state of chronic ambiguity’ (Honkasalo, 2001) by individually developing correct coping strategies. The notion of chronic is generally understood as life-long and as such stable. However, as Johannesen (2011) notes, ‘chronic’ is not equatable with ‘stable’. The experience of chronic pain is unstable; it fluctuates, is unpredictable and is not necessarily controllable. Johannesen challenges the notion of individual coping and offers an alternative that takes into account and works with ‘the unpredictable, the unsayable, the diffuse’ and leaves that ‘which can't be mastered be’.
She posits that chronic pain is a social phenomenon, indicates how it is constituted between people and describes how its relational dynamics influence its experience; those involved are interdependent on each other and the individual, even when alone, is in relation to others. Relation and sociality are closely intertwined with identity and sense of self, as on a very basic level, one can consider identity as something that is established in relation to others.
Through our work with theatre, we have explored how the inability to articulate or even begin to reach for and share with another a vague sense of ‘something’ inevitably fosters a relational gap with the other and generates feelings of insecurity, fear, depression and loneliness when the attempt to express or ‘manage’ the unmanageable fails. As indicated by Jackson (2005: 346), a person can end in a chronically liminal state where they become not only estranged from the world of others, but also from their conception of self… ‘In the end they are nowhere’ (Gotlib, 2013: 54); their identity and sense of self crumbles. Although our work with Peter shows how the dynamics of this insidious estrangement occur, it also shows how opportunities emerge from the tension in crucial moments of social interaction that can lead to new insights and ways of being and acting.
Patients with pain live in a social ecology of private and professional lives as everybody else. As pain is an inner state, it is invisible to others per se, but pain shapes the patients’ social behaviour and affects and threatens the fabric of their lives. Where a patient with pain experiences and feels pain, others are witness to that suffering and are affected by what they experience. In this case, we consider ‘others’ to also include the broad range of professional practitioners that patients with pain must relate to as well as their near relations or work colleagues. For example, GPs with, for the most, their non-specialist knowledge of chronic pain are often left frustrated in their inability to fully address a patient whose affliction continues.
However, as we have seen in our work with theatre, asking people and practitioners to venture into the unknown of the ambiguous or unmasterable challenges notions of personal and professional identity. People are reluctant to relinquish roles and sense of self they know well. The Good Chronic Pain Patient rhetoric can be invoked to avoid the ensuing personal or professional doubt with the result that nuances of suffering, broken life narratives and sense of despair are never allowed to surface. They are kept in the shadows as latent themes that inevitably influence personal, family and work life.
By attending to the relational dynamics of chronic pain, our theatre work has revealed a degree of nuance as to how the suffering and its attendant feelings of hopelessness and despair can seep into and infect relations with others. Through the workshop improvisations, health practitioners could experience alternative forms of practice and discourse and engage first-hand issues of suffering, doubt, hesitation, identity and self-understanding. Alternative practices that do in fact better pain patients' sense of well-being and reinforces threatened social relations.
Our improvised theatre work, quite apart from the workshop experiences it gives to the participants, also provides a means to both support and challenge current chronic pain theory and practice in general. By taking the relational turn to chronic pain, we have shown that a range of issues and nuances emerge. We will now focus our attention on and explore how these might influence the way healthcare practitioners choose to act.
Ethics and healthcare practice
In another project, we were asked to work with 300 nursing students at a university in London. They had all written short stories about incidents they had experienced as student nurses on hospital wards, which we would use as the basis for a theatre workshop. Four of the stories had been chosen because of their ethical dilemmas, and we met with the four students the day before the workshop. We went through each of the stories by acting them out, with the students acting as both directors and extra actors. By the end of the day, we had created and videotaped the scenes we were going to play the next day for their fellow students in the auditorium. The workshop was planned to be a mix of students and our actors playing the roles from the students' stories.
One of the scenes is about a Muslim man with senile dementia who is being fed by a trained nurse, Angela. Rachel, a student nurse, passes by and notices that the man is being fed with non-halal food. As she passes she hesitates, but finally suggests to Angela that the demented man should have halal food. Angela answers that as he has dementia, he ca nnot tell the difference. This is in fact clear, as the old man obviously likes the food he is being given. On stage, we see how the student nurse is about to answer, but does not do so. The other nurse continues to feed the man until the facilitator stops the scene and asks audience for a response.
This scene we play for the 300 students clearly engenders a sense of recognition and reflects how student nurses feel powerless when they discover something that is wrong, leaving them with an ethical dilemma. Although wrong, how can a student confront 20 or 30 years of nursing experience?
In the narrative presented by the student the day before, the old man's daughter, on visiting her father, immediately discovered her father had not been fed with halal food. On stage, the student nurse playing Angela lies to the daughter and says she is unaware the food is non-halal food which the audience knows is not true. This lie poses an even greater dilemma for the student nurse, Rachel. The discussion among the 300 students is heated. What could Rachel otherwise do? How can a student nurse handle this kind of dilemma? Is it even possible for someone so low in the hierarchy to act in such a situation and if so what should she do? Most of those in the audience cannot say what else a student nurse could do.
To explore the situation further, the facilitator suggests playing a scene where Rachel meets the daughter by chance in the waiting room. The two student nurses playing the daughter and Rachel improvise the following scene.
When Rachel, the student nurse, sees the daughter, she freezes for a moment: Daughter: Hi – you're one of the nurses on my dad's ward aren't you? Rachel – Uhm – student nurse, yeah. Daughter: Did you happen to see him at lunchtime today? He was being fed a meal that just wasn't his. Do you know anything about that?
Facilitator: Let's stop for a moment. He turns to the audience. What would you say? Please discuss this with your neighbour for a moment. The reflection and conversation that follows is intense, as most of the 300 recognise feeling powerless, vulnerable and caught in an ethical dilemma. The next half an hour is a mix of conversations and trying out suggestions on stage.
For those of us running the workshop, this was an important moment, as it was the unexpected and unplanned outcome of mutual improvisation. The facilitator improvised setting up the scene between the student nurse and the daughter. They improvised with each other not knowing where the situation would lead and the audience amplified the intensity through their spontaneous reaction. From the improvisation, the opportunity to be emotionally confronted with an ethical dilemma emerged.
The student who had the original experience with the non-halal food situation had been watching, and afterwards, she said that ‘stepping out of the situation and watching it changed my perception about everything’. We heard from both her and the other students that this was an important moment for them as students, as it enabled them to re-negotiate with themselves the need to find a way to break the role of being a silent student on a ward whilst wanting to do the right thing.
Referring to Mead, Griffin (2002) describes values as emerging in the action one finds oneself taking when one is in the tension between conflicting, idealised and abstract cult values, such as doing what is right for the patient and being loyal to a colleague. For the facilitator, the opportunity to confront the students in their ethical negotiations by letting the student nurse meet with the patient's daughter emerged, not as a deliberate choice that could be referred straight back to Mead's understanding of values emerging in the temporal processes of relating, but more as a live, partly unconscious wish to act on an insight that came from the situation as a whole that, if acted on, could elicit a further response from the others and himself.
Working live from moment to moment
As in the examples above, engaging an improvised mode of relating creates a quality in the conversation (Buur and Larsen, 2011) that can lead to a sense of meaning that cannot be otherwise achieved. This demands having an eye for the overall situation while sensing the nature of the moment as it emerges. The sociologist Norbert Elias called this the paradox of involvement and detachment (Elias, 1956). A paradox one could almost describe as being in two temporal attentions at the same time.
For professionals, this means that when consulting with a patient, a practitioner engages in a conversation on a personal level, whilst at the same time keeping a professional distance. Medical practitioners, such as doctors and nurses, work live with their patients. They have to respond in the moment to what is said or done. As seen above and in other situations, for example, shared decision-making in the interaction between cancer patients and doctors in a hospital, when working with medical practitioners, the actors and workshop facilitator engender situations where it becomes legitimate to reappraise what professional healthcare practice could be and what being present in a doctor-patient encounter could entail as regard the risk of embracing the unknown. But, as improvising in the unknown evokes feelings of risk, uncertainty and vulnerability, it influences to a greater or lesser degree one's sense of identity. Efforts to avoid that risk will result in one being less present, which will in turn affect the situation. ‘Knowing who you are’ is comforting, while ‘being present’ may be anxiety provoking. As Patricia Shaw describes it, working live is characterised by ‘the spontaneous change in the sense-making processes through which we organize ourselves and the experiences of being more or less spontaneous, more or less at risk’ (Shaw and Stacey, 2006: 15).
But, despite this aversion to engage risk, be in two temporal attentions at the same time and be present in the vulnerable encounter, the discussions among professional participants in our workshops often led to a greater understanding of the role of a medical practitioner and of what constitutes his or her professionalism. Good healthcare practice means investing oneself in the conversation by surrendering to its emergent quality and relational resonance.
The flow back and forth
It is intriguing to ask: How is it possible to gain the insights we do with these practitioners? How can we better understand the contribution our improvised theatre engenders? In a sense, if one were to follow the videotaped dialogue from any workshop, it could be read aloud as a narrative, which begs the question: Why use theatre to play out a scene? What other dimensions and experience does theatre offer?
We play out small scenes, which result in the audience being critical of how an interaction is carried out. As the participants reflect together about how the scene developed, a range of opinions are offered. Or maybe it would be more accurate to say, the discussion develops into a need to see how the conversation might otherwise be carried out. To do this, it is necessary to turn back to improvisation. According to how the participants, including the actors and facilitator, react and respond, the improvisations shift back and forth between what happens in the improvisation and the participant response, often through several iterations. It is very much in this, and from this, dynamic and emergent shifting back and forth that the essence of working live improvisation lies. Each iteration of improvisation or reflection colours any current understanding, which in turn influences and transforms the emergent flow and understanding of the overall situation. During the improvisation, actors, participants as actors and the other participants are all influencing the situation as it evolves from moment to moment. It is an ongoing response to what is collaboratively engendered that unfolds in real time. It is not the performance of a known narrative or situation. On the contrary, it purposefully explores the potential in the unknown of the known in a situation, the expression of which is gradually articulated as a collaboratively constructed narrative of new understanding and experience.
Any new understanding that emerges is not the sum of reflection after a scene has been played out. The learning that emerges, its warp and weft are woven together as an emergent dynamic in the temporal flow of back and forth between improvisation and reflection. The one supports the other. In that sense, one can consider these interwoven iterations as a learning process that leverages the participatory nature of communicative interaction between people (Stacey, 2001) where learning emerges as thematic patterns of meaning (Stacey, 2003) in the ongoing relating between those involved (Heape, 2015). It is also worth pointing out how the work with theatre improvisation evokes reflexivity, as also noted by Pässila et al. (2015).
Fictitious reality
Working live with theatre is not a laboratory for later implementation (Schreyögg and Höpfl, 2004), but is a means of engendering change in the present. It is not a separation of fiction and reality in time, but fiction and reality as paradoxically at work simultaneously (Larsen, 2006, 2008). In the workshops we have described, the participants discussed the situations they saw played out as if they were real. From experience, we know that for improvised theatre to work, it is important the fiction resonates with the participants’ experience. If an improvised situation is too fictitious, the audience tends not to find it that interesting to work with. On the other hand, if the fiction gets too close to known problems, the audience may refuse to get involved and only criticise the acting. In the temporal moment-to-moment interaction, we look for a sound level of ‘fictitious reality’ (Larsen and Friis, 2006) where the participants not only get involved in what goes on, but also read themselves into what is happening and discuss from their experience.
Being present
But how does the situation seem to the actors? In an improvised process you are, as an actor, acting in the unknown. You might know where you want to go, for now, but must react to what happens at each step, which may change the intended direction. The paradox of improvising means acting in two apparently opposite ways: being skilled and experienced in what you are doing, yet at the same time acting spontaneously. This is simultaneously knowing and not-knowing. The question is to what extent we try to control our improvising or are willing to run the risk of not being in control of what we are doing. Do we dare trust that meaning will emerge as we spontaneously and skilfully work our way forward? How do we stay present in this ever-changing flux?
Being present is mandatory for the actors, otherwise the theatre improvisation will die and audiences will be bored. This is also true of actors improvising with non-actors as described above. Keith Johnstone (1999: 59), who has spent a lifetime training actors in improvisation, defined presence as a degree of listening, but realised it is not enough to be a good listener. After having observed many actors improvising, he realised that apart from listening and being interested in what your partner is telling you, ‘you must be altered by what's said’ (1999: 59). Being altered in this case means you cannot stay unaffected, but will have to change a little, lose some control and become someone slightly different from who you are, which may feel scary. The fear being that you could make a fool of yourself.
The poor improviser tries to remain the same throughout an improvisation, no matter what a partner does or what happens. The poor improviser will often insist on his or her own ideas rather than follow those of others. By attempting to stay in control, nothing changes or is resolved. What is needed in an improvisation is to move from something known to something we could not know that emerges in the collaboration between the actors. Good improvisers are willing to pick up on new ideas, which means they lose some control. They become vulnerable in the unknown situation, as they do not know what they are in the midst of, where they are heading or how they will handle it. And ‘who am I if I can't handle the situation?’ which also brings questions of identity into play.
Improvised theatre as explored above encourages people to mutually explore themes that might otherwise stay hidden, as was the case for Cochrane for many years. George Herbert Mead argued that mind, self and society emerge in ongoing social interaction. By drawing on theatre methods, we explore the moment-to-moment interaction in the present, where the actor works from experience, as do the other participants and the facilitator. Together they explore a fictitious situation that is linked to known practice, yet engages the unknown in the known. The fiction feels less dangerous. Together, through a number of iterations, people change their practice as an improvised response to the resonance of the situation as it unfolds. Together they weave a new, believable, healthcare narrative of practice to life that makes sense.
Footnotes
Acknowledgements
We would like to thank the patients and health professionals in Denmark who took part in the chronic pain theatre workshops, the conference participants at the Health and Illness conference, Tenerife, 2016, and the very active nursing students at Kingston University. We also thank John King and Karen Norman who persuaded us to work with the 300 nursing students at Kingston University.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.