Theatre in Health and Care

Theatre in Health and Care

Also by Emma Brodzinski MAKING A PERFORMANCE: DEVISING HISTORIES AND CONTEMPORARY PRACTICES (Co-authored with Helen Nicholson and Katie Normington)

Theatre in Health and Care Emma Brodzinski Senior Lecturer, Royal Holloway, University of London, UK

© Emma Brodzinski 2010 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted her right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2010 by PALGRAVE MACMILLAN Palgrave Macmillan in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN13 978–1–4039–9708–1

hardback

This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Brodzinski, Emma. Theatre in health and care/Emma Brodzinski. p. cm. Includes bibliographical references and index. ISBN 978–1–4039–9708–1 1. Theater in medicine. 2. Theater—Therapeutic use. 3. Performing arts—Therapeutic use. 4. Drama—Therapeutic use. I. Title. R702.5.B76 2010 616.89'1523—dc22 2010023766 10 9 8 7 6 5 4 3 2 1 19 18 17 16 15 14 13 12 11 10 Printed and bound in Great Britain by CPI Antony Rowe, Chippenham and Eastbourne

In loving memory of Lavinia Jessie Richardson

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Contents List of Illustrations

ix

Acknowledgements

x

Introduction: Theatre in Health and Care: A Developing Field

1

A developing field

1

Perspectives on health and care

3

Arts in health

8

Research and evaluation

10

Art or instrument

15

Theatre in health and care

19

Outline of the project

22

1 Embodied Spaces: Theatre in Health Institutions

26

Introduction

26

Institutional context

26

IOU Theatre

32

Theatre-Rites

40

Big Apple Circus Clown Care Program

45

Conclusions

53

2 Specialist Knowledge: Theatre in Health Education

56

Introduction

56

Health education and approaches to health

56

Theatre and social change

59

Theatre in Health Education

62

NiteStar

68

Nalamdana

76

Conclusions

86

vii

viii

Contents

3 ‘But I Already Have a Voice …’: Ventriloquism, Theatre and the Healthy Citizen

89

Introduction

89

Legislative context

90

The voice of theatre

92

Mind the Gap

95

The Lawnmowers

105

Conclusions

116

4 Superficial Wounds: The Problems and Possibilities of Medical Simulation

119

Introduction

119

Context

119

The development of simulation

120

Troubling simulation

123

Women and Theatre

126

Operating Theatre

135

Casualties Union

142

Conclusions

149

Concluding Thoughts: Performance Indicators

151

Appendix: Other Useful Resources

160

Notes

167

Bibliography

170

Index

180

List of Illustrations 1 Performers from Ladder to the Moon interacting with an audience member

17

2 Dr Stubs blowing bubbles through a stethoscope

52

3 NiteStar company members in Sex and Other Matters of Life and Death

73

4 The Lawnmowers in Walk the Walk

109

5 A Casualties Union member in a car-crash exercise in North London

148

ix

Acknowledgements This book has been developing for many years and the material has been presented in various forms at a number of conferences. I would like to say thank you to my peers for the thoughtful feedback and insightful questions that they offered throughout this period. Thank you also to Paula Kennedy and her team at Palgrave for commissioning the book and for their patience in seeing the project through. It has been a real pleasure to meet so many dedicated and talented artists during the research process for this book. I would like to thank them for their sheer generosity and openness in sharing their working processes – allowing me into their rehearsal rooms, their performance spaces and sometimes even their homes. To all the artists mentioned in this book thank you. I hope that I have captured something of the vibrancy and skill that you bring to your work. I was fortunate to be awarded a grant from the Arts and Humanities Research Council to carry out research visits in connection with this project and I am very grateful for the opportunity to witness a range of practice. Thank you to my colleagues in the Drama Department at Royal Holloway, University of London who provide a supportive and stimulating environment within which to work. Thank you also to my students who continue to educate and inspire me. Special thank yous go to Sarah Gorman and Deborah Munt who gave thoughtful and insightful feedback on draft material. Thanks too to Gerry Harris and Lib Taylor for their support of the project. Many thanks also to Johanna Govan and Mark Richardson who were excellent and resourceful research assistants. Thanks more generally to my family and friends whose love and care help keep me healthy. I am grateful to the Brodzinski triplets for keeping kicking to a minimum during the writing up of this book! Also thanks, of course, to Harvey the Staffordshire Bull Terrier for constant companionship and deep thoughts!

x

Introduction Theatre in Health and Care: A Developing Field

A developing field I carried out a recent search on the NHS jobs website with the keyword ‘arts’ and it brought up 146 results – 139 of these related to posts in ‘state-of-the-art’ facilities; six were arts therapists’ posts; and one was for an assistant on an arts and health project based in the facilities directorate of a large regional hospital trust. Although unsystematic and lacking in scholarly rigour, which I acknowledge may not be the best way to begin a book, this research task does offer some information on the current position of arts in health practice in the UK. Firstly, it acknowledges the investment in health under the Labour government, which saw spending in the area double in real terms after 1997 as state-of-the-art healthcare, and particularly public health initiatives, were made a priority. Secondly, it represents a development in the status and proliferation of the art therapies within mainstream healthcare. This can particularly be seen to be related to the registration of arts therapists with the Health Professionals Council which monitors health and care practitioners. Finally, it is testament to the fact that there are arts and health professionals working within the NHS even if they are few and far between – one job out of 146 does represent an improvement. The developing area of arts in health, the growth of arts in health professionals and the emerging scholarship within the field are at the heart of this book. I shall be considering the ‘state of the art’ in terms of current practice and exploring the dialogue between the arts in health and, more specifically, theatre in health. I bring an active interest in 1

2 Theatre in Health and Care

the field developed over some time. I began by working with Vital Arts at the Royal London and Barts Hospital and have since collaborated with Open Art, an arts in health organization based in Huddersfield. As well as practical engagement I have conducted research and contributed to policy documents. I have also taught on the Performing Medicine course, sharing findings from my research interests on the representation of health and medicine in performance. Most recently I have been involved in a project that has been examining creativity in health and care – with a particular emphasis on the health and care workforce. It has been a great privilege to be involved in this work and I have been honoured to witness a range of innovative and efficacious projects. I hope that the research represented here will be of use to the colleagues whom I have met along the way – arts, health and arts in health practitioners; professionals in related fields; and students across the fields of medicine, health and care and the performing arts. Even though I also work as a dramatherapist, or perhaps particularly because I am a dramatherapist and aware of the rigours of that particular discipline, I will not be including the work of arts therapists in this survey. I see my research in arts in health as running in parallel to my therapeutic practice but acknowledge the differences between them. The British Association of Dramatherapists (BADTh) have carried out a thoughtful enquiry in this area and their website provides a useful definition of the boundary between the two practices. To the question ‘What is the difference between drama in health or education settings and Dramatherapy?’ it answers: Dramatherapy is a psychological therapy. This means that the process of the therapy and the relationship between the therapist and client is of prime importance. During their training, Dramatherapists gain an in-depth understanding of how to combine the art form with psychotherapy practice … Artists working in health care or educational settings may engage people in creative projects that will enhance well-being and increase self-esteem. Their input may be deemed to be therapeutic rather than providing the in-depth therapy offered by Arts Therapists. (www.badth. org.uk/) It is the particularity of arts in health and, within that, theatre in health that this book seeks to address and this introduction aims

Introduction

3

towards some working definitions of health and care, arts in health and (applied) theatre in health. This chapter begins with a brief exploration of the discourses of arts and health. I then offer a potted history of arts in health practice in the UK in order to provide socio-historical context for the rest of the study. While the book often focuses on examples of practice from Britain, the theoretical framework seeks to place those practices within a global context and draw out principles of practice that might be applied internationally. The initial review in the introduction also includes a consideration of the place of performance among other arts in health practices. I take time to consider the problems and possibilities of evaluation within the field which opens up debates that are revisited later in the book. Finally, the introduction will explore the research methodology for the book, setting out the selection process for the case studies which are the subject of the main body of the text and foregrounding their role as indicative examples which gesture towards a wider range of practice. I begin with the dialogue between arts and health which sits at the core of this book.

Perspectives on health and care In his 1959 Reade Lecture, British scientist and novelist C. P. Snow articulated what he saw as the breakdown in communication between the sciences and the humanities – which he identified as the ‘two cultures’ of contemporary society (1993). He perceived a lack of compatibility in ways of thinking with what he broadly characterized as a social-constructionist approach within the humanities (that sees knowledge as socially constituted), and a belief in objectivity within scientific method. Fifty years later more subtleties are recognized in this distinction as quantum theory is embraced more widely, and subjectivity within the sciences is acknowledged. This has brought a different perspective on scientific method but it is still possible to identify what arts in health researcher White terms ‘cultural antagonism’ between the disciplines (2009: 14). Thus arts in health faces the challenge of looking to combine two aspects which sit either side of the divide, as health and arts/theatre are commonly separated into categories labelled science and art.

4 Theatre in Health and Care

Sociologist Hardey identifies a biomedical model of medicine emerging in relation to the development of the natural sciences in the Renaissance period (1998: 5). Breakthroughs in scientific knowledge such as the publication in 1628 of Harvey’s theory that the heart acts as a muscular pump moving blood around the body through the blood vessels affected the way in which medical practitioners approached the body, fundamentally introducing the idea of the human form as a machine. Hardey describes the new biomedical model as ‘dualistic, mechanistic, reductionist, empirical, interventionist’, whereas that which came before in terms of healthcare and healing may have been seen as a more holistic approach (1998: 9). The new medical practitioners sought to use scientific methods of observation to identify disease and prescribe a treatment. They also made use of technology in their ministrations to patients. Rather than a more holistic emphasis on the well-being of a person Hardey suggests that, from the Renaissance period onwards, health was seen as an absence of disease measured by empirical markers. In more recent years the biomedical model of medicine has been challenged. In particular, during the 1970s, sociologists shifted their critical attention from what was seen as an ‘illness perspective’ to what was proposed as a ‘health perspective’ (Hardey, 1998: 28). This shift embraced philosophically and politically radical approaches to health. Thinkers on the left such as Illich critiqued the practice of medicine and its power over people’s bodies. Indeed, Illich went so far as to argue that medicine may be harmful – introducing the idea of iatrogenic disease.1 Other critics explored spiritual, emotional and social aspects of health and how they related to the physical body. So, for example, the so-called anti-psychiatry of R. D. Laing sought to challenge the fundamental belief in the psychiatric practice of the 1960s and 1970s that considered mental illness as a biological phenomenon without any socio-political resonance. Laing understood psychotic symptoms as expressions of distress and perceived the family as the genesis of much mental disturbance, which necessitated the consideration of context when diagnosing or treating clients. The 1970s saw a move towards what is termed the social model of health. This model of health takes into account how aspects other than the presence or absence of disease have an impact on an individual’s health. Some of these wider determinants might be a person’s culture and belief system or levels of income. Health might also be dependent

Introduction

5

on access to good-quality housing, opportunities for educational attainment, and people’s social and community networks. There is a recognition, then, of a whole system of health which relates to wider environmental, political and socio-economic conditions in which people live. This wider understanding of health has thrown a different light on governments’ responsibility in terms of health provision. The World Health Organization (WHO), the leading authority for health for the United Nations, acknowledges that governments are the stewards of health resources and that the provision of healthcare embraces all the goods and services designed to promote health (www.who.int). A central aspect of the Welfare State established in post-war Britain was the provision of the National Health Service (NHS) which promised healthcare free at the point of delivery. However, the perspectives on health emerging in the 1970s proposed that the formal provision of health services is only partly responsible for the impact on health. Indeed, as arts in health researcher Smith notes, ‘estimates of the contribution of health services to overall health are placed at 20%’ (2003: 7). Smith goes on to cite recent research which suggests that issues such as self-esteem and participation in social networks have a significant influence on an individual’s health (2003: 8). This had led governments to have a wider perspective when planning for health provision. The recent Labour government in the UK engaged in some radical experiments in health promotion. Initiatives such as Health Action Zones and Healthy Living Centres were designed to tackle social issues relating to health and well-being.2 Tessa Jowell the (then) Minister for Public Health stated: What I really hope is that the Healthy Living Centres will have a rounded vision which encompasses the psychological dimensions of health – which seeks to work with local agencies to alleviate the problems which feed a mentality of despair and which tries to build the self-confidence, self-esteem and self-reliance which is the bedrock of good health. (Quoted in White, 2005: 8) This commentary indicates how the UK Labour government sought to have a more holistic perspective on well-being and to pay attention to the social model of health. A second wave of this thinking was enacted through the 2004 public health White Paper Choosing Health. This document signalled a move away from an emphasis on

6 Theatre in Health and Care

illness to an emphasis on health. It also represented a cultural shift in its focus on transferring responsibility for healthy behaviours from health professionals to the individual. There has always been a balance between the duty of government and the rights of the citizen and, in this initiative, the British Labour government adopted a preventative policy of providing people with information and opportunities to make what were seen as ‘healthier choices’ (Department of Health, 2004). This strategy was supported by proposals for more individualized and person-centred care. While White’s critique of this agenda as a ‘consumerist approach’ which encourages an individualistic perspective and emphasis on ‘lifestyle choices’ may well be right, this development in policy can be seen as part of a wider shift in perspective on health and care provision which has been termed the ‘New Public Health’ (White, 2009: 41). The New Public Health can be characterized as an approach which is concerned with both environmental elements and preventative measures at a personal level with the provision of therapeutic interventions as appropriate to achieve change. Ashton and Seymour, both of whom have worked for the WHO, state: The New Public Health goes beyond an understanding of human biology and recognises the importance of health problems which are caused by lifestyles … the environment is social and psychological as well as physical. (1988: 21) This emphasis on the social and psychological elements of health provided a receptive environment for the exploration of how the arts might be of value within healthcare provision and for an emerging dialogue between the arts and health. A return to the use of arts in health and care can be seen as a return to traditional healing practices, before the Renaissance and the emergence of Snow’s ‘two cultures’. Miles, a specialist in the history and theory of art, observes that healing was historically seen as an art and, within Hippocratic medicine which treated the humours and understood sickness as an imbalance within the body, the arts were often employed to soothe the spirit of the ill person (1997: 241). Thus, Apollo was the god of both medicine and poetry, and music was an integral part of the worship at the temple of Apollo at Delphi as it was thought to aid the healing process. There is also a long tradition

Introduction

7

of visual art within the hospital setting. In early modern European hospitals devotional images were often displayed not only to offer comfort to the sick but also to exhort them to prayer for healing. For example, the architect Wells-Thorpe notes that the fifteenth-century hospital Santa Maria della Scala employed leading artists and sculptors to create an uplifting environment (2003: 12). There is another tradition, too, that of the community arts movement, that sought to promote well-being through engagement in artistic activity. Counter to the dehumanizing experience of the factories the Arts and Crafts movement, which emerged in England in the late nineteenth century and then spread to America, sought to enable the craftsperson to take pride and gain fulfilment from their labours. The beauty of the objects that were produced – furniture, pottery, etc. – were also intended to enhance the lives of those who used them. These principles of the social role of art and engagement with arts activities at a local level to produce life-enhancing artefacts can be seen to be at the heart of the community arts movement that emerged in the UK in the late 1960s. This movement, however, also encouraged amateur involvement in arts and crafts activities as a means to promote well-being. Within such cultural developments it is possible to identify the genesis of arts in health in the contemporary sense of the term. At this point it seems important to acknowledge that I am using the terms ‘arts in health’ and ‘theatre in health and care’. I do not make a distinction between this phraseology and other titles such as arts and health, arts for health, healing arts and so forth and have only selected ‘arts in health’ as it is the most familiar to me. Broadly speaking I agree with the definition that the Centre for Medical Humanities offers which states that arts in health are: creative activities that aim to improve individual/community health and healthcare delivery using arts based approaches, and that seek to enhance the healthcare environment through provision of artworks or performances. (Quoted in White, 2009: 2) I also agree, however, with Smith’s opinion that the desire to pin down arts in health activity through an agreed definition is a red herring that may work to limit the scope of the field (2003: 9). Like Smith, I am aware that the field is still developing and that it may be too early to offer definition. Thus a general sense that arts in health

8 Theatre in Health and Care

aim to apply artistic processes to offer a perspective on health and/or improve health and well-being seems to be a useful holding position. It is my hope that this book will highlight how theatre in particular may function within this milieu.

Arts in health It is important to acknowledge that arts in health has been developing as a particular mode of practice within the last 30 or so years, and tracing that trajectory, as well as its historical precedents, is useful as a means of contextualizing the contemporary practices I will be examining. White traces the general beginnings of arts in health in the UK to the community arts movement of the late 1960s which championed art with a social purpose (2009: 13). In particular White cites the SHAPE network, developed in the late 1970s and early 1980s, as an early example of arts in health practice. The SHAPE network is still in effect today and is a disability-led arts organization which initially focused on improving access to the arts for service users.3 Also, in 1973, Peter Senior founded the Manchester Hospital Arts Project and began working as a ‘hospital artist’ making work for and within the hospital (Senior and Croall, 1993: 9). It is also important to note at this point that, while commentators such as White make a distinction between hospital-based arts practice and community arts (which he sees as being more concerned with health promotion) (2009: 31), the work I present here encompasses a range of dramatic and aesthetic practices and explores how they might be applied to different contexts. While I acknowledge that context is incredibly important for applied arts practice, I also recognize that there are a shared history and concerns and so within this study I will not be separating out the two. Senior’s Manchester project was groundbreaking and he reports the way in which the work took hold and developed. Senior notes that, by 1983, 65 British hospitals were funding some sort of arts provision and, by 1992, there were at least 300 projects around the country (Senior and Croall, 1993: 15). This, alongside the development of community-based arts in health projects in primary care facilities, led to the recognition of this type of work as a distinct sector. Since the mid-1980s the King’s Fund, an independent charitable organization with a brief to improve health and care within the UK, had supported

Introduction

9

an Arts in Health Forum and in January 2000 they facilitated the establishment of a National Network for the Arts in Health (NNAH), alongside the London Arts in Health Forum.4 The National Network enabled the creation of a central archive as well as a clear focus for advocacy work within the field. In addition, the NNAH provided its membership (which reached approximately 500 in its first year) with a funding guide, reading lists and a membership directory as networking and sharing good practice was recognized as very important for the development of the field both nationally and internationally.5 A particular aspect of the UK experience has been the interaction of government agencies and arts in health practice. In 2000 the Health Development Agency published: Art for Health: A Review of Practice in Arts-based Projects that Impact on Health and Well-being. The agency’s reporters identified over 200 community-based arts in health projects which were funded by a mixture of local authorities, charitable trusts and regional arts boards. The responses received to the Health Development Agency’s questionnaire led the researchers to conclude that the employment of arts could have significant health benefits, particularly in the area of mental health. In 2002 Arts Council England produced Arts in Healthcare, a directory of arts in health organizations and projects which gave a sense of the vibrancy and diversity of the field. Governmental interest in the arts in health appeared to grow during the early years of the new decade. In 2003 the Institute for Public Policy Research hosted a seminar series on the social impact of the arts and, in the same year, Ambitions for the Arts committed Arts Council England to establishing an effective partnership with the Department of Health and considering regional and local partnerships with key organizations already engaging in arts and health (2003). In 2004 the Department of Health launched a review of arts in health. Also in 2004 Arts Council England publicized its commitment to developing a national arts in health strategy. Alongside the shift in emphasis signalled by the Department of Health’s publication of Choosing Health, it seemed that there was a real groundswell of interest in the potential of arts in health and care. However, as Lara Dose, director of NNAH observed: Politicians appear to be sufficiently brave to set targets high enough to raise eyebrows and expectations, but too scared to try anything innovative to ensure these are achieved. (2005: 16)

10 Theatre in Health and Care

The National Network itself ran out of funding in 2006 and had to suspend its activity. Funding pressures within the NHS meant that Health Action Zones had been ‘wound up’ by this point and many Healthy Living Centres were struggling to maintain themselves. The joint prospectus for arts in health by Arts Council England and the Department of Health was delayed in publication. White suggests that this was because of concern about criticism in the press (2009: 32). There certainly had been negative media coverage of arts in health activity. In November 2005 the Guardian wrote of the ‘boiling insanity’ of the NHS buying ‘aesthetically pleasing but medically useless objects’ (quoted in Smethurst, 2006: 8). Practitioners were aware of this dynamic too. Senior quotes an arts co-ordinator in a Midlands hospital who states: ‘We have to play down what we’re doing. It’s controversial; some people are not sure about money being spent on art’ (Senior and Croall, 1993: 77). Yet, in 2007, A Prospectus for Arts and Health was produced with the foreword announcing the intention of ‘celebrating’ the benefits of the arts for health and well-being (Arts Council England, 2007: 2). Although it was launched against a background of cuts in arts provision, the prospectus at least signalled a recognition of the wealth of good practice within the field and the potential for developing the work further.

Research and evaluation A key section within A Prospectus for Arts and Health is ‘research and evidence’, which considers the data available to substantiate the impact of arts and health. The notion of evaluation and the importance of evidence has always been important within the arts in health field, although it has also been contentious in terms of what constitutes evidence. Some within arts and health have looked to empirical data, the language of the scientific culture of healthcare, while others have defended a more qualitative approach. So, for example, nursing researchers Lambert and Lambert note significant increases in salivary immunoglobin A (IgA) (an antibody that protects against infection) as a result of interaction with arts-based activity (quoted in Warren, 2008: 185). Research scientist Staricoff, however, concludes that exposure to arts in hospitals can diminish stress levels and ‘help take patients’ minds off medical problems’ (2001: 6). The different negotiation of outcomes represents different approaches to health.

Introduction

11

Most arts in health projects seem to assume a social model of health with a more holistic outlook on well-being, but this is not always explicitly stated. Arts in health practitioner Angus notes the problems that these assumptions may cause. He states: Arts for health appears to be working in the context of medicine and the health service, and so it may be assumed that it has similar aims. However, it is often trying to do something quite different to medicine. (1999: 1) Where health providers and governmental organizations may be looking for particular, measurable clinical benefits from a project, arts practitioners may be attempting to have an impact more in terms of what arts in health researchers Kilroy et al. term ‘eudaimonic well-being’ – a holistic experience relating to congruence and the feeling of authenticity (Kilroy et al., 2007: 20). However, there may be complementary aims that can be negotiated between the parties. Angus notes the importance of having clearly stated aims for the projects that all the stakeholders can sign up to. He also suggests that the development of a clear rationale will support a rigorous discussion of core issues around health and well-being within the evaluation reports of arts in health projects (1999: 5). Angus posits that arts in health activity, and the discussion between the ‘two cultures’ that it engenders, may serve to develop a broader understanding of health. This is a view that the editor of the British Medical Journal appears to share. In an editorial in 2002 he wrote: ‘If health is about adaption, understanding and acceptance, then the arts may be more potent than anything medicine has to offer’ (quoted in Smith, 2003: 28). There is, then, a recognition of the efficacy of arts in health, but the field is still struggling to develop a framework within which to reflect on the impact of such work. Evaluation is always a hot topic at arts in health conferences, sometimes perhaps to the detriment of other possible discussions, but it is a subject that sits at the heart of the field as it often hinges upon the dialogue that is necessary between arts practitioners and health practitioners. It is possible for health and arts practices to inhabit the same space without engagement, but interaction rather then co-existence is necessary if arts and health practitioners hope to explore the connections between disciplines and develop new

12 Theatre in Health and Care

pathways. Ideally, interdisciplinary endeavours involve artists and clinicians as equal partners in collaboration, who have a level of respect and understanding of each other’s work to ask interrogative and apposite questions – as well as the ability to push for new questions and new answers. Such a process, however, faces the problem of communication in that each party in such an encounter will have its own particular frame of reference and concordant professional language which may be a barrier to interaction. White quotes Gail Bolland and Josie Aston, working on the TONIC (the arts programme at Leeds General Infirmary and St James’ Hospital), who reflect upon the difficulties in communication that they face in their role of facilitating artwork within a hospital setting. They state: ‘There’s a lot of jargon in the NHS, even the names of the departments. We need to understand their culture before we can begin to change ours’ (quoted in White, 2003: 14). There is a general assumption (not always true) that artists are intuitive and clinicians are evidence based, and that these aspects will need to be balanced within any given project. Sensitivity to developing appropriate methodology for particular contextual frameworks is necessary in order to ensure that realistic objectives can be met. Detailed understanding of the particular dynamics of a project is also important. It may be that clinician and artist are articulating similar findings but in different ways and that a process of interpretation is necessary. It appears that rigorous dialogue is called for, particularly in an environment where strategic policy, through increasing emphasis on person-centred care and improving health and care environments, can be seen to draw arts practices and health practices into ever closer relationship. In order to develop experimental and exploratory projects, the clear articulation and reception of expectations, possible methodologies and findings are of utmost importance. As thoughts materialize in words, language is the most significant mode of communication. Linguistic theory posits that, in order to have effective and equitable communication between parties, either a common language or a translatory process is required. It is debatable whether a common language has been achieved in the realm of arts in health. It is also arguable as to whether a common language is desirable, as such a compromise would run the risk of losing the richness and descriptive powers that professional vocabularies contain. Rather than generalism, which may iron out the subtleties of language and shadings of

Introduction

13

meaning, it seems that pluralism in the practice(s) and idiom(s) of arts in health is a useful methodology. Yet, while this ensures a vibrancy of approach, it also necessitates a translatory negotiation. The translatory process at its best is one which harnesses difference and expands understanding rather than being reductive. This is a complex process and, in a paper co-written with Deborah Munt, I explored the professional role of, what we termed as, the arts in health broker who may act as a translator within the process (Govan and Munt, 2001). The broker role may be fulfilled by people from different fields – administrators, artists, clinicians, etc. – who will all bring their particular specialisms to bear on the role. However they come to it, the role of the broker appears to demand the same capacities. The key qualities of a broker include the capacity to: analyse a situation; to problem solve; to synthesize; to undertake research; and to identify possibilities. Arts in health brokers may work as itinerant practitioners or as part of a larger arts organization or health institution, yet, wherever they are sited, brokers are well versed in both arts and health vocabularies and their fluency in both languages helps to facilitate equitable and effective communication which itself can open up new possibilities. The broker may be instrumental at different points within a project but is most likely to be important at the development and evaluation stage. An important issue within the area of development is the cultivation of projects that are rich in dialogue and allow for creative synthesis. Development is a key stage in exploring possibilities and setting the parameters of a project, and effective communication between the collaborating parties is obviously an important element in this process. As already stated, communication within an arts in health project may be problematized by the fact that participants come from separate fields of experience with parallel frames of reference and differing vocabularies. A broker’s translatory skills are paramount at this stage as inadequate dialogue can seriously impair the realization of experimental, exploratory and groundbreaking projects. Further than that, an arts in health broker can have an important catalytic role to play in the development of a project. Rather than working at the lowest common denominator of understanding between collaborators, a skilled broker can facilitate an expansive, yet contextualized, understanding of differing interests and expectations. The broker may be instrumental in pushing boundaries – in terms of both health outcomes and arts

14 Theatre in Health and Care

practice – and this is because the mediatory role may work to encourage trust and thus the right climate for experimentation. Mediation can also serve to ensure that the equality of the partners within the project is maintained. For example, the broker may be part of a work to identify a need or opportunity within a health and care setting and, as a result, commission an artist as an expert/consultant fit for purpose. This type of practice, focused on clarity of aims and objectives, should avoid an artist being asked to deliver an art form that is not suited to a particular situation. It should also avoid the compromising of health outcomes and guard against misunderstandings of what is required and what is deliverable. Evaluation is where the translatory process is brought into focus most clearly. It is often the most contentious area of a project, with arguments about evaluation being too reductionist for the artist – taking away from the essential experience of creativity for participants – while the clinician or health manager may require empirical evidence of health benefit. The important question appears to be whether different parties are talking about the same thing but in different ways. It would appear that it is possible to apply different interpretations to the same events and, through the application of different professional competencies, to develop an evaluation process that satisfies all parties. White suggests that the CORE evaluation model (Clinical Outcomes in Routine Evaluation) may be a useful tool for arts in health evaluation (2009: 214). CORE has been developed for use in psychotherapy and counselling and, as such, it addresses ‘well-being’ issues relating to emotional as well as physical states. Yet, it is also recognized within the NHS as a standardized system for measuring clinical outcomes.6 Such systems do seem to be a useful reference point but, as White himself notes, would need adaptation to arts practice. Indeed I might suggest that, while acknowledgement of benchmarking practices is important, it is useful for evaluation methodologies to be part of a negotiation at the beginning of any arts and health project in order to develop appropriate methodologies for particular contextual frameworks that are sensitive to particular outcomes of particular collaborations. This will undoubtedly mean a rigorous process of negotiation and exploration between the parties involved and here again a broker can be useful, enabling the practitioners to enter into a process together and considering what can, as well as what cannot, be achieved.

Introduction

15

Art or instrument White notes that ‘arts in health is often referred to as a “tool” to improve health, yet this seems to reduce it to mere functionality’ (2003: 4). Theatre scholar Jackson too, in his examination of applied theatre practice, explores the nuances of arts activity in the service of another agenda – a distinction that he summarizes as ‘art or instrument’ (2007). It seems, particularly within arts in health, that the arts aspect may be viewed as a means to achieve a health goal (i.e. an instrument) rather than exploring the qualities of the arts activity in itself. Practitioners recognize that arts can be a very useful vehicle for health messages and a means to engage with communities, but Sue Roberts exhorts practitioners to maintain the value of the particularity of the art form itself. She warns: an arts project needs to be absolutely crystal clear about its artistic purpose and integrity … [or] it will become a health project which just happens to use the arts, rather than arts development in a health setting. (Quoted in Angus, 1999: 8) In terms of the two cultures speaking to each other it seems important that they should maintain equal status rather than one purely serving the other. In practice this often means that practitioners need to have a keen awareness of the problems and possibilities of their specialism and to be in dialogue with the health practitioners and services that they are involved with in order to consider how the social and aesthetic functions of art may be brought into play. There are many different ways of negotiating projects which may fall under the arts in health umbrella. Some may be educational projects working to deliver particular messages in an engaging manner; some may be focused on encouraging a sense of community through collective creativity and, at the same time, identifying the health needs within that community; some may offer the opportunity for participants to gain creative skills and hence enhance a sense of personal well-being; and some may be ‘pure’ art – that is, projects which do not have particular health outcomes in mind but seek to present artworks in a new context which might be a hospital or a health centre. Within this range of practice it is important that all parties are clear on the arts/health emphasis and how the art form will be employed.

16 Theatre in Health and Care

Many artists working within the health and care sector are orientated to work from a community perspective and a political belief in the right to access to the arts and the potential for the arts to open up possibilities. Nevertheless, it is important that they also recognize their work as aesthetic practitioners. Here I am using theatre practitioner Boal’s definition of art as a ‘special kind of knowledge’ (2006: 20). The particular kind of experience that interaction with the arts might engender is that which is seen by Jackson as holding the potential to take people on some kind of journey – psychological, emotional – the kind journey we might not have taken otherwise. It may involve in a retreat from the everyday, or it may be a detour, offering vantage points from which to see the everyday in a new light from a new angle. (2007: 36)

of us us or

Jackson notes that the aesthetic experience is that which arises from the total experience of the work once it has been shared with and received by the audience. It exceeds the intention of the creator(s) and may even provoke a range of responses as it is processed by spectators. The recognition of the aesthetic dimension of an arts in health project opens up the potential of the work from a functional transaction to a creative encounter. Acknowledging the aesthetic aspect of the work also recognizes the active, co-creative, role of the spectators. Arts in health companies such as Ladder to the Moon – a theatre company who work with older people and staff in hospital and care homes, particularly with individuals who are living with dementia – are guided by a mission statement to ‘create bold and inventive theatre’ alongside improving quality of life and see everyone as having the right to participate in cultural activity – working with everyone within the settings they find themselves in (www.laddertothemoon.co.uk) (Figure 1). The invitation to engage with high-quality artwork offers a different timbre of experience which goes beyond the interaction with the performers and remains after the event itself. In investigating a history of art in hospitals Baron quotes the words of Albert Camus in noting that ‘In this world there is beauty and there are the humiliated and we must strive, hard as it is, not to be unfaithful either to the one or to the other’ (1999: 21). It seems that a balance between the aesthetic and social impact allows for effective arts and health practice.

Introduction

17

Figure 1 Performers from Ladder to the Moon interacting with an audience member

Often there will need to be negotiation over the emphasis on process or product. Artists may be focused on realizing a particular vision for their work which does not allow space for others to participate, or health practitioners may be looking for a particular kind of intervention within a tightly defined timeframe which restricts consultation and organic development. Cleveland Arts note the problem that they have come across in a range of projects. They state: ‘there is a tension between the artistic and the social aims and objectives of the programme … a more useful focus could be on the value of the creative process’ (quoted in the Centre for Arts and Humanities in Health and Medicine report Seeing the Wood for the Trees, 2004: 17). The tradition that emerges from community arts and the more experimental practice of the avant-garde and neo-avant-garde is an emphasis on the creative process as a means of exploration and expression. The collaborative and improvisatory process of making a piece of work and the journey of discovery it entails may be more significant in terms of impact on self-esteem, community building and so forth, than what is produced at the end of a project. Again, there needs to be dialogue and understanding from all the stakeholders as to where the emphasis of the project is going to lie in order that frustrations and misunderstandings are minimized.

18 Theatre in Health and Care

There may be suspicion of working practices on both sides of the arts/health team. Senior reports the experience of Ruth Priestly who ran a project at the Royal Victoria Hospital in Belfast. She said of the work: ‘It has made people more aware of different forms of art, and is helping break down limiting ideas about what art is, and where it belongs’ (quoted in Senior and Croall, 1993: 41). The biggest hurdle she felt was being respected as a co-professional. She reports: ‘People make all sorts of wrong judgements about artists: that they’re lazy, they don’t have any money, they take drugs and so on’ (quoted in Senior and Croall, 1993: 41). Priestly found that it took time to build up trust and to convince the hospital staff that she had sufficient expertise. The presence of an artist can bring a very different dynamic into play and they may be seen as, or even actively agitate as, a threat to existing practices. The health and care sector can be seen as having a risk-averse culture. In one way this is appropriate and welcome – the health and care sector is often dealing with very vulnerable people and so the desire is to maximize safety. Health and care researcher Titterton examines the emphasis on risk assessment within the health and care sector in the UK and the drive to develop guidelines for practice which will minimize uncertainty (2005: 73). Titterton understands this movement to have been bolstered by the agenda of clinical governance which has heightened awareness of risk management among managers within the field. Denise Tanner critiques risk management’s emphasis on the recognition and management of problems. She warns that such a problem-finding approach may be depersonalizing as it allows professionals to overlook individuals and their needs within a management framework which may, in turn, be experienced as limiting and restrictive rather than empowering (quoted in Titterton, 2005: 90). So the problem which faces artists working within the health and care sector is how to encourage creativity in a risk-averse climate. Senior counsels a sensitivity to and understanding of the structures within which the project is functioning but also a distance which allows for creative thinking and new possibilities (Senior and Croall, 1993: 41). With such complex negotiations in play, it is important that arts in health is recognized as a particular kind of specialism which requires particular skills and support. Senior suggests that artists working in this sector may need to be encouraged to view their artwork in a different way which opens it up to others (Senior and Croall, 1993: 7).

Introduction

19

Experience and training regarding the particular demands of the settings that they are working within will enable artists and their partners to develop projects that are both more efficient and more innovative. White also recommends professional support and supervision for those working in health and care environments in recognition of the particular challenges of such work (2009: 207). There are now some training courses that specialize in preparing students for work in the health and care sector. For example, the Arts, Health and Wellbeing Programme at the University of the West of England (UWE) includes a module on ‘Participatory arts facilitation in health and social care settings’ (www.uwe.ac.uk). As the field continues to develop, more arts in health professionals are emerging, building up a wealth of experience and sharing good practice. There is a need to document this practice and hopefully this book, alongside other research in the field, will work towards disseminating this information.

Theatre in health and care In other accounts of arts in health practice, theatre appears to be under-represented. For example, in Staricoff’s nationwide survey of arts in health activity (2001), theatre and drama in health are only mentioned twice, with most of the work documented relating to music and visual arts interventions. Staricoff’s is not a biased survey, but a representation of the sort of work that is popular within the field. It makes sense that music and visual arts are more popular media within health and care settings as they are both more containable and more sustainable. Pictures on walls do not necessarily interrupt the day-today working of a health and care setting – although there are many examples of contentious pieces of work that have impacted upon particular units.7 Music may also be employed in the background to provide an ambience and, while it might not always be a harmonious encounter, does not need to take up the space and time that the performance of a play or a drama workshop would require. The basis of drama is interaction and, while that can prove to be a real strength when seeking to engage with a client group, it also places demands on a setting. People may feel much more exposed and vulnerable when invited to enter into a role-play exercise during a workshop than they do listening to a piece of music, and more thorough preparation for this kind of encounter and detailed follow-up are often needed.

20 Theatre in Health and Care

Drama workshops are also much more dependent on the personality of the workshop leader than a musical intervention might be. For all arts in health practitioners sensitivity is important, but it is especially necessary for the kind of emotional work that theatre may touch upon either intentionally or accidentally. Companies that may be used to more robust settings may need to engage in quite a shift of emphasis when working with people who are vulnerable and/or ill. Senior notes that there were concerns about the way in which theatre artists would be able to manage the particular hospital environment that he was working with in Manchester. He remembers partners saying: ‘we don’t want theatre groups coming in here with their clodhoppers on, shouting and swearing’ (Senior and Croall, 1993: 77). While this is a bold stereotype, most probably relating to political theatre groups of the late 1970s and early 1980s – the era that Senior is recalling – it may be that particular theatre forms are less accessible, and less appropriate, for a health and care audience than others. In this book I shall be examining a range of interventions which function within different environments. Another important issue in the context of health services that are constantly attentive to value for money is the ephemeral nature of theatre. Whereas a mosaics project may leave behind an environment-enhancing installation, there may be no physical evidence left of a theatre project which may have been very costly and labour intensive. Performance scholar Phelan observes: ‘Performance and theatre are instances of enactments predicated on their own disappearance’ (1997: 2). The visceral and in-the-moment nature of theatre can be a real strength in the work, and being ‘present to the moment’ a liberating and healing experience for participants. The performance may deal directly with particular issues or it may be a starting point for a journey of reflection or an access point for other kinds of interventions and services – for example, therapy or specialized health advice. The vibrancy of theatre might, however, be considered too intense for health and care settings. Loppert discusses the ‘Theatre for Health’ project that was launched at the Chelsea and Westminster Hospital where she was director of the arts project. She comments that the project was a nice concept, with its resonances of operating theatres and the links between hospitals and theatres – and it was decided that all

Introduction

21

the works of art should have a theatrical theme; but a hospital is not a theatre, and many of the works which were originally installed – photos of athletic dancers in leaping poses in a waiting room for less than healthy people; photos of toy theatres; fantasies on the movies; watercolours of theatre rehearsals – were inappropriate and have, where possible, been replaced. (1999: 77) The Chelsea and Westminster is one of the few hospitals that has spaces that are suitable for performance but it is clear that they are cautious about how to negotiate the theatrical encounter. I think it is of note that Loppert is describing documentation of the theatrical event, the detective’s chalk, if you will, that outlines where a body has been. Perhaps people might have been less disturbed by a live interaction with a rehearsal process than they were with its image? Dealing with the live encounter and not documentation has its own problems. The key issue for funders is often that it is hard to see where the money has gone. Thompson (2006), in his examination of applied theatre practice, discusses the efficacy of applied theatre. He notes that a hoped-for immediate transformation in the target audience as a result of an intervention may not happen but, instead, the experience of an applied theatre project may serve to provide tools and experiences the impact of which may not be realized until months, or even years, after the event, which clearly is not measurable in postproduction evaluations. Funders may, therefore, prefer to invest their money in tangible artefacts that enhance the environment. Theatre in health and care can be understood to come within the remit of ‘applied theatre’. Applied theatre is a fairly recent category of practice that draws together work that is conducted outside mainstream theatre venues and that is often designed to be of benefit to the individuals and groups involved. Applied theatre is used as an umbrella term which covers activities as diverse as reminiscence theatre with elders, through theatre in prisons, to Theatre in Education. Research within applied theatre is attentive to both process and product and recognizes that practitioners may employ a range of strategies as appropriate to their context and client group. Research also recognizes the interdisciplinary nature of the subject area which draws upon educational theory, psychology, anthropology, linguistics, geography and so forth in order to explore and explicate the particular concerns of the context within which practitioners are working.

22 Theatre in Health and Care

As I have already noted, theatre ‘applied to’ a setting does not mean that it is devoid of aesthetic integrity. Indeed, many commentators view the aesthetic encounter as fundamental for the efficacy of applied practice. When beginning this research I believed that the book would very much reflect an applied theatre text with an emphasis on contextual detail and efficacy of practice. My research questions included: How can theatre practices be applied to the development and delivery of health and care provision? What definitions of health might be applied? What sorts of organizations are involved in this work? What sort of activities do they engage in? Why do some theatre practitioners seek to support and others to subvert the work of official health and care agencies? How do they articulate and evaluate project objectives? What is the effect of culture on practice? How do theory and practice relate? These questions have guided the research process and remain within the work. However, as the research progressed I realized that an important aspect of the study was the way in which the elements of performance – space, audience, story, the dynamics of the mimetic encounter – were brought to bear on work within health and care contexts. As a result the book has shifted to encompass a more general interrogation of what we might term the aesthetics of performance practice as they relate to the particular area of theatre in health and care.

Outline of the project There is a wealth of grass-roots activity within arts in health but, as the vibrancy of the work lies in on-going practice, projects often remain undocumented and without a developed framework of evaluation. There are current moves to rectify this, including a number of general surveys of practice, and I hope that this book will serve to speak to such developments in the field by providing an analysis of case studies, framed within a coherent interrogation of the application of theatre within the health and care sector. White discusses the dearth in research material and it is my hope that this book will contribute to the research culture of arts in health – not merely conducting evaluations of particular projects but taking a broader perspective on the field, considering underpinning theoretical issues and drawing out principles of practice (2009: 208). This project draws on a blend of qualitative research and the application of critical analysis

Introduction

23

which reflects the work of other researchers in this area. I was very fortunate to receive a grant from the Arts and Humanities Research Council (AHRC) which has enabled me to carry out fieldwork and has allowed me to meet with practitioners and participants and get a sense of how the practice works ‘on-the-ground’. Although the AHRC were generous, my resources were still limited and, in order to maximize impact, many of the examples are based in the UK. The book was never intended to be a comprehensive survey of the field, but to open out debates and discussions in the area, and I have undertaken to consider a variety of forms and contexts which reflect the diversity of the field, furnishing contextual detail as appropriate. This is significant as, particularly within this area, where work takes place often provides highly site-specific criteria that influence how the work evolves. The emphasis on British practice in the main body of the text pre-empts the detail in this introduction on the arts and health milieu in Britain. The indicative case studies are addressed within the text with reference to relevant theoretical models – so the negotiation of power is examined from a Foucaultian perspective as I highlight moments within theatre and health and care projects that resist the specializing gaze of medicine and promote the assertion of the patient’s narrative. In this way the book blends a programme of qualitative research and the application of critical analytical methods. I see the work as broadly sitting under the umbrella of applied drama and, like other research in this discipline, it is rooted in performance and theatre studies, yet the critical analysis borrows, as necessary, from related disciplines such as sociology, anthropology, education, psychology, politics, philosophy and cultural studies. The identification of key concepts provides a focus for enquiry, and this study of theatre in health and care will engage with multidisciplinary discourses with an emphasis on the conditions of theatre production and reception. The research aims to provide a critical examination of theatre in health and care interventions. I have taken a broad definition of theatre in health and care practice, and sections of the book will examine a range of contrasting interventions in areas such as service delivery, training and advocacy. I trust that focusing on current practice has allowed me to examine the significance of the live, theatrical encounter in a manner which allows the voice of the practitioners to come through and pays particular attention to the effect of context

24 Theatre in Health and Care

on the performance work under discussion. It has also enabled a state-of-the-art viewpoint on a field that has undergone significant growth within recent years. The ephemeral nature of performance means that it is difficult to capture – I have drawn on my own observations of practice and the observations of others, recorded documentation of performance and interviews with practitioners and participants. This is, of course, selective but I have chosen material which I hope will provide useful insight into a range of practice and contexts. The book is organized thematically, beginning with an overview of the field and then moving into more detailed exploration of particular modes of working, explored through reference to case studies selected to illustrate practice and act as cornerstones for discussion. The book is divided into four chapters, each dealing with a different aspect of theatre in health and care practice. Again, this is not an exhaustive account but an examination of key trends. Chapter 1 focuses on space and examines the use of theatre within institutional buildings. Drawing on the notion of the hospital as a human system, this section will consider projects which have endeavoured to ‘humanize’ health and care institutions through the use of performance-based practice, and how these have interacted with the practices of large establishments. Case studies include site-related work at Barts and the Royal London carried out by IOU Theatre and the on-going activities of the Big Apple Circus Clown Care Program in New York. Chapter 2 considers the efficacy of performance as a teaching tool and highlights the use of narrative as a communication vehicle. The chapter examines the relationship between drama and pedagogy and the critical and practical tensions which may arise in projects that seek to combine theatre and education. Key case studies are the community-based work of Nalamdana in southern India, and NiteStar, a pioneering peer-education programme based in New York. Chapter 3 takes a wider perspective on health and investigates theatre as a forum for the exploration of the politics of health and care. The particular focus is the employment of theatre models as a mode of advocacy for service users with learning disabilities. Work by companies such as Mind the Gap and The Lawnmowers is investigated in order to explore how the embodied nature of a theatrical intervention may speak to the democratization of health and care provision. Chapter 4 examines the ways in which the mimetic nature

Introduction

25

of theatre has been exploited to afford a safe space within which to practise the skills of being a medical practitioner. It analyses the work of professional training companies Women and Theatre and Operating Theatre as well as considering the large-scale simulations of Casualties Union. The conclusion to the book reflects upon the application of theatre to health and care and considers possible developments for the future. Due to the underdeveloped dissemination of information within this field I have also provided an appendix that furnishes contact details for the companies included within the book as well as an indicative list of other relevant resources. I hope that these will prove useful to readers. While this book cannot promise to offer any clear answers to the questions which surround the field of arts in health, I hope that it will add to the debate from the specialized perspective of the problems and possibilities of theatre.

1 Embodied Spaces: Theatre in Health Institutions

Introduction The hospital is like a living body; seen from the outside it is full of mysterious hidden processes which can fascinate and terrify us. Inside, patients and staff exist in a symbiotic relationship, moving around a complex system on a joint quest to heal. (IOU Theatre publicity material) This quote from IOU Theatre, a British company renowned for their site-related work, is indicative of their approach to their residency at the Royal London Hospital in 1999. For IOU, the body of the hospital was a starting point for their production Consulting Room III, and I would argue that, while the influence may not be so explicit in the artwork, the body of the hospital is a key element for any theatre production within a clinical institution. The issue of space is central to such work, as the material presence of the health institution is in direct relation to the physical encounter of the theatrical event. In this chapter I will be drawing on three case studies to examine the centrality of the corporeal within the liminal space of the hospital and explore the problems and possibilities of theatrical interventions within the physical bounds of health institutions.

Institutional context Another starting point for IOU was the work of literary theorist Susan Sontag, who in Illness as a Metaphor states that: ‘Everyone who is 26

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27

born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick’ (1991: 3). IOU and many other artists have been inspired by this notion of crossing over into another, parallel, realm and the artistic potential of exploring that alternative space. Sontag defines illness both in terms of a ‘landscape’ of biological disease and in terms of a socially constructed system of meaning; and artistic projects such as IOU’s allow for an exploration of ‘alternative’ landscapes that work to deconstruct and problematize social codification. Sontag notes that the experience of illness is often expressed through metaphor in order to carry across and be translated into the language of the kingdom of the well. This view is supported by Michael Wilson, who attempts to draw together theology and health education. He argues that ‘The language of science alone is insufficient to describe health; the languages of story, myth and poetry also disclose its truth’ (quoted in White, 2009: 17). This perspective suggests that artists, whose work is often infused with metaphor, may be useful practitioners within a healthcare environment. Companies such as IOU may be comfortable with embracing the metaphorical dimension of the human experience and to find a means to express it. Written from personal experience, Sontag’s statement captures the experience of illness in modern, Western, society.1 The ill person is taken out of everyday social circulation – shifting from the kingdom of the well to the kingdom of the sick. This is usually a literal removal into a space reserved for the unwell. Separation may span from the specially made-up sick bed – on the sofa within a person’s own home – to the isolation unit of the hospital. In his essay ‘Sickness as Cultural Performance’, anthropologist Frankenberg notes that: ‘Acute episodes of sickness are taken out of time with symbolically marked boundaries, reinforced by ceremonial bedrest and special foods’ and, through examining ritualized elements of the separation of the sick from the well, he posits that it is possible to extrapolate both practical and symbolic impulses behind such a division (1986: 616). Practically, the removal of the sick into centres of segregation minimizes the possibility of infection and disturbance to the body social. Symbolically, an ill individual enters a realm where s/he is exempt from the routine and convention of everyday life. So we might understand this realm as what anthropologist Victor Turner terms a liminal state. It is a time out of time where different social rules and conventions apply. For the ill individual, idiosyncratic

28 Theatre in Health and Care

dietary regimes, the wearing of night-clothes during the day and the limitation of movement may mark the body’s special status to the self and others. Turner says of the liminal state: During the time spent in this condition, a person abandons his or her old identity and dwells in a threshold state of ambiguity, openness and indeterminacy. Only after undergoing this process may one enter into new forms of identity and relationship, and rejoin the everyday life of the culture. (1974: 232) Turner notes that the entrance into a liminal space (across the threshold into neither/nor) not only allows individuals to change who they are in relationship to society, but also offers them a chance to reflect on themselves and their interrelationship with the community as a whole. The defining status of sickness, and the sense of another realm, is particularly heightened within the hospital. Within this institution, although other social indicators such as gender and race may come into play, the defining feature of the person is their illness and they are there as citizens of the kingdom of the sick. Frankenberg, drawing on literary theorist and philosopher Kenneth Burke, describes the hospital as ‘a staging post between origins and destinations’ and highlights its status as a place of transition and its role as the container and mediator of fragile states (1986: 616). In thinking about the institution of the hospital, it is important to be aware of the vulnerability of the liminal space as well as the opportunity to explore that it offers. Cultural geographer Yi Fi Tuan believes that a fundamental human activity is to ‘attach meaning and organize place and space’ (1977: 5). In his philosophical reflections on contemporary society he notes that humans have a particular aptitude for symbolization and that their organization of place and space is often endowed with the impulse to make concrete representation of values and beliefs. This idea can be linked to sociologist Parsons’ study Social Structure and Personality, wherein he draws the conclusion that ‘health and illness are conceptions built into the institutionalized structure of societies’ (1964: 112). As a functionalist, Parsons is concerned with the smooth running of society and acknowledges that separating out illness has a productive role to play. For Parsons, the well are those who are able

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to be economically active and the ill are those who are not able to fulfil such a role. Having a socially sanctioned, institutionalized, space away from the economically productive order is seen in Parsons’ work as socially functional – in that the removal of the sick allows for the smooth running of society. Parsons understands sickness as a ‘socially institutionalized role-type’ that places an individual in a particular relationship with the social order (1964: 274). He proposes the idea of ‘socially institutionalized’ illness both in terms that it is sanctioned – employers are bound to offer sick-pay, etc. – and because there are institutions related to episodes of sickness.2 Parsons identifies the sick role as a means of social regulation, allowing a forum for anti-social – that is, not economically productive – behaviour within the bounds of the social structure. Access to the privileges of the sick role is held primarily in the hands of professionals who bind the legitimation of illness into the ascribed goal of getting well and returning to a functional office in public life. Indeed, returning to full health is seen by Parsons as a form of work for legitimated ill individuals. The realm of the sick is one only to be visited yet, while the individual is ill, s/he is excused all usual social convention – even politeness is not expected of the sick person – and others are expected to support and accommodate the sick person. The hospital acts as a container for such a liminal state. The hospital can be seen to afford sanctioned separation and suspension of everyday responsibility to the sick, on the proviso that they accept the role of good patient and strive to return to their everyday activities. Studies have identified that people who conform to hospital rules and are compliant are considered to be good patients and receive a different quality of care from those who are considered to be more difficult (Lorber, 1975). This notion of role-play between the inhabitants of the hospital was key to Parsons, who notes that: ‘the therapeutic function [of the hospital] was conceived as performed by a type of person-in-role, acting vis a vis another person-in-role, a patient defined as sick’ (1964: 337). This idea is developed in later sociological work by Goffman, who considered the institutional flavour of medicine from a more interactionalist perspective. He identified hospitals as ‘total institutions’ where human needs are bureaucratically organized and contained (1991). His interactionalist studies examined the procedures and what he termed the institutional ceremonies of hospital life, and highlighted the institutional

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language, codes and particular roles performed within the hospital as well as the way in which people may be labelled and/or coerced into particular forms of behaviour. From such studies it seems that the contemporary, Western hospital tells a particular story: a person enters and becomes a patient; they are treated in order to get well and then return to their everyday lives. Staff are clearly delineated from the patients, and their professional roles, belonging to the kingdom of the well, differentiate them from the liminal experience of the sick. The hospital is governed by rules and codes of conduct, people have professional titles such as Dr. Within the UK, NHS hospitals are institutions which serve as part of state provision and embody beliefs about the body social. This is quite different from the medieval hospital. Hospital comes from the Latin ‘hospitale’ which literally means hospitality. There were four main types of medieval hospitals which offered care and lodging: leper houses, almshouses, hospices for poor wayfarers and pilgrims, and institutions that cared for the sick poor. These were charitable institutions that cared for those who needed it and were most usually religious and staffed by nursing sisters. It was a site of philanthropy rather than specialist care. There was rarely surgical or medical attention; the hospital was rather a place for a sick person to find rest and spiritual comfort. But, with the birth of modern medicine in the eighteenth century, hospitals began to develop into more professional institutions where qualified doctors practised. In The Birth of the Clinic, philosopher and sociologist Foucault examines the development of the clinical institution and the kind of practice which went on within it. He identifies the ‘gaze’ of the doctor as an important instrument as the clinician assumes a superior position and surveys the passive body of the patient (1997: xii). Foucault posits: the minute but decisive change, whereby the question ‘What is the matter with you?’, with which the eighteenth-century dialogue between doctor and patient began (a dialogue possessing its own grammar and style), was replaced by that other question ‘Where does it hurt?’, in which we recognize the operation of the clinic and the principle of its entire discourse. From then on, the whole relationship of signifier to signified, at every level of medical experience, is redistributed: between the symptoms that signify and

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the disease that is signified, between the description and what is described, between the event and what it prognosticates, between the lesion and the pain that it indicates. (1997: xix) Here Foucault identifies the link between the professionalization and narrativization of disease where the medical practitioner became the privileged interpreter of illness. Previously the private doctor would have been working for the patient and only been paid if the patient recovered. The wealthy patron/patients would expect the doctor to be gentle and self-effacing and to attend to their illness on their terms, as they described what they considered to be wrong with them and how they would like to be treated. In the shift from the private home to hospital the clinician assumed authority and took control of the space. So, within the new medical institutions, diseases were codified and classified and patients were organized according to their type of illness for the ease of the doctors who would observe patients during rounds of the hospital. The discipline of medical geography encompasses the consideration of the therapeutic landscape. Prior, a key figure in this field, posits that space is socially produced and she has examined the way in which hospital architecture expresses social codes and medical knowledge. She notes: ‘A ward is essentially a point for the intersection of socio-medical practices’ (1988: 94). This landscape, loaded with social meaning, may have negative as well as positive associations. Arts in health projects have demonstrated awareness of the hospital as a space of transition – with all the associated fears and fantasies that this vulnerable state engenders – and worked to mediate difficult thoughts and feelings through creative means. In this chapter I will examine how artists have worked with the landscape of the hospital, and suggest that, rather than the ‘empty space’ that Peter Brook famously posited (1972: 11), practitioners need to negotiate healthcare institutions as spaces loaded with social meaning. The three case studies within the chapter offer three different ways of negotiating the clinical space: IOU Theatre seek to articulate the languages of the space, Theatre-Rites work to animate the space and the Big Apple Circus Clown Care Program attempt to turn the establishment upside down. This range of strategies offers a window into the potential role(s) of theatrical performance within the institution of the hospital.

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IOU Theatre IOU Theatre began their project from a perspective of illness as a ‘margin between life and death where mental and physical battles are fought’ and perceived the hospital as an appropriate site to highlight and explore the social interactions that frame such struggles (Sobey, 1999). IOU are well versed in site-related performance work which has the constitution of the performance environment as a fundamental concern; and seek to occupy and investigate the possibilities of a space. Performance scholar Kaye defines this type of practice as work which may ‘articulate exchanges between the work of art and the places in which its meanings are defined’ (2000: 1). Kaye identifies the origins of this type of work within the neo-avant-garde of the 1960s and there are certainly clear links between this form of practice and the avant-garde concern with the relationship between art and life. Thus, IOU’s work sought to examine the everyday codes, behaviours and beliefs located within the hospital site and to translate them into their performance event. When developing site-related devised performance, practitioners often use space as one of the ingredients of the creative process, and interacting with the space may provide a springboard of creative ideas; an important element of the creative process for the company was the period in which they were resident at the hospital. Consulting Room III is an example of a piece that grew out of an investigation into a site and sought to be accessible and engaging for those who inhabit that place on a day-to-day basis. IOU (initially an acronym of International Outlaw University) grew out of Welfare State International – a devising company comprising a range of visual and performing artists. Welfare State saw themselves as ‘engineers of the imagination’ and sought to resist Western capitalist ideology through creating radical and generally large-scale artwork (Coult and Kershaw, 1983). They looked to make their work as accessible as possible, using techniques such as firesculptures and food as an integral part of performances in order to engage with their audience. Welfare State believed that audience members would be stimulated by participation in a creative product and so the work was often fully participatory and began with the audience. The activation of the imagination was intended to result in political consciousness-raising as alternatives to the status quo were envisaged. This could be at micro or macro scale. So, for example,

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Welfare State’s title for their 1997 lantern procession in Ulverston, Cumbria, was Visions of Utopia, in which lanterns made by local people in community workshops were carried by their makers along the local streets. Kershaw describes how the body of a town may be inhabited and transformed by such a procession which, through its presence on the streets disrupting usual activity, can serve to activate a kind of ‘solidarity’ through collective action (1996: 147). IOU split from Welfare State in 1976 and sought to work particularly with landscape. The company began with a commitment to open-air, public performances which they saw as democratizing theatre practice and opposing elitist sensibilities. Buildings and landscapes continue to be important to the work, often acting as the inspiration for a show, with the practitioners in IOU understanding themselves to be imaginatively responding to the environment and their response as professional strangers may work as a form of social agitation in that: ‘An audience will shake off its inertia when it experiences the surprise effect of space transformed’ (Burt and Barker, 1980: 72). Like Welfare State, IOU understand creativity and imagination as important factors in consciousness-raising and, in working in a space that may be very familiar to audience members, they seek to catalyse a process of ‘re-seeing’ which might be traced back to avant-garde conceptual artists like Marcel Duchamp, who reframed everyday materials as works of art, thus inviting the spectator to view them with a fresh perspective and challenging the orthodoxy of the artistic establishment.3 While IOU’s artistic policy still emphasizes experimentation and the importance of imagination and collaborative practice, their agenda is nowadays often less radical. Richard Sobey, executive administrator for IOU, stated that they don’t see their current work as being ‘about issues … we don’t do politics’ (1999). They do, however, address potent social concerns such as health and the environment but often through fantastical metaphor. So, for example, Tatoo (2003) presented ‘a fuming army of petrol driven insects and a monstrous mechanical egg factory’ (www.ioutheatre.org). The company’s move towards a more conservative outlook may be due to their desire to work in conjunction with other agents and institutions – such as universities and cultural centres. Consulting Room III was an example of such a collaboration between the Royal London Hospital, the Greenwich Festival and Docklands International Festival.

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The Royal London event was part of a larger project. The piece, performed on-site in the hospital on 9–11 July 1999, was called Consulting Room III and followed Consulting Room I where IOU worked with nine artists from the Netherlands around the theme of illness and remedies to develop a public installation which was presented as part of the Oerol 98 Festival. In March 1999 IOU collaborated for a two-week period with six more artists on the same themes to develop a further installation piece in Glasgow. Consulting Room III at the Royal London employed core members of the company, and, again, resulted in public performance. This work was followed by Consulting Room IV, which was an education project with fashion students at Batley exploring costuming ideas for the development of a larger performance piece to be called Cure. The final stages of preparation for Cure resulted in Consulting Room V, where material from each of the Consulting Room projects was presented in a public exhibition in Dean Clough (the company’s base in Halifax, West Yorkshire). Cure itself was a site-specific show made for the underground spaces of Dean Clough. It was mounted in November 2000 as part of the Huddersfield Music Festival and then reworked in May 2001 for the x.trax International Showcase in Upper Campfield Market in Manchester. Throughout its various stages of development the piece drew on the creative expertise and personal interests of the contributing artists, as well as the resonances of the various sites within which they were working. The final piece was described by the company as: a richly visual and darkly humorous look at the art of medicine. Plagued by an infectious collection of characters with some unorthodox curative devices, a hapless patient enters a realm of unearthly hospital routines in a display of rude health and angelic hallucinations. (www.ioutheatre.org) This piece bore traces of all its previous incarnations as it sought to negotiate issues of health and sickness in a metaphorical manner. The work at the Royal London and Barts Hospital was important to the development of Cure in that it was the only work-in-process that took place within a clinical setting. The hospital is the oldest in London, since Barts dates back to 1123 when St Bartholomew’s Hospital was founded for the sick and the poor in Smithfield.

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The hospital also has a long history of arts patronage. In the 1730s William Hogarth painted two canvases for St Bartholomew’s designed to impress guest dignitaries and inspire them to make a donation to the institution. Vital Arts – a charitable organization set up with a small grant from Barts and the London Charity in 1996 – reflects a different, and more contemporary, conception of arts in a hospital setting. Like Hogarth’s paintings, the arts project team see themselves as catalysts, but their focus is not on an elite but on the resident community. The organization has carried out a range of work, from improving the healthcare environment through commissions related to refurbishment of wards; to enhancing the delivery of healthcare with interventions such as a project with the occupational therapy department where artists and medical staff collaborated to help patients with hand rehabilitation. Vital Arts also curate visual art exhibitions and run a staff arts club to encourage access to the arts. An important part of the work is brokering relationships between artists and clinical staff – the type of activity outlined within the Introduction. For example, they recently commissioned illustration collective Peepshow to develop a landscape for the Retinoblastoma Unit within the hospital. In facilitating such collaborations Vital Arts acknowledge the different needs of the contributing partners and look to negotiate an outcome that is beneficial to all parties – particularly the end users. When IOU were in development for Consulting Room III they approached Vital Arts to help facilitate the project. The theatre company were looking to employ their usual working practice of using ‘the character of the place to help shape the piece, so that [the] performance can crystallize around it’ (Burt and Barker, 1980: 74). Sometimes IOU work to transform a space, but such ‘taking over’ can be problematic and, in this case, it was important that the company were able to work around activity within the space in order to allow it still to be used for its medical purposes. IOU submitted initial ideas to Vital Arts and looked for feedback as to how their plans might work within a hospital environment. The arts team were initially concerned about the patient and staff benefit and whether it would appeal to the user group. Their report read: If the project intends to ‘demystify the language of medicine’ we have to be sure that it will not then wrap it back up in another

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kind of language that is just as difficult to understand. (D. Munt, personal communication, 1999) There was a difficulty with the fact that IOU had begun from a place of metaphor and was working to a creative and artistic brief, as this orientation had to be married with the focus of the clinical staff to use the hospital building to provide clinical care and help people to feel better. The development of the project was related to Vital Arts’ agenda that artists should be integrated into the body of the hospital, yet they were aware of the need to negotiate this carefully. Vital Arts felt that: there would need to be some fairly intense activity so that staff and patients have a strong sense of connection and ownership when the performance takes place. (D. Munt, personal communication, 1999) Rather than Consulting Room I and II, where artists had been the sole contributors, Consulting Room III was to place an emphasis on the consultation process in order to enrich the performance project. IOU came to the project with some strong thematic concerns. They were excited about the possibilities of the hospital site and its metaphorical resonances. Their proposal document asserts their perspective on the hospital as a living body. As part of the work-in-progress the company were looking to collate quotations on health, illness and cure to ‘represent the internal thoughts of the creature’ (Sobey, 1999). IOU hoped that exploring the inner processes of the hospital would help to provide a ‘fresh and imaginative take on the complexities of the institution’ (Sobey, 1999). Yet the complexities of the institution meant that information was hard to gather and processes hard to uncover. As the hospital is a busy working environment, Vital Arts suggested gathering material via questionnaires on lunch-trays etc. but this did not yield the results the company had hoped for. A series of singing workshops with voice teacher Brenda Rattray were developed that would give hospital staff an access point to the project and provide them with benefits while developing material that could be used within the final production. The focus on the end product within these workshops can be seen to be problematic as IOU wanted the singing group to rehearse and perform a series of songs written by

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the company rather than allowing for a more organic process where staff input was sought. Even then it was difficult as the group was new and its members were not able to perform during their work hours. Original plans had performers singing from hospital balconies but, again, this was problematic as consideration had to be paid to patients who might be lying in beds nearby. In an attempt to encourage interaction with patients as inhabitants of the institution, Vital Arts set up a series of workshops which took place on the wards. The work with patients involved Rattray and a guitarist visiting the wards in the morning, singing and getting to know people as well as introducing the project. In the afternoon Rattray returned with IOU member Adam Gent to interview patients who had volunteered for this process. The company reported that they had found this aspect of the work ‘very humbling’ (Sobey, 1999). A key member of IOU had experience of a serious illness and, before this intervention, the company had been working primarily with his material as well as songs from previous health-related work. IOU asked people about their feelings and dreams while they had been ill, and their responses to the idea of illness as a journey. This process of collating metaphor as alternative modes of expression can be understood as fitting with the company’s concern and politicized perspective of medical narrativization. Metaphorical narrativization can be seen as a resistant tactic that gives voice to those who might usually be silenced in the hospital context where, as Foucault argues, the medical narrative rather than the patient’s perspective is given precedence (1997: 78). At the outset IOU were particularly concerned with language and the way in which things were named and described. They wanted to explore ‘the secret languages and codes of medicine’ (Sobey, 1999). The company, with consent, used the metaphorical patient narratives within the performance (and also in Cure) and recordings of individuals’ stories were broadcast to the audience in an intimate manner through specially constructed drip bags that were to be held to the ear. This intervention can be seen to affirm the importance of the individual patient’s narrative within the medical encounter and provide a different vocabulary to the standard clinical terminology to describe disease. The workshops with patients were followed by a week’s making period at the IOU base and then the company travelled down to spend eight days on site at the hospital – three days of which were

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spent constructing two ‘sound gardens’ either side of the main Garden Square. This was a residency that required much planning and co-ordination, with Vital Arts balancing the need for high-level risk assessments alongside the company’s need to make noise and have free access to the site. The initial research and development for the piece had included a residency at the hospital that sensitized the company to the site and allowed them to observe the workings of the institution and to consider the way they might function within it. During their residency the company maintained a sense of themselves as expert outsiders, coming in to gather information and offer professional skills through workshops, but they also worked with their own experiences of illness which they mapped onto the data that they collected as they created the piece. The poetic symbolization of space was important within the piece as the audience were witness to fantastical sights such as levitating beds. The fact that the central Garden Square was taken over by the performance was also significant. As in the ‘happenings’ of the 1960s which sought to activate social spaces, people moving through the site may be confronted by the performance space and be invited to experience the hospital site in a new way. It is possible to draw similarities between this work and the seminal practice of Allan Kaprow, whose event Fluids (1967) took place throughout Los Angeles. Large, rectangular ice structures were placed throughout the city and left to melt. Members of the public might come across the structures during the course of their everyday activities and, due to the presence of the blocks, be invited to view the site from a different perspective. Kaprow wanted spectators to be active within his events rather than passive receptors and he spoke of them as ‘players’ rather than audience members (1993: 126). Similar to the environmental work of Kaprow, audience members were encouraged to be participants in the IOU event. As part of the performance, audience members’ names were called and they were invited to enter a waiting room before being led through a labyrinth of plastic sheeting. Rather than the audience being passive spectators, the piece encouraged them to participate in a new negotiation of the site. Not all inhabiting the site, however, were able to access the performance work, as much of the dramatic action took place within white constructed boxes and only those with tickets were able to go inside. This arrangement appeared to set up a hierarchy of participation.

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The company employed the theatrical nature of the hospital environment with its costumes and props as a key aspect of the presentation although, in IOU’s unique style, the strangeness of the hospital environment was exaggerated. The structures resembled a crazy blend of military field hospital, whitewashed allotments and excavation site, and the performances themselves were a journey through a sterile and stylized medical environment and ran three times over three days. The British Medical Journal described one element of the performance environment as a ‘contraption resembling a mis-marriage of washing machine and motorized umbrella [which] looks as terrifying to the medically trained eye as most of the medical equipment in daily use looks to patients’ (Knight, 1999). This commentary suggests that the artist’s outsider’s eye offers a new perspective to an audience from the medical community, delivering a sense of the uncanny which may match the experience of the non-medical audience member. Responses to the piece were varied and reflected a spectrum of interest as the ‘indigenous’ hospital community of East End Londoners – who had been allocated 75 free tickets to the show – mixed with the visiting festival-goers who had obtained tickets through an external box office. The issue of ticketing was hotly contested and there was much debate about the ownership of the space and its position as a public institution. In this case, audience members, who represented a spectrum of class and ethnicity as well as medical interest, eventually came together through their relationship to the environment. David Wheeler, artistic director of IOU, confessed that on first arriving at the site he had wondered whether it was appropriate to be occupying the real working space of a hospital with a piece about a fictional institution. He felt, however, that feedback from staff describing how they had been encouraged to look at their occupation from a different perspective validated the work. Performance theorists Burt and Barker claim that the work by the company encourages an audience to ‘re-examin[e] their own mythologies’, which may prove to be a radical encounter and, in this case, it seemed that the metaphorical nature of the work allowed the audience to ‘re-see’ everyday practices (Burt and Barker, 1980: 76). Consultation between itinerant artists and institutional hospital arts projects will always be a complex negotiation. This project demonstrated the importance of a flexible approach and the ability, of both

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parties, to adapt working practices during a protracted consultation process. On reflection, Sobey stated that navigating a path through the structures of a hospital had proved more problematic than he had foreseen. He recognized the importance of working in partnership with the permanent arts team in a way that perhaps had become something that was less marginal and more within the jurisdiction of the institution. The experience of hosting the project also caused Vital Arts to re-examine the role of theatre in a healthcare setting in terms of both the efficacy of using the hospital site as a venue and the potential of theatre as a tool to improve environments and services. They noted that theatre is much more disruptive than visual art as there are literally ‘foreign bodies’ moving about within the hospital complex.

Theatre-Rites The next case study, Hospitalworks, was also part of a series of site-related performance projects – which included Shopworks, Pilloworks, Cellarworks, Millworks, Houseworks and Tentworks – created by TheatreRites, a UK-based company, formed in 1995, specializing in imaginative works for children and adults. The company draw on a range of artists in their work, including sculptors, installation artists and videomakers as well as more conventional theatre practitioners, and, as part of their profile, had built a reputation for innovative site-specific work. Hospitalworks was co-commissioned by Polka Children’s Theatre and Theater der Welt, a theatre festival in Stuttgart, Germany. The production was first staged in the Mayday Hospital in London in May 2005 and was then recreated in a hospital in Stuttgart later in the year. Like Consulting Room III, the piece was not site-specific in that it was created for only one place, but it was site-related in that it worked with the resonances of the hospital building in the creation and presentation of the performance. The same publicity material was issued for both versions of Hospitalworks with the strapline ‘Deep inside an ordinary hospital lies an extraordinary place’ (company publicity). This soundbite makes clear the company’s intention to inhabit the body of the hospital and take their audiences within it. The piece was framed as a fantastical journey of discovery, with the audience guided through a series of rooms that housed performance vignettes and installations. The audience for the London performances were instructed to congregate

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in the main foyer of the hospital. Like IOU, Theatre-Rites had to be aware of the space as a working environment and consider how they might negotiate bringing their audience into the space and through to the disused ward that was being used for the main body of the performance. The audience were collected by a company member and taken through the main building of the hospital to a waiting room. The adventure of the piece appeared to begin on this initial journey through the ‘real’ clinical space. During my visit on 14 May 2005 one of the mothers in the audience said to her child ‘It’s like a magical mystery tour’ as they were led through the corridors. The purposeful walking seemed to sensitize the audience to the space and children were pointing out places and items of interest to the adults accompanying them. The piece claimed children’s fascination with the game of doctors and nurses as a starting point and the medical space certainly seems loaded for children. Social worker Sheridan has examined fears and fantasies about the hospital and how this might impact upon their experience of the institution (1975). These perceptions are also fed by televisual representations of the clinical environment. Doctors receive the lion’s share of professional representation on television. In Doctoring the Media, Karpf notes that a survey covering one fortnight of British radio and television in the late 1970s discovered that there were 34 programmes (both fictional and non-fictional) which covered medical issues (1988: 1). My own straw poll in 2009 drew similar results. Many of the programmes are centred around hospital dramas and I would suggest that this is because this, rather than community-based practice, is where the institutional flavour of medicine is at its strongest and facilitates the expression of a complete world within itself – what Goffman termed the ‘encompassing tendencies’ of the institution (1976: 15). Many of the TV programmes are set in emergency departments. It seems to be that the ‘hot’ medicine of casualty is more suitable for TV medical drama. Paul Atkinson describes the characteristics of this type of clinical practice: the ‘hot’ medicine taught in Casualty … is entirely different from the ‘cold’ medicine of normal teaching on the wards … ‘hot’ medicine is marked by its immediacy, when neither patient nor student has had the chance to rehearse the history and the whole

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business is less stage-managed, and medical action must often be taken there and then. (Quoted in Sinclair, 1997: 31–2) The suitability of ‘hot’ medicine for TV may not only be in its immediacy and drama (which also applies to surgical procedure).4 In addition, rather than the slow decline of degenerate illness, acute disease is an episode of illness that leads to crisis, and crisis, as Turner has highlighted, is a key element in drama (1974: 37). Hot medicine provides drama, tension and resolution, which can be seen to reinforce medical discourse in that medical practitioners usually successfully identify and treat the illness within the course of an episode. The acute incident also facilitates an episodic structure as the event is literally kill or cure, and this type of format allows for a high turnover of storylines and guest artists. Of course, most hospital dramas are aimed at an adult audience, whereas Hospitalworks was advertised as being suitable for three to six year olds. It seems, however, that programmes for children are influenced by the adult format. For example, Me Too!, a current BBC children’s programme, features Dr Juno’s Hospital, whose theme tune emphasizes the drama of the hospital: It’s so exciting in the hospital Trolleys guiding people through the doors Flashing blue lights come up to the door I’m rushing here and there. (Barnes, 2008) Dr Juno, one of the central characters in the show, is a harassed doctor whose storylines emphasize how busy she is and the fast pace of hospital life, reflecting representations in adult dramas. A review of Hospitalworks picks up on these elements within the piece. The reviewer notes that the piece is ‘Like Casualty … but weirder’ (Gardner, 2005). The piece certainly attempted to communicate the drama of the hospital with swishing curtains and officious staff. Another reviewer also noted how the piece enrolled her within the drama and reports that: ‘I am rushing down a corridor …’ (Max-Prior, 2005). Institutional corridors and tracking shots of the efficient medical team or lone doctor running to a patient are stock images within the TV medical drama which promote an appreciation of the professionalism of clinicians who are able to act within dramatic

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circumstances. So, from the beginning of the piece as they moved through the building, the audience for Hospitalworks were encouraged to engage both with the material space of the hospital and with the social and aesthetic drama which is associated with it and, like IOU, Theatre-Rites demonstrated their awareness of the space being loaded with meaning and exploited that within their performance piece. Theatre-Rites promised that ‘the ward will be transformed into a performance space’ and it is possible to see how the company employed the performance of everyday life, as well as performance codes from the TV medical drama, to animate the space (company publicity). The publicity promised a space which was ‘magically transformed by performance’ but, rather than transformation, I would suggest that the space was heightened by performance. The company worked directly with the materiality of the building, with the conceit being that the objects within the ward – beds, lamps, pillows, etc. – were not well. Thus it was a piece of truly environmental theatre in that the environment was performing – as extendable lamps and so forth appeared to come to life and take on human attributes. This did appear to be magical for the young audience; for example, one child reported that her favourite piece of the show had been the snoring pillow. The performers, who were all in the role of medical staff, paid careful attention to the medical equipment. So, for example, a ‘poorly’ lightbulb was changed with the use of a kidney bowl, and a sickly bed had its tummy rubbed. This element of the work appeared to resonate with children’s interest in doctors and nurses, and the interplay of professional role and power over the body of another alongside the opportunity to care and cure. The portrayal of authority was significant within the piece, and submission appeared to be important. From the beginning a disembodied voice announced the waiting time until the ward opened for visiting time and then audience members were told to ‘shush’ as they entered. The performers/staff were all in uniform and the proceedings of the ward were supervised by the character of Matron who was very much in control. This also appeared to relate to the conventions of the hospital drama where hospitals are rarely run by administrators, as they are in everyday life, but by a powerful clinical figure – usually a doctor. Rather than the idealized personality of the TV drama described by Karpf, Matron within Hospitalworks was not a likeable figure and, at points, it seemed that she was intimidating

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to the children. One moment saw her demanding ‘whose been sitting on this bed with smelly shoes?’ which made the child in front of her cry. There was no room for comfort and reassurance in the frantic events that took place. Audience members were ushered to sit on beds which were then wheeled about by the nurse characters in a manner which reinforced the passivity of the visitor to the hospital in relation to the professional activity of the staff. Like TV medical dramas, Hospitalworks appeared to uphold the supremacy of clinical practice and focused on the movements of the clinical staff. Another similarity to TV medical drama was the way in which Hospitalworks emphasized the use of medical equipment and technology with a heightened attention to the detail of items found on hospital wards through their animation as puppets. Karpf identifies the climax of this type of drama, arguing that: Surgery occasions the icon of the medical drama, the operating theatre scene: with its close-ups of masked, gowned and concerned doctors (the eyes have it); its cutaways to respirator and cardiograph ... the mounting drama of the doctor’s clipped instructions as bleeps of danger accelerate. (1988: 184) The climax of the drama within Hospitalworks was also an operating scene. Again, this event appeared to prove distressing to the audience as fast-paced music and flickering lights signalled the onset of an emergency and the performers gowned up and put on face-masks while the audience had to reorientate themselves to the new focus of the action. The scene of the operation itself, where surgical scissors were employed to cut down and mend a light which fell from the ceiling, took place behind a gauze and contained none of the realism of TV drama but its immediacy still moved the audience – one of whom stated ‘I want to go home’ while others sobbed and held on to nearby adults. Overall this was an uncomfortable experience and the applause at the end of the operation seemed to indicate a desire to clearly distinguish the events as performance. The relationship between the real and the imaginary, as in all performance work, was important to this piece. The piece was staged in a real hospital with real objects yet it drew on fictional conventions to engage with the drama of the hospital. One young audience member in particular appeared keen to clarify the boundaries between

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fiction and reality and, after the show had ended, asked one of the performers if they were a real nurse or not. Theatre-Rites did not afford a strong fictional frame for the piece which may have set a different tone. There was a structure of breach, crisis and resolution – in that the piece ended with the ward being ‘better’ – but there was no real narrative to the piece, with the focus instead on the business of interacting with the material environment. Theatre-Rites won a Wellcome People award for ‘providing a dynamic and inspirational introduction to medicine’ for the show.5 The piece was seen as educational, with the intention of encouraging the audience to see the hospital from a new perspective. Yet, perhaps like IOU, the piece appeared to draw on fantasies and representations currently circulating in the cultural climate.

Big Apple Circus Clown Care Program Clown doctors, however, represent a different approach to the institutional space. The clowns celebrate their status as foreign bodies within the hospital that offer alternative perspectives on authority. Big Apple Circus Clown Care Program is a pioneering company in this field and was formed in 1986 by Michael Christensen (aka Dr Stubs). The programme was developed out of his work as co-founder of the Big Apple Circus, and the Clown Care Unit see themselves as sitting squarely within the circus tradition. Christensen began his performing career with the San Francisco Mime Troupe which produced outdoor, highly physical and radical performance work. Christensen met Paul Binder during this period and they first developed a comedy juggling act and then went on to set up Big Apple Circus which, from the beginning, had an overall charitable purpose. But, following the death of his brother, Christensen wanted to develop his public service and soon after began to develop the concept of Clown Care. An invitation by Dr Michael Katz, then Chairman of Pediatrics, to deliver a presentation at Columbia Presbyterian Medical Center, opened up the doors of the hospital to the possibilities of Clown Care and the (dis)order of circus. The history of circus can be traced back to the Romans, whose circus performances included chariot racing and fights to the death. The roots of contemporary practice, however, lie with Philip Astley who, in the 1770s, developed an equestrian show that also included clowning. Astley developed the circus ring, which established a

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different kind of spectator–performance relationship. Theatre scholar Wiles notes that ‘speeches generate frontality, while interaction and displays of physical action generate circularity’ (2003: 164). Wiles goes on to assert the emphasis on the human at the centre of the ring and the way in which this performance form allows visual access to all aspects of the body, which allows for an awareness of the vulnerability of the performer. This notion of interaction and the openness of the performer is important to the work of the Clown Care Program, who are clear that they do not work with the concept of the fourth wall that puts up a barrier between audience and performer but, instead, seek to make a direct connection with those who come into contact with their performances and a common humanity. This form of performance is quite different to the work of IOU and Theatre-Rites, who set up a theatrical frame for their work within hospitals with a clearly delineated performer–spectator relationship. Another fundamental aspect of Clown Care work is the employment of parody – or ‘clown logic’ – which is the basis of circus clowning. Within the traditional circus arena, the clowns would make fun of the ringmaster, the figure of authority. What literary theorist Mikhail Bakhtin describes as the carnivalesque, and the principle of the world turned upside down through the reversal of authority, can be seen to be at work within the circus. The Roman feasts of Saturnalias are generally recognized as the ancient forerunner of carnival activities. They embodied the essential spirit of the transgression of daily conventions and excesses of behaviour. The feasts were sites of licentiousness, and slaves would banquet with their masters. A King of Chaos was elected from the slaves and, for the duration of Saturnalias, he had the rights to his master’s concubines and gave out ridiculous orders that had to be obeyed by everyone. At the end of the festivities he was unthroned, signifying the return to normal order. The carnival, according to Bakhtin, was characterized by: ‘laughter, by excessiveness (particularly of the body and bodily functions), by bad taste and offensiveness, and by degradation’ (quoted in Fiske, 1989: 81). The implications of carnival were not just internal, the ramifications spread to the wider society. During the whole of the Middle Ages, Bakhtin argues, this culture of laughter resisted serious officialdom. By dramatizing the comic side of absolute truths and supreme authority, it highlighted the ambivalence of reality and introduced new forms of symbolic action. Those

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involved felt liberated as they experienced the symbolic and concrete suspension of social barriers. Bakhtin perceives the carnivalesque festivals as rituals of equality and it is possible to identify within such events the characteristics of Turner’s notion of liminality – a community feeling through the suspension of norms and privileges. Turner described how liberation from conformity to norms will often result in the participants experiencing ‘communitas’ or ‘anti-structure’. In her work O palácio do samba, Maria Julia Goldwasser applies Turner’s theoretical analysis to the carnival in Rio. She says: Anti-structure is represented here by Carnaval, and is defined as a transitional phase in which differences of (pre-Carnaval) status are annulled, with the aim of creating among the participants a relationship of communitas … where all are placed without distinction on an identical level of social evaluation, but the equivalence which is established among them has a ritual character. In communitas we find an inversion of the structured situations of everyday reality … ‘To make a Carnaval’ is equivalent ‘to making a chaos,’ where everything is confused and no-one knows where anything is. In Carnaval, men can dress as women, adults as babies … ‘what means what’ becomes an open possibility by a magical inversion of real statuses and a cancellation or readjustment of the barriers between the social classes and catagories. (Quoted in Turner, 1987: 83–4) This anti-structural carnival can be identified in the work of the Clown Care Program that invokes organized chaos within the hospital. Although the rules of everyday life are suspended within carnival, another set of codes of behaviour and structures of activity comes into force. Goldwasser gives an example of how play might be facilitated by structure through her examination of the strict rules of samba schools. While they celebrate the licentiousness of the carnivalesque, the schools are carefully governed. As part of her study of a school she drew up an organizational chart and noted that it resembled that of a major firm or government department. The Clown Care Program too, while it is committed to play and creativity, has a well-developed company structure with regulations and policies that ensure the safe and smooth running of the organization and the care

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of those they come into contact with. The Clown Care Program was the first clown doctor organization to develop significant artistic and financial resources, and a grant for a five-week pilot project at Babies Hospital in New York City from the Altman Foundation prompted the company to codify the guiding principles of the organization. The four pillars of the work were seen as: 1 Children are not in charge in the hospital so they should be put in charge of clowns. Thus, for example, clowns should always ask the child’s permission before they enter their room. 2 Clown doctors should become more helpless and needy than any child, this reversing the usual dynamic of the patients being seen as helpless and doctors ‘fixing’ them. 3 Clown doctors are not there for what is wrong but what is right. They should seek to work with the child beyond the illness and search for the ‘shimmering spirit’. 4 Clown doctors are there for parents and staff as well as children. The message to adults should be ‘play is good’. (Christensen, 2006) These guiding principles, based on carnivalesque precepts, have been the basis for the on-going work of the company and have informed the training programmes which are now in place. Potential clown doctors, after a two-stage audition process which assesses their skills as performers and their personal suitability for work within the demanding environment of the hospital, undergo a rigorous training programme which makes up a one-year apprenticeship. This process recognizes the particular skills that are needed to work within the hospital and the training relates to the ways in which their artistry as a clown might be adapted to work within a hospital context. Another very important aspect of the induction process is training in hygiene and clinical/governmental procedures. Unlike companies such as IOU and Theatre-Rites, Clown Care’s primary work is with patients and, although they bring with them the spirit of carnivalesque and circus, they see themselves as working in partnership with the medical staff and, as such, they need to be able to facilitate clear communication within an interdisciplinary team as well as ensuring patient safety at all times. Whenever they arrive on a ward the clown doctors will check in with the medical staff for a briefing and this will be done ‘noses down’, that is, not in

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clown character, so that information can be processed appropriately. Clown doctors always work in pairs, in the tradition of clown marriages that allow the duo to play off each other, but an adaptation for the work in the hospital is that one of the pair will play a supervisory role and will be responsible for filing a report at the end of a shift.6 Monthly meetings also monitor the clown’s work and provide a space to discuss scheduling, to rehearse new material, but also to engage in what the Clown Care Program terms ‘emotional hygiene’ where, with the support of a therapist, performers can explore any issues that the work has raised for them (Clown Care Unit, 1991: 90). With 97 performers working in 18 medical facilities, the management of the company is a considerable undertaking and there are a number of administrators, as well as a team of directors, who support the practice. The members of the company report that there can sometimes be tension between the need to manage the work and the need for freedom in the work, but the professional status of the company allows the clown doctors freedom within the institution of the hospital. The professional clown doctors have more autonomy of movement within the hospital than the volunteers on other hospital programmes. They may have areas which are suggested to them to visit or not, but they are generally self-regulating. Their working day may resemble other medical workers as they clock on for their shift, put on their uniforms and then debrief before leaving, but the spirit of the work remains anti-structure. The company are careful to ensure that they are sending out ‘clowns not clones’ and encourage creativity and play but within the boundaries of their brief as clown doctors (Clown Care Unit, 1991: 25). As one clown doctor (Dr Bedhead) put it: it is about ‘being disrespectful, respectfully’ (2006). Thus there is a careful negotiation between the Big Apple Circus Clown Care Program and the hospitals that they work with. The company see their practice in direct relationship with the institution. The Clown Care training manual says: ‘Welcome to the hospital – your perfect straightman’ (1991: 26). They acknowledge that an important dynamic within their work is the anti-authoritarian and anti-structure nature of the clown. For the Big Apple Circus Clown Care Program the ‘hospital room replaces the circus ring, the doctor replaces the ringmaster, and all the rules, procedures, order and authority structures of the hospital world become the source of parody’ (1991: 9). In particular it seems important to note, in an

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arena where the corporeal is so significant, the particular relationship that the clown has to the corporeal realm. I have noted the way in which the hospital may seek to discipline the body whereas clowns have a carnivalesque approach to the body. The clown’s own body is a carnivalesque site of excess. Bakhtin notes that, within the carnivalesque, features of the grotesque body were exaggerated; likewise, the clownface accentuates facial features, hair and clothing may be unruly, while appendages such as noses and feet are bigger. In negotiation with the hospital space, the clown doctors often wear less make-up than those who work outside the hospital setting because of the intimate nature of their work. Another adaptation to the hospital environment is the customized white coat that the clown doctors wear. Clown doctors are parodies of their medical co-workers – with names such as Dr Bedhead and Dr E-B-D-B-D – and their un-uniforms (uniforms with extras such as badges and polka-dot trimming) signal their role as insider outsiders. They are recognizable as hospital workers but also as offering a very different service to the clinical care. The costume is an important element to the clowns, providing a ritual element as they en-role and de-role. Dr Bedhead noted that it was important to ‘check your shoes on the way out’, that is, to acknowledge that the clown doctor character is left behind at the end of a shift when the costume is taken off (2006). The clown also has an anarchic attitude to the body. Bakhtin notes that the carnivalesque is often concerned with the ‘lower stratum of the body, the life of the belly and the reproductive organs’ (1984: 21). The clown does not have the usual propriety about the body and resists that discipline. Thus, the clown doctors may engage in gags that relate to bodily functions – such as comic routines about farting. Indeed, one of the Clown Care doctors even claims to be a fartologist! In the spirit of respectful disrespect, these scenarios are not meant to embarrass or disgust but to reveal the vulnerability of the figure of the clown who perhaps cannot control his/her bodily function and may mirror back to the child her/his own experience of being ill and in hospital and/or offer the opportunity to have mastery. As the principles of practice indicate, the vulnerability of the clown is at the heart of the work and it is this willingness to be weak and open which allows them their power. A revealing anecdote by Bernie Warren (aka Dr Haven’t-A-Clue) who established the ‘Fools for Health’ programme in Windsor, Ontario tells of a consultation

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between medical staff and clown doctors about a patient that the clinicians were just not able to reach. The advice that the clown doctors gave was that: ‘All you have to do to get her to participate is to show her your knickers’ (quoted in Twohig, 2004: 213). This simple phrase seems to encapsulate the perspective of showing vulnerability and looking for a shared humanity in order to promote effective healthcare. The clown doctors parody medical procedures. They set up their own examination protocols – for example, eye tests using rubber chickens, or red-nose transplants where a clown nose may be applied to a patient or carer’s face. Often the child is asked to assist in the procedure, placing them in the role of the expert, as the codes of hospital life are parodied. The clown doctors may take tricks and instruments into the hospital but they often also make use of the material they find there – for example, making instruments out of medical technology. This process is different to the work of TheatreRites in that the performers are not just animating the objects but actually subverting them in a carnivalesque manner. Dr Stubs gives an example of such a playful inversion (Figure 2): Many times I have shown a child a stethoscope and watched his or her body recoil in fear. I take the parts that usually go in the ears and place them into my mouth, dunk the end in a soap solution, and by gently blowing, form bubbles at the other end of the stethoscope. The child relaxes and moves forward. I’ve simply taken an image of the hospital, and brought a sense of delight to it. (Clown Care Unit, 1991: 27) The clown doctors can be seen to operate outside of, and sometimes contrary to, usual cultural rules and norms. They are looking to make the hospital environment more child-friendly and seek a direct relationship with the patient. They may offer ridiculous, alternative logic – for example insisting that a child should have meals consisting of the four basic food groups: chocolate cake, cotton candy, pizza and beer! As well as offering different ways of seeing, the clown may also offer the opportunity to explore different ways of behaving. For example, during a visit with Big Apple Circus Clown Care in January 2006 I witnessed a bed-bound child being given a ‘magic’ zapper that could control the body of the clown. He was then able to make the

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Figure 2 Dr Stubs blowing bubbles through a stethoscope

clown do all sorts of crazy stunts, expressing a physical virtuosity that the child may have desired for himself. Clowns may offer interaction with imaginative journeys and holidays that the child might like to take or re-enact familiar routines that comfort the child in the strange environment of the hospital. As well as solace, however, Warren notes how clowns may act as scapegoats (2008: 80). S/he may be the stupid, ugly, naughty one that enables the child to act out feelings of frustration and anger within a safe framework. The clown doctor is not a performer in the traditional sense. They are an intervention in the space and are experienced as such rather than an end-on, picture-frame performance. Working within the tradition of circus there is a participatory relationship between actors and spectators. As Bakhtin asserts: ‘Carnival does not know footlights’ (1984: 7). The performance is not contained and the clowns move through the hospital space engaging those whom they come across along the way. This is, of course, handled sensitively as there are some who do not wish to interact, but, for those who are open to the encounter, the clown doctors offer an opportunity for participation. For example, I witnessed the clowns interact in an out-patient’s waiting room – beginning with talking in cod-French to a woman wearing a beret. The manual instructs that the clowns always leave on a high note – this is not a performance designed to end with applause – and, once they had left, I observed the change

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of atmosphere in the room as patients began to speak to each other, which seemed to demonstrate the communal nature of the carnivalesque. For many of the patients where the clown doctors work, the clown doctors become part of the hospital experience for them. They may become attached to ‘their’ clown and look forward to their regular rounds. The appearance of the clown may offer a welcome distraction or may also serve to sweeten a difficult moment – as clowns may help in medical procedures, for example, providing a fanfare as the child mounts the couch for an examination. There may be concerns about the clowns being used by medical professionals to assist in persuading patients to comply, seeing this as an attempt to recuperate that which it seeks to disrupt (Fiske, 1989: 100). However, Fiske notes that: carnival may not always be disruptive, but the elements of disruption are always there, it may not always be progressive or liberating, but the potential for progressiveness and liberation is always present. (1989: 101) This potential, through the spontaneous invention of clowns as they inhabit the hospital building, may be seen as challenging and even unwelcome by some clinicians. Christensen reports being told by a senior doctor that ‘Clowns don’t belong in the ICU’ (intensive care unit). To which he replied ‘neither do children’ (2006). Rather than dealing with symptoms and cures, the clown doctors are looking to relieve disease that may arise as part of the hospital experience, and they place an emphasis on the human encounter, with a focus on the child behind the illness. They offer a different mode of healing.

Conclusions This chapter has examined three very different case studies of theatrical interventions within the hospital institution. Working within the hospital building offers challenges to both the company and the host institution and I have noted how the foreign bodies of a theatre company may prove to be much more disruptive and difficult to house than a visual art installation. Hospitals are justifiably cautious about hosting performance events, which can be challenging

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for companies seeking to undertake this work. Indeed, Theatre-Rites found Hospitalworks the most challenging of their site-related pieces in that it was very difficult to find venues that might be willing to accommodate them. For those hospitals that are willing to explore the possibilities of performance it seems that a commitment to dialogue from both sides is very important. This may be difficult to negotiate as, even though they called the piece Consulting Room, IOU, like other companies, appeared to have come to the site with particular ideas and concerns. Artists may find themselves challenged by the living reality of creating work within a functioning institution. Western healthcare can be seen to be delivered in institutional packages with its own codes and conventions. While this might be challenging to penetrate from the outside, the hospital can offer a clear infrastructure with systems that could prove invaluable to a project. The case studies in this chapter offer different models for negotiating hospital bureaucracy. IOU were supported by an inhouse arts team that were able to broker the relationship between the artists and clinicians and locate benefit for both parties. A more long-term partnership has been developed between the Big Apple Circus Clown Care Program and the facilities they work in. Indeed, the Clown Care Unit have developed their own administrative structures to support the particular demands of the hospital environment and, as such, provide in-house the sort of training and information regarding physical and emotional hygiene that organizations such as Vital Arts may have to provide to visiting companies. However it is communicated, it appears important to note that the hospital environment makes particular demands on performers and calls for particular skills. These may be developed through the process of working, as in the case of IOU, or primed before entering the space as in the Clown Care Program, but it is important that they are acknowledged in order to minimize the difficulties faced by the performers in the Theatre-Rites piece which might have been even more challenging had the audience been patients. Working outside a theatre building always stretches performance work, but working with the resonances of a hospital site, and all the fears and fantasies associated with it, adds another level to the work. This seems to be one of the reasons why theatre companies want to work within the clinical space. The hospital is innately dramatic, with people in role and the occurrence of acute

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episodes. Goffman discusses how contemporary hospitals draw on an ‘elaborate scientific stage’ as a backdrop for their everyday performances of clinical medicine and it seems that performance events may seek to exploit that theatricality, employing medical technology, or mock medical technology, to explore the everyday drama of the hospital (1976: 34). Companies such as IOU Theatre and Theatre-Rites appear to offer their audiences a point of reflection to look again at the space and consider its dynamics (1976: 34). Other practitioners, such as the Big Apple Circus Clown Care Program, focus on the people within the space rather than its materiality and, while they too transform medical objects to their own ends, their impulse to work against the scientific stage opens up a carnivalesque approach that challenges the social order within the hospital setting. The Clown Care Program embodies a different approach to the individual and employs the theatrical commitment to human-to-human contact which exceeds a dramatic frame. The various performance strategies explored within this chapter all serve to heighten space and invite spectators to experience the hospital in a different way. The commitment to communication in particular is recognized as being beneficial to health and the institutions advertise the presence of performers within the facility as part of the health benefits.

2 Specialist Knowledge: Theatre in Health Education

Introduction Health promotion researchers Lawrence Green and Marshall Kreuter define health education as: ‘any combination of learning experiences designed to facilitate voluntary actions conducive to health’ (quoted in O’Donnell, 2002: 364). This chapter will consider the efficacy of theatre as a teaching tool and a catalyst for action within health and care. I will examine the relationship between drama and pedagogy and the critical and practical tensions which may arise within projects that seek to combine theatre and health education. I shall consider the history of the use of theatre as an educational intervention and examine how drama has been used to impart knowledge and open up opportunities. In particular, I shall focus on the importance of narrative as a means of engaging with an audience. The chapter draws on international case studies – the community-based work of Nalamdana in southern India and the peer-education programme of the NiteStar Program in New York – both of which deal with AIDS/HIV/sexual health education. In examining the work of these companies I shall remain sensitive to contextual detail which shapes the practice – in terms of cultural climate, disease iteration and healthcare provision.

Health education and approaches to health With the industrial revolution in eighteenth-century Europe, the human body became of significant economic interest. What people 56

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ate, how they slept, and how they cleaned and clothed themselves began to matter as employers became concerned about the fitness, and therefore productiveness, of their employees. The presence of a philanthropic middle class also made an impact through public health initiatives, which often focused on improving sanitation and living conditions in urban conurbations. By the twentieth century, recommendations regarding the health of the population had grown exponentially, both within government and from non-governmental organizations (NGOs). Developments in scientific knowledge led to public campaigns against serious infectious diseases such as tuberculosis, venereal diseases and cancer; and issues related to healthy living, such as diet and drug abuse, were also subjects for health promotion activity. The World Health Organization (WHO), set up after World War II as a lead body for health within the United Nations system, defines health promotion as enabling people to increase control over and to improve their health, and this principle of personal empowerment appears to be a central tenet of health education. Ashton and Seymour draw on their experiences with the WHO to explore what they term the social model of ‘new’ public health, prevalent in the late twentieth century, which promotes action at a community level (1988: 37). This is contrasted with the earlier medical model which is based on the promotion of the rights of the individual and on making choices based on scientific data. Both models, however, seek to influence people’s behaviour. Critics such as Coveney suggest that health promotion may be seen as a political activity through which bodies are regulated. Coveney draws on a Foucaultian perspective and positions health educators as gate-keepers to knowledge where the population is diagnosed as sick and in need of ‘modification through mass education strategies’ (1998: 463). These strategies often hinge on consciousness-raising and seek to engender a ‘self-reflective, selfregulating individual’ – who, in the case of the new public health model, will also take an active role in her/his community, identifying health problems and examining possible outcomes both for themselves and for others (Coveney, 1998: 464). This process is viewed by Coveney as effective in that ‘health becomes a personal and social responsibility through the duty to be well, individuals and communities watch over their own and each other’s habits’ (1998: 466).1 In Foucaultian terms, bodies police themselves, having internalized the

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messages of government. Consciousness-raising is developed through the intervention of experts who engage the individual in, what Philip Barker terms as: ‘material practices and technologies of reflection and introspection’ (quoted in Coveney, 1998: 465). Thus, within the field of health promotion, there is the perspective that there are those who hold knowledge and there are those who need to be educated. Communication arts scholar Kistenberg, in her survey of the ‘AIDS crisis’ (particularly in the USA), identifies expert doctors and medical researchers who are ‘privileged with the right to say what AIDS is’, who sit in contrast to the ‘victims’, who are dependent on the care and instruction of others (1995: 17). Cultural and literary historian Sander Gilman, examining health promotion campaigns relating to HIV/AIDS, notes that the HIV-positive body was stigmatized and was shown only as a ‘site of suffering’ rather than one which held any valuable knowledge (quoted in Griffin, 2000: 63). Gilman observes that the AIDS health campaigns in the USA focused on ‘beautiful’ bodies who were ‘at risk’ and ‘in need of protection’ (quoted in Griffin, 2000: 63). It seemed that, while groups such as ACT UP were campaigning for those living with AIDS and their needs, health promotion agencies targeted heterosexual couples with messages seeking to outline the ‘threat’ that they faced in order to ensure the preservation of their integrity. It could be understood that experts had taken a decision on where to focus resources and whose health was worth protecting. In such campaigns some lifestyles may be seen as healthy while others are viewed as unhealthy, and moral judgements may be attached. In viewing health promotion as an instrument of government, Coveney argues that it ‘provides for us an ethics; a means by which we can assess our own desires, attitudes and conducts in relation to those set out by expertise’ (1998: 466). An awareness of this suggests the importance of remaining sensitized to the political aspects of the practices outlined within this chapter and the scope of its impact. I am interested to examine whether theatre practitioners in the field of health education support or subvert the work of official health and care agencies and how they constitute their expertise in relationship with their target audience. This chapter will examine two recent health education programmes. Both case studies reflect a unique vision of health promotion, with the first focusing primarily on personal behaviour change and the latter taking on a broader empowerment/environmental

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model of health promotion. Significantly for this study, both seek to employ theatrical techniques to communicate with their audiences and I want to consider how such an encounter may impact upon the health promotion activity.

Theatre and social change In her survey of theatre’s potential to teach, Redington acknowledges that playwrights from Sophocles to Strindberg have used their plays to transmit information to their audiences (1983). As a public forum, theatre provides a platform for addressing social issues, and Redington notes that playwrights have made use of this potential to present political opinion or attempt moral instruction. Although this has been occurring throughout theatrical history, a particular change happened at the beginning of the twentieth century with the rise of the avant-garde. The Modernists rejected Romanticism and looked to a ‘modern’ engagement with the new technological age that they perceived about them. Modernism believed in reason and trusted that the exposure of wrong-doing, and subsequent consciousnessraising, would lead to social change. Most significantly, Modernists sought to employ artistic practices as a catalyst towards political activism. Modernists can be seen to be engaged in ideological warfare with the establishment where form was the battleground. This celebration of artistic form led to a wealth of artistic experimentation which sought to encourage spectators to see the world around them from a new perspective – from the Futurists’ mechanical dances to the Dadaists’ sound poetry. The Modernists aimed to foreground the alterable nature of events and to encourage the critical observation of social behaviour with a view to development. As part of this movement, theatre practitioners were experimenting with the potential of performance as a site of education and activism. A significant experimenter in theatre was the Expressionist dramatist Bertolt Brecht (1898–1956). Literary scholar Russo considers how Brecht’s innovations in practice drew on historical pedagogical models to maximize the impact of his theatrical work. Russo examines the way in which Brecht can be seen to be employing Socratic dialogue within his epic theatre to engage with his audience. This can be understood as being fully in accord with Brecht’s Modernist intention to raise consciousness and promote independent thinking

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and action. Russo argues that there is a ‘spectator-centred focus’ and direct attention on the way in which an audience might receive material which sits at the heart of Brecht’s work (2003: 257). Brecht was clearly concerned with the behaviour of the audience and he sought to address them directly and shock them out of the passive consumption of a play into active engagement with material. Brecht’s theatre, like other Modernist artworks, was based on reason rather than feeling and he intended his work to appeal to the critical faculties of the spectator. In Brecht’s epic theatre the emphasis was on the narrative – the way things happen – rather than plot – what might happen. In ‘A Short Organum for the Theatre’ Brecht states: Everything hangs on the ‘story’; it is the heart of the theatrical performance. For it is what happens between people that provides them with all the material that they can discuss, criticize, alter. (1964: 200) This focus is significant in that it brings the audience into the action and introduces the idea of change. Brecht’s work rejected the inevitability of the tragic form with a plot that arises from the weaknesses of the tragic hero – for example, Macbeth’s tragic flaw of pride means that he is destined to die – but attended instead to outlining how things happen within the story and the choices that are made which lead to those particular turn of events. The notion of alterability is essential to Brecht’s work as it opens up the possibility that things can be transformed, which is fundamental to his ambition that theatre be employed to effect social change. Brecht’s Lehrstück (or teaching play) The Exception and the Rule is an example of the way in which he encouraged the audience to be sensitive to the narrative of the action and to look out for possibilities for change. The piece opens with direct address to the audience by the performers who are not yet in character. They urge the spectators to observe the action of the play carefully: We ask you expressly to discover That what happens all the time is not natural For to say that something is natural … Is to Regard it as unchangeable. (Brecht, 1977: 37)

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As with other Modernists, Brecht wanted his plays to promote reflection upon life outside the theatre and thus, while the story related to everyday experience, it did so in a way that invited critical attention. So, within the action of The Exception and the Rule, the audience are witness to a ruthless Merchant in a far-off desert who kills a coolie because he mistakes a genuine offer of kindness – to share drinking water – for a threatened attack. The coolie’s wife attempts to bring a court case against the Merchant but the judge rules that the Merchant was right to be suspicious of the coolie and that his claims of self-defence are justified. The distancing of the setting and the broad ‘types’ of characters is intended to allow for a more objective perspective on the action and for cognitive connections to be made between this scenario and the workplaces/ courtrooms that are more familiar to audience members where perhaps the audience can recognize that the poor are discriminated against. The performance style of the epic theatre supports the focus on the narrative with basic settings – which may just be a piece of cloth to indicate a river rather than full boxed sets. Epic theatre also employed Gestic acting which seeks to demonstrate rather than inhabit character in order that the audience do not get drawn into relationships with personalities within the plays but remain aware of their status as types of figures. Thus, it was intended that the audience should not just feel sympathy for this particular coolie but become aware that this figure represents many coolies who may suffer at the hands of unscrupulous masters, and thus stimulate action. The story is that which is seen to be engaging for the audience as it offers a window on experience. As the opening statements indicate, an important aspect of the teaching play is to demonstrate that the world is changeable. As a Marxist, Brecht had a particular social agenda and wanted people to come to a state of consciousness and take action in order to make a particular kind of revolutionary social change. Thus, the end of the play addresses the audience and exhorts: And where you have recognized abuse Do something about it! (1977: 60) Thus the learning plays invite active engagement with the material and conscious reflection on social behaviour. Brecht believed that

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the Lehrstücke were examples of how the stage might be didactic and he celebrated the potential of the theatre as a place of reason and teaching. Brecht saw his work as teaching the performers as well as the audience members. He wanted people to learn through the rehearsal process. The Lehrstücke were designed to be performed outside conventional theatre spaces by groups such as factory workers and schoolchildren. Through actively engaging with the ideas, Brecht believed that people could learn through the process of creation. He himself was also open to learning, and schoolchildren’s strong response to the first version of his play He Who Says Yes, which deals with the relationship between the individual and the community, led to the writing of He Who Says No, which considers how old customs and ways of being might be revised. Brecht’s work was committed to challenging convention and opening up things for debate, which is a mode of practice that has remained important within educational theatre. Yet the work was also fun and playful too. Brecht believed in Spass – the pleasure of working things out and the joy of a logical conclusion. His plays actively drew on the cabaret tradition of the Modernist avant-garde and employed comedic characters and comic moments. Brecht argued that theatre should seek to ‘make its moral lesson enjoyable’ (1964: 180). Comedy was seen to be of use by Brecht in that it is an attack on the philosophy of tragic inevitability as the audience are encouraged to see events as a consequence of choices and thus changeable. Thus, for example, a custard pie may be just about to land in Stan Laurel’s face but, at the last minute, he ducks down leaving the man behind with mess on his jacket. As in the Modernist cabaret, music was also used within the plays to highlight particular moments of drama and provide counterpoint as well as underscoring.

Theatre in Health Education Brecht’s epic theatre was a model of practice for those who sought to use performance as a social intervention and was a significant influence on practitioners in the field of Theatre in Education (TIE). TIE has been identified by theatre scholar Jackson as beginning in the mid-1960s in Britain – particularly with the formation of the Belgrade Theatre TIE company in 1965. The aim, as the title suggests, was to employ theatre as an educational tool and to

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provide an experience for children that will be intensely absorbing, challenging, even provocative, an unrivalled stimulus for further work on the chosen subject in and out of school. ( Jackson, 1993: 1) Skilled workers, often with experience of both drama and teaching, would work as actor/teachers, combining performance and pedagogy. TIE projects most commonly worked as ‘programmes’ with preparatory and follow-up work complementing a performance presentation. Preparation work might take place in school prior to the theatre company’s arrival with the exploration of a theme or reading information about a particular set of characters. Follow-up work might again be led by a teacher with children responding to the action of the play – for example, writing letters to the characters – or it might involve a developmental workshop with members of the theatre company. The work would be tailored for a particular audience – in terms of age group etc. – yet designed to tour to a range of venues as companies often included visits to a number of schools and community spaces as part of a project. In her study of the relationship between theatre and education, Nicholson notes that ‘many early TIE practitioners were motivated by Marxist politics’, and saw theatre as an important and effective way of raising consciousness (2009: 20). Thus, not only did they embrace a Brechtian aesthetic – with Gestic acting which engages in theatrical demonstration of behaviour as a didactic tool; the centrality of the narrative to encourage audience members to think and ask questions; and direct relationship with the audience – they also embraced his radical political agenda and avant-garde spirit and positioned themselves in opposition to mainstream culture. Such companies were inspired by the artistic innovation of Modernists and, as Nicholson observes, regarded themselves as ‘independent-minded cultural provocateurs rather than uncritical followers of government agendas’ (2009: 12). This could prove problematic, as TIE projects were offered free to audience members and were often supported by funding bodies such as government agencies which had particular agendas and targets for the work that did not match the ideals of the artists. Broadly speaking, funding came from the Arts Council in the 1960s and from Local Education Authorities in the 1970s. The 1980s were difficult for TIE companies as there was a significant reduction in government funding. Companies had to be innovative and find new sources of funding

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for their work. This meant a diversification in the field as some companies specialized in museum work, for example, and others engaged in the emerging practice of Theatre in Health Education (THE). Theatre in Health Education has been criticized for being too ‘message focused’, often at the expense of the artistic integrity of the work. Playwright David Edgar caricatured the practice in a newspaper article, lamenting the ‘dumbing down’ of artistic work by stating: ‘Small theatre-in-health-education theatre groups … have been given checklists of morally improving messages to insert into plays about bullying’ (quoted in Nicholson, 2009: 10). It is true that THE funders often have a very particular set of criteria about the piece they are commissioning and the outcomes they are looking to see – for example, reduction in teenage pregnancy rate or cessation of smoking. They are looking to employ theatre in order to disseminate health messages in an entertaining manner in order that they are memorable and sustainable. Funders have also been attracted to THE by the possibility that audience members are not just passive recipients of information, but that the interactive nature of the projects will allow for dynamic engagement with the material. Ideally this will employ both good artistic practice and good teaching practice as it recognizes the importance of active learning and the possibility of dialogue. Negotiations are, however, often complex. Jackson provides an example of the heated discussions which took place between a health promotion service and the theatre company they had commissioned to produce a programme around sexual health. The health experts were keen to see clear, direct and measurable messages communicated, whereas the artists were looking to create the framework of an engaging human drama. Happily, Jackson reports that the final product was pleasing to both parties but he also notes that: ‘not all such partnerships turn out so well’ (2007: 206). As with all other health interventions, the funders of THE need to justify the efficacy of the practice. Denman et al. note that, in the UK, ‘special “ring fenced” monies’ have been set aside by health authorities for Theatre in Health Education programmes (1995: 4). The monies have particular (often policy) objectives attached to them and, often, evaluation and measurement of meeting outcomes and objectives are an important element of a THE project. As a lecturer in Health Promotion, Denman is keen to evaluate the efficacy of a particular project which employs a play and a workshop yet observes that there

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is no standardized method of evaluation. Denman notes that: ‘existing studies differ both in the outcomes that they set out to measure, the methods used in the evaluation and, to some extent, their findings’ (1995: 4). The debate surrounding evaluation was touched upon in the Introduction and it may be, indeed, that it is appropriate that there is no standardized methodology, but it can lead to problematic studies that may not be as insightful as they might have been. The following are some examples of Theatre in Health Education evaluations which give an insight into practice in the field. Elliott et al. (1996) recognized that, in the 1990s, theatre was regularly employed in HIV and AIDS education but they were troubled by the methodology of research regarding its effectiveness. In particular they were concerned about the lack of control groups or comparisons. Their study, based at their Addictions Resources Centre, sought to evaluate the efficacy of a THE production in regards to the knowledge, attitudes and behaviour of young people. This was compared against a ‘standard’ health education seminar (1996: 321). Interestingly the study notes that ‘there was little impact on the knowledge and attitudes of either audience’ but, reading the findings, it appears that there were some important differences (1996: 321). For example, 42 per cent of the health education group thought that buying condoms was embarrassing compared with 17 per cent of the theatre group. It might be suggested that this is because a theatrical performance is able to provide a model for behaviour through, what Jackson terms as, ‘audience surrogate characters’ (2007: 185). In this instance theatre can be seen as giving a practical example of how things might happen as opposed to a seminar talk which provides theory. The researchers also noted that young people who had attended the play appeared when questioned to be more willing to adopt behaviour which ‘could be seen as leading to safer sex practices’ (Elliott et al., 1996: 331). Again, perhaps this was a result of action that was modelled in the performance. Those questioned emphasized how much they had enjoyed the play and how they had felt it was realistic, indicating a high level of engagement. The seminar, however, was viewed by the young people as boring and the summary score of the seminar group appeared to show ‘lower levels of agreement with themes expressed in the presentation’ (1996: 331). Fundamentally, however, the study concluded that seminars were more economically feasible and, with

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many health authorities, this is the bottom line and one which may marginalize THE practice with its emphasis on the qualitative nature of the experience rather than quantitative statistics. Again, this returns to the problem of evaluation, as health promotion manager Blakey and sociologist Pullen’s evaluation of a drama-based sex education project employed more qualitative methods such as semistructured interviews, and their findings were much more positive, leading to their conclusion that: a dramatic production of some kind can act as a trigger for less inhibited discussion, and act as a catalyst for opening channels of communication between teenagers and adults. (1991: 161) Blakey and Pullen also noted the importance of the immediacy of the performance within the THE programme, as well as the usefulness of the workshop sessions which allowed for a shift from exploring hypothetical to real-life situations and the use of fictional space to try out ideas and behaviours. The notion of the performance as part of a wider package is significant. Elliott et al.’s study appears problematic as it was not revealed to the group in advance that they were going to see a theatre event and yet, as I have noted, the idea of the programme – with preparation before the event and follow-up after – is a model of good practice within TIE and most work needs to be viewed within this context. Public health specialists McEwan et al. evaluated Body Talk, an HIV and AIDS awareness programme which comprised a play and a workshop. Their results seemed to indicate that the workshop had not only been important for embedding the knowledge communicated in the play but also in promoting communication among the peer group. One respondent said: if we hadn’t done the workshops I would probably feel a bit embarrassed with the boys here, but since we did do the workshop everyone could just talk to each other and it was much better. (1991: 157) It seems like this type of impact will have efficacy beyond the health education aims and objectives. THE programmes draw on experiential learning methods which encourage active participation and

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may carry the dual benefits of more general drama education – with its exploration of interpersonal skills and creative imagination, alongside the communication of particular subject information. Nevertheless, evaluations such as those which happened on the Body Talk study often focus on pre- and post-tests that examine subject knowledge which, in this case, showed little difference. Like Elliott et al., however, McEwan et al.’s study highlights that there were shifts in attitude so, for example, following the THE intervention, students felt that both sexes were responsible for contraception. The study concluded that drama was more successful in affective change rather than imparting knowledge. This could, firstly, be to do with the availability of sexual health information – two-thirds of students surveyed in this study felt they knew enough about HIV and AIDS both before and after the project. It could also relate to Jackson’s observations of the dangers of polemics. Jackson argues that a theatre experience can offer an audience member the opportunity to creatively engage with events. He is cynical about projects where ‘creative gaps’ which actively invite discussion are filled by a subtext, that is, the required response is preordained by the commissioners and/or makers of the project and audience members are merely being asked to rehearse the ‘right’ answer rather than genuinely reflect on their own responses (2007: 180). Jackson observes that audiences are sensitive to this dynamic and may close up and not be so receptive to didactical material. Like Jackson, McEwan et al. conclude that THE projects work best when they are not seeking to indoctrinate but, instead, to offer a space for self-reflection. McEwan et al. note that, when evaluated in terms of value for money in imparting information, THE may be seen to be too expensive but, they argue: Compared with educational programmes which have empowerment as a principal objective, however, theatre-in-education programmes which deal with the subject are apparently more tenable. (1991: 160) As playwright Dylan Cooper states, theatre is not a ‘living leaflet’ but an ‘emotional medium’ which may have more far-reaching benefits than knowledge enhancement (quoted in Jackson, 2007: 228). It is worth noting that the evaluation examples I selected all relate to projects around sexual health and HIV/AIDS. In his survey of

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THE practice, practitioner-theorist Ball argues that the ‘most significant factor in the development of Theatre in Health Education has been the emergence of HIV and AIDS’ (1993: 228). Although he recognizes a general developing interest in health promotion, and more particularly in innovative ways of communicating ideas, he observes that the ‘crisis’ of AIDS and HIV instigated a sense of urgency and a desire by health educationalists to disseminate information by any means possible, which meant a willingness to experiment with theatre and, ultimately, the release of funds (1993: 228). Ball documents that, in 1991, there were at least 14 HIV/AIDS THE programmes in the UK. This concern with HIV/AIDS within education is a worldwide phenomenon and the two case studies I am concentrating on in this chapter include examples of HIV/AIDS/sexual health programmes from the USA and from India.

NiteStar The NiteStar Program (incorporating Star Theater) is a New York-based company that ‘use drama, music and peer education to help guide preadolescents, adolescents and young adults as they confront the many challenges of growing up in the age of AIDS’ (www.nitestar.org). The company was founded by Cydelle Berlin in 1987. Dr Berlin (a specialist in adolescent sexuality and development) had been working with adolescents and was troubled by the manner in which the physicians and other healthcare providers whom she worked with dealt with sex education. She likened it to aversion therapy that was ‘not about education, [but] about fear’ (2006). Berlin was concerned about the suppression of information regarding AIDS and HIV in the United States. She comments that President Ronald Reagan didn’t discuss AIDS in a public forum until a press conference four years into the epidemic, by which time more than 12,000 Americans had already died (2006). In the context of the developing AIDS epidemic, Berlin was looking to create a programme which would encourage discussion and dialogue and provide useful information and support to young people. In 1988 NiteStar was awarded start-up funds from the US Conference of Mayors. The project was originally housed at Mount Sinai Medical Center’s Adolescent Health Center in upper Manhattan, but moved after ten years to St Luke’s-Roosevelt Hospital Center (a full-service community and tertiary care hospital in Harlem) due to

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lack of funding. Funding has always been an issue for the company. They are attached to the clinical department – which itself functions within America’s private system of healthcare – but raise their own funds. As has already been noted, funders may have particular objectives for their monies so, for example, the company were funded through the Office of Adolescent Pregnancy for one particular project that fits their criteria. Funders may also have restrictions that they place on the work; for example, in the past the company have been asked not to discuss condom use as it conflicted with the ethics of the funding body, which led to protracted negotiation as the company refuse to censor their work. The work of the company has continued to grow and currently has a repertoire of five productions which are presented to young people, youth providers, parents, care-givers and the general public. NiteStar is part of the St Luke-Roosevelt Hospital Center’s Adolescent Health Center’s AIDS prevention and treatment programme, but the manner in which it employs performance means that it is a quite different sort of work to the other health initiatives that it works alongside. From the beginning of the work the company championed the potential for theatre to promote change. The aim of the company to ‘[help] young people make informed decisions’ fits with McEwan’s proposition that theatre be used as a tool for self-reflection (www.nitestar.org). In developing their programme, NiteStar actively drew on the British TIE model. They sought to present relevant material to their audiences in an engaging manner which they hoped would promote discussion. A significant aspect of their work is that they employ young people, ages 15 to 25, to develop and present the shows. As in the TIE model, the company members are not just performers but have an instrumental role to play in the whole programme and are described as actor/educators and need to offer considerable skills in both areas as they shape the programme. Potential company members are carefully screened through an extensive audition, interview and call-back process in order to ensure that they reflect the philosophy of the company and are committed to the goals of the NiteStar programme. Peer education is a central tenet of NiteStar. Once they have joined the company the actor/educators receive in-depth health training, on college-level programmes, in sex education, health and theatre. In particular they receive specialist teaching on sexuality training

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communication which is designed to equip them to be expert facilitators within the programmes they work on. In developing the programme, Berlin states that she has drawn on the work of psychologist Albert Bandura, who engaged in studies of social learning and developed theories related to observational learning which, broadly stated, posits that people learn how to behave, and how to change their behaviour, by watching other people (1977). Thus, an important element of the theatre event is the modelling of behaviour. As in Elliott et al.’s study, NiteStar present adolescent characters who change their behaviour from risky to safer, not only demonstrating that this is possible but also offering strategies for how this might happen. In their training manual on theatre-based techniques for youth peer education, Berlin and her collaborator – theatre consultant and previous artistic director of the company Ken Hornbeck – state: ‘Research has shown … that adolescents tend to adopt the behaviours of those whom they regard as role models’ and thus, in their productions, they are careful to craft characters who are familiar in type and attractive to their audiences – that is, wearing cool clothes and using age-appropriate language (Berlin and Hornbeck, 2005: 9). These characters are developed through improvisation and kept up to date as youth culture changes. Improvisation is a central strand in the company’s theatre-making methodology – allowing a collaborative and democratic approach to the work that can reflect current concerns and interests as each season brings new company members to work on the project. It is not just the characters but the performers themselves who are carefully selected to reflect the ethnic diversity and cultural interests of the company’s target audience. McEwan et al.’s study noted that having actors of approximately the same age as the audience members had a real impact on the reception of the work. One respondent said: ‘Because she was about the same age as us … so it could happen’ (1991: 157). For NiteStar, an important aspect of the work is the peer-to-peer contact which is strengthened through the post-show discussions that are facilitated by members of the company. NiteStar seek to be non-judgemental and do not approach the work from an authoritative stance. Instead Berlin sees the work as being grounded more in ‘problem-solving than giving advice’, with company members encouraging the audience to engage in the process of reflection and discussion (Berlin, 2006). There are, however, safe-sex messages

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and desirable behaviours modelled within the work so, although there is no didactic message, particular perspectives on situations are presented. An interesting dynamic within the work, highlighted by artistic director Cheryl Paley, is that the actors are often going through the issues themselves and, in some ways, ‘the actors are the clients’ (Paley, 2006). NiteStar provide a lot of support to company members – in particular a retreat at the beginning and end of every year which is for processing personal as well as professional material. It is also envisaged that working as part of ensemble will prove to be a supportive environment and, as in Brecht’s Lehrstücke, the process of rehearsing and developing the productions will allow opportunities for discussion and exploration. Also like Brecht’s theatre, NiteStar acknowledge that ‘at the heart of great theatre is a great story’ (Berlin and Hornbeck, 2005: 10). Their shows are performed with very basic settings and it is the attraction of the narrative which holds the audience’s attention. Paley states that they start the devising process with the question ‘what story has to be told?’ (2006). The company have developed a range of work to appeal to different age groups. Berlin’s expertise has allowed a careful crafting of the health education material in order that it is pitched at an appropriate level – thus the same issues can be explored with third graders and twelfth graders but via different types of approach. Currently in the repertoire are: The Best That I Can Be for fifth and sixth graders in which characters grapple with the onset of puberty. Other issues explored within the piece are precocious sexual activity, pregnancy prevention, HIV/AIDS, personal boundaries, divorce, intimate contact and appropriate/inappropriate touching, and peer pressure. Everybody’s Doin’ It has been designed with seventh and eighth graders in mind. The show also deals with puberty, with the male experience explored more fully than in the fifth- and sixthgrade presentation. There is also an exploration of homosexuality and homophobia, and of experimentation with drugs and alcohol, in combination with peer pressure and bullying. The Rec is a show aimed at High School students and deals with HIV/AIDS and other sexually transmitted diseases and explores abstinence and teenage pregnancy. Dramadotcom is a show aimed at a more general young adult audience which addresses domestic violence, date rape and GLTBQ hate crimes. Pandemic is designed for presentation and conferences and in community settings and is an adaption of the documentary film

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Pandemic: Facing AIDS (2002). Finally The Living Quilt is a collaboration with St Luke’s Roosevelt Crime Victims Treatment Center and the Center for Comprehensive Care and reflects on the relationship between HIV/AIDS and domestic violence. NiteStar’s production profile clearly indicates thematic priorities but they are equally committed to creating vibrant and engaging theatre. The performances are high-energy pieces which seek to promote what Paley terms as ‘active involvement’ (2006). The scripts, as I have already noted, come directly from the young people who devise the work, and the stories are designed to reflect, and encourage reflection upon, the contemporary urban, American experience. So, for example, The Best That I Can Be follows a group of classmates with recognizable scenes of classroom life. This is in heightened form for the audience with an emphasis on humour – so in one scene we see a group of boys running around with sanitary pads on their heads. The Rec is a good example of how the company’s work embraces popular culture as the story centres on the creation of a reality TV show and, more generally, the company use contemporary cultural references and forms such as rap music within the productions. Yet while the company present the familiar, as in the work of Brecht, they are encouraging their audiences to reflect on the scenes before them. The stories often hinge around the dilemmas that the characters find themselves in, and the narrative is devised and presented in such a manner that the choices made are clearly delineated. The central concept of modelling for and reflecting back to the audience also shapes the creative product in that the stories are often told from the adolescent point of view. At every point the company seek to avoid what Paley terms ‘the cringe factor’, ensuring that they are making relevant and accessible shows (2006). A very important aspect which works towards the lack of embarrassment are the genuine ‘creative gaps’ that NiteStar build into the work. They do not have a moralistic subtext but offer their scripts as open texts and stimuli for discussion. This has brought them into conflict with authority. The documentary Sex and Other Matters of Life and Death documents the company’s interactions with the NYC Board of Education in 1996 when a change to the curriculum was proposed, suppressing discussions or demonstrations of condom use (Figure 3). NiteStar members were very vocal at a public meeting, defending young people’s right to information. Berlin reflects on the conservative impulse that she

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Figure 3 NiteStar company members in Sex and Other Matters of Life and Death

perceives in contemporary American society that wants to legislate and dictate what is right and wrong. NiteStar, however, want to give young people the information to make choices for themselves. The NiteStar Program believes that providing information and space for reflection will provide young people with the tools they need to make less ‘risky choices’ but acknowledge that this cannot be guaranteed (Berlin, 2006). This does raise issues within the company and Berlin notes that each company member has to ask themselves ‘how can you live with the fact that you cannot control other people’s behaviour?’ (Berlin, 2006). Overall the company see theatre as an effective way in which to start a conversation among young people about issues relating to health and sexuality which they hope will translate into informed practices. As is common in Theatre in Health Education, NiteStar’s performances are presented as part of a larger programme. Contact is made with the school/host venue prior to the event and the company seek to enter into a dialogue around the subject of the presentation. This

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may involve identification of how the work might be embedded within the curriculum and/or it may address the particular context of the host venue. For example, a school might state that there have been a particularly high number of teenage pregnancies and then NiteStar would try and incorporate that material into their work with the young people. After each performance (which last from between 25 and 40 minutes) there is a question and answer session for the audience facilitated by a member of the company who has not been performing. The actors remain in character and the audience are invited to engage in the process of ‘hot-seating’ them, asking questions and offering advice related to the actions of the play. Hot-seating is a wellused technique within Theatre in Education work, where performers in character literally sit in the ‘hot-seat’ in front of the audience and respond directly to their questions and comments. This structure is also often used in rehearsals to help actors to flesh out a role and this might be quite a free-form encounter. In a post-show discussion it is likely that the facilitator will be more actively involved in order to, as NiteStar describe it, ‘find the delicate balance that exists between staying on task and remaining flexible’ (Berlin, 2006). The experience is quite a precarious one in that it can be seen as an improvisation between the audience and the performers as the audience suspend their disbelief and enter into a real relationship with the fictional characters and the performers seek to honour audience members’ contributions by responding with integrity while remaining committed to the character. Jackson describes a problematic encounter in a British TIE programme when an actor used a hot-seating session to assert his own opinions on the subject. Within such a finely tuned moment the audience are very sensitive to the performer’s responses and, in this case, quickly picked up on the shift in dynamic and, as a result, the young people became withdrawn. Jackson notes that: Young audiences usually understand there is safety in talking to and arguing with a character, but, as soon as they think the views expressed are what the actor himself or herself really thinks, an aesthetic dividing line has been crossed. (2007: 195) It is therefore important that sufficient preparatory work has been done with the performers to enable them to create well-developed ‘back-stories’ for their characters and to have had the opportunity to

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practise responding to a range of questions in role. Within the event the facilitator, if there is one, can help to keep ideas in play and the aesthetic world intact. Following each discussion NiteStar company members also reflect on events and consider their responses within the hot-seating session and whether they felt that they were pitched at the right level. This is particularly important in their work as, since their audiences cover a wide age range, the performers need to make sure that they are providing age-appropriate responses to the audience interventions. Ideally hot-seating encourages an understanding that events can be seen from different perspectives. An interesting dynamic in the age of the confessional chat show is that audience members are used to a format where they offer their opinions on the actions of others in the guise of advice, but actually this may be quite judgemental. An example captured in the documentary Sex and Other Matters of Life and Death shows a Junior High School student offering his opinion to a character who has been discussing masturbation. He views the practice as ‘nasty’ (1996). The facilitator has to work to keep a dialogue open and other options in play so, for example, in this case she responds by affirming that people have different approaches to sexuality and gives the character the space to argue that she sees nothing wrong in masturbation. As well as hot-seating, some of the NiteStar programmes have more developed follow-up programmes. For example, Am I Normal? runs as a seven-week project. The first week of work within the school focuses on the show and an introduction to the characters: Emily whose sister has had a baby who she now has to babysit; JB who wants to be a rapper and is exploring the idea that you don’t have to have sex to be a man; Mya who spends a lot of her evenings in internet chatrooms while her mum is working; David who is caught in the middle of his parents’ divorce; and Jessica who just wants to be popular but is struggling with the fact that she is the first girl in her class to wear a bra. This initial intervention is followed by a series of workshops which involve role-plays with the characters and facilitated discussion around key issues. Week two deals with puberty; week three anatomy; week four sexual abuse; week five HIV; and week six negotiation and refusal. Week seven is a wrap-up session which sees the participants involved in play-making as they create their own role-play which allows them to practise behaviours that they might take into their everyday lives. This work, which is

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laddered as a developmental experience, is designed to draw out the educational themes of the initial intervention. The intensive focus of the work allows for in-depth exploration, and the practical theatre work allows for an embodied embedding of knowledge. Berlin and Hornbeck suggest that example workshop objectives could be ‘to help participants feel safe and free to discuss sexual health issues without embarrassment or restraint and the sessions are a space where dialogue is encouraged’ (2005: 16). NiteStar report significant change in both sexual behaviour and negotiation behaviour for safe-sex practices. They note that the more developed the follow-up programme, the more effective the intervention as, with each session, participants become more familiar with the material and the company members and a greater amount of information is able to be provided. Berlin and Hornbeck developed their training manual in order to disseminate their ideas for practice and to communicate their belief in theatre as an educational tool and in the impact of peer education. The manual is currently being used by the United Nations (UNFPA), and Berlin regularly works as a trainer with delegates from Northern and Eastern Europe. The company see this model as one which can be rolled out as an HIV education tool and taken to different countries, although there needs to be a recognition that each new context will have its own issues regarding HIV/AIDS.

Nalamdana India’s AIDS problem is growing at a fast pace. HIV emerged later in India than it did in many other places, but this has not curbed its impact. In 1987 a National AIDS Control Programme was founded to provide national co-ordination for responses to the crisis. Its activities included monitoring, blood screening and health education. By the end of 1987, out of 52,907 people who had been tested, around 135 were found to be HIV positive and 14 had AIDS. Most of these initial cases appeared to have occurred through heterosexual sex, but, at the end of the 1980s, a rapid spread of HIV was observed among injecting drug users in Manipur, Mizoram and Nagaland in the north-eastern states of India. Infection rates rapidly escalated throughout the 1990s, and have increased even further in recent years. In 1992 the Indian government instigated the National AIDS Control Organization (NACO), a body charged with the formulation

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of policies, and the direction of prevention work and disease-control programmes relating to HIV and AIDS. It also launched a Strategic Plan for HIV prevention. This plan involved the creation of administrative and technical bodies which would be responsible for HIV/ AIDS programme management – including the establishment of state AIDS bodies in 25 states and seven union territories. Despite many developments, including improvements in blood safety, the crisis continues to deepen in contemporary India with steep rises in the number of new HIV infections, and the disease is acknowledged as affecting all strata of Indian society – not just the groups such as sexworkers and truck drivers that it was originally associated with. India’s first cases of HIV were diagnosed among sex-workers in 1986 in Chennai (previously known as Madras) in the state of Tamil Nadu in southern India. Nalamdana are a health education company based in Chennai who are seeking to develop effective and targeted health education programmes. Nalamdana means ‘Are you well?’ in Tamil and their logo of the kolom (a traditional threshold decoration) was chosen to represent the power of people coming together. The company was founded in 1983, supported by funding from the Echoing Green Foundation in New York, with the aim of using a range of communication methods to disseminate health messages across a range of issues. The company function as an independently funded NGO. They are development rather than relief focused with an emphasis on education. The company have employed methods such as ‘tele-dramas’ (similar to Western soap operas) and interactive puzzles, but had a special commitment to the use of street theatre as a popular form with which to directly interact with their audience. The founder of Nalamdana, Uttara Bharath, made contact with R. Jeevanandam who, with a group of his friends, had been producing health-based street theatre in Madurai, and together they developed the work of Nalamdana. From 2000, in recognition of the growing problem, the company have focused on AIDS work and looked to use their skills and networks to promote HIV/AIDS awareness. While both Nalamdana and NiteStar are using theatre as a means of communication in relation to AIDS and HIV, Nalamdana, working in the Indian subcontinent, have a very different cultural context to NiteStar. While NiteStar note a conservative impulse in the USA, there are strict religious and cultural codes in India regarding sexrelated issues which make it difficult to openly discuss sex-related

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health or social problems, which are seen as very private issues. There are also different ideas about health provision. Khanna, a scientific officer for the Sports Authority of India, observes that, even though the right to health has been affirmed by the supreme court in India, in ‘reality health is a low priority concern for the government’ (2006: 1). Harriss-White and Subramanian, in their introduction to a study of India’s social health system, note that, in the early 1990s, public spending on the spectrum of social services was 3.5 per cent of GNP and that public spending on healthcare had been particularly low (1999: 23). So, even though a national health policy has been adopted, lack of resources – in terms of both money and staff – is a barrier to the development of viable healthcare delivery programmes. Health provision is predominantly in the private sector and, due to the inevitable pressure of market forces, the emphasis is therefore on the more profitable curative medicine rather than disease prevention, leaving NGOs such as Nalamdana to provide health education services. This provision is made even more problematic by widespread illiteracy. Like NiteStar, Nalamdana are dependent on monies from funders in order to offer their services to their audiences for free. One of their main funding streams currently comes from the Ford Foundation, Earthwatch programme. The aims of the Ford Foundation are to: ‘strengthen democratic values, reduce poverty and injustice, promote international co-operation, advance human achievement’ (www. fordfound.org). The company have a productive on-going relationship with the Ford Foundation, but with other funders they have found, like NiteStar, that there have been problems with organizations wanting them to deliver particular messages in return for financial support. Nalamdana decided that a clear mission statement would help them negotiate any difficult interactions. The company developed the following statement: Nalamdana uses creative, innovative and entertaining methods of education and communication to teach semi-literate and illiterate communities how to make better-informed decisions about their health and their families. (www.nalamdana.org) The emphasis is placed on choices rather than particular objectives – leaving creative gaps for personal reflection and development – but,

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like NiteStar, Nalamdana promote preventative behaviours and demonstrate the benefits of them. So, for example, they mounted a play about the importance of being tested for cancer and the life-saving impact it might have. The effect of such a message was immediate as, following the performance, 62 people caught the bus to the hospital! Nalamdana look to funders who share their health-promotion aspirations and principles and seek to build up a partnership with them. This can be a precarious business as funding priorities change – for example, Earthwatch is changing its emphasis to more environmental concerns, which will leave a gap in Nalamdana’s support system. Nalamdana are also looking to be in partnership with the community, so they have to make sure that the three-way communication fits and that funders, especially international bodies, are aware of the intricacies of the local climate. Like NiteStar, Nalamdana are looking to model behaviours in their productions. They seek to present recognizable scenarios wherein the characters take advice and reflect on their own situations which may act as a catalyst for discussion among the audience. Also, like NiteStar, the company use performers who come from the communities they are performing to. This is especially important as they speak the local dialect and can ensure effective communication. It also is a useful way of connecting with the public and lessens their status as ‘outsiders’ in that company members are former rickshaw drivers etc. who have a first-hand understanding of the community and so are able to communicate empathetically. This has proved to be a problematic strategy, however, as people who join the company have gone on to become quite famous – performing in tele-dramas and films – which makes them less available for work with Nalamdana. The company have, however, used this situation to their advantage in that they recognize audience members may be more keen to see a show with a celebrity in it and may even prove more willing to trust what they say because of their public presence. The building of trust is central to the work and the company always make a point of when they arrive at a village to take time to get to know local people a little before the performance events. One of the ways they do this is through auditioning people to take part in the cultural programme which precedes the main production. The company have found that people are less receptive to their messages if they go straight into the drama and that a cabaret of music and dance

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warms up the audience and creates a conducive atmosphere. The company then sense when it is the right moment to commence the play. The appearance of local people in the performing area from the beginning is also important in that it acts as a precursor to the post-show discussion where people are invited up onto the stage to offer their thoughts and opinions on the show and the issues raised within it. A typical presentation will take place in the evening, in an open-air space within a village or urban slum. The company create an improvised stage, using blankets and clothes to create a backdrop. After the pre-show cultural programme, which lasts for about 30 to 45 minutes, the company present a one- to two-hour show which will be followed by a question and answer session and may end with information regarding nearby HIV testing centres etc. The following day the actors return to the site to run smaller workshops addressing issues arising from the show. Like NiteStar, Nalamdana are committed to making culturally appropriate theatre. In Nalamdana’s case making sure that the drama is engaging is very important as, due to the nature of street theatre, if the audience are not engaged they will leave. For example, in one village performance the company lost their audience due to the water tanker arriving! They are also aware that, for evening performances, they have to compete with television and so they have decided that the productions should be ’75 per cent entertaining’ (Balaji, 2006). As already noted, they employ TV and film actors and also employ TV and filmic styles – particularly Bollywood and south Indian film. Cultural critic Lutze proposes that: ‘The Hindi film appears to be perhaps the most powerful cultural product based on non-Western aesthetic principles’ and, in working to develop a culturally relevant model of communication, Nalamdana draw on that model with comedy roles and love interest that are immediately recognizable (1985: 28). They argue that their work needs ‘masala’ (or ‘spice’) and make sure that the dramas include the heightened emotion and passion of the Bollywood form (Balaji, 2006). The company state that, when developing a script, they actually think of it more as a film script than a drama script, by which they explain that they develop a basic scenario out of which they look to create scenes that move at a fast pace ‘like a movie’ (Balaji, 2006). There is never a lag between scenes as even a small lull could prompt audience members to leave. The style of performance echoes popular film too. Lutze describes

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Bollywood as ‘excessively melodramatic’, yet Nalamdana see the heightened style as appropriate to their work as subtle internal shifts can be signalled loudly to the audience of around 700 to 1000 that they regularly attract (1985: 31). The Bollywood form is accessible and facilitates a dramatic spectacle that draws their audience in while providing a recognizable narrative framework that allows for an aesthetic distance and engagement with the health message. Just as with NiteStar, the story is a central element of Nalamdana’s work. When advertising their productions the company never say that they will be presenting a play about AIDS. Instead they say that it is a ‘play with good messages that is funny’ (Balaji, 2006). They have found that if they place an emphasis on AIDS then no one comes to watch. Thus, AIDS/HIV is a distinctive undercurrent within the work rather than in the foreground. They see their work as dramas with positive health messages at the end and, throughout the pieces, they are aware of their duty to keep their audiences entertained. The company look for a hook to draw their audiences in. So, for example, they acknowledged that boys may have no interest in breastfeeding but the story of a young couple in love allows the exploration of the theme within an engaging context. At the same time they recognize the need to interest the older women and so may include a character who offers traditional wisdom to the young lovers. They note that ‘the audience didn’t ask you to come’ and recognize that the performance is part of the encounter and a means to forming relationships and promoting discussion (Balaji, 2006). The company maintain an attitude of respect towards their audience members. They acknowledge the need to consider gender, language and caste, and are also sensitive to levels of illiteracy, although they note that their audiences are not illiterate ‘in terms of the mythological’ (Balaji, 2006). Their audiences also see a lot of street theatre and the company acknowledge that village people have good artistic judgement. Nalamdana can draw on classical models but are always careful to present things in a clear and simple manner. They are also vigilant about didacticism. They recognize that their health messages may contradict advice given by community elders and they want to be sensitive to the cultural climate. This more ‘environmental’ approach – that is, approaching people as a group rather than as individuals – is an important difference in the work of Nalamdana

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and NiteStar and reflects on the cultural climate they are working in. Nalamdana place an emphasis on family and community relationships and how decisions may impact on the wider society. Methodologically, however, the companies share many strategies. Nalamdana seek to encourage dialogue rather than challenge and, like Brecht, see comedy as a powerful tool in that it not only makes people laugh but also makes them think. Nalamdana also approach their work from a perspective of asking questions rather than providing answers. This spirit of dialogue has proved capable of opening up considerable insights; for example, in discussion with a group of migrant workers they discovered that the men had been engaging in anal sex in the belief that having sex with other men did not constitute being unfaithful to their wives. The men had not realized that they were potentially putting themselves at risk of contracting HIV/ AIDS and, once they were aware of the danger, they were keen for the company to communicate the message and address others engaging in this sexual practice. The company are open to adapting their work for different audiences. They field-test their scripts and work with a basic structure that can be shaped up for regional variations in order that the stories reflect the day-to-day lives of audience members. An important dynamic within the work is that the company play in both urban slums and rural villages. The town/country divide is a significant consideration in Indian society and the company develop their shows in order to create empathy with their audiences. So, for example, for a rural audience, they include a dependable hero who has migrated to the city for work; while a solid urban character will be included to appeal to the city dwellers. Nalamdana also acknowledge the comic potential of stereotypes – for example, the drunk country uncle. The company also adapt the dialogue according to setting, using local slang and accent as well as references to local landmarks such as the temple as a means to build rapport. Information gathered through pre-performance visits, alongside knowledge of traditional forms of music and dance, help the company to develop narratives which are both affecting and efficacious. The company also draw on their knowledge of the audiences to make pragmatic decisions about their performances. They acknowledge that the women will come last, after they have finished the cooking. In urban areas performances need to be scheduled between 6pm and 9pm in order to

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accommodate the schedules of housewives and local workers. In the villages the migrating workers are back later so the shows often start later at 8.30/9pm. The company are careful to place important health information at the end of the show in order for it to reach the maximum number of audience members – including any latecomers. As with NiteStar, music is an important element of Nalamdana’s performance work and functions best when it is culturally specific. Just as the young people watching NiteStar performances recognize, enjoy and remember the popular ballads and rapping presented as part of the New York shows, the southern Indian audience also enjoy the musical element of the work. Tamil Nadu has a rich heritage of folk music which the company tap into, but they also employ contemporary cultural forms. As Nalamdana perform on such a large scale, the music enables audience members who may be very far from the stage to follow the subtleties of the action. So, for example, in one production the company played the soundtrack from a well-known Bollywood film under a scene of a family quarrel, which highlighted the significance of the moment as comparisons with the filmic narrative could be made. Just as in the Bollywood form, Nalamdana’s productions can be seen as melodramas where music serves to underscore the dramatic action and heighten emotion. This is a popular and effective element of the performance and is often used as a way into follow-up discussions and on-going education as the company distribute free music recordings to audience members with songs that include health messages. As well as drawing on traditional musical forms, the company are also indebted to the art form of Terrukkuttu, which is a form of folk theatre native to southern India and still popular in the Tamil Nadu region. Terru means ‘road’ and kuttu means ‘powerful’, and the phrase can literally be translated as street theatre. Terrukkuttu has traditionally been part of Hindu festivals where religious stories would be recounted. Working with this traditional form, Nalamdana describe themselves as delivering ‘response-driven participatory street theatre’ (Balaji, 2006). Although they do not need a theatre venue, finding a place to perform can be problematic especially if they wish to reach the whole community. The company have to be careful to locate a neutral space in order to minimize caste conflicts and they need to have an exit strategy in place just in case unrest does break out. The company recognize that their work is quite politicized and their

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previous involvement in politics has caused difficulties – for example, community leaders had given permission for a play about voting in elections to be performed but the play promoted the fact that people could change their leader and offer criticism, which was not well received. Personal politics can be equally combustible; for example, one of the company’s productions tells the story of a girl forced into a family marriage. Arriving in one village the company were advised by a local health worker that there was a wedding taking place with a young woman marrying her maternal uncle and that it would not be advisable to perform the play. As always the preparation work is important and the company are sometimes able to frame stories as happening in the ‘next village’, which allows them to address controversial material with an element of distance. They also recognize the importance of being flexible and removing/adding scenes at the last minute, which is very much part of the Terrukkuttu tradition. It is important that Nalamdana are wise about the interventions they make as they want to be able to facilitate follow-up work and promote partnership with the communities they work with. In his report to the Rockefeller Foundation on the work of Nalamdana, Dagron observes that: ‘Theatre provides a public and non-intrusive forum for communication. In addition, plays are ideal to reach target groups and facilitate immediate feedback’ (1993: 197). Nalamdana recognize the efficacy of theatre as a means to reach people and to address them as a group. In communities where it is usually necessary to get permission from husbands to talk to their wives, a theatre performance enables direct contact with the whole community, which they hope will open up discussion, if not with company members then at least within the community itself. In the traditional model of Theatre in Health Education the work is designed as a package, with pre- and post-show activities that are as significant as the performances themselves. The company see the plays as points of connection. It is possible to understand as a kind of theatre barter in the terms that Eugenio Barba offers it, where performance is offered to the community but, instead of a performance form being offered in return, Nalamdana are looking for an openness for discussion around health issues.2 Nalamdana company members note that before the performance happens people do not recognize them and may have questions about the motives for their visit. The performance is an opportunity for the audience to evaluate the skill

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of the company, which then leads to people being more receptive to company members – even offering them food and hospitality. Often audience members visit the backstage area during a performance to discuss the events of the show and raise issues that the company can then address in post-performance work. The company also use this process of familiarization to introduce health workers that they are in partnership with in the local area. Often the end of a production will see both community leaders and health workers sharing the stage with people from the community, who come up to share what the evening has meant to them. Pre-production work within the community often takes the form of what the company term ‘pre-test sensitization’. The company randomly select 10 to 20 audience members and use questionnaires to gauge their level of pre-existent knowledge before the performance and they then meet with them to measure again after the performance intervention. This method of evaluation suggests that the dramas are effective in communicating information about HIV/ AIDS. For example, the rate of correct answers regarding whether mosquito bites could pass on HIV increased from 42 per cent pretest to 98 per cent post-test (Valente and Bharath, 1999: 204). Other questions may not be so directive and may address local superstitions – for example, ‘eating papaya during pregnancy causes abortions: true or false’ – or else may elicit opinions on a subject: for example, ‘the ideal age for a woman to get married is …’. Sometimes company members will run workshops in local schools prior to performances and, in one such workshop which I witnessed in July 2006, there was a real buzz as students embraced the opportunity to discuss issues. Ahmed, in his critique of what he terms ‘Theatre for Development’ with social messages presented by NGOs, notes that there is little room for ‘Freirean dialogue’ in such work, but my observation would be that, even though Nalamdana have particular messages they wish to share, they do seek to enter into discussion and debate and to provide information that people can decide how they want to use (Ahmed, 2002: 211).3 Nalamdana want to empower communities that are socially underprivileged and enable them to realize their potential. This is most clearly demonstrated in their women’s empowerment programme which seeks to encourage and develop women as local leaders who wish to speak to and on behalf of their community.

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Follow-up discussions often begin with the question: ‘which characters did you identify with?’ Nalamdana recognize the importance of the narrative as a vehicle for learning and understanding and are careful that health messages are woven into the character rather than layering on separate issues. Rather than the agitational-propaganda style of work which Ahmed is so critical of in Bangladesh, Nalamdana wish to create fleshed-out and evocative dramas which do deal with complex situations while raising pertinent health issues. So, for example, one Nalamdana drama deals with the story of a young man who is about to be married and finds out that he is HIV positive. He doesn’t want to tell his family as they will then know that he has been sexually active but, equally, he does not want to infect his new wife, so he is left with a dilemma which he must resolve and the audience are witness to the choices that he makes. Singhal argues that Nalamdana’s work serves to reduce stigma as the drama represents those living with HIV/AIDS as ordinary and even prominent members of the community, and the plays certainly work to raise awareness of HIV/AIDS-related issues that can be addressed in follow-up work (Singhal and Rogers, 1993: 325).

Conclusions Theatre in Health Education makes use of drama as a vehicle for communication and provocation. It employs the artistry of skilled practitioners who seek to combine both educational and creative impulses to develop programmes of work which will be effective in speaking to their target audiences. While there is the potential for theatre to be used as a manipulative tool which presents powerful messages about how people should behave, most THE companies see themselves in the tradition of political provocateurs whose role is as catalysts for change. In addition, audiences for THE performances demonstrate themselves to be insightful readers of cultural texts who are able to detect and resist attempts at indoctrination. THE projects are commonly seen as interventions in long-term processes of self-reflection and/or community development. Both the political and the methodological agenda may prove to be problematic as THE companies seek funding for their programmes from agencies who demand value for money and immediate, quantifiable results, and both companies under discussion have found it important to be

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astute in their choices of partners. THE companies often find themselves in complex negotiations with both funders and the communities as they work to deliver the best outcome for all concerned. There is an evidential base that suggests theatre is an effective tool for health education and it seems that there can be particular impact in terms of modelling behaviours. This chapter has looked at Nalamdana and NiteStar. The companies work in very different contexts with different types of audiences but they share a social learning approach to health education which can be related to the work of Bandura. The companies make use of theatre as a tool for active engagement and employ peer education and popular forms. Productions which feature recognizable scenarios and characters are used to offer up behavioural options to audiences. Company members do not present themselves as authoritarian experts but as peers who are able to share knowledge. Kistenberg argues that: It is only when we look at specific performances, how they are received, circulated, debated, or ignored, that we can begin to understand whether or to what extent they reproduce or challenge existing systems of power and authority. (1995: 177) Considering NiteStar and Nalamdana in context highlights the ways in which both companies make use of elements within their social milieu to open up dialogue which may run counter, or even be resistant to, dominant cultural messages. Comedy, in particular, is an important tool within the work as a way of challenging the status quo and foregrounding the idea that change is possible. As appropriate to their social settings, the companies seek to mobilize different forms of reflection and dialogue. Within the USA, NiteStar are more focused on personal choices, whereas Nalamdana’s work in southern India has a more family/community perspective. In his consideration of TIE as an art form and/or instrumental tool, Jackson observes that separating out social and aesthetic concerns is problematic in Theatre in Education, and the case studies in this chapter indicate how important the artistic vehicle is for the educational experience (2007: 2). Although funders’ criteria may relate to policy objectives rather than artistic merit, in practice there is a recognition that without compelling drama the audience will disengage – switching off in the case of the New York students NiteStar work with

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and literally leaving the performing area in the case of Nalamdana’s audience. Both companies value the power of narrative as a fundamental communicative tool and, while playwright David Mamet states that ‘the only thing dramatic form is good for is telling a story’, Nalamdana and NiteStar recognize that telling a good story may serve to bring about social change (quoted in Jackson 2007: 24).

3 ‘But I Already Have a Voice …’: Ventriloquism, Theatre and the Healthy Citizen

Introduction The World Health Organization’s (WHO) constitution asserts: Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity … The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. (1946: 1) This wider perspective on health and well-being informs this chapter and opens up the consideration of health as a right of citizenship. Set against the backdrop of the UK government’s Valuing People: A New Strategy for Learning Disability for the 21st Century (2001), and the consultation process which led to Valuing People Now (2009), this chapter focuses on the interrelationship between theatre, health and care, and enfranchisement. Drawing on case studies, the chapter explores the efficacy of drama and theatre in health advocacy projects with people with learning disabilities. Through invoking the theatrical practice of ventriloquism, I will seek to problematize the notion of ‘giving people a voice’. The chapter will also employ current discourses around active citizenship and performance-based theory on embodiment and enfranchisement, to move towards an exploration of how engaging in theatre practice may serve to enable participants to realize their potential as healthy citizens and 89

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develop the voice they already have as a means of expressing their personhood.

Legislative context The WHO’s definition of health was devised in 1946 and represents a contemporary approach to the rights of all citizens where to be healthy is to be socially integrated. It follows a period of history when those perceived as being ‘subnormal’ were considered to be a risky presence within society and were therefore removed from the proceedings of everyday life and placed in specialist care homes. As late as 1916 ‘mental defectives’ were not seen as being entitled to the same rights as ‘normal’ persons and in need of a particular type of paternalistic care (Concannon, 2005: 17). It wasn’t until 1985 in the UK that the Secretary of State and Social Services commissioned the Independent Review of Residential Care (Wagner, 1988). This review took up a more rights-based approach to service users and looked at how their thoughts and opinions might be part of the planning and delivery process of the support they received. The commitment to care in the community changed the landscape of care provision for people with learning disabilities, with an emphasis on integration rather than institutionalization and on well-being rather than illness. Valuing People: A New Strategy for Learning Disability for the 21st Century was published in 2001 and endorsed a shift in policy towards the recognition of the rights of citizens with learning disabilities. The White Paper advocated the active participation of people with learning disabilities in social life, including decision-making relating to their own day-to-day lives.1 As social policy expert Concannon points out, however, closer examination of Valuing People reveals that this approach is not actually rights-based but consumer-based. For example, the document proposes that: ‘direct payments were keys to helping [people] gain greater independence and control’ (Department of Health, 2001: 11). Concannon, along with other critics of this methodology, note that it relies on the capacity to make choices. He says: It is easy to offer choices to those who have never learnt to make them, to offer difficult ones to those who can only manage simple choices, to offer none at all when it is quicker and more expedient for someone else to make the decision. (2005: 63)

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So this process of ‘normalization’, as it was perceived, was problematic in that it demanded certain modes of behaviour and sought to consult with people in a way that might not be appropriate or useful for them. Particular issues were identified around health and healthcare. Valuing People Now responded to Healthcare for All (2008), an independent inquiry into access to healthcare for people with learning disabilities which was commissioned in response to Mencap’s report Death by Indifference (2007) that highlighted the fact that people with learning disabilities have poorer health and problems accessing care. Key recommendations related to authorities working in partnership with people with learning disabilities and their carers to plan care in order to ensure the dignity and safety that was perceived as being lacking in the current system. One government solution for enabling engagement and partnership is advocacy. Learningdisabilities.co.uk notes that ‘Advocacy is about having your voice heard … This can be hard for people with learning disabilities.’ There is no doubt that advocacy can be useful and can certainly help people to get better service, but a report by researchers Peter Beresford and Suzy Croft (quoted in Hogg, 1999) suggests that it can also be a problematic and potentially damaging process. They posit: ‘the presence of an advocate may make other staff feel that they do not have to argue for the person’s rights or develop the skills needed to enable people to speak for themselves’ (quoted in Hogg, 1999: 26). Hence the ‘does he take sugar syndrome’ where professionals speak over the heads of the person they seek to engage with. In addition, Beresford and Croft suggest that: ‘Professional advocates may feel that they have to present their clients in a negative light in order to make a stronger case for them’ (quoted in Hogg, 1999: 26). This, again, may be disturbing for the person who is caught in the middle of such an interchange. It may be that advocacy engenders a state of ventriloquism where a person is objectified and someone else speaks for them and offers their perspective on the individual’s world-view. Goldbatt (2006) observes that ventriloquism, or speaking in another’s voice, is actually focused on the process of speaking and listening to oneself. A ventriloquist asks questions to which s/he provides the answers through the manipulation of a puppet – and, within the advocacy system, it might be suggested that professional advocates might speak to other professionals about a system with which they are

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familiar and comfortable with negotiating, without engaging with the personhood of the client. This can serve to disempower the very person that the system seeks to empower as ‘giving people a voice’ may mean that their voice is actually drowned out. Another advocacy option which Valuing People acknowledges is self-advocacy. The document states that the development of the self-advocacy movement is a testament to how people with learning disabilities can instigate changes in service planning and delivery (Department of Health, 2001: 46). Self-advocacy and ‘finding your own voice’ is in itself a complex process. In their book on learning disability and theatre, Palmer and Hayhow argue that: it has been assumed that, despite being different to each other, people will all have equal access to verbal expression, if not to public acknowledgement of that expression … Yet for those with learning disabilities these assumptions quite simply do not hold true. (2008: 29) They propose theatre as a vehicle which offers people an opportunity to communicate without or ‘beyond words’ (2008: 70) in a form that validates this different mode of communication and opens up public space for other kinds of ‘voices’. This chapter will examine the practice of two theatre companies where people with learning disabilities have worked to create their own theatre pieces relating to pertinent health issues. Within their work I identify a more liberatory mode of ventriloquism, identified by Goldblatt, where the work of art speaks on behalf of the artist (2006: 48).

The voice of theatre The companies under discussion may not define themselves as advocacy agencies but they could be seen as working as advocates. Theatre pieces have been commissioned as part of health advocacy processes and I want to consider why theatre might be particularly useful as a means of formal communication within this arena. The principles behind care in the community and documents such as Valuing People constellate around ideas about participation and people being active members in their local community. Chantal Mouffe’s theory of citizenship as participation where the individual enters into the

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broader social frame and engages in collective action, proposes a state that is both a form of self-actualization and a means of social change. Mouffe’s work highlights the tension between the social/ collective and the rights of the individual – but teases out the idea of participant citizenship which blends social and domestic aspects of citizenship. Participant citizenship appears to be appropriate to the issues that documents such as Valuing People raise. Valuing People is concerned with how people with learning disabilities may have particular concerns relating to rights pertaining to their own bodies and domestic choices within the wider social context. Mouffe’s theory is worked with by Nicholson in her examination of the way in which drama may be applied to citizenship. Picking up on Mouffe’s notion of embodied citizenship and assertion that citizenship is understood in terms of ‘acting’ as a citizen, Nicholson asks: If citizenship is about acting as a citizen, with all the implications of performance that this phrase entails, how might practising drama encourage people to become active participant citizens? (2005: 21) This is a question that I wish to explore further within the chapter. The embodied nature of theatre appears to be central to this enquiry. Palmer and Hayhow can be seen to be drawing on Derrida in their examination of communication beyond words, as Derrida notes how the theatrical event may avoid the cultural privileging of text and writing and allow other forms of speech, such as the ‘writing of the body’ where body language is able to communicate visually and kinaesthetically with audience members (1978: 191). This form of practice is seen as offering a radical challenge to the status quo. Palmer and Hayhow (2008) trace a history of political performance that enabled participants to have a forum in which to discuss issues that might have been overlooked by mainstream culture. They look back to activist art such as agitational-propaganda performance and living newspaper practice that dramatized immediate responses to events of the day but, further than that, they celebrate the tradition of devised performance – a collaborative and democratic practice in which participants bring their own lived experiences and interests as material to create a piece of theatre. Experimental devising practice has also worked to challenge realist models of theatre and explored

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non-naturalistic, non-linear forms of performance which, rather than presenting the singular voice of the author ventriloquized through the actors’ mouths, seeks to develop collective creative work that may speak of new possibilities through visual demonstration as well as verbal articulation. Within such practice there is an emphasis on process rather than product, and the process of crafting the show may be a process of exploration as the co-collaborators seek to get under the skin of particular issues. Tim Etchells, director of experimental theatre company Forced Entertainment, suggests that artists ‘play with what scares [them]’ (1999: 66). Overall this method can be understood as being a process of exploration and articulation. A devising company may use the creative space to explore their perspective on the world – both as individuals and as a collective. They may engage with subjects ranging from sexual politics (e.g. My Sex Our Dance by DV8) to the Gulf War (e.g. Desert Rain by Blast Theory), and this creative encounter can be seen to echo Goldblatt’s proposition that the artwork speaks on behalf of the artist expressing their perspective on the subjects explored and exercises speech beyond the written text. Further to this process of articulation, Palmer and Hayhow note how experience of dramatic processes may ‘encourag[e] awareness of self and others’ so that the work can speak back to the performers (2008: 61). They see the engagement of the body as a key element – citing Jacques Lecoq’s assertion that ‘the body knows things about which the mind is ignorant’ (Palmer and Hayhow, 2008: 72). Cattanach notes that people with learning disabilities may not be encouraged to partake in sport and physical activity and there may be a reawakening of embodied knowledge through engagement with drama (1996: 5). She asserts that exercises that focus on physicality promote participation and, reflecting on Nicholson’s point, creating theatre certainly demands not only active involvement on behalf of the individual who may need to move his/her body in a particular way to create the image they wish to represent, but also a commitment on behalf of the group as members to rely on each other to provide physical support for the activity. Jon Palmer formally worked with the theatre company Full Body and the Voice, whose name indicates the centrality of the corporeal in his approach to theatre making. In their creative process the theatre company members with learning disabilities were not working through somebody else to

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enable their voice to be heard, but presenting their own voices and bodies as channels of communication. This relationship between the body and the voice is important and theatre voice coach Rodenburg (2000) discusses how the way in which some people speak (their tone, projection, intonation, etc.) may be disenfranchising, and notes how, through theatrical mechanisms/exercises, the voice may be developed to a point where the person is enfranchised. People may, therefore, literally be given a voice through theatre, or given the confidence to speak through the experience of hearing themselves speak in front of others. Palmer and Hayhow, however, are also interested in the way in which communication goes beyond words and see performance as an opportunity for the body to give voice to alternative modes of speech. Palmer and Hayhow quote Tom Shakespeare, campaigner for disability rights, who notes that: One of the things that racists and bigots of all types do is to deny their victims an emotional range, deny their feelings, make them into an object. (2008: 175) They see theatre as allowing possibilities for creative, affective expression which may allow people the opportunity for full participation in social debate rather than being an objectified ventriloquist’s dummy. In this chapter I shall be examining the work of two companies: Mind the Gap and The Lawnmowers, and consider the theatrical and political strategies they employ to communicate both with their audiences and between themselves in a manner that promotes health and well-being.

Mind the Gap Mind the Gap are a professional theatre company based in Bradford, West Yorkshire. The company was formed in 1988 by theatre practitioners Tim Wheeler and Susan Brown and, although the intention was to work with people with learning disabilities, the aim was always to focus on art form rather than a political agenda. As the current website says: ‘It’s more than drama about disability, it’s professional theatre by disabled people’ (www.mind-the-gap.org.uk). It is important to note that, while it might have political impact,

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the crafting of theatre and its particular formal possibilities are paramount. Wheeler still works as artistic director, shaping the creative explorations of the company. Mind the Gap identify five key principles behind their work: to create high-quality theatre; to dismantle barriers to the arts; to widen life choices; to make voices heard; and to create new audiences. They seek to reach these objectives through a variety of activities: national touring, a resident acting company, theatre outreach sessions, an accredited training programme and an actor’s agency. A significant touchstone within the work of Mind the Gap is Augusto Boal’s Theatre of the Oppressed. Wheeler came across the practice of Brazilian theatre practitioner Boal (1931–2009) in the late 1980s and he took up the key principles and applied them to his own practice with Mind the Gap as the company developed. Indeed, Boal ran training sessions with the company in 1992. The Theatre of the Oppressed is a model of theatre practice that engages with the issue of communication. It is based on the belief that all human relationships should be of a dialogic nature. It acknowledges that social dialogues may turn into monologues as one party becomes the oppressor and the other the oppressed. The Theatre of the Oppressed seeks to reactivate dialogue through active intervention. Boal believed that theatre was a fundamental tool for human beings and proposed that everyone is able to act and use theatre. Boal developed an ‘arsenal of the oppressed’ which he saw as providing tools for discourse through heightening awareness and developing the expressivity of the body (1992: 60). In Games for Actors and Non-Actors, which is often used in training and rehearsal settings, Boal set out a range of exercises that promote: feeling what we touch; listening to what we hear; seeing what we look at; and the memory of the senses. Boal believed that engaging in these exercises can catalyse a freedom of expression and, once the body is free to express, Boal proposed that people can move into action. Boal’s Theatre of the Oppressed, as its title suggests, has a political agenda. He linked the action of theatre with participation in social life. He famously suggested that theatre can be a ‘rehearsal of revolution’ (1979: 141). A central idea within the practice is that of the ‘spect-actor’ (1979: xxi). Rather than passive audience members, Boal, drawing on the work of Brecht as discussed in Chapter 2, advocated an active engagement with theatre. For Boal, theatre was

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fundamentally a physical activity and he believed that observation should also be corporeal. So, in Forum Theatre (see below), the spect-actor (or active spectator) is invited to get up from their seat and demonstrate alternative scenarios they might suggest for the dramatic action. The structure of a Theatre of the Oppressed event encourages engagement and looks to stimulate the audience towards action. Boal’s methodology drew on the work of the Brazilian theorist Paulo Freire (1921–97), who, in his Pedagogy of the Oppressed, notes that ‘every human being … is capable of looking critically at the world in a dialogical encounter with others’ (1993: 14). Boal saw Freire as a father to his theatre work in its drive towards dialogue and its commitment to empowering people to critically engage with the world around them. Freire’s work particularly unpacked the process of education. He was against what he termed as the ‘banking’ system of education where students are viewed as containers to be filled – a monologic process – and favoured a pedagogical model of investigative partnership where a process of articulation and enquiry is encouraged (1993: 53). Another important reference point for Boal was Freire’s notion of word-and-action, which emphasizes the relationship between language and deeds as realized in Freire’s literacy projects. Boal’s early ‘image theatre’, which took place in the favelas or slum areas of Rio de Janeiro, reflected that practice; they encouraged active participation and dialogue around issues as they were suggested by participants rather than working to preordained objectives. Boal realized that he had to listen to the people and work with them rather than seek to motivate them to meet his agendas, as this placed him in the position of an oppressor. Freire says: Pedagogy which begins with the egotistic interests of the oppressors (an egoism cloaked in the false generosity of paternalism) and makes of the oppressed the objects of its humanitarianism, itself maintains and embodies oppression. (1993: 36) Boal decided that the Theatre of the Oppressed would not seek to indoctrinate or ventriloquize, but to provide a forum for discussion and promote the idea of participant citizenship where the theatre event allows for a discovery by ‘the citizenry … [of] that which they carry within them’ (1998: 128).

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Over his long career Boal developed a range of methodologies, but one of the most influential – and this has been particularly influential for the work of Mind the Gap – was Forum Theatre. Forum Theatre takes as its starting point material which is known to the group to which it is presented. The process follows quite a structured format. A group of performers work on the material in hand – for example, access to benefits – and create what is known as the ‘model’, which is a play (which may be one scene or a fulllength drama) that outlines the details of the oppression. This is then developed and rehearsed but with the intention that the drama is, in effect, incomplete as a problem is presented without a solution. This openness is designed to encourage a response from the audience that it will later be presented to. A Forum Theatre performance occasion will be compèred by a figure known as the Joker, who begins proceedings by explaining the rules of the event. The Joker outlines the format and en-roles the audience as spect-actors in that s/he explains that their interventions will be invited. After reaching the end of the rehearsed script, in which the oppressed character(s) fail to overturn their oppression, the actors begin the production again, although often in a condensed form. At any point during this second performance, any spect-actor may call out ‘stop!’ and take the place of the actor portraying the oppressed individual (this actor stays on stage but to the side, and may give suggestions to the spect-actor who has replaced him/her). The spect-actor then offers, through active participation as the character within the scene, a suggestion of how the situation might be dealt with differently for a more positive outcome. The Joker encourages a discussion in the audience about how successful they felt the intervention to be. The idea is not to find an ‘ideal’ solution, but for there to be a spirit of experimentation and dialogue as audience members share their ideas and experiences and, the intention is, witness (and perhaps even partake in) models of behaviour which may be useful within everyday life. An example of a piece of Forum Theatre by Mind the Gap is Never Again, a piece that is still offered by the company as part of a training package for front-of-house staff aimed at making arts venues more accessible and ‘user-friendly’ for people with learning disabilities. The ‘model’ is a short play that gives an account of a young person with a learning disability when she goes to see a performance at her local theatre. It is realistic in style with segments of direct address to

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the audience. The story follows Anna, who wants to see Death of a Salesman. She first has to persuade a member of her family to accompany her to the play. She then has to negotiate problems at the box office with an uninformed and unhelpful box-office assistant. Even then she has difficulties in finding her seat and, once she does, suffers from a poor view and intolerant fellow audience members. She decides to leave but is left with no one to go home with and no money for the bus. After walking home she is met by her mother who berates her for her late return. The action of the play was based on consultation with young people with learning disabilities and developed directly out of their experiences. This process sets up an interesting negotiation, as group members offer up their individual experiences, which are then crafted into a story that is owned by the whole group. It may be difficult to find consensus or troubling for individuals to let go of details that are important to them but it is important for this methodology that a collective outcome is achieved.2 The show draws attention to economic and physical obstacles to access, as well as attitudinal and discriminatory barriers. In addition to its employment as a training tool with theatre staff, the piece has also been performed to other young people with learning disabilities. Within the forum event the young people had the opportunity to try out different strategies such as asserting their rights or countering refusal with politeness. The intention was that this process would encourage the young people to see themselves as social actors with the ability to change the responses that they encounter as well as participant citizens with constituted rights to access etc. Wheeler (2005) is clear about the need for a pedagogic framework for such encounters. He says that it is important not to assume that the transition from learning within the forum to behaviour in everyday life will occur unaided and, for this reason, the company situate the forum work as part of a wider package. Mind the Gap do not only perceive the theatrical experience of Forum Theatre as being valuable, but also acknowledge the form as a useful training vehicle. Palmer and Hayhow note that, due to the lack of formal training for performers with learning disabilities, a director will have to take on the role of trainer within the rehearsal room in order to allow the actors to develop the skills they need for a project (2008: 3). Mind the Gap have been trailblazing in their development of specialist training courses in theatre skills for adults

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with learning disabilities. ‘Making Theatre’ is a course, accredited by the Open College and run at the company base in Bradford, which is open to beginners and covers acting, stage management, design, directing and workshop skills. The company also co-ordinate ‘Staging Change’, a national training programme for learning disabled actors to provide the kind of professional training that Palmer and Hayhow note is important for the development of the profession. Originally Mind the Gap recruited six students on an annual basis for the ten-month course which was delivered at Mind the Gap’s base, and through week-long residencies at drama schools such as the Oxford School of Speech and Drama, Guildford School of Acting and Mountview Theatre School. Changes in funding specifications have meant that the programme could not continue to run in this format, but the company are still committed to supporting learning disabled performers gain access to professional training and look to help individuals find local provision. Mind the Gap believe that the arts can ‘deliver a voice’, in that theatre training may empower and give confidence for those practitioners to become self-advocates (Wheeler, 2005). I witnessed an assessment on the ‘Making Theatre’ course at the company’s Bradford base in December 2005. A small group of students had been working intensively on a Forum Theatre module and keywords were displayed on the walls of the studio. In preparation for the assessment they had been through a process of rehearsal to create a Forum Theatre piece on a subject that held resonance for them. The students had drawn on their own experience as well as sharing information within the group to create the performance model which dealt with a young man trying to gain entry to a cinema without a ticket in order to tell his brother that his father was in hospital. The event was their second level of assessment in Forum Theatre, which runs as a core component within the programme, and the students were being examined on their jokering skills. Jokering requires an overview of the forum process, and the ability to communicate with spect-actors and encourage dialogue. The student who was being assessed was understandably nervous but was able to present herself well to the assembled audience (which included myself as a stranger to the group and a camera-person who was filming the event for external moderation) and she clearly demonstrated understanding of body language and vocal tone when speaking to a group. What she

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did appear to struggle with, however, were the particular formulation of words that she had to deliver in her role as Joker. She embodied a spirit of dialogue and was encouraging of the interventions that were made. She was able to listen and respond but the formulation of the words troubled her. She was unsuccessful in her assessment and it raises interesting questions as to the place of language within the forum event. Dwyer notes that: ‘it is largely through speech that the joker enacts a pedagogical role which may be crucial in shaping the ideological contours of the event’ (2004: 201). It seems useful to question whether this model then reproduces a hegemony of verbal communication that may prove difficult for people with learning disabilities. It could be argued that such work provides a carefully structured model for the development of successful communication where mastery will ensure access to a particular form of discourse. Yet, it is also important to reflect upon the form of the discourse and the danger of ventriloquism within such encounters. Mind the Gap also work with another of Boal’s methodologies: Legislative Theatre. In 1997 Boal entered the party political arena in his native Brazil and campaigned with the slogan ‘have the courage to be happy’. His campaign was successful and he was duly elected as a vereador (legislator) on Rio de Janeiro’s city council. Boal’s theatre company became his office staff and they worked to develop a process that has been termed Legislative Theatre. This system develops the Theatre of the Oppressed in a manner which allows parliamentary application. Boal used Forum Theatre with a wide range of groups in the Rio district and encouraged them to explore issues that were important to them. The forum sessions ended with the proposition of laws that might be passed to help their situations. After an editing process, Boal proposed the laws to the Chamber. Thirteen laws were passed as a result of this process. Boal described this process as one in which ‘the citizen makes the law through the legislator’ and saw this work as a continuation in the development of dialogue where ideas are articulated through consultation rather than enforced from above (1998: 10). He also celebrated the active nature of the process which moved forward through deeds rather than words. Boal framed his book on Legislative Theatre with a quotation from the Cuban writer José Martí, which reads: ‘doing is the best way of saying’ (Boal, 1998: 1). Rather than parliamentary debates, Boal was interested in the engaged discourse of the forum sessions.

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Boal described how forum sessions may be an educative experience as words like ‘oppressed’ are introduced and explored. He noted that people ‘take pleasure in increasing their vocabulary’ (1998: 45) as they work on the forum. I have already acknowledged that this might be problematic, and my observation with Mind the Gap would indicate that there is clearly a lexicon of Boalian practice. It seems, however, that this vocabulary extends beyond the words themselves to include the language of the body in space. Legislative Theatre projects employ the same ‘arsenal of the oppressed’ as Forum Theatre to raise awareness and build confidence and skills, but towards the particular goal of political action. In his work Boal saw that ‘Every exercise, every game, every technique is both art and politics’ (1998: 48). Boal did not separate out form from content and viewed rehearsals as a ‘cultural-political meeting’ where ‘the citizens ... will be making the theatre’ (1998: 48). Even though he perceived the work as political activity, Boal emphasized the importance of image and sound to create an aesthetic space that serves to focus attention and set the appropriate tone for the rehearsal/vocabulary building exercises. Thus, it is through the art form that social intervention occurs and there is the possibility of Goldblatt’s more emancipatory ventriloquist action which occurs through creative expression. Legislative Theatre has been used successfully for health-related projects. One example is a project entitled Brighton and Hove Rocks, developed in June 1999 through a consortium of voluntary-sector partners in conjunction with East Sussex Brighton and Hove Health Authority. The brief was to involve those who feel excluded from involvement in planning and policy decision and to feed their priorities into a new local Health Improvement Programme (HIMP). The Local Health Authority wanted an ‘open and wide ranging discussion, in plain language, with trained facilitators’ (www.scip.org.uk/ rocks/theatre.htm). They developed a workshop programme where participants were invited to contribute ideas around the social causes of ill health and what they saw as important potential changes in policy. Drama was suggested as a useful vehicle for consultation, and theatre practitioners with experience in synthesizing dialogue within a creative form were commissioned to work on the project. The project had quite a short timescale so, rather than working with a number of communities to develop a theatre piece, which would have been the preferred option, the performance company created

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one play with people from various communities and developed one central character experiencing social exclusion as a ‘model’ which they hoped would resonate with a wide range of people. The scenes from the play covered many issues and there was criticism that perhaps the piece tried to deal with too much, but the feedback from the experience of being presented with relevant material, which the audience were then invited to respond to, was very positive and the event produced useful material which fed directly into the HIMP report. One council member in the audience commented on the embodied nature of the event and the way in which it allowed the authorities to access a different quality of information. He said: I thought it was a brilliant way of engaging people, very real, visual and easy to understand. I loved the way people were doing it instead of writing or reading about it. (www.scip.org.uk/rocks/ theatre.htm) Mind the Gap have also worked with Legislative Theatre, although in a more specialized manner. The rhetoric of documents such as Valuing People places an emphasis on consultation with people with learning disabilities, but without a clear sense of how this might happen. Mind the Gap felt that Legislative Theatre, with its inclusive working methods and dialogic tone, might be a useful mode of practice. ‘People Like Us’ was a health advocacy project developed in conjunction with Bradford Social Services. The focal issue of the piece was the provision of health education for young people with learning disabilities. Mind the Gap performers worked from their own experiences to devise a piece of Forum Theatre that examined the relationship between a young Asian girl and a white boy – both of whom had learning disabilities. In examining race alongside other issues the company recognized that they had created a contentious piece of theatre but felt it important to reflect the realities of the Bradford context. There was also the element of making visible those who may be doubly invisible – through both race and disability. The resulting piece of theatre was performed at the company’s base in front of local councillors. This in itself was significant as the councillors were invited into the performer’s space to witness the piece that they had created. Through engaging with the work, officials reported having come to a greater understanding of core issues around health and sex

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education as perceived by the young people. Members of the invited audience noted that the realistic re-enactments of events brought abstract concepts to life, and the invitation to make a direct response was both useful and challenging. This event was able to bring policy makers and service users together in a creative and equal environment where both were able to speak, and the language of theatre facilitated the creation of policy recommendations which were then taken forward to the council. This kind of meeting is unusual, and Mind the Gap performer Zara Mallinson notes that the work of the company ‘gets people with learning disabilities involved in stuff they might not get to do’ (www.mind-the-gap.org.uk). Company members clearly value their role not just as professional artists but also as advocates for those who do not share the same platform from which to speak. Critiques of Legislative Theatre note that it derives from a contentious root. Mutnick argues that such forms of critical pedagogy embrace a tradition of democracy, going back to the Greeks, which has historically excluded or marginalized women and other groups (2006: 35). It is possible, however, to view this practice as a reclamation of a patriarchal form which serves to allow a diversity of voices to speak. Dwyer’s critique is more interrogative of the particularities of the practice and asks whether the form itself carries ideological baggage. He asks: to what extent does a given dramaturgical modelling of a particular social problem bind us to discursive regimes which allow only certain ways of thinking about and carrying forward the process of social change? (2004: 209) Dwyer raises the question as to whether ventriloquism may be embedded in the Legislative Theatre form that seeks to engage in the discourse of politics on its own terms. It might, indeed, be useful to draw on the work of Mouffe, who acknowledges that democracy is more than a set of procedures and, rather than consensus, calls for ‘agonistic pluralism’ that allows for a range of voices and healthy contestation (2000). The work of The Lawnmowers might be seen to embody that more pluralistic model, which allows for the expression of individual experiences.

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The Lawnmowers The Lawnmowers are an independent theatre company for people with learning disabilities based in Newcastle. Their artistic director, Geraldine Ling, finds the structure of Boal’s Forum Theatre quite restrictive and perhaps limited in its creative scope. She also suggests that the technical language of the Theatre of the Oppressed is difficult for people with learning disabilities and, in her work, she seeks to simplify it. So, rather than using terms such as oppressor/ oppressed, Ling will use words like good/bad. Ling’s approach is key, as the role of the artistic director within a theatre company is of great significance – literally providing the artistic direction. When working with people who have learning disabilities Palmer and Hayhow suggest that such figures are also educators and mediators between the worlds of the play and of the actors and that of the potential audience (2008: 125). There is clearly the potential for ventriloquism here – just as in writer’s theatre actors may be serving the text, in director’s theatre the actors may be serving the vision of a director. It appears particularly important when working with people with learning disabilities who may not be enfranchised because of lack of performance experience or lack of confidence in speaking for themselves and must be handled carefully. Ling’s work with The Lawnmowers can also be seen to have a strong training element – indeed, like Mind the Gap, the company had a training company called Liberdade – but her work is a different blend of influences. In her work as a director Ling has employed an eclectic approach – blending Boal’s techniques with those developed by Dorothy Heathcote, a pioneer in Theatre in Education, to create a unique and vibrant form of working. Ling began her career working in a Steiner school, which takes a holistic approach to child development – with an emphasis on spiritual, physical and moral well-being as well as academic progress. The Steiner learning environment is generally very creative and social interaction is highly valued. From this work, Ling went on to be part of a team in a Mental Health Unit and then undertook an MA with Dorothy Heathcote which developed her theatre and facilitation skills. Heathcote is a key figure in drama education. She developed a methodology of teaching which placed importance on the material that students bring to the learning encounter. Like Freire, Heathcote viewed learning as a process which may be facilitated by the teacher

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rather than an encounter where wisdom is imparted from the teacher to the student. Heathcote worked with what she termed ‘The Mantle of the Expert’, which is the principle of putting the students in the position of expertise. So, for example, in a project Heathcote set up around King Arthur, students were enrolled as beekeepers examining the practices of the dark ages for a BBC documentary. In assuming the role of expert, students were encouraged to make positive choices and recognize the skills and abilities they already had. This can be seen to fit with Freire’s principle of ‘replacing the educational goal of deposit-making with the posing of problems of human beings in their relations with the world’ (1993: 60). Heathcote’s starting position was not to look to impart information but to work from an oblique perspective to unveil knowledge. So, the project on King Arthur was developed in response to a request for a project exploring language skills. The scenario facilitated the exploration of verbal reasoning, writing and listening through a creative medium and sought to respect and empower the individuals involved. Heathcote’s work appears to embody Freire’s theory that everybody, no matter how ‘“ignorant” or submerged in the “culture of silence” he or she may be’, is able to engage in a critical dialogue (Freire, 1993: 14). This pluralistic learning was experiential with the teacher-in-role alongside the pupils. So, for example, Heathcote participated as an interviewer from the BBC who asked the beekeepers about their work and elicited information. Heathcote saw her methodology as being useful for people with learning disabilities in that it does not place an emphasis on getting things right but, instead, seeks to go beyond task to engage with a deeper, mythological or even universal aspect of the challenges and possibilities of being in relationship with other people. Thus it was her hope that, rather than skill-building, posing a problem to a group of people may serve as a catalyst for them to explore issues together and find connection to their own interests and those of others. The activity and dynamic intervention are seen as the key ingredient in the process as those enrolled become active participants. In a paper written in 1978, Heathcote explored the particular possibilities of employing her process with people with learning disabilities. She acknowledged that, within the climate of care as it was then, her work was seen as being provocative because it looked to challenge and expand horizons. In addressing the question:

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whether ‘happy cabbages’ are preferable to ‘emergent exploratory people’ … I can only say to myself when I ask that question of myself, ‘please life, let me participate in my living existence’. (Quoted in Johnson and O’Neill, 1984: 153) Heathcote gives the example of an imaginative, mythological project where she was working alongside people with learning disabilities and they were interacting with her as an extraordinary figure in a gold cape in role fighting a great black bird. This participatory approach with its archetypal resonances seems to fit with Palmer and Hayhow’s suggestion that drama may provide a useful tool in promoting imagination and enabling people with learning disabilities to access their internal worlds which are often ignored or left unexplored, while encouraging active participation and external expression (2008: 30). After graduating with her MA, Ling worked with a women’s community arts collective and used techniques from Heathcote such as role characters, blended with Forum Theatre. In 1986 Ling went to work with a group of people with learning disabilities in Gateshead. The group worked together devising and performing shows and, in 2001, they formally established themselves as an independent theatre company. As the company’s work has grown they have developed an identity as one of the leading self-advocating companies of people with learning disabilities in the UK. Their particular method of self-advocacy employs theatre as a means of social change, as they create issue-based performances with accompanying workshops. The self-advocacy work centres on the work of the core group of performers (currently: Andy Stafford, David Champion, Paul King, Andrew McLeod, Emma Slocombe, Chris Moules, Gemma Bartley, George Copeland, Steven Nichol) all of whom have learning disabilities. The company’s creative work develops out of exploration of issues that resonate for them and have included topics such as sex, Elvis and the health service. The company have trained with both Boal and Heathcote as well as acting as trainers themselves. Like Mind the Gap, the work functions on many levels – both form and content – and a significant aspect of their advocacy project is the status of the performers as professionals. As well as the theatre work the company also incorporate ‘The Krocodile Krew’, who provide nightclubs for young people with learning disabilities in

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the local area and help with training others in running club events nationwide and they previously ran a training theatre company. In a survey, members of the company (including actors, apprentices and the nightclub team) noted that what was significant for them was working within the company. The status and identity that come with their jobs are an important aspect of the work and, from their position of empowerment, the company look to actively help others with learning disabilities. Performances often have accompanying workshops that allow the audience a more active, participatory role. The company perceive that the particular drama model they employ in their theatre work can offer space for exploration. Ling states: A big thing about what we are trying to do with people, or for people, is helping them to become independent and that involves them making decisions, and sometimes making decisions in a role work situation helps people to make decisions in real life. It’s very difficult, people need a lot of support as they come to learn to make decisions for themselves. (2006) So, the theatrical form of investigation and acting-in-role is seen as a useful tool for personal growth but the topics the company deal with also challenge their audiences to think and reflect more widely as the content is often politically relevant. The company’s first show after becoming an independent theatre company was Walk the Walk (2003) (Figure 4), which dealt with Valuing People. As noted earlier, Valuing People (Department of Health, 2001) was the first White Paper on learning disability for 30 years and set out an ambitious and challenging programme of action for improving services. Valuing People outlined a more integrated approach to services for disabled children and their families as well as a commitment to providing new opportunities for adults. In particular, the proposals promised improvements in education, social services, health, employment and housing as well as general support for people with learning disabilities. As a company who had committed themselves to working particularly with their own brand of Legislative Theatre, The Lawnmowers sought to explore this piece of legislation and its history and consider its potential for people with learning disabilities and how it might be usefully applied. Walk the Walk was billed as the company’s response to the government White Paper. In developing

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Figure 4 The Lawnmowers in Walk the Walk

this project the company created a full-length show designed to be played to audiences in venues such as community centres as a piece of entertainment which also raised awareness and stimulated dialogue about what this legislation might mean in practice. The show was not presented as a prologue to a formal forum discussion but was complete within itself, and employed trademark humour to explore and communicate the complex issues it negotiated. Walk the Walk pays close attention to the detail of the White Paper; indeed, the piece is structured around the document with the play addressing each element and considering its application. A significant aspect of the piece is putting the proposals in context. Here it is possible to trace the influence of Heathcote, as the company drew on a wealth of research to create realistic scenarios. Within the piece Nick (who is referred to by his own name) has created a time machine that allows the performers to travel back in history and see how previous government Acts have affected people with learning disabilities. They look at the Poor Laws of the 1830s and institutionalized care. The show is frank about the harsh treatment that people received and the company recognize that audience members have cried at their representations of people held in Victorian institutions and displayed for the moral edification of the masses. There is a starkness to this part of the work, with company members in striped uniforms, heads hung down as they are displayed. Only after the

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re-enactment do they raise their heads to tell the audience how they feel. With trademark humanity the company also reveal the feelings of the institutional masters who wished that they did not have to take responsibility for those in their care. The creative process saw the primary research material the company members uncovered translated into role work where the performers were able to get an understanding of what the characters might be feeling. This was then crafted into a scripted narrative with particular roles. Alongside the historical research work was investigation into the current policy proposals. Within the piece Nick receives a package with his copy of Valuing People and the performers respond to its contents. The piece translates the formal language of the report into a more accessible format through a playful voice-over. For example, the document is introduced as follows: This new plan offers many things You all need to know the changes it brings To lead interesting lives it gives you the chance To go out at night and have the last dance It supports independence and having more choices The report listened to many voices. (2003) An important aspect of mounting the production was a commitment by the company to help others understand how the legislation might affect them and a general belief in the importance of accessibility and advocacy where necessary. The company report for 2004/5 shows an image of official gobbledegook (papers with ‘jargon’, ‘pointless survey’, ‘bureaucracy gone mad’ written on them) being run over by The Lawnmowers with lawnmowers! The company certainly seek to critique official discourse and open up an inclusive dialogue. Within Walk the Walk, a voice-over embodies the voice of authority and the performers reply to the articulation of official jargon with the repeated phrase: ‘fine words but look what happened to me’ (2003). Throughout the piece this refrain precedes reconstructions of prejudice encountered in different areas outlined by the legislation – for example in the world of work – and opens up the issues of the difficulties of day-to-day life. Within Walk the Walk, this dialogue with the voice of authority develops into what we might understand as a kind of carnivalesque

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multivocality which draws on a range of voices given equal status. The piece is punctuated with staged musical numbers that make use of popular culture and icons such as Elvis, which give weight and expression to the passionate views of the performers. Not only does this structure play with content, as the words of well-known songs are changed, it also plays with form. There are elements of the Brechtian epic song but the celebratory and kitsch nature of the performance is more akin to the post-modern appropriation of popular culture seen in the work of companies such as Forced Entertainment which open up a reflection on performance culture itself; and the final result is part-karaoke, part-political broadcast. For example, Paul sings ‘Are you Lonesome Tonight’ – complete with hip-swinging swagger – but the words have been changed to describe the situation of being alone in your own community flat. He croons: I’ve a tiny wee flat And I’m so proud of that … But I couldn’t care less If some pals made a mess They’re not here and I’m lonesome tonight. (2003) Each performer delivers a rousing solo – ranging from Status Quo numbers to siren songs by Marlene Dietrich – and these moments of theatre allow both an exciting excess and a pragmatic response, as there is licence to talk about day-to-day reality in such a fantastical moment. This might be linked again to the theories of Heathcote, who stated: ‘When we reflect on our world, even if we indulge in fantasy … we are inexorably led eventually to real events’ (quoted in Johnson and O’Neill, 1984: 149). The fantasy of time travel and pop stardom within the piece is grounded through relation to everyday reality, and what comes through most strongly is a real sense of personal power, which is apparent in what we might term the ‘jouissance’ of the singing.3 Interestingly, the performers’ voices are not strong and so a backing track supports the numbers, yet it is the complete embodied voice that is compelling in these moments. The passion with which Sharon sings ‘believe me’, echoing the words of Dusty Springfield as she reaches up, head thrown back, has a presence which demands attention from her audience.

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Beyond, and in addition to, the political efficacy of such moments, the vibrant performance style is well crafted to capture the attention of the company’s target audience. The company note: We do shows for people like ourselves, and that is important because there is not much of this work about. It’s important to let people know they have the same rights as anyone else. (Lawnmowers, 2001: 4) The company use their skills as artists and their embodied presence lends weight to the message that they are communicating. The passion and vibrancy of Walk the Walk serves as a living example to their audience that people with learning disabilities have something useful to say and can be taken seriously. The fact that the performers reflect their target audience is very important and was built into the fabric of the set for Walk the Walk. The time machine, which is central to the piece, tells the performers that the people they need are in the mirror and the company then look into a mirror placed on the set and see themselves and the audience. This leads into the title song of the piece which exalts people to: Walk the walk Bin the blackboard and ditch the chalk The answer is staring us right in the face We are the answer, here is the place. (2003) This is a true ‘Heathcotian’ moment where top-down teaching has the potential to be usurped by a sense of personal empowerment as the audience are invited to recognize the knowledge they have. The performers tell the ‘voice of authority’ – ‘you are the weakest link, goodbye’ – leaving them to close the show speaking for themselves (2003). In their roles they mirror the audience and provide a positive reflection which opens up possibilities. Company members are clear that part of their work is as role models. They note that other people with learning disabilities see them on the stage and realize that they may be able to achieve their own personal goals. The different personalities and interests of the acting company appear to be an important aspect of the work. The documentation video of Walk the Walk was intercut with autobiographical details

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about the performers and their personalities and this certainly shaped the performance event itself, as their personal experiences were drawn on to create the scenarios and their personal styles acted as impulses behind the more fantastical elements of the work – for example Paul’s interest in Elvis. This links back to the power of the devising process and the potential for it to be a vehicle for sharing a personal perspective on the world. The Lawnmowers devise their work and bring their own material to bear but, unlike Forum Theatre, where individuals’ stories may become caught up in a group story, the way in which The Lawnmowers work means that they can still own their own narratives. Within Walk the Walk they say ‘look what happened to me’ (2003). This is partly a theatrical convention within the piece but it does signal a different approach than that of forum, which works with a model character. Although they do work with role, The Lawnmowers present themselves as themselves and this style of autobiographical performance has particular ramifications. Autobiographical performance might lead, as performance scholar Hargrave notes, away from a discussion about the quality of the acting to an examination of quantities of acting (2009: 47). Indeed, this form of work has even been termed ‘non-acting’ by Kirby, as it appears to work against a masking role and to communicate with the audience in a direct manner (2002). Non-acting can be understood as functioning in the tradition of the Modernist avant-garde in that it is not a mimetic practice that seeks to represent a fictional character, but a reframing of reality that seeks to blur the boundaries of art and life. The Lawnmowers have not received any drama-school-based performance training and, as such, their work may not have the polish that other performers may have, but they are seeking to make connections and communicate rather than create a naturalistic performance experience. Indeed, the non-naturalism of their performance events can be seen as part of the intervention they provide. In discussing the work of Richard Hayhow’s company The Shysters, Whyman says: we usually see acting as involving the actors getting rid of their own personal mannerisms in order to be ‘inhabited’ by the character – whereas here the learning disabled actors’ habitual way of expressing themselves enhances the performance. (2006: 12)

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Rather than using performance as a ‘normalizing’ tool, it may indeed be a platform for difference. Non-acting can be used as an investigative performative practice that frames the everyday in a manner which reflects upon the constitution of identity itself and allows different possibilities of ways of being to be opened up.4 A rehearsal process may allow for a reflection on behaviours and beliefs and the opportunity to choose and shape the presentation of self. So, for example, performer Sunny Patel Jones states: ‘To me being a Shyster means you can be your own person, before I wasn’t at all, now I am’ (quoted in Whyman 2006: 15). It seems that the creative process can be a liberating experience that allows for a full sense of personhood and embodiment which, in turn, may be seen as an effective performance strategy. Govan et al. note that: ‘The emphasis on the “presence” of the actor in performance, and the rhetoric of truthfulness, honesty and authenticity, have now become commonplace descriptions of good performance’ (2007: 29). The authenticity of work of companies such as The Lawnmowers can be seen to facilitate their relationship with their audience as they offer something that is ‘real’, even within a fictional framework. Methodologically, the use of personal interests and narratives as source material leads to a multifaceted creative process that reflects upon real-life data to shape performance pieces. As with other autobiographical narratives, autobiographical performance work often fuses factual material with fictional elements. The processes of production which bring together truth and fantasy are highlighted by Renza, a post-modern critic who, with reference to the bricolage which may constitute an autobiographical narrative, disputes the idea that the self is a coherent unity which might be called ‘authentic’. Rather than viewing autobiography as a direct communication between the essential selves of the author and her/his audience as earlier commentators on the field had done, Renza foregrounds the process of creation which sits at the heart of the production and reception of autobiographical texts. He notes that the production of autobiography is a result of a reflection upon personal experience which will be subject to the filters of memory and personal editing. Instead of seeing autobiography as a direct reflection of reality or a purely fictional creation, Renza posits that: We might say, then, that autobiography is neither fictive nor nonfictive, not even a mixture of the two. We might view it instead

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as a unique, self-defining mode of self-referential expression. (1980: 295) Renza highlights the way in which an autobiographical text may trouble the binary opposition of truth and fiction through inhabiting a creative space in-between that blends elements of both factual detail and fictional fantasy around the persona of the performer. The Lawnmowers play with persona, as company members are referred to by their own names within performances, yet they may play with different types of behaviours within the performance event. ‘Their’ stories, as they relate them to the audience, may be based on their own experiences but also draw on other sources in order to develop and/or theatricalize events. There is a sense of authenticity to the work, as it is based in the realities of the experiences of the performers, but it is also embroidered for presentation – a process that Renza notes is part of the usual processes of autobiography. The performers in The Lawnmowers talk about being recognized and known by their audience members while, of course, people may only know what they do of them from their performances on stage. This sense of connection, however, is an important element of the advocacy work of the company. As in the previous chapter, the performers may be seen as modelling behaviour for audience members which may help them in their personal development. Workshop sessions, which often run in conjunction with the performances, are another important element of developing the voices of the audience members and are seen as a space where people can rehearse their own responses. Alongside Walk the Walk, the company ran themed Forum Theatre sessions to deal with each aspect of the legislation. Other workshops are more tangential to performances but just as important in terms of empowerment – including practical drama sessions and cookery demonstrations. Such workshops ran alongside Finger On the Pulse (1999), which was a piece that explored healthy living and relationships with health professionals. This is another clear example of a living advocacy document and was, indeed, sponsored by advocacy services. The show employed humour to articulate the company members’ thoughts and feelings and express issues which were important to them. So, for example, they presented a short scene around a consultation questionnaire with a patronizing voice-over that explained that some questions

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had been left out because they were deemed to be ‘too difficult’; that some answers were rigged; and that other parts went too fast for considered opinions to be given. The piece was used in training for medical practitioners with the hope that it would heighten awareness of issues of importance to people with learning disabilities and used the theatrical form as a means of sharing experiences from the service user’s perspective.

Conclusions Ed Thomas, a leading figure in the disability rights movement in America, states that ‘the process of coming to speak for oneself is absolutely vital to the process of developing one’s own political agenda’ (quoted in Conroy, 2009: 2–3). Finding your voice and having it heard seem a fundamental act of citizenship where personhood is recognized. There is an acknowledgement that, within contemporary culture, certain voices are privileged and that being heard publicly may involve a process of imitation – as those less empowered actively ape the words of the powerful, or else ventriloquism – where the less empowered are ‘given a voice’ by those who are more privileged. Giving voice may be motivated by benevolent intentions, but ultimately may lead to a double silencing as those who are seeking to have their voices heard are subject to a process whereby the powerful speak and listen to themselves through the mouthpiece of those they would seek to empower. This chapter has explored theatre as a tool for ‘speaking’, both with and beyond words, and how this may be made use of by people with learning disabilities. Artist and theorist Kuppers notes that people may experience a lack of agency and opportunity along with the label ‘disability’, but there is great potential within the arts for disabled people to be originators of artistic social texts and practices (2003: 12). From a Marxist perspective we might understand theatre making as owning the means of production and a tool for enacting an intervention that is controlled by the ‘workers’. The nature of theatre as a public forum where performers may have the experience of being able to present their perspective to a collected crowd of attendant spectators, also appears to be an important element of the medium and one which may make possible a different kind of ventriloquism – where the artwork speaks on behalf of the artist(s).

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In her reflection on the practice of a range of theatre companies working with learning disabled people, Whyman comments that: ‘Many people who attend performances by people with learning disabilities say that not only have their perceptions of people been changed, but also their ideas about theatre have been challenged’ (2006: 9). This chapter has considered how theatre companies have developed new and vibrant ways of working from a synthesis of forms, and enabled insightful and catalytic articulation of thoughts and feelings. The rehearsal room may provide the opportunity to experiment with new ways of speaking and provide a safe space for expanding a person’s vocabulary. Working beyond text can also prove liberating, enabling speaking bodies and flights of fantasy that move beyond everyday reality to a more mythological realm. Writers such as dramatherapist Anna Seymour have noted the integrity of such work and the way in which it is developing a new aesthetic ‘in which learning disability is integral yet invisible within it’ (quoted in Whyman 2006: 9). Thus, what is important in such work is the art form which communicates with the audience and perhaps gestures beyond the politics of learning disability to wider concerns of humanity. As Ostrow suggests in his introduction to Goldblatt’s work on ventriloquism: This notion of pronouncing one’s understanding in one’s own name with one’s own voice … represents an open-ended and therefore progressive model of the potential of human interaction. (Goldblatt, 2006: xvi) The human encounter is, of course, central to the theatrical experience, and the process of presenting a personified account of interaction with a political system or concept may be a powerful event for those who witness it. The language of bodies and voices and the sheer presence of the performers on stage may serve to concretize and clarify complex socio-political negotiations. In this chapter I have been considering how this type of encounter may be of use within health and care and the promotion of healthy citizens. Engagement with the creative expression that theatre offers may, in itself, offer health benefits. Certainly company members report an increase in well-being as a result of their artistic work. It may also be used as a tool for engagement, consultation and advocacy. Amidst government recognition in the UK that changes need to be made to

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the health and care system in order that it serve people with learning disabilities better, theatre has proved to be a useful channel for communicating and processing information. Through performance, companies such as Mind the Gap and The Lawnmowers have been able to enter into a dialogue with official discourse and make their voices heard.

4 Superficial Wounds: The Problems and Possibilities of Medical Simulation

Introduction There are some wounds that pose no threat to the individual, even though, on the surface, the person appears to be in distress. In reality their injuries are self-inflicted and have been painted on with make-up. Such wounds have been designed to have an effect on the witness, engaging them in the drama of supposed suffering and prompting them to react in the appropriate manner. The dictionary definition of a superficial wound identifies it as apparent rather than real and this chapter seeks to negotiate, and trouble, that terrain. In particular I will examine how simulated events may serve to move those who witness them and engender a real response with lasting effect and how this may be employed in medical training. The chapter begins with an examination of the context for medical simulation and continues with an exploration of a range of case studies that exemplify the problems and possibilities of such practice.

Context There has been a shift in emphasis in medical education in the past decade. The publication of Tomorrow’s Doctors by the General Medical Council in 1993 (then revised in 2003) recommended that medical schools move away from a model of imparting knowledge to delivering an educational experience that encourages critical analysis and the development of clinical skills such as the ability to work well as part of a team and establish effective relationships with patients. 119

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Medical schools responded with innovations in the undergraduate curriculum which included an understanding of communication skills as an essential aspect of medical education. Tomorrow’s Doctors states that: Students must have opportunities to practise communicating in different ways, including spoken, written and electronic methods. There should also be guidance about how to cope in difficult circumstances … breaking bad news etc. (2003: 8) Medical schools now commonly have courses in communication skills although there is considerable variation in the way that communication studies are taught. One important route for such training has been through interaction with real patients, but this approach has particular problems. Firstly, real patients need medical care and cannot just be used for training. So, during a session, all must be mindful of any necessary treatment. Secondly, patients’ own awareness about the quality of care they receive may mean that they are unwilling to be used as case studies for medical students. There is also the contextual detail that there have been dramatic reductions of in-patient beds leaving a smaller patient pool to draw on. Spreading a group of students throughout a hospital may make it difficult for a tutor to monitor their work. The matter is further complicated in regards to postgraduate training as the European Working Time Directive limits the number of hours a registrar is allowed to work with patients, which also has an effect on training methods. This context has meant there has been a new emphasis on the use of simulation.

The development of simulation In the 1970s simulation became a popular approach to teaching ‘advanced’ skills such as problem solving because of the way in which it can offer realistic experiences within a safe and reflective environment. Within contemporary medical schools simulation takes place in a range of ways from role-play to virtual learning environments. Complex technical medical simulation was introduced in California by Professor David Gaba of Stanford whose training as a pilot had introduced him to the processes of Crew Resource

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Management (CRM) exercises. Gaba developed a course for anaesthetists which employed the principles of CRM and the development of a simulated environment to train staff in the management of crises in the operating theatre. Such events make use of highly equipped mannequins known as human patient simulators that have capacity for airway intubation and other such procedures and so allow practitioners to practise specialized technical skills. This clearly has an advantage over using real people as the risk to patients can be minimized. It also avoids the problematic practice which Ker describes where medical students practise intimate examinations on anaesthetized patients who may not have given consent for such procedures to take place (2003: 35). Students need to rehearse medical procedures, and simulation gives them the opportunity to do so within a safe environment. Medical educators Owen and Plummer report that ‘many students find learning procedures on patients very stressful’ and a simulation may serve to lessen that anxiety (2002: 640). Simulation also has pedagogic advantages in that, with a simulated patient, the dummy can be programmed so that the complexity of the task can be controlled and any complications pre-set and anticipated by the trainer. There are no surprises within the encounter and the teacher and the student can focus on the task in hand rather than having to worry about the medical care of the patient. Technical skill is at the centre of such activity and the exercise may be successful even if the procedure goes wrong if the student recognizes her/his mistakes. Simulation also allows a wealth of modulations and the presentation of a range of scenarios that the student might go on to meet. As Professor of Anaesthesiology Good notes, ‘statistically, most critical incidents will not be encountered during supervised training, but they will be encountered several times during a career’ and simulation allows for those encounters to be anticipated (2003: 18). As well as technical skills, simulation is also seen as being useful for ‘soft skills’ such as communication and teamwork. Role-play has been an important tool, used to encourage students to recognize the importance of empathy and compassion in clinical encounters. Medical schools promote this form of simulation as pedagogically useful in that it allows the role-player to exercise their critical and emotional faculties as they respond to a real person. Both sides of the role-play are briefed as to the parameters of the role-play. So,

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the person playing the patient may be given contextual information such as: Robert Wyman is a 54-year-old manager of a small business manufacturing stationery items. He has just arrived in a hospital ward, having been sent there by his GP because he has unexplained chest pain. The pain has now settled, but he is pretty worried. The ward sister has just told him that the admitting doctor is busy, and has asked him if he will speak to a medical student first. (Ricketts, n.d.) This information, developed as part of a training programme which works as a collaboration between Guildford School of Acting and Southampton University Medical School, sets up a realistic framework for the interaction with the medical student and gives the simulator some character notes to work with. The simulators are given more detailed clinical information to be given as part of the history, for example: He first noticed the pain in his chest about three weeks ago, at night, which he attributed to eating fish and chips for tea. It settled, but on several occasions since … he has had a similar pain, and today’s attack was particularly severe. (Ricketts, n.d.) They are also given further information for use only if it is directly asked for, such as: ‘the pain hasn’t been anywhere else other than his chest’ and ‘he loves detective stories on the television’ (Ricketts, n.d.). In order to aid the reality of the situation, the simulator is not given the full diagnosis. They are, however, given quite a lot of personal details – in this case about an upcoming family wedding – that adds to the complexity of the human encounter. The medical student will have been primed through her/his studies on particular medical procedures that s/he should follow and will enter into the scenario with the knowledge that, although the role-player will present a realistic case study, they are not a real patient. The focus of the exercise is not clinical but educational, often with particular assessment goals in place. Kneebone et al. comment that this framing may result in a ‘quasi-clinical’ environment which blends reality and fiction, yet this form of teaching is seen by medical educators as a valuable space for

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students to gain real experience (2003: 50). A report commissioned by the Nuffield Trust states that: doctors are increasingly becoming specialists, ‘technicians’; there is thus a crucial need for them to develop judgement – which is learned, not taught. (Philipp et al., 1999: 48) This work in role-play has developed into the employment of actors or whole theatre companies to deliver pieces of theatre that seek to engage medical students in an immersive experience that seeks to enhance clinical skills.

Troubling simulation Medical educators and researchers Bligh and Bleakley (2006), however, question the notion of the usefulness of simulation by positing French philosopher Jean Baudrillard’s notion of the simulacra. In ‘Simulacra and Science Fiction’, one of the essays that make up Simulacra and Simulation (1994), Baudrillard traces the development of simulation alongside a linear progression of history and offers three orders of simulacra. He begins with the symbolic order where the modus operandi is that of the counterfeit, a disguise or false image that functions in relation to a base reality. Baudrillard identifies mass production as shaping the next order of simulacra with the utilization, in the industrial period, of mechanical means of reproduction. The third order of the simulacra is seen as arising in the twentieth century against the backdrop of the information superhighway and cybernetics. The simulacra of simulation is what Baudrillard terms the hyperreal. In this phase he proposes that the poles of fiction and reality have imploded, and the simulacra no longer equivocates or reproduces the real; rather that the real is generated and reduplicated by and through simulation, producing something that is more real than real – the hyperreal. Baudrillard argues that the function of the hyperreal is similar to the simulacra that have come before in that it works to preserve the reality principle (essential to the smooth running of social order) through concealing the fact that what is presented as the real is not real. Bligh and Bleakley (2006) posit that medical simulation is an example of the ‘hyperreal’, with scenarios presented as real that are actually fabricated – thus the

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immersive experience of the operating theatre that has been preprogrammed, or the primed, angry response of the patient to a request for consent. While I would agree with these authors that simulation has a complex relationship with authenticity, I would question whether it is actually an example of the hyperreal. Baudrillard quotes ‘Ecclesiastes’, which he says states: The simulacrum is never what hides the truth – it is truth that hides the fact that there is none. The simulacrum is true. (1994: 1) I would suggest that a medical simulation is not hiding the fact that there is no truth, as there are medical crises that exist and bodies really go into trauma. Simulation looks to mirror and reproduce such processes. It also does not seem reasonable to suggest that students do not differentiate between their experiences in a simulation and their experiences on the wards. Research shows that students are often painfully aware of the false nature of the scenarios which leads to awkwardness in their execution. The framing of exercises where ‘time outs’ for discussion are frequent would suggest that participants are aware of levels of reality where the scenario may be realistic but not real. However, I agree with Bligh and Bleakley that Baudrillard’s theory may be useful to unpick what is going on within the simulated scenario and how the real and the imaginary may dovetail within such a mimetic encounter. In invoking the simulacrum, Baudrillard attempts to problematize the discussion of representation, moving on from the binary distinctions between model and copy and the shadowy likenesses that Plato proposed in The Republic. For Plato, mimetic praxis involved the representation of nature and the mirror of absolute truths in poor imitations. Plato was particularly scathing about the practice of theatre. He was suspicious about the power of theatre to beguile an audience into believing copies of reality and argued that there was no useful place for actors in his republic. Plato had an interest in distinguishing between the authentic and the inauthentic. Deleuze characterizes Plato’s project as an attempt to trace a ‘narrative of foundation’ (1998: 46). This narrative is considered significant by Plato because it is that which facilitates order and separates good from bad. Plato notes that the true Statesman is the well-grounded claimant and is suspicious of the manipulative power of the false claimant who may

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bear an external (aesthetic) resemblance to the original but not a moral one. Plato views the bearing of external markings but nonadherence to the perfect ideas of the model as rendering the copy shallow and open to misuse, hence his suspicion of mimetic practice. Plato’s pupil Aristotle, however, was more positive about drama and sought to outline its social efficacy. Aristotle described mimesis as a vehicle for education where human actions are highlighted, through imitation, and the audience’s attention is guided to a moral recognition of the effects of behaviour (Aristotle, 1992: 3). I would suggest that the Aristotelian perspective on mimesis is a useful tool for the consideration of medical simulation. Aristotle understood the fictional framing of tragic events as a positive aspect of the stage drama, allowing audience members the opportunity to reflect upon everyday life. Rather than viewing the drama as a pale reflection of reality, Aristotle emphasizes the significance of the drama as an alternative reality. Aristotle posits the importance of mimetic representation, and theatre in particular, as a safe space where audience members may watch troubling actions safe in the knowledge that it is only an illusion. Yet he also proposes that an illusory scenario may have real effects. Aristotle proposed the process of catharsis where gazing upon the wound or the figure in extremis can evoke pity and fear and lead to the purgation of emotion. By purgation, Aristotle was borrowing on medical terminology relating to cleansing, but he also wanted to invoke an educative element of ‘reordering’ that may send the individual back into society with a different perspective. What was significant to Aristotle was the moment of recognition or anagnorisis – the change from ignorance to knowledge – that happens for the tragic hero within a play and also, hopefully, for the audience member as they come to a new level of realization. An Aristotelian model of theatre allows for an understanding of a mimetic encounter that may serve to educate and enlighten within the safety of a fictional framework. This perspective allows for an understanding of the manner in which witnessing simulated trauma may have a real and lasting impact on an audience member, and was explored by Sigmund Freud, who detailed the beneficial effects of mimetic practice. In this chapter I shall be drawing on the work of Freud in considering trauma as being not only a mark to the body but also a psychoanalytical term which refers to that which has been

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experienced without the subject being ready and thus continues to trouble the subject. In terms of medical practice, trauma may be invoked when a practitioner is faced with a difficult situation which they feel unprepared for and I am interested to examine how simulation may help them to prepare emotionally, as well as technically, for such an encounter. Thus the interweaving of the tangible and the psychical is a key element in this work. The case studies in this chapter span a spectrum of mimetic practice, from staged drama to impromptu performance, in order to explore the various modes of mimetic encounter employed in this area. I remain sensitive to the issue of authenticity, and the blending of reality and fiction, and shall be examining how the different models balance these elements. However, I do not wish to employ a post-modern concept of the blurring of truth but to understand how fictional representations are framed as such while maintaining a meaningful relationship to reality. I will begin with an examination of a work which is overtly theatrical. Women and Theatre create identifiable theatre pieces and use fictional scenarios to enhance the training of medical practitioners in the field of communication studies. I will consider how fabricated events may serve to move the audience and stimulate change. Secondly, I will explore Operating Theatre, with a particular emphasis on how their work can be understood as ‘real role-play’. Finally, I will consider the practice of Casualties Union and the way in which their high-fidelity simulation demonstrates the potential for drama to teach both technical and communication skills.

Women and Theatre Janice Connolly, artistic director of Women and Theatre, believes that ‘the next best thing to having an experience, is watching someone have that experience’ (2005). It is this belief in the power of the mimetic encounter that drives the work of the company. Like Aristotle, Women and Theatre view simulation as a means of providing information which develops understanding. They work with theatrical simulation to play out health-related scenarios for health professionals, service users and the wider public and do not see their work as sited in technical training but offering a more holistic perspective on clinical situations. On their website they describe

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their work as ‘focusing on communication’ and they seek to encourage discussion and understanding, particularly within the field of health and care (www.womenandtheatre.co.uk). The company are recognized experts in the field and, in 2004, were overall winners of GlaxoSmithKline’s Impact Awards which recognize excellence in community health for their ‘commitment to improving the quality of human life and making a real difference to the health of the community’ (www.womenandtheatre.co.uk). Women and Theatre are based in Birmingham. They were formed in 1983 and, as the company name suggests, initially they focused on addressing issues of particular significance to women. From 1989 the company widened their scope of interest due to their desire as artists to develop their practice and they now undertake a range of projects that span health, education and probation – which currently also includes a men’s health piece. The common denominator of the work is a commitment to promoting well-being through the medium of drama. They believe that their productions should match the reality of the community they are serving and state: ‘We aim to reflect the language and lives of ordinary people, giving voices to those not usually heard’ (www.womenandtheatre.co.uk). The company perform in a variety of settings from theatres to community centres in order to meet their audience where they are. Women and Theatre work out from their local community and have developed a unique process of research which feeds into the development of their scripts. The research work begins with in-depth consultation with the particular group(s) that the project addresses – both professionals and the general public – gaining primary research information through interviews, consultations and workshops. When working with the public, the health professionals who have commissioned the piece will often help in finding participants for the research process. However, the company recognize that this may lead to a biased research process and so they also endeavour to carry out their own, independent research. This research phase helps the company to identify the key characters that should be involved in the drama and the place in which it should be set. In other words, the research process identifies the parameters of the simulation in order that it relate to reality. The researchers are also the performance-makers, which the company see as facilitating a smooth transition between the research phase

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and the crafting of the performance package as the characters can be fleshed out by the performer/researcher’s experience of real life. The company also prefer to work with performers who have experience of the subject matter in hand, so, for example, many performers who had experienced breast cancer auditioned for the show The Learning Curve, which deals with three women’s experiences of the illness. The company work in partnership with a range of agencies. A regular collaborator is Walsall Health and Community Arts which acts as a broker for arts in health projects in the area, bringing together packages of funding around areas of need. Although Walsall Health and Community Arts has a strong background in Theatre in Health Education, Women and Theatre are clear that they do not offer Theatre in Health Education which, as outlined in Chapter 2, aims to impart clinical information to a particular target group. They understand their work with medical practitioners as being about encouraging clinicians to reflect on their practice, understand their patients better and rehearse possibilities for change. The company recognize the importance of working with medical practitioners as they see clinicians as having the ability to make direct changes. Similar to health education, the intention of the work is often to invoke change – Connolly notes that ‘the project is a failure if people go out saying in a whisper “I still think the same”’ – but this form of change is more commonly a reordering rather than the introduction of a new agenda (2005). Connolly discusses how the company have to negotiate the agendas of funders. She comments that there is a lot of funding for projects with a black and white educational agenda, for example: ‘smoking is bad’ (2005). Because the company do not wish to work in this way, but rather to explore the grey areas of human experience and the conflict which is the basis of drama, they often turn down commissions. Their intention is to make good theatre and not just to act as a mouthpiece for funders, and to invite reflection rather than simply imparting information. Humour is an important element in their performance style. As noted in Chapter 2, comedy encourages a critical, intellectual response rather than the emotionalism that tragedy procures and invites the audience to see events as a consequence of choices and thus changeable. The company see their theatre work as both funny and moving because it connects with people’s real recognition as, in Aristotelian terms, the audience

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members see their real-life experiences reflected in the drama and acknowledge the choices that have been made. The company see this process as encouraging critical engagement with the material and ultimately meeting the goal of promoting communication through providing a resonant catalyst for discussion. Two examples of practice are indicative of the company’s work. Scoffing was a piece commissioned by Birmingham Dieticians Service for GPs to show patients’ experiences of obesity and to ‘promote an awareness of dietetic services’ (www.womenandtheatre.co.uk). The piece had an educational orientation but it was not intended to be didactic; rather it sought to promote a space where clinicians might take time out from their everyday concerns to reflect upon and rethink their interactions with patients. Horley examines medical training spaces and suggests that a medical simulation facility should be designed to ‘enhance the transfer and acquisition of medical, surgical and communication skills’ (2008: 3). Although they are not clinical environments, Horley recommends that simulation centres should mimic clinical environments in order to create the ‘clinical and educational ambience’ (2008: 3). Such facilities may include mock operating theatres which aim to be as realistic as possible for an immersive experience. Theatrical presentations, such as Scoffing, however, do not seek to reproduce particular clinical environments. They may be staged within a hospital setting (the performance I saw took place in a training room of a general hospital) but they often look to explore issues beyond the purely clinical encounter. In this case Women and Theatre sought to set up what Turner termed a ‘liminal’ space, which was a time out of time where different possibilities could be explored (1982: 20).1 The three stage flats of the set delineated a performance space which the audience sat in front of in a horseshoe arrangement. The minimal staging, however, did not seek naturalistic representation but, through use of props, costume and music, suggested a range of settings in which the action of the piece took place. Scoffing is a one-woman show whose narrative follows the story of Nettie. The audience meet the character as she is waiting for her first appointment at the dietician and, during the 40-minute play, she reflects on her life and her relationship to food. Other figures appear through her reference to them and the actress takes on the persona of supplementary characters including a number of doctors who are

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shown to be unhelpful in their encounters with Nettie. So, for example, one doctor figure states: Now Mrs Biggs I’m not coming out to see you – you know why your back’s gone – you’ve got to lose weight – it’s as simple as that. It’s your weight. There’s nothing I can do for you till then. (Connolly and Moorthy, 1998) This material, taken from the research process, had been crafted into a high-energy performance, delivered in an up-front style which presented exaggerated, yet recognizable, figures. Nettie, the central character, addressed the audience directly and sought to engage them. The character comments at the beginning of the play: ‘welcome to my fat world’ (1998). Women and Theatre hope that their work will sensitize medical practitioners to acknowledge the importance of context for individuals and their presenting symptoms, thus, for example, Scoffing demonstrates the impact that Nettie’s upbringing and socialization to food has on her world-view. Unlike role-play, the theatrical encounter allows the audience to witness the character in a range of settings as scenes shift in place from waiting room to Nettie’s home. Contemporary theatre practice troubles Aristotle’s notion of the three unities of place, time and action but it does allow for a fluidity of form. Women and Theatre make use of the possibilities of fluid time, so, for example, Scoffing includes scenes from the character’s past as well as present. As such, the theatrical simulation enables a lot of information to be communicated and a depth of character realized. Humour is employed as a means of connection and there were many laughs of recognition in the performance that I saw in October 1999 at a GP refresher day in High Wycombe. The fact that the event was scheduled as part of a training day appeared beneficial in that the audience were already in reflective mood and the discussion that followed the performance was engaged and contemplative. Interestingly the High Wycombe audience seemed to deal with the play as clinical material. In the post-show discussion they referred to Nettie as a ‘client’ rather than the character, which seemed to indicate a high level of engagement and a blurring between reality and fiction. The audience members also seemed to have been able to use the presentation to recognize their own behaviour. One doctor said, ‘she’s right, we are patronizing, aren’t we’ – which prompted a ripple of laughter in

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agreement. The discussion continued as to how behaviour might be modified to be more effective when working with patients and sought to ground the theatrical intervention through relating it back to real life. Scoffing, therefore, is an example of how the fictional format of a play may act as a stimulus for reflection and, ultimately, for change. The safe environment of dealing with a real person presenting an imaginary character has the benefits of live interaction while at the same time not presenting a real patient who requires treatment. The play can be understood as being between fiction and reality, enabling emotional engagement but without the risks of a real consultation. Literary critic Schier (1989) highlights the dual reality of the drama which may allow an audience member to disengage from the action because they are aware that it is not real, but notes that this framework may also allow a person to engage more fully with expressions of what Jacques Lacan terms the Real – that is, that which troubles the psyche and has not been able to be processed, or ‘resists symbolization’, as Undrill puts it (2000: 134). Schier explores how emotional engagement may function in the theatrical encounter. He states: ‘in real life close knowledge entails intimacy, but intimacy entails predicament … [in art] we need have no impulse to block out the full awfulness of this situation’ (1989: 24). In philosopher Walton’s terms, a person may ‘exten[d] [them]selves to the level of the fiction’ in a manner which allows them to acknowledge the suffering presented and so the fictional encounter engages with elements of real experience and allows individuals to deal with matters which may be troubling to them through a concrete encounter (1978: 23). However, as Freud notes, there is also a need to shield the self from the intensity of emotion that may arise in response to a heightened situation and here the fictional framework means that there are no consequences to that which is enacted onstage and thus the significance of the mimetic encounter remains at the centre of the experience. Literary scholar Nuttall sees mimesis as the key element in an audience’s experience. He states: ‘[one can] luxuriate in such grief as [one] never could in the face of real, actual pain’ (1996: 17). This comment returns us to the issue of the negotiation of reality within the fictional frame. Nuttall suggests that: the representative sign must be distinguishable, as having a signlike character, from the thing it signifies; or representation will not be perceived to have happened. (1996: 17)

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So the crafted theatrical event can be understood to signal the ‘time out of time’ nature of the drama where, in Platonic terms, the representation can be distinguished from that which it represents. The referral to the character of Nettie as a client within the follow-up discussion raises questions about the process in this instance. This might indicate that the audience did not differentiate between the character presented and the real patients that they see. This might have meant that a strong psychical connection was made and, as a result, they were not able to have critical distance on the material which might have impacted on what they might have gained from the experience. Others in the room did not speak during the discussion, and it may have been that they found the action hard to accept as true and so did not fully suspend their disbelief. As I have already noted, the distinction between the real and the theatrical is not as clearly defined as Nuttall suggests. Even within direct mimetic action, Aristotle acknowledged, in The Poetics, the problem of the real, and commented that the drama will be unreal at the level of palpability but real at the level of possibility. People may perceive the presentation purely as a teaching tool, but that need not be problematic as long as they agree that it might happen, as that allows their imagination to engage with the presentation and the possibility of the arousal of pity and fear in relation to the action and, Women and Theatre hope, an emotional reordering that has impact on the work that they will return to outside the event. As well as projects addressing the interaction between patients and practitioners, Women and Theatre have also produced work directed at helping health professionals to talk to each other. Working It Out was ‘an interactive training session’ developed in collaboration with Southern Birmingham Community Health Trust which centred on Integrating Nursing Teams (INT) in Primary Care. During their research process the company became aware of the fact that INTs were a contentious issue which had raised lots of concerns in the professional community. The company acknowledged the rivalry and suspicion that was going on in private and their performance project aimed to bring it into a public forum. As an independent company, Women and Theatre recognize that they have licence to bring a fresh perspective to a situation and, as artists, they can work to craft that into an event that engages the audience. Connolly describes the company as ‘saying the unsayable’ as they use their outsider status to voice

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the concerns of health professionals in a public forum (2005). Women and Theatre state that they seek to deal with issues ‘at the cutting edge of people’s consciousness’ and see theatre as enabling a process of recognition (www.womenandtheatre.co.uk). The play, which grew out of their consultation with INTs, followed the characters of Linzi – a health visitor, Steph – a district nurse and Jaqui – a practice nurse and was designed to be used as a stimulus for discussion. As audience members witnessed the characters’ personal and professional lives – culminating in an unsuccessful INT meeting – a process of anagnorisis/recognition appeared to take place as the company had hoped. The piece showed examples of bad practice as well as good, and Connolly states that ‘people recognized what we were presenting and it sped up the following discussion as we had been saying things that they had been thinking to themselves’ (2005). It seems that the company’s method of presentation gives permission for audience members to explore what they might see as getting it wrong. There is no hidden agenda of right answers but the invitation to explore ‘warts and all’ (Connolly, 2005). This heightened the second half of the session when the participants were invited to reflect on their response to the play before working in smaller groups to interview the characters in turn. The whole group then would come back together and the characters fed back the advice and comments they had received. The feeling was that very honest feedback came from the participants as they fully engaged with the world of the play. Company-collated quotes from participants support this perspective. Feedback included: ‘I really thought I knew the characters.’ ‘Excellent performance of real-life situations.’ ‘Superb, I got sucked into thinking that the cast really were nurses.’ Such responses raise a similar point to the reference of Nettie as a client. It seemed significant to participants that the simulation was realistic; and the realism seemed to convince them that the presentation was being delivered by those from within the profession, that is, in Platonic terms those who have an authentic claim to the knowledge. It is hard to know how people would have responded if there had been clear signals that these were not nurses. The frame of the theatrical encounter was clearly in place but this seemed to have

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been transcended by participants as they acknowledged them as one of their own. Does this make the simulation effective or not effective? It certainly allowed for a level of discussion, but it also might have prevented the beneficial effects of a clearly signalled fiction. There were many real elements within the production which were gained through detailed research. The company describe how they do not just work with Stanislavski’s idea of the magic if – which proposes that an actor enters into a role by posing the question to her/himself – ‘if I was ??? then I would …’. Women and Theatre also choose to work with the detail of what Stanislavski termed ‘the given circumstances’ where the character is fleshed out with reference to factual information (Stanislavski, 2008: 10). The company do not just work with imaginative leaps but also with factual information and this seems to lend the work its authenticity as they blend creativity and realistic details into well-crafted performance pieces which are accessible and relevant to their audiences and provide the security of the clear framework of beginning, middle and end. The foundation within reality appears to help Women and Theatre to ground the work in relation to real-life outcomes through follow-up discussion and workshops. Framing scenarios for viewing encourages careful attention, and Connolly notes that ‘People notice in the actors things they would do themselves, like not making eye contact when a patient walks in’ (2005). This resonance in the viewer may encourage personal connection which may be further enhanced within a post-performance discussion. So, for example, at the end of the performance of The Learning Curve, a piece about breast awareness which I saw at a community centre in London in 2006, the performer/facilitator asked the audience what messages they would give to each of the characters within the play if they were their friends. This continued the suspension of disbelief which had been invited through the theatrical presentation but also encouraged connections to real-life experience. One piece of advice that was given by an audience member clearly came from her own experience of breastfeeding that she had shared earlier in the post-show discussion. This blending of reality and fiction demonstrates an investment in the theatrical encounter which can be seen to help to strengthen the application of the aesthetic drama to the world outside the performance space as personal experience is validated and reflected upon within the heightened environment of the performance space.

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Connolly’s belief in the importance of theatre as a medium which ‘affects you emotionally’ (2005) is also central to the work of Operating Theatre. They also appear to value the fact that performance is: ‘not just facts and figures, it’s about feelings and human communication’ (Connolly, 2005).

Operating Theatre Operating Theatre was founded in 2001 by Dr Dominic Slowie, Carol Clewlow and Julia Darling. The company have engaged in a range of projects but a core element of their work has been concerned with medical training. Slowie, who was a senior medical tutor at Newcastle University’s Medical School at the time of the company’s conception, was dissatisfied with role-playing as a means of medical training. While he appreciated the benefits of what role-play could offer, he found it ‘too reductive’ and felt uncomfortable with an approach that focused on the technicalities of communication as a skill rather than acknowledging that it is part of the human repertoire (2006). He perceived that role-playing could be seen to encourage students to keep to a ‘script’ rather than working instinctively. In his sociological study of medical training, Sinclair comments on the potential problems of role-playing. He suggests that such activity: may actually exaggerate the existing theatrical aspect of ‘seeing patients’ … it seems entirely likely that the ultimate effect is only to emphasize the general dramatic qualities of medical training. (1997: 221) As British Medical Journal contributor Lempp notes, many medical schools in the UK have overhauled their overt curriculum in the light of reports such as Tomorrow’s Doctors that emphasized good clinical care and developing skills for working with patients (2004). While changes in teaching and learning were seen as innovations in developing practice, it is possible to identify how they may represent superficial adaptations which still serve the underpinning hidden curriculum of the professional performance of medicine. Sinclair’s study notes the pressure on contemporary medical students to deliver polished performances in situations such as the presentation

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of patients on the ward round, with stress heightened by classes in communication skills which provide models for practice. Sinclair observes the students’ articulation of performance anxiety. One of Sinclair’s subjects complained: ‘It’s all so theatrical! Be slick at this! Be slick at that! We need acting lessons’ (1997: 241). It seems that role-play sessions may be viewed by the students as a type of technical coaching, rather than encouraging empathic response. Sinclair’s study goes on to give an account of medical students’ preparation for their final clinical exams where they rehearse together and critique each other’s performances as they work to develop a convincing manner of presentation, drawing on what they have been taught in terms of verbal and physical communication. Medical educator Hodges notes the importance of ‘impression management’ in medicine and highlights the significance of performance-based assessment in promoting its importance with an emphasis on form rather than the quality of the human encounter (2003: 1137). Slowie observed that his students seemed to feel exposed during role-play sessions. He perceived that they felt a pressure to perform and were concerned about being judged as peers and tutors commented on the quality of their interactions. It is possible to see that, rather than enhancing communication, such interventions place an emphasis on delivering a coded performance. Further, I would suggest that this kind of work is awkward because, as Bleakley argues (Bligh and Bleakley, 2006), while role-play is designed to give students a realistic experience, it is actually problematic in its artificiality. The patient simulator is encouraged to enter into role and be as realistic as possible. I have already noted the wealth of personal detail that is given to participants. They are also encouraged to ‘flesh out’ the role. Sanger-Katz comments that: a good simulator is worth their weight in gold … it brings out the creative side of the person. They make it alive and they make it real to the student. It’s that reality that makes it work. (2007) The medical students, however, are given basic instruction in preparation for the role-play. They are not encouraged to be creative with the material, but to use the scenario as a rehearsal for their professional life based on skills teaching. This is a complex negotiation particularly when a student doctor is asked to behave ‘as if’ they

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were already qualified. At this point it becomes a fictional encounter as the student is being asked to be a self which they are not, that is, be themselves as a doctor. It is not real because they cannot respond authentically, but they are unable to freely extend themselves to the level of fiction and improvisation as they have been taught how things should be. When staging a scenario, medical educator Stafford notes (2005: 1083) that medical students in a role-play situation may draw on aspects of their personalities to develop their role in a manner which she likens to the work of Stanislavski, as employed by the professional performers in Women and Theatre who flesh out their work with reference to the ‘magic if’. Again, this makes the roleplay situation complex in that, quite often, professional performers are employed to work as patient simulators which puts them at an advantage in the performance stakes. The ‘patients’ are comfortable with simulating and grounded in their role while the medical students are grappling with knowledge which is yet to be embodied. So, rather than an emphasis on external delivery, in the work of Operating Theatre Slowie chose to focus on internal engagement and a depth of reflection. In collaboration with writers Carol Clewlow and Julia Darling, he looked to develop a model based in theatre. The practice of role-play or standardized patients is very common in medical training. Good notes that human-patient simulators are used by approximately 30 per cent of all medical schools in the USA as well as hundreds of other centres internationally (2003: 15). The use of theatre with medical students is less common. Operating Theatre were particularly unique in that they developed an original method of working that is embedded into the curriculum. There are five points of contact between Operating Theatre and the medical students during their first two years of study. Point one comes in week four of the first term and the final session is at the end of the second year. During my visit to witness the work in October 2006, John Spencer (Professor of Medical Education) commented that the programme allows students to get to know the way in which the format works and this familiarity means that they are willing and able to get more involved (2006). Throughout their work, Operating Theatre use material drawn from real life and seek to engage with the real experience of the medical students they are working with. So, for example, the first session takes place as part of a lecture on pregnancy. This session comes within the life-cycle module which deals with the basic medical sciences behind

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processes such as gestation related to a patient case study and a community placement. Within the pregnancy lecture Operating Theatre’s intervention was framed as a means of allowing insight into the clinical processes that the students would be entering into. In a truly Freudian manner, the theatrical vignette the company delivered presented a scenario that might be causing anxiety for those in the room as they prepared for their first placement. The play followed medical students Lucinda and Mark as they met with their allotted case study – Sophie. Like Women and Theatre’s work, the piece involved direct address as the young woman entered the lecture hall and spoke to the medical students directly about her experiences. Dramatic tension was built up as Professor Spencer announced that the patient was going to be late – which provoked an intake of breath from the keen medical students! The performer then dashed into the lecture theatre and her dramatic entry signalled the entry into a fictional scenario. This was a complex negotiation as the audience of students were in a lecture theatre expecting to be introduced to a ‘real’ patient. Instead they were witness to a performer in character who addressed them in a confident style and provided a wealth of contextual information about her thoughts and feelings which might not have been so forthcoming in a ‘real’ encounter. Unlike the work of Women and Theatre, the performers in this vignette had no additional settings to delineate a performance space but sought to inhabit the lecture theatre as a heightened space of performance in itself. Perhaps, in this case, it was closer to Horley’s recommendations of a simulation space that foregrounds the educational aspect of the work. Val McLane, director of Operating Theatre, however, noted the difficulties of working in such a space for the performers as they shifted, within the performance, to a scene that supposedly takes place in Sophie’s home (2006). Their awareness of theatrical presentation – diction, sightlines, etc. – meant that they approached the presentation in a different way than a lecturer might. As Connolly of Women and Theatre notes, ‘drama is more dynamic than somebody lecturing you’, and this dynamism infused the preparation and presentation of the work to communicate in the most effective way to the audience (2005). As well as the character of Sophie, the students witnessed two other performers in character emerge from within the lecture theatre in character as medical students Mark and Lucinda who went on to

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interview the patient. The ‘real’ medical students were able to observe how Lucinda and Mark interacted with Sophie. It was interesting to note that the performers’ characters were more two-dimensional than the patient’s – but it seemed that perhaps this allowed more opportunity for the audience to project their own ideas and fantasies upon them. Once the 15-minute performance section was over, the student audience were invited to ‘hot-seat’ the characters, asking questions which the performers provided improvised responses to. This set up an awkward dynamic as, although all the characters were seated next to each other in a line at the front of the lecture theatre, they responded as if the others could not hear them. This reflects on the issues that Jacobsen et al. raise when examining theatrical simulations where ‘The audience and the moderator could discuss the patient as if she were not present’ (Jacobsen et al., 2006: 5). This seems problematic as the prime learning outcome of such interventions is the promotion of empathy and relating to patients directly. Jacobsen et al. note that in such cases ‘The students are reminded of the obvious that in real life patients should never be discussed without taking notice of the patient’s presence’ yet this is what is being modelled for the students (Jacobsen et al., 2006: 7). It is also problematic for the performers, as it demands a complex negotiation of character – do they pretend the others aren’t there or think of how their presence might affect their response? It seemed that they decided to respond as if the others were not there as that facilitated a more ‘honest’ response since the performers were aware that they needed to model certain behaviours which would have been inhibited by the acknowledgement of the other characters. In this case it might have been more useful to be hot-seated one at a time in order to be more ‘authentic’ in the encounter. Such an innovation might help to develop this work, but typically in this type of teaching the participants must keep up with two different ‘worlds’ at the same time: the fiction and the reality. A student noted of a similar piece of work: ‘We could ask the patient, which you could never do in a consultation, really ask her how she, as the patient, experienced it’ (quoted in Alraek and Baerheim, 2005: 11). The problem is that the performer isn’t really a patient and some students also report that it can be difficult to look past the artificiality of the situation. After the Operating Theatre performance, however, students I interviewed said that the presentation had been

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very useful in ‘bringing the project to life’ and allowed an insight into ‘what we might be doing in a couple of weeks’ time’. It seemed that a key element of the Operating Theatre intervention is that the medical students weren’t acting. Like the work of Women and Theatre, rather than having to respond ‘as if’, they could respond as themselves within the situation, they were able to enter into a thought experiment with behaviours, but were mostly encouraged to reflect on their own responses and to rehearse strategies for future interaction. The importance of the reflective, subjective approach was thrown into relief as this event took place the day before the students visited the dissection room. Indeed, as they came into the lecture theatre they picked up the briefing sheet on the female pelvis. The dissection room might be seen as the epitome of the objectivizing gaze of medical science. Medical student Finlay notes: This may sound melodramatic, but the profound impact of the dissection room sessions should not be underestimated. They are the first bridge leading us away from the lay public towards the medical world … [it] instills in us the understanding of the importance of emotional distance from what we see before us … As a coping mechanism, it is inevitable in the clinical years that one distances oneself to some extent from patients as people, seeing them more as ‘cases of disease’. (Finlay and Fawzy, 2001: 4) In contrast, Operating Theatre promoted an engagement with the patient as a whole person, complete with their own worries, concerns and expertise. Students appear aware of the impact that it has on them emotionally. In a survey by Operating Theatre, 92 per cent of students felt that the learning points would not be delivered better in a lecture (Slowie, 2005: 129). Slowie believes that empathy is integral to understanding and argues that deep, empathic understanding provides students with the ability to ‘think autonomously’ and apply their knowledge flexibly to the unique situations they will meet (2005: 13). So, in Freudian terms, Slowie posits that the theatrical experience may alleviate the potential for trauma. For Freud, an association with the tragic hero/ine allows an audience member to envisage her/himself carrying out heroic deeds without having to undertake any of the risks associated with those actions.

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Like Women and Theatre’s director Connelly, Slowie champions the play/fictional world as a means of gaining experience. He notes that a vivid theatrical experience may provide a form of embodied knowledge that will be invaluable for a clinical practitioner. He believes that interactive theatre is effective in that it allows students to ‘safely experience new perspectives on emotive or sensitive issues’ (2005: 18). Another Operating Theatre event gives an example of how this work might be developed beyond the purely verbal feedback of Women and Theatre participants to active engagement in simulation. Who Else is in the Room? is a laddered workshop that considered the influences that each participant brings into a consultation. Like the pregnancy lecture, the session begins with a short play which is carefully crafted to communicate key ideas around subtext and external influences to a consultation which is then followed by a hot-seating session. The work is then opened up more fully to the participants as they are invited to enter into the action as if they were a player in the drama. They are invited to think about some of the other figures that may be ‘in the room’ during the consultation, such as the patient’s boss or daughter. They write some lines to the character from the drama, which they then deliver, encouraging imaginative engagement and emotional connection with the action. In the final phase of the work participants are invited to create a tableau from which they deliver their lines. Slowie sees this opportunity to be physically involved in the dramatic encounter as an important element in that it can serve to ‘concretize subconscious processes’ (2006) and allows an embodied experience. Participants are asked to enter into the feelings of characters, which brings the complexity of feeling into the simulation. Debriefing becomes very important in such work as studies have noted students who role-play can be left carrying feeling which does not appropriately belong to them; so participants are able to articulate experiences in a debrief session (see Stafford, 2005: 1084). Responses have included feedback that participants appreciated the different method of reflection that the workshops provided and the opportunity to witness work through a different kind of mirror (Slowie, 2005: 98). Slowie works from the premise that medical students do not need to be taught empathy but given the opportunity to open up. Rather than medical training which, as Bleakley notes, comes from the root trahare ‘to drag behind’, Operating Theatre appear to work more within the

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model of collaborative knowledge production where medical education, in its widest sense, replaces medical training (Bleakley and Bligh, 2008: 90). The company have sometimes found it difficult to justify the sort of work that they undertake – it requires lots of resources and it is hard to gather quantitative data on outcomes. Slowie notes (2006) that they are working within a different paradigm from more conventional, task-based medical education.2 Within an Operating Theatre session, people do not ‘learn’ to communicate, and are not assessed according to skills, but participants may have developed a more empathetic perspective. Such results are hard to quantify but, as dramatherapist Landy asserts (1994), even just an expanded role repertoire with access to a range of ways of being is useful to an individual when interacting with the world and, one would guess, particularly useful to clinical professionals who may find themselves in complex and emotive situations. As Aristotle notes in The Poetics (1992: 11), catharsis and emotional becoming are significant elements of emotional development. The work of Operating Theatre moves away from ‘performing’ empathic behaviours to inhabiting them as a rehearsal for real-life encounters.

Casualties Union The activities of Casualties Union are the nearest to ‘real life’ on the spectrum of simulation that I am examining. Like role-play, they stage scenarios that are improvised in the moment but their work is not based on character but on the member’s own personality.3 Thus, in Casualties Union events, ‘real’ information is interwoven with fictional medical conditions but the fabricated injury or illness itself is represented with great care in order to be able to reproduce symptoms realistically. Casualties Union pride themselves on the attention to detail that they put into creating simulated wounds. As I will detail, make-up is seen as an essential element of the work and the practitioner’s skill is such that the wounds that are created can be worked on by medical professionals – even to the point of operating on them in theatre. I am interested in this unique and complex blend of reality and fiction and also in the mix of the superficial representation and authentic commitment that the work of Casualties Union represents. Casualties Union were a product of wartime Britain, set up by Eric Claxton in 1942. The organization grew out of the Surrey County

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Civil Defence Rescue School (SCCDRS), which was founded in 1940 to train people to take part in post-bombing rescue operations. The school prized realism, preferring to use real people as ‘casualties’, rather than dummies, in order to provide what they saw as the most effective learning experience, and organizers of large-scale disaster exercises (such as BAA and the emergency services) are still reliant on Casualties Union to provide realistic ‘victims’ for experiential training. This work pre-dates a lot of other experimentation in simulation, and technology has clearly opened up new opportunities, but Casualties Union still perceive themselves as having an important role to play in terms of the human encounter that they provide. The organization is still thriving, with branches all over the country and a systemized method of working. Casualties Union have produced their own training manual to guide beginners through their skills portfolio, supplemented by the deeper medical information in London’s book An Atlas of Injury: A Guide to the Art and Practice of Casualty Simulation (1990). The emphasis on the artistry of the work appears important. There has always been an emphasis on realism for Casualties Union and the text of An Atlas of Injury outlines accurate medical details (including diagrams) in order that the simulator has sufficient clinical knowledge to support his/her work. So, for example, the manual details the workings of the hip: The hip has a ball and socket joint in which the ball is the knoblike end of the femur which rests securely in the socket, known as the acetabulum, in the side of the pelvis. (1990: 91) The material is easy to read yet gives a significant amount of anatomical detail. While similar to other simulators I have discussed, in that the organization takes advice from medical professionals, unlike the other companies Casualties Union expect their members to have an embodied knowledge of the clinical processes they are presenting. Casualties Union assume a basic understanding of anatomy from those coming into the organization. Many of the members are trained first-aiders but some have to carry out considerable study in order to meet the required level of knowledge for practice. In addition to this clinical knowledge, members are required to have a certain amount of performance skill. An Atlas of Injury differs from a medical textbook in that, as well as anatomical detail, it also includes

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directions for acting. For example, when presenting a fractured hip, An Atlas of Injury suggests: Because the injury is at least moderately severe the patient, even when fully conscious, is usually quiet unless moved; this is very painful and provokes a cry. There is often pain in the back because whatever happens at the front of the pelvis may be accompanied by fractures where the sacrum meets one or both iliac bones … This is not a cause of spontaneous complaint but the patient will complain of this if moved or pressed upon in the affected area. (London, 1990: 46) These detailed instructions act as the basis of the individual’s performance, building on contextual, medical information to enable the performer to present a representation which is realistic enough to allow for a lifelike encounter. Casualties Union’s approach to performance has an emphasis on external elements. While the performers are aware of internal processes, they pay particular attention as to how these are manifest in order to perform to their particular audience of rescue service professionals who are learning how to identify injuries from the symptoms that a patient presents at the scene of an emergency. This type of performance demands a particular type of preparation. Performance scholar Harper describes the process by which a performer pays attention to the external details of the role as follows: The experience the actor undergoes can thus be said to be one which is parallel to the real, an experience which then aligns him [sic] with that of the spectator, the former distinguished solely by the corporeal demands of the act of theatrical representation. (2000: 89) Thus, while being in the moment and delivering a realistic performance, the performer is engaged in a process that Harper describes as parallel to the real, in that the subject is split as both performer who lives in the moment and spectator who observes and critiques the presentation. It is arguable that there is a level of reality in observing the self; but we can understand Harper as referencing a state of ease where the person is not self-critical and not thinking about how

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they are presenting themselves. In this type of work the physical and verbal cues that the simulator gives are very important and thus heightened self-awareness is important. Casualties Union speak about themselves as dealing with the simulacrum, stating: ‘A good simulacrum is much better than books and pictures as a means to instruction’ (London, 1990: 157). When using the term ‘simulacrum’, Casualties Union seem not to be directly relating to Baudrillard’s notion of the simulacra but rather to the ‘shadowy likeness’ of the dictionary definition which relates to surface pretence. The members see themselves as staging realistic performance events and producing specialized performers, and their meetings are devoted to instruction and rehearsal. Casualties Union members undergo intensive training in performing and have to pass practical exams in order to progress within the organization. Trainees are assessed on their competencies in a range of areas including acting minor injuries such as fractured jaw; acting severe injuries such as a heart attack; and acting more complex conditions such as ‘altered levels of consciousness’. To reach the next level of advanced member, a person would need to display a higher level of acting – such as representing diabetic emergencies, as well as more complex and challenging injury make-up. As in role-play, members are given detailed notes on their injury which have been prepared in advance. The presentation of fictional symptoms is, however, fleshed out with details taken from their everyday life. Members are briefed to react to any situation as themselves and may use their own names and details of their own personal circumstance – for example, if they have small children they may be concerned, in an incident, that someone needs to get back to look after them. They may also use their own experience of illness to flesh out the scenario and respond how they think they would respond in that situation. As Maran and Glavin note with reference to Gabaesque simulations, ‘Unlike a 747, human beings differ vastly’, and the approach of Casualties Union allows for realistic role-play that presents the witness with all the quirkiness of individual people (2003: 26). An Atlas of Injury notes: So much of first aid is taught without the student’s [sic] having any opportunity of seeing the real thing. Convention takes the place of reality with the result that first aiders may not recognise the real thing when it occurs or, more frequently, may live in a

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sort of dream world that is governed by ‘The Book’ … only a suitably trained actor can remind the person handling the affected limb that it is painful and that handling it carelessly makes the pain much worse. (London, 1990: x) Casualties Union recognize the importance of simulation in preparing a rescue service (wo)man for their real work. Thus, rather than the popular medical school model of the standardized patient, this approach promotes non-standardized patients in order to facilitate a realistic, immersive experience. As well as work on their physical abilities to simulate, members are also required to become skilled in make-up. Again the emphasis is on reality and lived experience rather than book-knowledge, and those who are first-aiders can recall the appearance and behaviour of their real-life casualties for reproduction later. Members are urged to spend time practising and to be self-critical in developing their artistry of make-up. The make-up is skilled and subtle, and Casualties Union members are often asked to work on make-up for medical or first-aid training films because of their expertise in the area. Each member will have their own make-up kit with tools which are particularly useful to them. So, they will make up false skin that is accurately matched to their own skin colour. An Atlas of Injury notes that ‘false tissue should feel and look as much like real as possible’ and members take responsibility for authenticity (London, 1990: 22). One criticism of high-fidelity simulations has been that the simulator’s skin colour does not change despite trauma – but Casualties Union members can change their skin’s appearance, making themselves look pale by using props such as talcum powder or pallor cream and spraying water on a mixture of water and glycerine to simulate sweat in a way that accurately reflects real life (Good, 2003: 19). This use of what theatre-maker Etchells terms ‘prop biology’ can be seen to be effective in promoting realism (1999: 124). There is a lot of attention to the external in order to appear authentic and members may spend half an hour preparing for a five-minute simulation. This quote from Caroline Thomas, a senior instructor in Casualties Union, emphasizes the pragmatic realism of the work as she describes how she prepares to represent an open fracture: I find Mark’s and Spencer’s Chicago spare ribs are particularly good for this. You boil them and smash the ends about a bit with a hammer to get a nice jagged edge. (Quoted in Snell, 1998: 28)

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Casualties Union are engaged in high-level simulations which involve a lot of planning in order that the experience is realistic. Attention to detail is important and creativity in preparation is apparent in the work. Avant-garde theatre practitioner Artaud questioned whether real blood was needed in the theatre to move the audience (1985: 67). Perhaps, as anthropologist Mary Douglas noted, quoting JeanPaul Sartre: ‘Viscosity … repels in its own right, as a primary experience.’ She goes on to comment: ‘It’s stickiness is a trap, it clings like a leech; it attacks the boundary between myself and it’ (1966: 38). It could be that real blood is not needed because fake blood/wounds are just as repellent through suggestion and the possession of similar viscous properties. Caroline Thomas tells of an exam candidate who was faced with her simulating a ruptured varicose vein that oozed fake blood from an intravenous drip beneath her clothes. A short while into the simulation he commented, ‘I don’t think I can take much more of this’ (2004). It certainly seems that the prop-biology Casualties Union employ serves to heighten the sense of realism, and this combined with the emotional commitment of the performers can serve to engage audience members in response to the appellation of suffering. Like Women and Theatre and Operating Theatre, Casualties Union members present their performances to an audience with a professional relationship to the work but, unlike the more theatrical companies, they work in very close proximity to their audience so their performances need to be subtle and lifelike rather than actorly. The intimacy of the performance appears to aid the realism. Members are often working one to one with a supervisor observing and there is direct contact and no real distractions from the performance event. In my observation of the work I have been witness to some very tender and intimate scenes as the ‘sick’ are cared for. Yet, while the scenario may be lifelike, all the participants are aware that it is a simulation. The work is clearly set up; it may be in a ‘real’ place – for example, Heathrow Airport – but it will be a space devoted to the simulation. It is often a low-key event (Figure 5). For example, in June 2004 I witnessed a mock-up of a St John Ambulance first-aid post in a community centre hall. Yet entrances and exits to the area are marked and it is clear when people are ‘on’. The simulators talk about being ‘on-set’. People may come into the space with their injuries – which may be a very dramatic entrance as a door bursts open and someone dripping

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blood rushes in – or they may be ‘discovered’ in an environment by the medical professional. Scenarios are monitored, so there is always an off-stage area which, I would argue, troubles immersion. It depends on the level of work, but in training sessions there may be a lot of eye contact with the trainer outside the scene in order to get approval/ advice. The moderator will also feed in information such as stats on the patient – for example, ‘it has now been an hour and her breathing has deteriorated’, which moves the simulation on in time – and is also there to monitor the simulation. There is always a code word such as ‘no duff’ which will end the simulation. This is for the safety of all concerned as it may be that casualties are lying out in the cold for hours and they need to ensure that casualties do not really get ill. Real possibilities for this form of simulation can be identified. The services who draw on Casualties Union are very grateful for their expertise and the realism that they bring to the staging of incidents – however, the practice of ‘role-play’, as we have noted, can be reductive. I would suggest that, while the simulation of even high-fidelity role-play can be seen to focus on external delivery rather than internal engagement, theatre may enable a depth of reflection through recognition and catharsis.

Figure 5 A Casualties Union member in a car-crash exercise in North London

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Casualties Union’s journal shares tips on make-up but also on internal approach to the role. Edward Goodman from the Torbay branch offers notes on how to respond to questions realistically while in role as a casualty. He states: People who are ill or injured do not have the energy to respond clearly and promptly to questions. The blood supply, which will be limited by shock (if nothing else), is busy keeping them alive, and there is none to spare to hold a conversation … We too often fall into the trap of responding automatically. When asked a question, we need to show on our face that we are struggling with this challenge … Try to imagine how you would feel if you couldn’t remember your own name! To create ‘thinking time’ for yourself, you might … list in your mind all the possible replies there might be to the question … Not only does all this take a little while, but your brain has actually been working so the thought and concentration expressed on your face is easier, more natural and more accurate. (2004: 12) From this we can see that the ‘internal focus’ that is advocated by Casualties Union is fundamentally in service of the external representation. Yet interestingly they seem to be demanding the same ‘affective athleticism’ that Artaud demanded of his experimental performers (1985: 133). Artaud appeared to be acknowledging the need for performers to be able to inhabit extreme states without the aid of a cause and effect relationship and to be able to communicate the appropriate emotional state to an audience in order to move the witnesses. Casualties Union members also seek to draw on their resources in order to provoke affect in their audiences and to provide a realistic experience.

Conclusions Cultural critic Seltzer argues that, ‘representations, it seems, have the same power to wound as acts’ (1998: 261). This certainly appears to hold true in the use of simulation within medical training as Stafford gives an account of a student who cried at the death of a simulated patient (2005: 1083). French feminist Kristeva’s notion of the truereal and the foreclosure of reality within artistic discourse (or the

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suspension of disbelief in performance studies terminology), would seem to support and explain this phenomenon (1982). Within a fictional, dramatic representation the affective experience is what is of significance for the audience as a point of ‘real’ connection. The companies in this chapter employ the representational process of mimesis to engage with their audiences. The work they present offers space for reflection, recognition and emotional ‘reordering’ as they encounter, within a safe space, traumatic experiences that may challenge them in their professional lives. Bleakley argues (Bligh and Bleakley, 2006) that learning by simulation can result in a hollow performance. There are clearly limitations in a simulated encounter and it demands complex negotiations on behalf of both the performers and the audience members/co-participants. I would suggest, however, that theatrical simulation might offer the opportunity to develop a more nuanced performance within everyday life. Rather than the disembodied interaction of simulations involving inanimate mannequins, theatre events present the opportunity for an embodied encounter. Situations may be viewed within a wider context with an emphasis on an empathic connection rather than technical skill. Phelan states: One of the central assertions of theatrical performance is that the affective experience of the body can be authentically conveyed regardless of whether or not such experience is the consequence of a ‘real’ event or a well-rehearsed repetition of an imagined one. (1997: 105) The imagined events of the theatrical simulations draw on details from real life to craft scenarios which allow viewers to affectively engage and, thus, really encounter difficult material. As with other educational experiences, the opportunity to debrief and reflect upon the learning is offered but, unlike skill-based training, a complexity of response is acknowledged and an impact beyond the level of technical competency is envisaged. Thus, while the climate within medical schools appears primed to embrace simulation as a pedagogic practice, theatre-based medical training, with its challenge to utilitarian and empirical approaches, may still stimulate debate and provoke innovations in practice.

Concluding Thoughts: Performance Indicators

I began this book with a slapdash research exercise so it seems fitting that I finish with another. A Google search for ‘performance and health’ offers up mostly sites relating to performance indicators and assessing the performance of health systems. Such findings may be read within the context of what McKenzie understands as the contemporary performance culture. In Perform or Else (2001), performance scholar McKenzie examines the way in which the concept of ‘performance’ has been taken up within contemporary Western society and examines how different aspects of the performing culture may relate to one another as well as impact upon the individuals who function within it. McKenzie focuses on organizational performance, cultural performance and technological performance as different manifestations of the drive towards performing. Organizational performance is the type of performance that is evaluated in terms of profit and loss, efficiency and achievement; cultural performance relates to collective and individual activities on the social stage and may span from personal rituals, through rites of passage such as funerals and weddings, to rehearsed presentations of dramatic works; technological performance is also about effectiveness and the ability to carry out specific tasks and may be measurable in quantifiable means. Within this contemporary performance culture, McKenzie notes that: In health sciences, performance has emerged as a field studying the effects of pharmacological and physical therapies on activities such as work, sports and everyday life. (2001: 13) 151

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Thus healthcare is required to perform and deliver results, and the effects of interventions are measured. This is clearly noticeable in the UK where the NHS Performance Assessment Framework, introduced in 1999, sets out a range of performance indicators by which the efficacy of healthcare provision is assessed. Initially six areas of performance were outlined for health authorities. They were: 1 2 3 4 5 6

Health improvement Fair access Effective delivery of appropriate healthcare Efficiency Patient/carer experience and Health outcomes of NHS care.

Within each area a number of performance indicators were identified, so, for example, health improvement is measured according to: • • • • • • • • •

Life expectancy (male) Life expectancy (female) Deaths from cancer Deaths from circulatory diseases Suicide rates Deaths from accidents Conceptions below age 18 Decayed, missing or filled teeth in five-year-old children Infant mortality rates. (www.performance.doh.gov.uk/nhsperformanceindicators/2002/ index.html)

These indicators were developed through a process of public consultation and have evolved as the auditing process has continued to be developed. So, for example, in 2003/4 the performance indicators for improving health were: • • • •

Cervical screening CHD register Death rates from cancer, ages under 75 Death rates from circulatory diseases, ages under 75

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Diabetic retinopathy screening Flu vaccinations Health equity audit Immunization MMR Infant health Suicide audit Teenage pregnancy. (http://ratings2004.healthcarecommission.org.uk/Trust/Indicator/ indicators.asp?trustType=4)

It is possible to identify how health performance indicators may shift according to policy objectives and emphases as well as responding to innovations in the field such as the MMR vaccination. Nevertheless, this culture of performance management – or clinical governance – is now fully established within the NHS in the UK and the results of the performance measurements are reported annually to Parliament with an equal emphasis on making results available to the public. Performance indicators can be seen as a means of control, with health authorities that do not perform according to the given criteria being subject to criticism. It is within this culture of accountability and ‘clinical governance’ that the arts in health need to function and fit with meeting current performance indicators. In the cover notes for A Prospectus for Arts in Health (co-commissioned by Arts Council England and the Department of Health), the Department of Health’s statement reads: The department commissioned the Strategic Review of Arts and Health, and accepted its findings. The Department’s policy is that the arts have a major contribution to make to wellbeing, health, healthcare environments, to the benefit of patients, service users, carers, visitors and staff, as well as to communities and NHS as a whole. (2007: front cover) It seems then that the arts are considered to be able to play a role in meeting core health performance indicators, but there has been a problem in realizing the potential of this work. While the collaboration between Arts Council England and the Department of Health is potentially very exciting it also has problems because, as White notes, arts in health ‘straddles two sectors, policy makers from each can assume

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that the other should be responsible for its development’ (2009: 118). Public health, with all the inherent opportunities for arts interventions, has been rising up the political agenda yet, at the same time, funding pressures and restructuring have meant that arts in health has not developed as much as it might have and has not been able to prove its ability to perform. The Centre for Arts and Humanities in Health and Medicine (CAHHM) 2004 report Seeing the Wood for the Trees, notes that changes in NHS Estates and the dissolution of the Health Development Agency (which, since 2005, has become the National Institute for Health and Clinical Excellence – or NICE) has had a negative impact on arts in health activities as these two bodies were key partners in the development of the work (2004: 20). As there is no clear, overarching organization or department to take arts in health forward, the impetus for arts in health initiatives has tended to come from individuals who are passionate about the potential of the work rather than from a strategic plan. While this has allowed for organic and responsive projects it has meant a more piecemeal approach to the work. White argues that arts in health practitioners need to become more strategic in their thinking (2009: 238). High Quality Care for All: NHS Next Stage Review, a report led by Lord Darzi and published in June 2008, is the latest high-profile report to promote more creative working practices within the health and care sector (Department of Health, 2008). It also encourages partnership working between local authorities, primary care services and prevention services to provide grass-roots care for local populations. While it is troubling that there is no explicit reference to arts in health within the White Paper, Arts Council England were invited to contribute to the consultative process and the final document opens up possibilities for arts and health practitioners. The public health priorities identified by Darzi provide potential opportunities for the development of arts in health projects that clearly fit within strategic priorities through offering properties such as person-centred activity that leads to a greater sense of health and well-being. White argues that a fundamental difficulty for arts in health practice is that the sector ‘remains unorganised and largely invisible’ (2009: 118). I would argue that, although the field may not be as developed as it might, there is a growing sense of professionalization. Indeed, the one result from my Google research that related directly to performance and health in the way I have been exploring it in this book was a link to the Performance and Health BA (Hons) course

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at Edge Hill University. This pioneering course seeks to embrace the interdisciplinary nature of the field and produce professionals who have expertise both in arts and in the health and care sector. Modules on ‘Social Constructs in Health and Disease’ sit alongside units on ‘Applied Performance’, which develop those particular specialisms, as well as courses which seek to bridge the arts/health divide such as ‘Models of Creative Practice in Health’ (www.edgehill.ac.uk/study/ courses/performance-and-health#modules). There are also developing networks, international conferences and the recent launch of a new international journal.1 White recommends that, due to the particular pressures of arts in health work, models of professional supervision such as found in the arts therapies should be introduced into the field and there is evidence that these are being introduced – for example the ‘emotional hygiene’ sessions of the Big Apple Circus Clown Care Program described in Chapter 1 (White, 2009: 207). These moves all signal the shift towards a more developed and professionalized arts in health and care workforce, able to meet performance standards. The presence of more arts in health professionals whose ‘bilingual’ practice encompasses the discourses of both health and arts, should serve to challenge the division between the two cultures of humanities and sciences. Certainly in this book I have sought to present work which demonstrates creative synthesis and the potential for the application of theatre to health and care. I have examined a range of practices which share the common thread of employing the particularities of the dramatic art form and exploring how aesthetic concerns may, in turn, serve to enhance health and well-being. In 2005 Arts Council England and the Arts and Humanities Research Council jointly commissioned a research report into the social impact of the arts (Belfiore and Bennett, 2006). The authors of the report criticize the contemporary performance culture which places emphasis on measurable outcomes; and their historical perspective on approaches to the arts identifies different approaches to the role of arts and culture within society. Their study of over 150 philosophers, critics, artists, scholars, etc. led to the identification of eight categories of claims for the arts. These are: • • • •

Corruption and distraction Catharsis Personal well-being Educational and self-development

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• • • •

Moral improvement and civilization Political instrument Social stratification and identity construction Autonomy of the arts and rejection of instrumentality. (2006: 39)

The authors examine traditions of thinking which can be traced back to Greek thought (they acknowledge their Eurocentric bias) and of particular interest to this study is what might be termed the negative tradition which voices suspicions about the arts and the positive tradition which highlights the potential social function of arts activities. The negative tradition can be seen to have been authored by Plato who, as I noted in Chapter 4, articulated his mistrust of representation and saw no place for it in his republic. In answer to that, Aristotle argued for a more positive social function for theatre and the arts more generally. In this book I have recognized that there are those, like Plato, who are suspicious of arts in health, while others recognize the way in which the arts may provide catharsis, support well-being, be educative, political, a tool of citizenship and a means to create and express identity. There are also many who would defend what Belfiore and Bennett identify as ‘art for art’s sake’, who resist the notion of an art form as a tool and instead celebrate the special nature of the aesthetic encounter (2006: 7). This study has focused on the aesthetic elements of performance practice rather than on performance criteria and examined how those aspects of theatrical practice may function within a health and care setting. In Chapter 1 I considered the heightened space of the hospital and how theatre companies might negotiate the drama of everyday life that is played out within institutional facilities. An artistic sensitivity to the framing of space and the people within it appears to be central to such work and often the artistic lens opens up the possibility of seeing the space differently. I noted how important professional arts co-ordinators were in order to facilitate the verbal and visceral dialogue that happens within such projects. This type of work might continue to develop in importance if healthcare facilities are rated on their incorporation of the arts. Loppert observes of the Chelsea and Westminster Hospital: Perceptions are changing: at the hospital’s first open day … in answer to the question ‘Which area particularly impressed

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visitors?’, the answer that came almost top was ‘art/exhibitions/ drama/music’ second only to the operating theatres, and above maternity, X-ray, accident and emergency, physiotherapy and orthopaedics. (1999: 74) Certainly hospitals often advertise their arts programmes as part of the services that they provide for patients and, within the culture of patient choice and satisfaction ratings, this might prove to become more significant. As Ariail suggests: ‘as medical costs stabilize, a patient’s choice of provider will reflect perceptions of quality of care’ (1996: 14). Chapter 2 focused on drama as a vehicle for communication and provocation. As Aristotle proposed in The Poetics, a dramatic encounter can serve as an educational experience. He notes that as the audience are witness to a character they identify with going through a particular experience, they may experience a cathartic reordering of emotion which can be carried back to their everyday life. Other critics have suggested that this may not be an immediate effect but, nevertheless, there is the potential for experience in the aesthetic realm to have an influence on individual and community life. Within the health and care sector there is debate as to the cost-effectiveness of theatre interventions but there is, equally, recognition that it can have a particular kind of emotional impact. In Chapter 3 I foregrounded the embodied nature of performance and of its potential as a channel for self-expression both verbally and physically. McKenzie suggests that ‘performance can be read both as experimentation and normativity’ (2001: ix) and this chapter considered how experimentation with form and content within theatre may serve to destabilize social norms and values in a manner which opens up new possibilities. The final chapter considered mimesis more generally and explored how the aesthetic encounter might challenge a utilitarian approach to healthcare delivery and provide a more rounded experience. The rise of medical humanities and the understanding of performance of everyday life more generally in culture provide a backdrop for the reflection on professional role-playing. As Smith notes: The rise of arts/health activities can be understood in the context of an evolving critique of mainstream approaches to health … every encounter between a patient and a practitioner has an artistic as well as technical dimension. (2003: 8)

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This study has looked to identify how an overtly theatrical framework allows for the subtleties of human interaction to be explored. The book has taken a snapshot of contemporary arts in health practice and, through reference to case studies, has considered how theatre might be employed within the sector. The work has become more widely recognized in recent years but, in a changing political climate, it is challenging to see how things might develop. Evaluations of arts in health projects have demonstrated not only benefit in terms of well-being but also in terms of the financial bottom line which is so important when considering the performance of a healthcare intervention. Wikoff, Sculptor and Director of Healing and the Arts Project of the C. Everett Koop Institute at Dartmouth College, New Hampshire, observes the emphasis on value for money when considering arts projects and argues that ‘health care is driven by economics’ (1999: 150). Studies have shown that arts in health projects may have an economic impact. For example, Kilroy et al.’s report on the ‘Invest to Save’ project in north-west England notes that outcomes for patients included lowering levels of stress, depression and anxiety as well as reductions in blood pressure and intensity of pain. Significantly, this led to a reduced need for medication, which represents financial savings (2007: 14). As noted in the Introduction, evaluating arts in health projects is problematic as there is commonly a negotiation as to which performance indicators should be employed. While arts in health may deliver on identified government priorities, arts projects may have a very different agenda. There is, and in many ways rightly so, an emphasis on success within health and care. There is a great belief in the power of medical science to provide positive outcomes. It may be, however, that arts in health offer a different kind of approach, one which acknowledges happenstance and even failure. Arts in health practitioner Angus argues that: ‘As a culture we are too solution orientated. We need to accept that we don’t have to have all the answers’ and he sees the arts as a means to explore grey areas (1999: 8). The emphasis on process rather than product that can be witnessed in much of the work documented in this book may serve to provide a point of dialogue when engaging with medical discourse. I would also suggest that the interest in failure in contemporary performance may prove, within future work, to provide a useful counterpoint to the results-driven

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culture. In a review of a piece entitled My Body Did Everything I Asked, theatre-maker Tim Etchells states: The fascination with failure bespeaks a healthy distrust of glib or over-confident effect. Performance language has become selfconscious, self-doubting, hesitant. Nothing can be effortless now … In My Body no moment is whole, every second must be worked for and fought with. (1999: 207) This piece, which has particular health resonance as it was created through a collaboration between two men, one of whom has cerebral palsy, is foregrounded by Etchells as an example of an interest in experimental performance work in revealing the failure, or at the very least the strenuous effort to achieve, behind performance. In so doing, such work explores vulnerability and fragility, which it would seem could be a useful contribution to the field of health and care. In this book I have drawn on a variety of definitions of health and a range of performance practices. Cultural critic McLeod argues that arts in health ‘cropped up in the 1980s as a reaction to the technological starkness of the healthcare system’ (1996: 17). I would suggest that what can be seen overall in the practice of theatre in health and care is the centrality of the human encounter that sits at the heart of both healing and performing practices.

Appendix: Other Useful Resources UK government and national agencies Arts Council England www.artscouncil.org.uk/ The national development agency for the arts. The website includes links to key arts and health publications and events commissioned by the Arts Council. Department of Health www.dh.gov.uk/en/index.htm Government agency for developing health and social care policy. The website includes links to reports, consultations and initiatives within the health and care sector.

Regional arts and health networks Arts and Health South West www.artsandhealthsouthwest.org.uk/ This regional organization is active in support and advocacy activities in the arts and health sector. The website is very thorough and provides news updates, event information and a wealth of links to other organizations. Arts for Health Cornwall www.artsforhealthcornwall.org.uk/ Arts for Health Cornwall focus on the role of creativity in developing health and well-being. They provide support and information on activities within the region as well as acting on a broader scale as an advocacy organization. Arts for Health are also keen to develop an evidence base for arts in health and their website has a link to their evaluation database. In addition the site provides details on their regular networking meetings as well as details of training events – in particular the ‘Creativity in Care Settings’ course. Arts for Health – Manchester Metropolitan University www.artsforhealth.org/ Arts for Health have a research strand and the website includes links to Arts for Health consultations and reports. The agency also commission a range of projects which are documented on the site and there is information on current opportunities. 160

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Creative Remedies www.creativeremedies.org.uk/ Creative Remedies are the arts and health network for the West Midlands. Particular areas of interest are: patient care, health promotion, staff development and the built environment. The site includes a searchable index of arts and on health projects, artists, arts organizations and health professionals who have been involved in arts and health work in the region. There is also an advice section which provides useful information on setting up arts and health initiatives as well as information on opportunities within the region and current events. Critical Connections www.criticalconnections.org.uk/ Critical Connections are the arts and health development programme for Yorkshire and The Humber which is jointly funded by Arts Council England and the Department of Health through the Regional Public Health Group. The project seeks to support those active within arts and healthcare, as well as those interested in developing their practice in the sector, by providing information and networking opportunities. The website is a key outcome of the initiative and provides access to a database of arts and health contacts and programmes. Derbyshire Healthy Schools www.derbyshirehealthyschools.co.uk/en-GB/Theatre_in_Health_Ed.aspx Derbyshire Healthy Schools (DHS) support a range of Theatre in Health Education projects for primary and secondary schools in the Derbyshire region. The website provides information on past and current productions as well as a directory of theatre companies providing THE programmes. Greater Manchester Arts and Health Network www.wlct.org/gmahn/gmahn.htm The Greater Manchester Arts and Health Network is a subregional project which is funded through the Association of Greater Manchester Authorities and the Arts Council with Wigan Leisure and Culture Trust. The organization aims to promote best practice and the website includes case studies and a range of downloads of pertinent conference papers as well as guidelines on subjects such as evaluation. Hi-Arts: Highlands and Islands Arts www.hi-arts.co.uk/arts_health.htm HI-Arts have been working with the Health Promotion Department of the Highland NHS Trust since 1999 to develop arts and health activity in the region. The organizations have jointly produced two publications: a promotional brochure entitled Try this First, and Creative Routes to Health, a more

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detailed guide. Both publications can be downloaded from the website which also includes information on events, training and funding. London Arts in Health Forum www.lahf.org.uk/ London Arts in Health Forum functions as a membership organization. It is free to join and provides a newsletter, a programme of events and training sessions as well as offering advice and support both within and beyond London. The website provides information on particular case studies and the sector more generally. Praxis www.praxisartsandhealth.org.uk/ Praxis have grown out of a collaboration between Black Country Arts Partnership, Staffordshire University and creativityteam. The project is based in the West Midlands and seeks to provide a network of arts and health practitioners and to focus on sharing information and good practice. South East Arts and Health www.seah.org.uk/ A lottery-funded regional organization which seeks to promote arts, health and well-being. As well as posting current events, the website carries material regarding the regional strategic plan as well as detailed information about organizations working within the area and how to contact them. Suffolk Artlink www.suffolkartlink.org.uk/arts-in-health.htm The website includes a link to information about the Suffolk arts in health forum which seeks to offer networking opportunities for interested parties within the region.

International agencies Arts and Healing Network www.artheals.org/start.html The Arts and Healing Network is an online resource with news bulletins, case studies, and links to bibliographies and blogs as well as information on funding. Arts and Health Australia www.artsandhealth.org/ Arts and Health Australia (AHA) is a national networking and advocacy organization. The website contains details of forthcoming events and training programmes as well as examples of good practice and other resources.

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The National Network for Arts in Health Canada www.artsinhealth.ca/pages/about.html The National Network for Arts in Health Canada is a non-profit online organization set up to make information widely available to interested parties within the country and beyond. The website organizes information on case studies and materials according to themes – e.g. paediatrics, creative ageing etc. – and also contains details of how to join the organization. The Society for the Arts in Healthcare www.thesah.org/template/index.cfm The Society for the Arts in Healthcare is the major US organization in the field. The society organizes an annual conference and the website gives details of this and other forthcoming events. It also has details of how to join the society and gain access to their newsletter and dedicated funding streams. The website also has an online shop where you can buy a range of materials.

Academic research Applied Theatre Researcher www.griffith.edu.au/arts-languages-criminology/centre-public-culture-ideas/ publications/applied-theatre-researcheridea-journal Applied Theatre Researcher is an international e-journal. Its focus is performance work with specific participant or client groups in non-mainstream contexts. Areas covered include: drama and theatre in education, theatre for development, theatre in therapeutic settings, theatre in business, theatre in political debate and social action, theatre in life-long education, theatre in prisons, theatre in health education and awareness, theatre in aged care, theatre in hospitals and youth theatre. Arts & Health www.tandf.co.uk/journals/rahe Arts & Health is an international journal with an interdisciplinary brief which aims to serve a wide-ranging readership from artists and healthcare professionals to community workers and researchers in the public, private and voluntary sectors. The journal takes a broad approach to the field and encompasses arts in public health, health promotion, and health and care. Arts & Health is concerned with high-quality research, developments in policy, and best practice, and publishes empirical data, policy analysis and systematic reviews alongside theoretically based articles and descriptions of fieldwork. Arts and Health Research Programme, University of the West of England http://hsc.uwe.ac.uk/net/research/ The Arts and Health Research Programme is based in the Centre for Public Health Research. The programme is interdisciplinary in scope with particular emphasis on music and visual arts. Research includes systematic reviews and

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evaluations of projects, employing action research that allows for the inclusion of participants’ experiences. Activity within the centre feeds into the taught programme in Arts, Health and Wellbeing. ArtsHealth www.newcastle.edu.au/research-centre/artshealth/ ArtsHealth: Centre for Research and Practice is based at the University of Newcastle, Australia. It is an interdisciplinary centre that brings together scholars from the arts, social sciences, humanities, education, architecture and medicine. Research is organized under three broad themes: The Humanities/Creative Arts and Medical Science; Creativity, Culture, Community and Wellbeing; and Practice-based Research. The website includes information on research activities and conferences. The centre is also the editorial base for the Australasian Journal of ArtsHealth. The Centre for the Humanities and Health, King’s College London www.kcl.ac.uk/research/groups/khsc/healthsoc/medhumanities.html The Centre for the Humanities and Health brings together an international, interdisciplinary group of scholars from arts, humanities and health disciplines. The centre is currently engaged in a programme of research on ‘The Boundaries of Illness’ and is drawing on philosophy, literature, psychology and nursing, among other disciplines, to explore the theme. The website also includes links to the MA in Literature and Medicine at King’s College London. The Centre for Medical Humanities, Durham University www.dur.ac.uk/cmh/ The Centre for Medical Humanities is based in Durham University’s multidisciplinary School for Health. Its aim is to develop interdisciplinary research and educational initiatives that will foster interaction between the humanities, the arts and medical and healthcare practice. The website has information on the various research interests and activities of the centre’s members, with links to their publications and details of forthcoming events. The centre is also the editorial base for the journal Medical Humanities. Health and Arts Research Centre www.placemaking.com.au/Placemaking/Harc.html Health and Arts Research Centre, Inc. (HARC) is based in Sydney, Australia and is a non-governmental organization set up to undertake research and provide training for the benefit of local artists and workers, within the sector. The website includes details of activities and publications. Inspiring Transformations: Applied Arts and Health www.northampton.ac.uk/artsandhealth/ This website carries information on the annual international conference exploring the interaction of Applied Arts and Health hosted in collaboration by the Schools of The Arts and Health at Northampton University.

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Journal of Applied Arts and Health www.intellectbooks.co.uk/journals/view-Journal,id=169/ The Journal of Applied Arts and Health seeks to engage with artists, researchers, practitioners and policy makers and engages in critical reflection upon the field. It is interdisciplinary in scope and takes a broad definition of ‘health’ – including physical, mental, emotional, spiritual, occupational, social and community health. The journal offers space for interrogation of the efficacy of a range of practice as well as critical debate on wider theoretical frameworks. The journal takes an international perspective and welcomes contributions from around the globe. Peninsula Medical School, Universities of Exeter and Plymouth www.pms.ac.uk/pms/research/upstream The Peninsula Medical School has been conducting action research to evaluate the efficacy of the Upstream Healthy Living Centre. The website includes details of the project as well as linking to the wider activities of the medical school and its medical humanities programme. Performance and Health BA (Hons) – Edge Hill University www.edgehill.ac.uk/study/courses/performance-and-health This degree is designed to train students to work within health and care settings – both community and hospital-based work. The course combines investigation into both health and the performing arts through theory and practice. Performing Medicine www.performingmedicine.com/home.htm Performing Medicine is a partnership between performance company Clod Ensemble and Barts and the London Medical School, Queen Mary’s School of Medicine and Dentistry and the Department of Drama at Queen Mary University of London. The project runs a training programme for medical students which employs arts-based methodologies. It also stages public events and performances which encourage reflective engagement in the practice of medicine. RiDE: The Journal of Applied Theatre and Performance www.tandf.co.uk/journals/titles/13569783.asp Research in Drama Education: The Journal of Applied Theatre and Performance is a peer-reviewed journal which focuses on the application of performance practices to a range of settings – from community theatre to therapeutic contexts. The journal is international in scope and includes material from practitioners and scholars engaged in a variety of projects. RiDE publishes reflections on practice as well as engaging in current theoretical debates. Sidney De Haan Research Centre for Arts and Health www.canterbury.ac.uk/centres/sidney-de-haan-research/index.asp

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A primary focus for the Sidney De Haan Research Centre for Arts and Health is the examination of the value of music for the well-being and health of individuals and communities. The website carries details of their research projects as well as information regarding the wider arts in health context and links to Canterbury Christchurch University’s MA module in Health, Arts and Humanities.

Notes Introduction: Theatre in health and care: a developing field 1 Iatrogenic disease refers to adverse effects or complications caused by or resulting from medical treatment or advice. 2 Health Action Zones (HAZ) were launched in 1997 with the aim of reducing health inequalities between rich and poor. Rural and inner-city areas were particularly targeted and there were eventually 26 HAZs across the UK. The focus within the areas was addressing ill-health that results from poverty, and partnership working was encouraged between the different agencies and stakeholders within a particular zone. 3 For more information see www.shapearts.org.uk. 4 A second major initiative by the King’s Fund was ‘Enhancing the healing environment’ which funded nurse-led teams to work with patients and staff to improve NHS trust environments in London. In 2003 NHS Estates endorsed and encouraged this initiative. 5 White notes that a similar trajectory of development and constellation of organizations have taken place in Australia and North America (2009: 7). 6 For more information see www.coreims.co.uk/. 7 An example of such controversy is a Vital Arts project at the Royal London Hospital where artists were commissioned to make work for hanging in the fertility unit that proved to be uncomfortable for staff and patients and was taken down within a week.

Chapter 1: Embodied spaces: theatre in health institutions 1 This is very different in Eastern culture; however, this chapter is focusing on practices within the West. 2 It is important to remember that Parsons is examining contemporary Western culture where there is a developed superstructure. 3 The most notorious example was a mass-produced urinal which Duchamp sent for exhibition to a New York gallery in 1917. 4 As Ross and Gibbs note: ‘ear infections and sprained ankles make dull television’ (1997: 43). 5 www.sciencelearningcentres.org.uk/WebPortal.aspx?page=15&module= rep&mode=103&idrep=1828. 6 In traditional clown marriages, one clown is a ‘white-face’ – the voice of reason – the other is an ‘auguste’ – a mischief-maker. 167

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Chapter 2: Specialist knowledge: Theatre in Health Education 1 This could be linked to Parsons’ notions of a functional society outlined in Chapter 1. 2 Theatre Barter is a process developed by Eugenio Barba in his work with his theatre company Odin Teatret. The notion of barter is exchange with a community through performance. The company will share performance with the community and community members will share performance with the company. 3 See Chapter 3 for more on Paulo Freire.

Chapter 3: ‘But I already have a voice …’: ventriloquism, theatre and the healthy citizen 1 Valuing People defines learning disability as: The presence of: • • •

A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; A reduced ability to cope independently (impaired social functioning); Which started before adulthood, with a lasting effect on development.

Learning disability does not include all those who have a ‘learning difficulty’ which is more broadly defined in education legislation. (Department of Health, 2001: 14–15) 2 The challenges of collective decision-making and its role in creating homogeneity are considered by Mouffe (1999). 3 Jouissance is described by philosopher Roland Barthes as a type of bliss which occurs when the body breaks free from social constraints. 4 Performativity relates to an examination of the way in which social reality is ‘constituted’ through sign systems such as language and gesture. Phenomenological theorists such as Judith Butler view everyday life as a practice wherein performative acts serve to construct identity.

Chapter 4: Superficial wounds: the problems and possibilities of medical simulation 1 See Chapter 1 for more on liminality. 2 This difference in orientation may have been behind the move in 2008 from the Newcastle University Medical School to be based at Northern Stage in Newcastle. This residency highlights the theatrical emphasis of the Operating Theatre’s work and also allows them to reach a wider

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audience. They currently have 20 plays in their repertoire and tour to a range of audiences including medical schools and health conferences. 3 The term ‘member’ is used by Casualties Union in two ways. With a small m for someone who has completed a joining application form, been registered and paid their subscription and with a capital M for someone who has been a trainee, passed their first exam and qualified as a full Member.

Concluding thoughts: performance indicators 1 See the Appendix for further information on professional networks and organizations.

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Discography Barnes, L. (2008) Me Too!: The Album, Little Demon.

Filmography Kennedy, R. (dir.) (2002) Pandemic: Facing AIDS (HBO). Lawnmowers, The (1999) Finger on the Pulse: A Video About Health (Gateshead: Swingbridge Video). Lawnmowers, The (2003) Walk the Walk: A Video About Valuing People (Gateshead: Swingbridge Video). Weisberg, R. (dir.) (1996) Sex and Other Matters of Life and Death (New York: Public Policy Productions).

Websites http://ratings2004.healthcarecommission.org.uk/Trust/Indicator/indicators. asp?trustType=4 www.badth.org.uk www.bigapplecircus.org/community/clown-care.aspx www.casualtiesunion.org.uk/ www.coreims.co.uk/ www.edgehill.ac.uk/study/courses/performance-and-health www.fordfound.org www.ioutheatre.org www.jobs.nhs.uk www.laddertothemoon.co.uk www.learningdisabilities.co.uk www.mind-the-gap.org.uk www.nalamdana.org www.ncl.ac.uk/operatingtheatre/ www.nitestar.org www.open-art.org.uk www.performance.doh.gov.uk/nhsperformanceindicators/2002/index.html www.scip.org.uk/rocks/theatre.htm www.shapearts.org.uk www.theatre-rites.co.uk www.thelawnmowers.co.uk/ www.uwe.ac.uk www.vitalarts.org.uk www.who.int www.womenandtheatre.co.uk/

Index active citizenship and theatre, 93 advocacy and people with learning disabilities and citizenship rights, 91, 116 self-advocacy, 92, 107 ventriloquism and disempowerment, 91–2 and theatre, 92–116 aesthetic experience, 16, 22, 156, 157 affect and simulation, 149, 150 Ahmed, S., 85–6 AIDS see HIV/AIDS Angus, J., 11, 158 anti-psychiatry, 4 anti-structure and carnival, 47, 49 applied theatre, 21–2 Applied Theatre Researcher (e-journal), 163 Ariail, K., 157 Aristotle, 125, 132, 142, 156, 157 Artaud, Antonin, 147, 149 arts and medicine, 6–7, 11 see also arts in health; music; theatre in health and care; visual arts Arts and Crafts movement, 7 Arts and Healing Network, 162 Arts & Health (e-journal), 163 Arts and Health Australia (AHA), 162 Arts and Health South West, 160 Arts and Humanities Research Council (AHRC), 23, 155–6 Arts Council England, 9, 155–6, 160 A Prospectus for Arts in Health, 10, 153–4 Arts for Health – Manchester Metropolitan University, 160

Arts for Health Cornwall, 160 arts in health definition, 7–8 development, 1–3, 8–10 evidence and evaluation, 10–14, 21, 64–8, 158, 160 instrumental view, 15–19, 156 lack of priority, 153–4 professionalization, 154–5 see also ‘two cultures’ and ‘cultural antagonism’ Arts in Health Forums, 8–9, 162 arts therapists, 2 ArtsHealth, University of Newcastle, Australia, 164 Ashton, J., 6, 57 Astley, Philip, 45–6 Aston, Josie, 12 Atkinson, P., 41–2 audience and Brecht’s epic theatre, 59–60, 61 evaluation of theatre in health education, 65, 66–7 Nalamdana and empathy with, 79, 82 participation clown doctors, 52–3 Forum Theatre and spect-actors, 96–7, 98–102, 105, 115 ‘hot-seating’ in performances, 74–5, 139 practical difficulties, 36–7 pre-production questionnaires, 85 simulation and role-play, 141 and site-related performance work, 32–3, 38, 40–1, 43–4 people with learning disabilities, 112

180

Index

see also children as audience authenticity, 11, 114 and simulation, 124–5, 126, 134, 137, 139, 146, 150 authority of medical professionals, 30–1, 43–4 public health approaches, 57–8 reversal in circus and carnival, 46–7, 48, 49, 51, 53 autobiographical stories and performance, 112–15 avant-garde art, 32, 33 avant-garde theatre, 113 and social change, 59–62 Bakhtin, Mikhail, 46–7, 50, 52 Balaji, N., 80, 81 Ball, S., 68 Bandura, Albert, 70, 87 Barba, Eugenio, 84 Barker, C., 35, 39 Barker, Philip, 58 Baron, H., 16 barter: theatre barter, 84–5 Barthes, Roland, 168n Barts Hospital, London, 34–5 Baudrillard, Jean, 123–4, 145 Belfiore, E., 155–6 Bennett, O., 155–6 Beresford, P., 91 Berlin, Cydelle, 68, 70, 71, 72–3, 76 Bharath, Uttara, 77 Big Apple Circus Clown Care Program, 31, 45–53, 54, 55, 155 Binder, P., 45 biomedical model of medicine, 4, 30–1 Blakey, V., 66 Blast Theory: Desert Rain, 94 Bleakley, A., 123–4, 136, 141–2, 150 Bligh, J., 123–4 Boal, Augusto, 16 Forum Theatre methodology, 96–7, 98–102

181

Legislative Theatre, 101–2 Theatre of the Oppressed, 96–7, 101, 105 body corporeal and Clown Care Program, 50 liminal state of illness, 27–8 see also embodiment Bolland, Gail, 12 Bollywood and Nalamdana projects, 79, 80–1 Brecht, Bertolt, 71 The Exception and the Rule, 60–2 theatre and social change, 59–62 bricolage, 114 Brighton and Hove Rocks, 102 British Association of Drama Therapists (BADTh), 2 British Medical Journal, 11, 39 broker role between two cultures, 13–14, 54, 128 Brook, Peter, 31 Brown, Susan, 95 Burke, K., 28 Burt, S., 35, 39 Butler, J., 168n Camus, Albert, 16 carnivalesque and circus, 45–53, 110 Casualties Union, 126, 142–9 Casualty (BBC hospital drama), 41–2 catharsis, 125, 142, 148, 155, 156, 157 Cattanach, A., 94 censorship and funding, 69 Centre for Arts and Humanities in Health and Medicine (CAHHM), 154 Centre for the Humanities and Health, King’s College London, 164 Centre for Medical Humanities, Durham University, 7, 164 chaos: carnival and Clown Care Program, 46, 47

182

Index

Chelsea and Westminster Hospital, 156–7 ‘Theatre for Health’ project, 20–1 children as audience television hospital dramas, 42 for theatre and performance, 40, 41, 42, 43–5, 51–2 choice: policy and people with learning disabilities, 90–1 Choosing Health (White Paper), 5–6, 9 Christensen, Michael (‘Dr Stubs’), 45, 48, 51, 52, 53 circus history of, 45–6 see also Big Apple Circus Clown Care Program citizenship advocacy rights, 91, 116 Legislative Theatre, 101–4 participant citizenship, 92–3, 97, 99 and right to health and well-being, 89, 90–2 Claxton, Eric, 142–3 Cleveland Arts, 17 Clewlow, Carol, 135, 137 clinical governance: health performance indicators, 151–4 clown doctors, 45, 47–53 ‘clown logic’, 46 comedy and simulation, 128–9 and Spass in Brechtian theatre, 62 and theatre in health education, 72, 80, 82, 87 communication alternatives to voice, 95, 101 clown doctors, 48–9 and cultural differences, 12–14 and language, 12–13 negotiation and purpose of arts projects, 15, 17, 64 medical training and simulation, 119–20, 121–3, 126, 129–30, 135–6

communitas and carnival, 47 community arts movement, 7, 8, 17 Concannon, L., 90 Connolly, Janice, 126, 128, 132–3, 134–5, 138 consultation process and people with learning disabilities, 103 and site-related performance work, 36–7, 39–40 consumer-based policy approaches, 6, 90–1 Cooper, Dylan, 67 CORE evaluation model, 14 corporeal see body; embodiment cost-effectiveness, 20, 157, 158 costume and clown doctors, 50 Coveney, J., 57–8 Creative Remedies, 161 Crew Resource Management (CRM) exercises, 120–1 Critical Connections, 161 Croft, S., 91 ‘cultural antagonism’, 3–4, 11–14, 16, 155 cultural sensitivity: Nalamdana in India, 77–8, 81–3 Dadaism, 59 Dagron, A., 84 Darling, Julia, 135, 137 Darzi, Lord, 154 Deleuze, Gilles, 124–5 Denman, S., 64–5 Department of Health, 9, 160 A Prospectus for Arts in Health, 10, 153–4 Derbyshire Healthy Schools, 161 Derrida, Jacques, 93 devised performance, 93–4, 113 Dose, L., 9 Douglas, M., 147 drama demands of interaction, 19–20 as Platonic mimesis, 124–5, 131–2 training for adults with learning disabilities, 99–100, 105–7

Index

drama of everyday life, 32, 33, 38, 39, 43–4, 55, 156 sickness and removal from, 27–30 dramatherapy, 2 Duchamp, Marcel, 33 Durham University: Centre for Medical Humanities, 7, 164 DV8: My Sex Our Dance, 94 Dwyer, P., 101, 104 Earthwatch programme funding, 78, 79 Edgar, David, 64 Edge Hill University: Performance and Health BA course, 154–5, 165 education see health education and promotion; medical simulation; schools; training Elliott, L., 65–6, 70 embodiment embodied citizenship, 93 embodied knowledge, 141 embodied performance, 93–5, 157 see also body emergency medicine and TV drama, 41–2 ‘emotional hygiene’, 49, 54, 155 empathy and audience, 79, 82 and medical simulation, 121, 139, 140, 141, 142, 150 engagement see interaction; participation ephemeral nature of performance, 20, 21, 24 epic theatre of Brecht, 59–62 Etchells, Tim, 94, 146, 159 evaluation and arts in health, 11–12, 14 cost-effectiveness, 20, 157, 158 difficulties of evaluation, 21, 141, 158 medical simulation, 130–1, 139–40, 142, 148

183

theatre in health education projects, 64–8, 87 everyday see drama of everyday life failure: interest in, 158–9 Finlay, S., 140 Fiske, J., 53 follow-up programmes Lawnmowers, 115 Nalamdana, 80, 86 NiteStar, 75–6 Forced Entertainment, 94, 111 Ford Foundation Earthwatch programme, 78, 79 Forum Theatre, 96–7, 98–102, 105, 113, 115 Foucault, Michel, 30–1, 37, 57–8 Frankenberg, R., 27, 28 Freire, Paulo, 85, 97, 105, 106 Freud, Sigmund, 125–6, 131, 140 Full Body and the Voice, 94 funding and cost-effectiveness, 20, 157, 158 drama training for people with learning disabilities, 100 and political agendas, 64, 68, 128 theatre in health education, 64, 68–9, 77, 78, 79, 86–7, 157 Futurism, 59 Gaba, David, 120–1 Gardner, L., 42 General Medical Council: Tomorrow’s Doctors, 119–20, 135 Gent, Adam, 37 Gestic acting, 61, 63 Gilman, S., 58 Glavin, R., 145 Goffman, E., 29–30, 41, 55 Goldblatt, D., 91, 92, 94, 102, 117 Goldwasser, Maria Julia, 47 Good, M., 121, 137 Goodman, Edward, 149 Govan, E., 114

184

Index

Greater Manchester Arts and Health Network, 161 Green, L., 56 Hardey, M., 4 Hargrave, M., 113 Harper, S., 144–5 Harriss-White, B., 78 Hayhow, R., 92, 93, 94, 95, 99–100, 105, 107, 113 health citizenship and right to health and well-being, 89, 90–2 exclusion and theatre, 102–3 and performance indicators, 151–4 WHO definition, 89 Health Action Zones, 5, 10 Health and Arts Research Centre (HARC), Sydney, 164 ‘health brokers’, 13–14, 128 Health Development Agency: Art for Health, 9 health education and promotion, 56–88, 157, 161 evaluation of theatre in health education projects, 64–8 follow-up programmes, 70, 75–6, 86 funding, 64, 68–9, 77, 78, 79, 86–7 Nalamdana in India, 76–86, 87–8 NiteStar Program in New York, 68–76, 73, 77, 83, 87–8 and people with learning disabilities, 103–4 theatre and social change, 59–62, 88 ‘health perspective’, 4–6 health promotion see health education and promotion Healthy Living Centres, 5, 10 Heathcote, Dorothy, 105–7, 109, 111 Hi-Arts: Highland and Islands Arts, 161–2

HIV/AIDS and health promotion moral approaches in US, 58 theatre in health education projects, 65, 67–86 Hodges, B., 136 holistic approach to health, 3–6, 11 Horley, R., 129, 138 Hornbeck, Ken, 70, 76 hospital artists, 8 hospitals appropriateness of arts projects, 20–1 historical context, 30–1, 34–5 power relations, 30–1 in television dramas, 41–2, 43 as total institutions, 29–30 see also site-related performance work ‘hot’ medicine on television, 41–2 ‘hot-seating’ technique, 74–5, 139 human patient simulators, 121, 137 humanities and ‘cultural antagonism’, 3–4 humour see comedy hyperreal and simulacra, 123–4 iatrogenic disease, 4 Illich, I., 4 illness as liminal state, 27–8 social constructions, 27, 28–9 ‘image theatre’, 97 India: Nalamdana company, 76–86, 87 Inspiring Transformations, Northampton University, 164 Institute for Public Policy Research, 9 institutional context, 26–55 instrumental view of arts in health, 15–19, 156 Integrated Nursing Teams (INTs), 132–3 interaction and circus, 46 demands of, 19–20

Index

health education and theatre, 64 interactionalist studies and hospitals, 29–30 and medical simulations, 130–1, 132, 139 theatre barter, 84–5 see also participation IOU Theatre, 26–7, 31, 32–40, 54, 55 Consulting Room III, 26, 32, 33, 34, 35–6 Cure, 34 Tatoo, 33 Jackson, A., 15, 16, 64, 65, 67, 74, 87 Jackson, T., 62–3 Jacobsen, T., 139 Jeevanandam, R., 77 Jones, Sunny Patel, 114 jouissance, 111 Journal of Applied Arts and Health (journal), 165 Jowell, Tessa, 5 Kaprow, Allan: Fluids, 38 Karpf, A., 41, 44 Katz, Dr Michael, 45 Kaye, N., 32 Ker, J., 121 Kershaw, B., 33 Khanna, G., 78 Kilroy, A., 11, 158 King’s College London, 164 King’s Fund, 8–9 Kirby, M., 113 Kistenberg, C., 58, 87 Kneebone, R., 122–3 Knight, S., 39 knowledge transfer and evaluation, 65–7 and medical simulation, 141–2 Kreuter, M., 56 Kristeva, Julia, 149–50 ‘Krokodile Krew’, 107–8 Kuppers, P., 116

185

Labour government and health, 1, 5–6 Lacan, Jacques, 131 Ladder to the Moon company, 16, 17 Laing, R. D., 4 Landy, R., 142 language alternatives to voice, 95, 101 and communication difficulties, 12–13 Freire’s word-and-action concept, 97 of medicine in performance work, 35–6, 37 of official policy, 110 professional patronization, 115–16, 130–1 Lawnmowers, The, 95, 104, 105–16 Finger on the Pulse, 115–16 Walk the Walk, 108–15, 109 learning disability definition, 168n see also people with learning disabilities Lecoq, Jacques, 94 Legislative Theatre, 101–4, 108–9 critiques, 104 Lempp, H., 135 ‘lifestyle choices’ and health, 6 liminality and carnivalesque, 47 liminal space and simulation, 129 liminal states and illness, 27–8, 29 Ling, Geraldine, 105, 107, 108 London, P.: An Atlas of Injury, 143–4, 145–6 London Arts in Health Forum, 9, 162 Loppert, Susan, 20–1, 156–7 Lutze, L., 80–1 make-up and wound simulation, 146 ‘Making Theatre’ drama training course, 100–1

186

Index

Mallinson, Zara, 104 Mamet, David, 88 Manchester Hospital Arts Project, 8 Maran, N., 145 Marxist theory and theatre, 61, 63, 116 see also Brecht Max-Prior, D., 42 McEwan, R., 66–7, 70 McKenzie, J., 151, 157 McLane, Val, 138 McLeod, M., 159 Me Too! (BBC children’s programme), 42 media: negative view of arts in health, 10 mediation between arts and health, 13–14 medical geography, 31 medical professionals authority and power, 30–1, 43–4 clown doctors, 45, 47–53 patronizing attitudes, 115–16, 130–1 training see medical simulation medical simulation, 119–50 and changes in medical training, 119–20 development as training practice, 120–3 problematic issues, 123–6, 139, 150 role-play, 121–3, 148, 157 and theatre companies, 122, 123 Casualties Union, 142–9 Operating Theatre, 135–42 Women and Theatre, 126–35 medicine aims of arts in health in context of, 11 biomedical model, 4, 30–1 history of arts in, 6–7 professionalization and power relations, 30–1 Mencap, 91 mental health: arts in health benefits, 9

metaphor and illness, 27 and site-related performance work, 36, 37, 39 Miles, M., 6 mimesis and Aristotle, 125, 132 benefits of medical simulation, 131–2, 150 mimetic praxis and Plato, 124–5 Mind the Gap, 95–104 Forum Theatre approach, 96–7, 98–102 Legislative Theatre approach, 101–4 ‘People Like Us’ project, 103–4 Modernism and social change, 59–62, 63 moralizing approaches to health education in US, 58, 72–3 Mouffe, Chantal, 92–3, 104 Munt, Deborah, 13, 35–6 music in healthcare settings, 19, 20 in theatre in health education projects, 83 in work with learning disabled actors, 111 Mutnick, D., 104 Nalamdana company in India, 76–86, 87–8 Bollywood influence, 79, 80–1 follow-up programmes, 80, 86 women’s empowerment programme, 85 narrative and Brecht’s epic theatre, 60, 61, 63 importance in theatre in health education, 87–8 National AIDS Control Organization (NACO), 76–7 National Health Service (NHS), 1, 5 National Network for Arts in Health Canada, 163

Index

National Network for the Arts in Health (NNAH), 9–10 negotiation and purpose of arts projects, 15, 17, 64 New Public Health, 6, 57–8 New York: NiteStar Program, 68–76, 73, 77, 83, 87–8 NHS see National Health Service (NHS) Nicholson, H., 63–4, 93, 94 NiteStar Program, 68–76, 73, 77, 83, 87–8 follow-up programmes, 75–6 ‘non-acting’ of people with learning disabilities, 113–14 Nuttall, A., 131, 132 Open Art, 2 Operating Theatre company, 126, 135–42 Who Else is in the Room?, 141 oppression: Theatre of the Oppressed, 96–7, 101, 105 Owen, H., 121 Paley, Cheryl, 71, 72 Palmer, J., 92, 93, 94, 95, 99–100, 105, 107 parody and Clown Care, 46, 49, 50, 51 Parsons, T., 28–9 participation drama training and people with learning disabilities, 105–7 participant citizenship, 92–3, 97, 99 see also audience: participation; interaction Peepshow collective, 35 peer education approach, 69–72, 79, 87, 112 Peninsula Medical School, 165 people with learning disabilities, 89–118 legislative context, 90–2 personal experience and acting style, 112–14

187

ventriloquism and advocacy and disempowerment, 91–2 and theatre, 92–116 Performance and Health BA course, 154–5, 165 performance management culture, 151–4, 155, 158–9 Performing Medicine course, 2, 165 personal experiences and performance, 112–15 Phelan, P., 20, 150 Philipp, R., 123 Plato, 124–5, 156 Plummer, J., 121 politics and theatre funding and political agendas, 64, 68, 128 Legislative Theatre, 101–4 see also social change and theatre post-modernism and autobiographical performance, 114–15 power relations advocacy and ventriloquism, 91–2 in medicine, 30–1, 43–4 health promotion, 57–8 reversal with clown doctors, 48 reversal in role-play situations, 136–7 Praxis, 162 pre-production work Nalamdana questionnaires, 85 NiteStar’s preparatory work, 73–4 Women and Theatre’s research phase, 127–8, 134 Priestly, Ruth, 18 Prior, Lindsay, 31 professionalization of arts in health discipline, 154–5 and power relations, 30–1 public health historical context, 57 New Public Health, 6, 57–8 see also health education and promotion Pullen, E., 66

188

Index

Rattray, Brenda, 36, 37 reality and simulation, 123–4, 126, 131–2, 133–4, 149–50 realistic simulation of wounds and injury, 142, 143–4, 146–7, 149 and role-play situation, 136–7, 148 Redington, C., 59 reflective practice and simulation, 128, 130–1, 140, 141 Renza, L., 114–15 research on arts in health, 10–14, 160, 163–6 applied theatre, 21–2 outline of project, 23–5 see also evaluation and arts in health Ricketts, I., 122 RiDE: The Journal of Applied Theatre and Performance (journal), 165 right to health and well-being, 89, 90–2 risk management in health sector, 18 risk assessment and access for performance work, 38 Roberts, S., 15 Rodenburg, P., 95 role-play: simulation and medical training, 121–3, 135–42, 148, 157 role types: sick role and institutional context, 26–31 Royal London and Barts Hospital, 26, 33–40, 167n Consulting Room III (IOU Theatre), 33, 34, 35–6 Russo, E., 59–60 St Bartholomew’s Hospital, London, 34–5 San Francisco Mime Troupe, 45 Sanger-Katz, M., 136 Sartre, Jean-Paul, 147 Saturnalias and carnival, 46 Schier, F., 131

schools: Theatre in Education (TIE) movement, 62–4 science and ‘cultural antagonism’, 3–4 self-advocacy, 92, 107 Seltzer, M., 149 Senior, P., 8, 10, 18–19, 20 sex education evaluation of theatre in health education projects, 65–7 HIV/AIDS and theatre in health education projects, 65, 67–86 Seymour, A., 117 Seymour, H., 6, 57 Shakespeare, T., 95 SHAPE network, 8 Sheridan, M., 41 Shysters, The, 113, 114 sick role and institutional context, 26–31 Sidney de Haan Research Centre for Arts and Health, 165–6 simulacra (Baudrillard), 123–4 simulacrum and injury simulation, 145 simulation see medical simulation Sinclair, S., 135–6 Singhal, A., 86 site-related performance work, 32–55, 156–7 Big Apple Circus Clown Care Program, 45–53 IOU Theatre, 32–40 Theatre-Rites’ Hospitalworks, 40–5, 54 Women and Theatre simulations, 129 see also medical simulation Slowie, Dominic, 135, 136, 137, 140–2 Smith, T., 5, 7, 157 Snow, C. P., 3 Sobey, Richard, 33, 36, 37, 40 social change and theatre, 59–62, 88, 107 social model of health, 4–5, 11

Index

Society for the Arts in Healthcare, 163 Sontag, Susan, 26–7 South East Arts and Health, 162 space and institutional context, 26–55, 156–7 medical geography, 31 segregation of illness, 27–8, 28–9 see also hospitals spectators see audience Spencer, John, 137, 138 Stafford, F., 137, 149 Stanislavski, C., 134, 137 Staricoff, R., 10, 19 stereotypes of artists and performers, 18, 20 street theatre: Nalamdana in India, 77–86, 87 Subramanian, S., 78 Suffolk Artlink, 162 Surrey County Civil Defence Rescue School (SCCDRS), 142–3 Tanner, D., 18 televisual representations of medical issues, 41–2, 43 Terrukkuttu theatre, 83–4 theatre barter, 84–5 ‘Theatre for Health’ project, 20–1 Theatre in Education (TIE) movement, 62–4, 105 theatre in health and care, 2–3, 7, 16, 19–22, 157 see also health education; medical simulation; site-related performance work Theatre in Health Education (THE), 161 evaluation, 64–8 Theatre of the Oppressed, 96–7, 101, 105 Theatre-Rites, 31, 55 Hospitalworks, 40–5, 54 therapeutic landscape, 31 Thomas, Caroline, 146, 147 Thomas, Ed, 116

189

Thompson, J., 21 Titterton, M., 18 TONIC arts programme, 12 training academic courses for arts in health, 2, 19, 154–5, 165 drama training for adults with learning disabilities, 99–100, 105–7 for wound and injury simulation, 145–6 see also medical simulation translatory process, 13–14 trauma benefits of simulation training, 126, 140 Freudian view, 125–6, 140 Tuan, Yi Fi, 28 Turner, V., 27–8, 42, 47, 129 ‘two cultures’ and ‘cultural antagonism’, 3–4, 11–14, 16 attitudes towards artists, 18, 20 lack of priority for arts in health, 153–4 need for interdisciplinary training, 155 Undrill, G., 131 University of the West of England (UWE) Arts and Health Research Programme, 163–4 Arts, Health and Wellbeing Programme, 19 Upstream Healthy Living Centre, 165 Valuing People (White Paper), 89, 90–1, 93, 103 Walk the Walk as response to, 108–9, 110 ventriloquism and people with learning disabilities and disempowerment, 91–2 and theatre, 92–116 visual arts in healthcare settings, 19, 20–1, 35

190

Index

Vital Arts, 2, 35–8, 39, 54, 167n voice see ventriloquism vulnerability, 159 of clown doctors, 48, 50–1 Walsall Health and Community Arts, 128 Walton, K., 131 Warren, Bernie, 50–1 Welfare State, 5 Welfare State International company, 32–3 Wells-Thorpe, J., 7 Wheeler, David, 39 Wheeler, Tim, 95, 96, 99 White, M., 3, 6, 8, 10, 12, 14, 15, 19, 22, 153–4, 155

Whyman, R., 113, 117 Wikoff, N., 158 Wiles, D., 46 Wilson, M., 27 Women and Theatre company, 126–35, 137 The Learning Curve, 128, 134–5 Scoffing, 129–32 Working It Out, 132–4 women’s empowerment programme (Nalamdana), 85 word-and-action concept, 97 World Health Organization (WHO), 5, 57 definition of health, 89, 90 wound and injury simulation, 142–9