T/I,, An.\ if, P.\~c,/~f,r/~r,~o~~,. Vol. 10 pp. 233-239, Ankho International Inc.. 1983. Printed in the U.S.A.

THE IMPACT OF THEATRICAL PERFORMANCE ON THE

SELF-IMAGES OF PSYCHIATRIC PATIENTS

RENEE EMUNAH, MA, RDT and DAVID READ JOHNSON, PhD, RDT”

The mental patient is confronted with a rela- tively unanimous verdict about the value of his/her self from society. the family, and the hospital. The mental patient’s identity is inti- mately tied to failure, failure in a very profound sense. The negative self-images of psychiatric patients undermine the stability of every self- presentation, and make every interpersonal in- teraction a potentially dangerous event. In that the central task of theatre involves public presen- tation of self, it is difficult to imagine how pa- tients could negotiate such a challenge. Indeed, Cole (1975) suggests that theatre and schizo- phrenia are mutually exclusive. However, the- atrical production with psychiatric patients is not uncommon, though rarely reported. This paper will describe the authors’ experiences as drama therapists in producing plays with psychiatric patients. We will focus on the powerful impact of the group process on the patients’ self-images, and the struggle between the task of performance and the role of mental patient.

Public presentation of the insane has its roots merely two centuries ago, when for a few pennies one could go to see the insane paraded like ani- mals in public. This practice ended as the con- ception of insanity changed from one of posses- sion and animality to illness. Society’s fears and guilt were managed by hiding the insane from view (Foucalt, 1965), a practice which continued until very recent times. A significant reversal of this trend occurred during the past twenty years as attempts to integrate the mentally ill into the community began.

Theatrical productions, which often served as useful institutional distractions for mental patients (Goffman, 19611, have with greater frequency been presented to public audiences (Brookes, 1975; Johnson & Munich, 1975; Good- man & Prosperi, 1976; Rose, 1982). The com- munity mental health movement has apparently encouraged this bridging between hospital and community.

A play performed by the mentally ill for the public is a unique and powerful arena of self- confrontation, for the audience member who is both fearful of and fascinated by mental illness, and for the patient-actor who is seeking foregive- ness and expecting rejection. The authors have participated in these efforts over the past ten years. They have directed or produced a total of 19 plays by inpatient and ex-patient groups for public audiences in a range of settings. These settings will now be described.

SETTINGS

Y.P.I. Pluyers

Johnson directed six plays in a long-term in- patient psychiatric hospital. The plays were re- hearsed for two months and performed before public audiences. Several of the plays were then toured to nearby communities, schools, and other mental hospitals. The plays were usually developed through improvisation, though several utilized scripts. The casts included 5-12 patients and l-3 staff.

.‘Renee Emunah is drama therapist on the staff of Gladman Memorial Hospital-Day Treatment and Youth Center in Oakland. CA and Northeast Lodge of Pacific Medical Center in San Francisco. She is also on the faculty of Antioch University West, San Francisco and director of “Beyond Analysis.” TheatreiMental Health Project at Intersection Theatre in San Francisco. David Johnson is Assistant Clinical Professor. Department of Psychiatry. Yale University and Clinical Psychologist. Psychology Serv- ice. VA Medical Center. West Haven. CT. He is also President of the National Association for Drama Therapy.

233

234 EMUNAH AND JOHNSON

Johnson also directed or produced eight plays in a special community theatre group, Theater That, which consisted of both ex-psychiatric pa- tients and community people. The goal of Thea- ter That was to foster the patients’ integration into the community by providing them with a normative social experience. The plays were per- formed before public audiences who (other than relatives or friends) were not aware that the cast included ex-psychiatric patients. The plays included both scripts and improvisationally- derived dramas. The casts varied from 1.5-25 members, about half of whom were ex-patients.

Emunah directed several plays in a residential psychiatric treatment center. The plays were re- hearsed for two months and then performed at the center itself for an audience which included people from other community mental health facilities. The plays were developed through improvisation, and dealt primarily with the pa- tients’ real life experiences. The cast included 8-l 1 patients and l-3 staff.

Emunah also founded and directed a theatre group for ex-psychiatric patients, which served as a support system for people in transition be- tween institutions and the community. The plays were rehearsed for 6-8 months. and then per- formed in professional theatres, psychiatric insti- tutions, theatre festivals, and television pro- grams. The plays, which were developed through improvisation, revolved around personal stories and struggles of cast members, in particular their experiences as ex-psychiatric patients. The cast consisted of 6-8 members.

The authors discovered striking commonali- ties among their independent experiences with these theatrical productions. We will describe the basic elements of the group process and its impact on patients’ self-images ( I ) during the re- hearsal period, (7) during the performances, and (3) in relation to the social context of the produc- tion. We will then discuss the effects of different group structures on the intensity of self-revela- tion experienced by the patients.

THE REHEARSAL PHASE

Joining a performing theatre group elicits in- tense feelings of both excitement and anxiety. Excitement is felt because one has been admitted into a “special” group whose central task poten- tially results in overt approval from one’s com- munity. Yet for patients who are socially isolated or thought-disordered. the experience is largely anxiety-producing; they doubt their capacity to be an accepted member of any group. Further- more, the group has expectations and demands to meet. New members fear that the leader or other participants assume they possess certain skills or talent and will be disappointed upon finding they lack creative resources.

The fear of having nothing to offer. of being empty, or, as one patient described it, of “being a black hole.” is often manifested in early cries for a script or other externally-produced sources of material. This fear of emptiness can be seen as an attempt to ward off a deeper sense of inner worthlessness. Many patients expect to be ignored, embarrassed. or rejected. One schizo- phrenic woman was convinced that other cast members and the audience would smell a foul odor she imagined emanated from her vagina: surely anyone who came in contact with her would be disgusted. Another patient expressed this inner revulsion against the self through an obsession with her weight. Although a very at- tractive woman. she perceived herself as too fat and ugly to be part of a performing theatre group. She agreed to remain in the group only if she could be thickly cloaked during the performance, “Elephant Man” style.

Usually these anxieties subside as members become engaged in the initial group sessions, which are structured. playful. and devoid of pressure to perform. The patients’ anxieties may escalate when they apprehend that others do not perceive them in the negative way they see them- selves, and will expect too much from them. They may test the group leader and other members by missing sessions and/or deciding to drop out. as illustrated by the following example:

Don, who had participateci actively and appeared to enjoy the first three seGons. missed the fourth. with no prior notice. When the leacler telephoned him. he curtly said, “I decided to Jrop out.” Upon encour- agement to explore and <hare hi4 feelings around this

THEATRICAL PERFORMANCE AND SELF-IMAGE

decision, he exclaimed, “i don’t want you to think I‘m someone I’m not.” Don seemed to want the leader to realize he wasn’t a “reliable person we could count on” but a deeply troubled individual with a long psy- chiatric history. He feared he would disappoint the group. a fear which carried unendurable weight. Along with this fear was another unspoken one: he would count on the group, only to have it disappoint him.

The theatre group becomes a microcosm of the patients’ larger relationship to the world- their sense of belonging to it or alienation from it, their notions of omnipotence or inadequacy. Although each member of a performing theatre group is indeed “counted upon,” patients often exaggerate the extent of the group’s reliance upon them. They fear that without their partici- pation the group will collapse and therefore ex- pect tremendous pressure to be exerted on them. The converse of this grandiose notion is a fear of not counting at all, of insignificance and worth- lessness in relationship to the “talented” group. Relief is experienced with the realization that the group goes on functioning without them and that they do not in fact possess the dreaded power to destroy the group, but that they are certainly missed and cared for. The patients’ relationship to the group thus becomes clearer as reality mediates their fluctuating self-perceptions.

Before the performance piece is established, members are often able to form a cohesive group identity, facilitated by the playful interaction, the emphasis on improvisation, and the strong pres- ence of the leader. As in any drama therapy group, self-image is expanded through experi- mentation with a variety of roles within the safety and boundaries of the structured group. New aspects of the self are elicited by the sense of permission and freedom to be different; after all, one is only acting. As one weaves in and out of numerous characters, relationships, and situ- ations, rigidity of self-conception and behavioral response is confronted. Praise for small achievements in the group paves the way for ac- ceptance of the success and more dramatic change in self-image which is to follow.

By the middle of the rehearsal period, the play and the group have each begun to take on an identity of their own. The gradual construction of the Play. which has developed from scratch, and the gradual formation of the Group, which has

developed out of separate individuals, serve as a model to the patients for the creation of an iden- tity. The patients have begun to incorporate the identity of the group as their own, experiencing reassurance in being part of something larger than themselves. They now belong to an enter- prise with characteristics of both the family and a work-group which strives toward a specific goal.

On the one hand, identi~~ation with the group and with the play offers protection. Fear of em- barrassment and exposure among the cast is one of the forces linking them to each other and to the play. In competition with this force is the tre- mendous desire to define and differentiate the self. One wishes to personalize and “own” one’s role, and to have oneself become distinct within the play. The need to reassert individuality and inde~nden~e at this point is stimulated by the increasingly intimate environment, which evokes fears of being engulfed or trapped inside the group. The feelings of security, comfort, and joy which the identification with the group engenders may seem risky.

Patients frequently attempt to define their per- sonal boundaries by amplifying existing difficul- ties or conflicts and responding rigidly with less willingness to compromise. Other commitments may suddenly interfere with the rehearsal sched- ule. Some members may refuse to be in the group’s publicity photographs, or may insist on significant alterations in the play. Others may draw attention to racial differences. Adherence to regulations becomes associated with con- formity, and rebellion with independence. The degree to which the leader will modify the group structure in order to meet the idiosyncratic, per- sonal needs of individual members of the cast is challenged. Often a crucial confrontation be- tween the leader and a cast member highlights the fact that the play is a real task, in a real world, to be performed before a real audience, and requiring commitment and compromise from everyone. One member in an inpatient produc- tion stood obstinately at the door of the gym with a huge bowl of ice cream, despite the rule that there be no food during rehearsals, insinuating “you need me whether or not I follow the rules.” in another group, a patient refused to participate until she received an eggroll from the kitchen. In a production of ex-patients, a cast member wanted to go to Washington to protest the arms

236 EMUNAH AND JOHNSON

race during the final rehearsals. In each case. the director/therapist represents the reality of the task-that sacrifice of personal needs is required to create, as a group. an actual product. In this way, s/he supports the patients’ adaptive skills.

The other component to this acting-out behav- ior is the increasing anxiety about the upcoming performance. The self is not only contending with its relationship to the group, its relationship to the product or play, but the realization that outsiders, the audience. will soon be entering the picture. The self will be seen and judged by an objective outside world, which is unfamiliar with the internal group and individual process. The patients have very little conception as to how this outside world will perceive them. It is here that the performance group differs sharply from a non-performance group. In a performance group, the outside world (the audience) is a part of the group’s therapeutic context from the very be- ginning. The performance is seen as marking the climax of the group’s life. Members usually sense the development in their self-images as a result of the group‘s work in rehearsal, but the brutal and exciting confrontation with the audience is seen as a confirmation of it. The demands of acting in front of an audience are experienced as greater- than-ordinary demands, bringing about a sensa- tion at this point of taking leaps, not mere steps. To the cast members, it seems that the potentia1 achievement in the upcoming performance could compensate for hundreds of failure experiences.

But the patients are facing dangerous un- known territory. Success is unfamiliar and con- tradictory to their poor self-images. Failure, with its implication of subsequent rejection, is more familiar, but also devastating. The drama thera- pist can help the patients become aware of these fears, and encourage the group to share feelings and offer support to one another. The patients may feel: “If it’s a success then will my outside support systems abandon me. since they will think I have ‘made it’? What will others’ expec- tations of me be like, if i can succeed at this momentous event? What if I’m a big success but still feel miserable and scared inside and nobody knows it‘!” An internal battle with success is tak- ing place. The will to failure-the result of a long h&tory of rejection which one feels a compulsion to repeat-may even lead to outright attempts to sabotage the performance. Again. the individual

needs to test his/her power against the solidity of the group. Group interdependence is unavoid- able. and one fears both responsibility to others. and betrayaf by others. Most members. though furious at the saboteurs, also unconsciously identify with them.

In many ways the performance is like a planned crisis: one knows when it is coming. but no matter w)hat one does to prepare, that fright- ening moment on stage in front of the audience is soaked in possibility. The safety and structure of that moment can only come from within. One patient used to say: “Please, only one trauma per hospitalization!” This trauma is signalled usually about a week before the performance when the director and cast realize that there is no more time for testing, and only an all-out effort will do. The complex fears inherent in this process are then transcended by the immediacy of the task and the group’s cohesive effort. The members discover their basic trust in themselves, in others, and in the leader, which has slowly de- veloped throughout the rehearsal process. The cast finds itself prepared for success, rather than for failure.

THE PERFORMANCE PHASE

On stage. the patients present themselves in a new way. They make the audience laugh. cry, reflect; they have power. They are actors. not spectators; activators, not victims. Their strengths are apparent: their problems or symp- toms are much less visible than usual. They are being seen as integral parts of a close-knit group. They are receiving a lot of attention through ap- proved and constructive means. It is certainly a new image. The response and applause the patient-actors receive from the audience is gen- erally far greater than they had envisioned. Since in improvisational drama one creates and per- forms with one’s own self/body, ownership is nearly unavoidabie. The self is the material of the creation, and the self is being applauded. The impact on self-image is extraordinarily powerful. The fact that the achievement is shared with one’s group of patient-actors strengthens and in- tensifies the impact. The reaction is one of exhil- aration. pride. and affirmation of an identity. One patient described feeling as if she were “shouting to the world: ‘See. I’m able!‘”

THEATRICAL PERFORMANCE AND SELF-IMAGE 23-l

After the performance, the integration of the new positive self-image and identity poses a dif- ficult therapeutic task. The image of the success- ful actor whom everyone keeps praising collides with the former image of a mental patient with a poor prognosis. The “old self * may need to reas- sert itself to avoid confusion. Post-performance depression, an experience common to all actors, is pa~i~ularly acute for psychiatric patients. Tak- ing apart the stage-set, clearing away props and costumes, and witnessing the now empty per- formance space devoid of audience or life be- comes associated in the patient’s mind with dis- integration or destruction of the new self-image. Social withdrawal, superficial suicidal gestures, substance abuse, brief hospitalizations are not uncommon (Johnson, 19801. Given a supportive group framework, regularly scheduled workshop sessions, and ongoing rewards as tangible proof and reminders of achievement (i.e., performance videotapes, photographs, newspaper articles), symptomatic behavior gradually subsides and the new self-image is assimilated.

The opportunity to continue performing the play or to “take it on the road” often presents conflicts within the group. Some members rigidly insist on initial commitments and time frames. Stretching their potentialities yet further, pro- longing expectations, and reinforcing the new self-image as Actor threatens them. The grip on the success experienced and the positive self- image may be so tenuous that they want to safe- guard it, rejecting whatever might contaminate or jeopardize it. If there are no more performances, possibilities of failure are eliminated, and they can truly say, “I did it.”

If the performance group is terminated follow- ing the period of celebration and assimilation, many participants will challenge themselves by beginning a new project. Some audition for a play in the community, start a job or school, or com- mit themselves to something which, at their present level of functioning. they can adhere to and derive satisfaction from. If the group is ongo- ing, continuing members may suggest working toward a new performance or project. In general, increased self-esteem and renewed energy and optimism in life are manifested during and immediately after the performances, and then again beginning one to three months following the performance period. As one member put it.

“It’s like a new start in life and with myself; there’s so much I can do!”

THE CONTEXT OF PRODUCTION

In an inpatient setting, the cast members gen- erally perform to people who know them well: staff and fellow patients. The dynamics differ from a public performance in that this audience observes them in many contexts outside of the theatre group: in fact, the audience will see them the following morning. The audience is delighted and impressed with the patient- actors, and surprised to discover the extent of their strengths. In some cases, though, cast members may be inhibited. They are reluctant to behave in a new way in front of doctors, counse- lors, and peers, whom they know perceive them as capable of so much less and who may after- ward expect too much from them.

Because the cast members in an inpatient set- ting are part of a larger community-the institu- tion-the identi~cation with the theatre group and with the role of actor distinguishes, and in some sense elevates, them from their peers. This distinction can create conflict within the person and within the institution (Johnson, 1980), but can also enable cast members to detach them- selves from a prevalent negative self-image among inpatients: that of a hopeless and helpless individual. Increased identification with the role of actor and decreased identification with the role of mental patient is manifested even more clearly when the group performs at outside psy- chiatric facilities. After a show at an out-of-town mental hospital, the patient-actors were heard joking among themselves about their audience: “Boy, were t/y ever crazy!”

In a commumty setting with ex-patients, if the audience is aware that the people on stage have been psychiatric patients, then they also recog- nize the struggle and victory the process entails. The applause is not only for the performance, but for the actors as people. For the group members the potential split between self-image of actor and of patient may be minimized. They have the experience of being simultaneously successful and accepted as having a psychiatric history.

Beyond Anuiysis had lengthy discussions as to how to present itself to the public. At first the publicity ads for performances were somewhat

238 EMUNAH AND JOHNSON

ambiguous, but after a year they stated explicitly that the cast consisted of ex-psychiatric patients. It seemed that once having been successful the group was more secure with its identity, felt less of a need to hide its history, and attached less stigma to mental illness. In fact, the cast felt it had a purpose: to educate the community and to offer the public and institutionalized people a positive image of those who had been in the men- tal health system. After another year of suc- cesses, though, the question of how to describe the group re-emerged. This suggests that, once a certain degree of growth is achieved, the former identity of patient is perhaps ready to be shed. For some members, resisting identification as an ex-mental patient was from the beginning a healthy sign; for others it was an attempt to camouflage and deny existing problems.

If the group members have not only “come out” as ex-psychiatric patients, but have created a play about their own lives and selves, then the audience applause for the product is even more

intermingled with an applause for the actual people on stage. Rather than being a means for disguise, the play facilitates self-revelation and disclosure.

One scene in A T~~t~tlct~c~~ to Get into Dqjkult Sittrcc-

tiorls (Y.P.I. Players) consists of two patients con- fronting each other about drugs, sex, and their sick relationship. They end up on a bridge contemplating suicide. At each performance the outcome is different. Another scene begins with a patient-actor being tied into a straightjacket. The cast chants “We’re doing this for your own good” as he struggles to get out. The chant transforms into “free, free”; the audience joins in, and the volume increases until the patient breaks out.

In a scene from 1t1.\itlc Out (produced by B~~yoml Amr/~~.\i.\ ), a young man hears voices seducing him into suicide. During the scene. he gradually finds the strength to actively respond to the voices (which are played through the theatre’s sound system). As he gains power over the voices, he also realizes that they are a part of him. rather than an external phenomenon. The patient-actor‘5 actual dialogue with his voices var- ies at each performance.

In each of these examples, audience members,

sensing the immediacy and authenticity of the patient-actors’ struggles, were riveted to their seats. The patients’ struggles had become sym- bolic of everyone’s struggle. Personal fear had been translated into the language of theatre. All

three scenes were highlighted in reviews in local newspapers.

Transformation of self-image is heightened in these self-revelatory performances. They are reminiscent of the ritual purging ceremonies of primitive cultures, in which evil spirits are expelled in the presence of the entire tribe (Collomb, 1977). The patient-actors stand in front of many people, reveal parts of their insides. and are applauded. They experience a sense of ex- pelling the bad or sick aspects of the self. or. preferably, of acknowledging and integrating these aspects. Patient-actors who use the play to divorce themselves from actual problems find that the boost to their self-esteem is short lived.

Self-revelation by cast members affects the misconceived images a public audience often has of mental patients, presuming their problems to be foreign and bizarre. A kinship is established between the audience and actors. For the group members, who perceive themselves as alien. the audience’s identification with their struggles brings about a sense of belonging to the larger community rather than exclusion from it. The self, already part of a small group, now becomes part of the world.

SUMMARY

The process of a theatrical production pre- sents both challenges and opportunities to the psychiatric patient. Tremendous pressures are mobilized internally and externally for changes in self-image. The risks involved are contained by the support of the group and the drama therapist. who is responsible for monitoring the impact of the experience. The intensity of this impact seems to be particularly affected by three major factors.

First, the degree of the audience’s awareness of the patient status of the cast has a tremendous influence on the patients’ experience of the play. that is, the degree to which the patients feel their identities are laid bare in a public forum. It is our impression that the most powerful performances occur when the audience is aware of the cast members’ patient-status and consciously identi- fies with their struggles. In some performances of Theater That, the audience’s lack of awareness generated stress for the ex-patients. who felt they had to keep crucial aspects of themselves con-

THEATRICAL PERFORMANCE AND SELF-IMAGE 239

cealed. Their desire to have the bad parts openly acknowledged and forgiven by the community was in large part frustrated. The structure of the performance situation required them to express their internal distress through less direct, sym- bolic vehicles. On the other hand, certain ex-patients looked forward to shedding the psy- chiatric identity, and to testing themselves as “normal.”

The second major factor is the degree to which the script reveals the personal lives of the pa- tients. The actors experience a greater access to the self when the content of the plays approxi- mates their own experience. derived through im- provisation rather than from an external source. Generally, inpatients and many ex-patients pre- fer, and perhaps require, the direct link to the outside provided by an improvisationally-based script concerning their personal lives. The task of translating one’s personal issues into a portrayal of someone unlike oneself may be more reward- ing for patients further on the road to recovery. These patients are usually able to sustain the burden of maintaining a symbolic rather than a direct link between internal and external worlds.

The third factor is the degree to which the cast processes their personal relationships with each other and with their roles during the rehearsal period. Our experience indicates that patients utilize process sessions to help integrate new perceptions of themselves generated by the play with their “old” selves. Processing sessions of this type are particularly useful when the play is not concerned with mental illness, and/or the audience is not aware of the cast’s patient status. The cast then acquires certain functions of the audience: it openly acknowledges and legitimizes the personal transformations which take place within the members’ self-images. In several ex- patient performance groups, major revelations occurred in the cast meetings rather than in the performances.

The cast meeting, the script, and the audience are three interpersonal structures which organize experience at increasing distances from the self, through which the self can be disclosed. The ease or directness through which the self can be expressed at each one of these levels varies, according to the degree of “opaqueness” of each of these “membranes.” in the case of greatest opaqueness. with the audience unaware, the

script externally-derived, and little cast process- ing, any process of self-transformation is largely contained within the self. In the case of least opaqueness, with the audience fully aware, the script overtly concerning the patients’ lives, and active processing within the cast, the self is most opened to the world.

Many inpatients and ex-patients feel so cut off from the world and so isolated, that symbolic or indirect means of linking self and world prove inadequate. Generally, we have found that facili- tating the selfs access to the world by directly representing their struggles as mental patients in the content of the play, and in the audience’s awareness of their identities, has been most ef- fective. However, as they leave their hospital experience behind and develop their own links to the community, they are often capable of con- tinuing this work within themselves, or with therapist and friends. Thus, they are increasingly able to tolerate plays with greater opaqueness, often beginning at the audience level, then the script level, and finally the cast level. A network of theatre experiences varying along these di- mensions would be most advantageous to the re- covering psychiatric patient.

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COLE. D. (1975) T/W Tl?~,ft~~i~~ti Evrvzr. Middletown, CT: Wesleyan University Press.

COLLOMB, H. (1977) Psychosis in an African society. In C. Chiland (Ed.), Lorry-Tmn Ttvctrnrmr.\ ctf’ P.t_vchn?ic Strrr~~.~. New York: Human Sciences.

FOUCALT. M. ( 1965) ~~t~tt~,~s~\ trttd e;~,~~i~~tr;~~t?. New York: Random House.

GOFFMAN. E. (l%l) Asylttttr.s. New York: Doubleday. GOODMAN, J. 6t PROSPERI, M. (1976) Drama therapies in

hospitals. 77rc Drcontr Rnh~~. 20:2O-30. JOHNSON, D. (1980) Effects of a theatre experience on

hospitalized psychiatric patients. Ittr. ./. Arts P.yvchorhcr.. 7~265-272.

JOHNSON. D. & MUNICH. R. (197.5) Increasing hospital- community contact through a theater program in a psy- chiatric hospital. no.cpifrrl cfrrd C’cmt~~trttir~ Psychirrtt~. 26:435-438.

ROSE. S. i 1982) Producing ‘Our Town’: Therapeutic theater in a psychiatric hospital. ~~~.s~jr~i/ nnd ~~~~~~?z~f~?~r~ Ps,+ dziitrrx.. 33:101~~020.