Evaluating Outcomes of a Co-Produced Theatre-Based Experiential Learning Project in Psychiatry

Subtheme 1.1: individual development and wellbeing

Participants arrived at the project with varied experience of involvement in the performing arts and appeared to hold their personal experience as an important factor that drew them to the study. The vast majority highlighted a pre-existing interest in creative endeavours that were mainly held in their personal rather than professional lives and went on to explain that they saw the project as an opportunity to bridge their personal interest in the arts with their professional lives.

Participant #3 (P.3 Psychiatrist): ‘I always found things to improve – understanding my patients, improving communication skills, and learning through drama or any kind of resource other than medical books – very interesting’.

Alongside this, the novelty of the project and the potential for its application within their respective roles and wider lives appeared to be a motivating factor for several participants’ involvement within the group.

Participant #12 (P.12 Service user): ‘I come from a teaching background and we used to do a lot of these things, like role plays, even in teaching and learning. So it all sounded very innovative, and an interesting project, and very creative’.

Others saw the project as an opportunity to mitigate the isolation experienced during the COVID-19 pandemic.

Participant #10 (P.10 Service user): ‘She [facilitator] was trying to make sure that other service users don't get lonely or isolated at home and have that impact their mental health. So, something to keep them busy, and that's why I did it’.

Although there was curiosity and enthusiasm, participants across all backgrounds often started the project with a degree of apprehension, having had limited experience within the theatre or acting. They described that as the project progressed, their confidence improved, and the healthcare professionals in particular reported a wellbeing benefit often linked to enjoyment of the work environment. With time, many appeared to become more assured in the value of creativity within healthcare settings.

Participant #11 (P.11 Psychiatrist): ‘There were points last year when I felt very drained. I wasn't always enjoying my job, and I think this current project has just given me something in my week that is quite fresh and new’.

Subtheme 1.2: collective development and benefits of the group environment

The environment established by the POn team and the experience of interacting within the group were positively reported. Those taking part often reported feeling valued, valuing the contributions of other participants, and drawing reward from observing others develop throughout the project. Participants felt safe and able to express vulnerability, which seemed to foster a sense of connectedness and belonging that was derived as a significant benefit from the process.

Participant #4 (P.4 Clinical psychologist): ‘It was nice to see some participants, for example, didn't feel comfortable having their videos on at the beginning, but for the second half of the project, their cameras were on, and people were able to take more risks’.

The process facilitated by POn appeared to allow for an authentic reflective space. Breakout rooms for further exploration were highlighted as an important factor for participants who appeared to value the act of being able to reflect on a collaborative footing rather than being a solitary pursuit.

Participant #2 (P.2 Arts therapist): ‘Quite early on, when going to a breakout room we were given something to work on… it affected both of us – there was a time to talk about it as well… he was talking about his own confidence… and I was thinking about sort of familiarity I am with working in that way, but actually the confidence. I’m in a different place.. so yeah, it was having enough confidence to be able to enter into something which we were sharing together’.

Service users tended to report positively about being heard and having greater agency within the space. Doctors and therapists often spoke about the benefits of being held in, rather than holding, a therapeutic space. They described transactional aspects that were compared to usual working practices – being afforded the opportunity to receive, rather than give. Some participants experienced this on a more profound level than others.

P1: ‘I think it showed me that one of the phrases I tried to share with the group was about ‘imagination is magic-ing something new into the world’ and actually, I could say if I hadn't been there that that part of it wouldn't have happened. So I think, feeling that I could work somewhere where they trust my imagination’.

An aspect of the group that was viewed less favourably was that several members taking part in the project were from the same community mental health team. This imbalance was noticed by other members in the group and appeared to impact their sense of belonging.

Participant #6 (P.6 Consultant Paediatrician): ‘I felt like a bit of an outsider sometimes because there was a group of clinicians that knew each other’.

Subtheme 1.3: storytelling, play and embodiment

The POn workshops were structured to include using the shared experiences of participants to develop characters and a script. Several participants spoke of how they experienced developing their capacity to play, improvise and create stories. There was a sense that participants were able to grow into working creatively as the project developed.

P1: ‘I think the project… made me braver, made me trust my creativity. It made me realise that there was enough space to choose a role. I think, in the past, I thought “I can't fit into the work system – it's too limiting, the roles are too limiting”. What I realised is that I can do something like this and my creativity can be encouraged. That is massively healing’.

The development of storylines through the input of people from a wide range of backgrounds was frequently spoken about by all groups and individuals and described as having extended the participants’ understanding of others’ experiences. Many participants reflected on how they felt the variety of professional roles within the workshops enhanced the breadth of the storylines and enabled them to see things from a different perspective and expand their thinking.

P6: ‘I think this type of storytelling… helps to create compassionate experiences, because you begin to understand from all the different people's perspectives and you start to have a very holistic understanding of the system – of, you know, the patient, the clinician, the hospital environment, the clinic that you know’.

Participants described how the theatrical workshop activities demanded embodying the act of playing the role of another and how for some participants this was an enduring impact of the project.

P4: ‘The character development… could be something like, “Right, think of a colour” or “Think of what this person sees outside the window”, and, all of a sudden you're into your character's mindset and then you're acting it, and I think it's something very different, because in that way you're embodying and expressing the thought or the hypothesis you have in your head… you're living the relationships that you're considering’.

Furthermore, participants reflected on how the experience of sharing stories and creating together in this way had brought them insight into each other's lives. There was a recognition of the vulnerability of doctors as a professional group by the other participants. Participants reflected that, prior to the project, doctors were perceived as unable or unwilling to share their personal experience. By doing so during the project, stigma was reduced.

P12: ‘I think with service users and carers working together – they were able to see that even professionals can have mental illness…, it was very… nice to be able to share your experiences openly… It has definitely helped people to talk about their own struggles and mental health, and it has helped to reduce that stigma around mental health, regardless of whether they are a service user, carer or professional’.

Subtheme 1.4: therapeutic experience of the group

Although the POn project was distinct from, and not intended to be, a clinical mental health space, there was a strong sense that this separation was less clear in the experience of participants. The language they used often directly or indirectly implied a blurring of boundaries between the workshop and the clinic. Many of the participants spoke about how the project positively impacted their own mental health and how taking part in the sessions felt ‘therapeutic’.

P4: ‘I think it has helped me develop in some way … It was almost like a therapeutic group… I think having consistency and doing it weekly… the structure was the same every week and something about that was quite containing’.

Participants described feeling able to talk ‘openly’, ‘honestly’, being treated ‘equally’ and feeling able to be ‘vulnerable’ as important to the experience of the group. These attributes of the group were experienced by some participants as healing or therapeutic.

P1: ‘So there was a kind of bond within the group that we were vulnerable together. We had a safe space. But we all reaffirmed each other in our vulnerability and actually gave each other a lot of affirmation, so that's very healing’.

An experience of the group as explicitly therapeutic or as having improved their mental health, wasn't was not universal among participants. One participant with a background in arts therapy commented that although the workshops were not intended as therapy, the project may have benefitted from acknowledging the parallels and incorporating some of the aspects of therapy to enhance the experience.

P2: ‘I was very aware that it wasn't a therapy session and I was trying to hold the boundaries of working using theatre in a place where this is not run by therapists. And I suppose my argument would be… let's have a therapist in there and input in there, actually, because then you've covered everything and just have that clinical expertise…’

The freedom participants described in being able to explore roles not otherwise afforded during their day-to-day lives led to a collective experience of expanded perspectives that may not have been achievable through solitary reflective processes. In collectively building a script, thought was given to some work colleagues in a way that perhaps had not been before, such as maintenance staff and cleaners. As one senior medical doctor explained:

P3: ‘I found that when we were really being in that role and were playing it, I always felt strongly about each character, like a homeless person that one of our colleagues played, or a young adult that one of our service users played… so I really felt compassion towards those characters, as I said the cleaner, which was a really strong and powerful connection that I have felt’.

Furthermore, the outcome of the type of reflection experienced during the POn project not only appeared to help participants develop greater compassion but also prompted them to view individuals and systems more completely. With time, the layers of reflection and improvisation synergised, and participants explored together the roles they and others held and enacted. Participants spoke about their reflection on their place within the system as a whole and how individual actions have the potential to elicit far-reaching consequences.

P12: ‘Service users, carers and professionals might have their own perspectives, and to be able to understand when everyone comes together … it was really insightful and something I’ve learned a lot from. I have a better understanding now of people's personal and professional experiences and how they can play different roles in different situations’.

In opposition to this, one participant felt their perspective of other participants was relatively unchanged and that the project had little discernible personal impact.

P4: ‘Has it changed my perception of relationships with service users? Huh… not really. I’d say, I used my perception and relationships of past experience of service users, to inform the project rather than the other way around’.

Subtheme 2.1 facilitators and the project environment

Participants regularly described the environment created by the POn team in a positive light. Many spoke, or alluded less directly, to a culture of respect and equality where people were free to contribute as much as they were comfortable with.

P12: ‘Trusting, safe and supportive… that enabled people to… open up and… have the courage to share their experiences and be honest about them’.

At the outset, the facilitators and the group created a set of ground rules together. This shared experience was broadly remembered by participants as the starting point for the development of what became a strong bond that provided safety to share material that they had not shared within comparable NHS team group work or staff reflective spaces.

Participant #8 (P.8 Occupational therapist): ‘I believe that when you create an effective community then… individual difficulties can be held in it… Playing On creates community that enables people to share what they need to share. And so even in the characters I played, I mean, I think there was a high degree of vulnerability in the degree of my participation’.

Facilitators provided an ‘equal’ space and appeared adept at allowing participants to bring ideas to this space and at points actively modelled this approach in front of the whole group.

P5: ‘They listened, and they were empathetic and they reflected, and they came back to things. A good example is, I remember talking about something and then later when someone brought it up, and I thought, “Gosh, they remembered that”’.

Participants reported feeling comfortable in exploring topics in what was a ‘creative’, ‘playful’ environment. The idea that the environment was safe to make mistakes, experiment and, ultimately, learn was a perceived benefit to individuals.

P8: ‘We can't play… children can't play unless there's a sense of, like, safety. It is creating that space to kind of learn as well, isn't it, to learn from your mistakes. Essentially children are learning from… what sometimes doesn't work’.

Subtheme 2.2: process of the project

Participants recognised what they felt was a clear structure in terms of allowing the group to set boundaries which established trust and respect early on. Participants frequently commented on the provision of opportunities for reflection outside the main group in smaller group settings, such as breakout rooms, and valued these opportunities as contributing to the development of trust. Participants particularly enjoyed how sessions were introduced through warm-up activities that were experienced as entertaining and novel by many.

P6: ‘There was always this style of introducing ourselves at the beginning and it could be, these theatre-type techniques, like, ‘Imagine that you are a type of weather’ or ‘What's your favourite food?’, “What would you be?”, or “How are you feeling?”. And all of us introduced ourselves in that way, not in the way when you have a clinic meeting or something else’.

While some of the aspects of the workshops, such as the start time and the duration, remained fixed, much of the content of the workshops varied. Participants spoke positively of the variability and flexibility of the session content. The improvisation activities were particularly popular:

P11: ‘It was organic, it just came out of improvisations and grew each week’.

While this freedom to improvise was often seen as positive, particularly with participants who were therapists and doctors, some expressed their frustration with the perceived lack of direction and some disappointment in the perceived unclear overall aim of the project and the final performance.

P9: ‘A bit clearer about the intention of how we were going to work, maybe they wanted it to be quite open. Certainly I came into it not really knowing what I was coming into… but yeah, maybe just for me. It could’ve been a bit clearer really because I wasn't really sure what we were doing.

Subtheme 2.3: the online setting

The context of the POn project running during the COVID-19 pandemic meant that sessions initially commenced online. Participants came to the project with preconceptions that were generally in support of face-to-face rather than online sessions, feeling that the content generated would be ‘richer’. Largely, this did not change, with many feeling that the online setting negatively impacted the quality of the final piece of work. Others saw the lack of face-to-face group contact as a lost opportunity to interact and connect with others.

P8: ‘There are a lot of service users that I work with who don't have this facility’.

Conversely, several participants put forward alternative perspectives of the online setting, suggesting that it enabled less confident individuals to begin the project and that these participants had slowly built their presence in the sessions over the course of the project. Another suggested that the location of the project had ‘broadened their mind’ to the possibilities of working online.

P9: ‘You would think that if you can't see somebody and you’re in a conversation with them, you know, like you’re meant to be in the same room… it didn't seem to hold people back. But for some people it might actually mean they could join in, because actually being in a room with other people might have felt more difficult’.

Subtheme 3.1: hierarchy and Power

The doctors in the group were the most likely to comment on how their experiences of the workshops were different from how they were accustomed to feeling, communicating and interacting with service users and other healthcare professionals. Non-medical healthcare professionals also talked about a diminished experience of hierarchy in the project, describing this change consistently with direct reference to a ‘flattened’ or non-existent hierarchy.

P6: ‘It wasn't hierarchical. Generally, if you look at clinician-client relationships, there is a type of hierarchy and a power dynamic which that is a very sad thing in a way, but it has existed historically. Whereas this is a space where we're all on the same level’.

This change was universally seen as positive by both medical and non-medical healthcare professionals. It was often cited as contributing to being more ‘authentic’ when reflecting or improvising with the group. Non-medical participants in general observed and commented on the desire among the doctors to discuss power and hierarchy within clinical spaces as a theme in the workshops.

P8: A very significant theme that came from the medics was around hierarchy… they chose to be like the cleaner, or the person shouting at the cleaner, or… they reflected those themes. There weren't other people saying, “Oh, medics are like this”. So for me to see that, you know, we actually do have a lot more shared concerns and values than I might feel like at times when I feel very polarised… It was very helpful’.

Power and hierarchy were common themes of the improvisations and discussions within the group and in part shaped the final performance script. There was a sense that doctors’ interests were given priority within the final script. Not all the participants experienced a change in their perception of pre-existing roles. One service user described how they felt that prior roles endured to a degree over the course of the workshops and how they themselves continued to behave as if this was the case.

P10: ‘We all worked together and we were all equal. But I just thought of myself as a service user, and the therapists and the other doctors… I was a bit nervous and I made sure that I was careful what I was saying’.

This was strikingly different from another service user's perception of power and whose description of their experience was in keeping with how healthcare professionals had largely described the workshops.

P1: ‘There's a different power dynamic. So, we were all in an unfamiliar space, out of our comfort zone, choosing new roles, and it got rid of the power structure, the hierarchy, and I think… I felt very empowered, that I could choose my role in life or my role in the play’.

Healthcare professionals commented on their dissatisfaction with current healthcare practice and referred in complimentary terms to aspects of the workshops, such as the diminished hierarchy, that reframed the power dynamic inherent in more traditional medical model practice. One service user described their experience of traditional power dynamics in mental healthcare and the effect they felt their diagnosis had on medical professionals.

P1: ‘I think with mental health challenges, you can be defined by different diagnoses, and there's a struggle for a meaning to life… often you meet doctors and they're looking at you through a medical perspective and not seeing all your possibilities – or maybe that's a bit of a stereotype’.

There was concern from participants as to how less hierarchical attitudes to working would be sustainable within current systems.

P6: ‘We as a small group shifted culture, perhaps, and so we’re signed up to this way of thinking now, but then I have to go back to my regular system which doesn't think in this way’.

Subtheme 3.2: changing roles and values

Working together as a group of both healthcare professionals and service users precipitated many participants to compare their experience of being in the workshops with aspects of their work within, or use of, mental health services. Aspects of the workshop experience reported as less familiar within their regular mental health service routine, such as ‘flattened’ hierarchy and the authentic collaboration between healthcare professionals and service users, prompted reflections from some mental health professionals on how they feel mental health practice in its current form deviates from their values.

P6: ‘I think there was a very old-fashioned model before, that had you distance yourself in your ivory tower from the patient, from the client – you know, you're fixing them so you need to be better, different from them’.

Within the sessions, all participants described both the impact of changing roles brought about through taking part in the project in general and further role changes through scripted acting, improvisation and vicariously through observation. An occupational therapist described how they experienced changing roles within the project and the enduring effect this had for them.

P8: “The final thing I'd add that I've kept thinking about over the last few months is with, say, drama… People might have the perception that there's something about putting a mask on, but I think it's so much about dropping the mask… People hold on to their masks to hold on to power, really, I think. When you have the opportunity to be in another role, I think you can share… things with your colleagues that you could not share if you were just in a discussion’.

Some participants experienced the changes in the power dynamics inherited from clinical situations to be so significant as to lead to using their newly assumed autonomy to act in a way that felt novel and empowering. One service user described how they helped clinicians.

P1: ‘I think meeting different kinds of staff and people that experience services was really good. Some of them I didn't know, hadn't met before, and I found that I gave a lot of encouragement to them, because I thought, “Someone says there's this perception that they're helping us,” but I was actually like no, I want to encourage you, because I found I’ve done lots of people-participation work with lots of different staff, and some of the doctors were more limited in their role of who they worked with, so actually felt it was liberating to encourage them to have a role beyond their normal role’.

Healthcare professional participants commonly described feeling that participating in the project had enabled them to work with service users in a way that they would like to replicate within their working lives.

P9: ‘We're all on that continuum. I don't see my service users as “them” and “us”, and that's what was lovely when I think about what the project is, that people could show their vulnerabilities. And that's the reality of being a human being, you know, we all have vulnerabilities and it's just how we manage to cope with that. And people were seen in the group, which I thought was very powerful’.