Mental health difficulties remain a major source of burden and distress for individuals, families, health and social care providers with stigma a key target for educational campaigns attempting to improve care pathways and access to support. Stigma is a multifaceted concept having a range of drivers including shame and is thought to act as a barrier to successful help seeking and engagement with support services. The current paper explores some of the salient themes that emerged from a British university drama project on the impact of symptoms and behaviours associated with a severe mental health condition on a young couple's relationship and reflects on the opportunities for connection with an audience provided by the medium and experience. It is suggested that enabling the impact of mental ill health to be explored in a protected environment such as theatre can allow for reflection and empathy to develop, with potential for positive impact on awareness understanding and stigma. Elements of the drama setting and narrative are explored, and analogies are made with the emerging literature on post-traumatic growth.
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Mental ill health remains as one of the great unresolved issues of our times, having an impact at every level of society and being associated with enormous burden, cost and individual hardship. Despite the ubiquity of mental health difficulties and the many advances in understanding of risk factors and development of effective treatments, general populations across the world continue to hold poor levels of emotional literacy and understanding alongside high levels of stigma in relation to mental ill health. This situation is associated with low awareness of early signs and symptoms, late help seeking, shame, discrimination and enormous burden across personal, social, vocational and health service domains.1–5
The current paper explores some of the salient themes that emerged from a British university drama project on the impact of symptoms and behaviours associated with a severe mental health condition on a young couple's relationship. The ‘monologues’6 were developed and presented by Newman University Community and Applied Drama Laboratory (CADLab) at the Midlands Arts Centre in West Midlands in the UK and follow ‘Simone’ and ‘Brian’ as their lives are challenged by the emergence in Simone of what in psychiatric terminology would be described as bipolar disorder with psychosis. The impact on their ‘ordinary’ lives and personal relationship as they cope with the additional imposed roles of ‘patient’ and ‘carer’ is given voice in separate monologues ‘I care’ and ‘Simone’ where each characters’ perspective and hard-won insights are emotively described from within the stage setting of a Greek labyrinth.
Their dramatised journey faces them with issues of loss, grief, shame and stigma, and the audience is challenged to engage with the actors in role to discuss some of their responses and observances immediately after the performance. We have described the elements of the production and audience participation in more detail in a previous paper. The dramatisation was inspired by a series of case study conversations with people with lived experience of bipolar disorder that was made available on the UK Royal College of Psychiatry website 2012 combined with advice from an expert panel of carers and professional staff and the assimilation of medical model-based diagnostic criteria alongside media reviews of this topic.
Here we focus on the dynamics of stigma, shame and transformation that remain highly relevant for individuals experiencing the impact of mental ill health with reference to recent psychological research and literature. We ask why stigma remains so intransigent in relation to mental illness when mental ill health is known to be highly prevalent and explore devised theatre as an appropriately safe medium within which an audience can engage with and consider the human impact of stigma and mental ill health. We further explore whether the experience of mental ill health can in some cases provide a catalyst for a new and deeper relationship with life drawing from the literature on post-traumatic growth (PTG). We additionally contemplate the stage setting of a labyrinth beyond its role as a stage device and describe an analogy with the ‘hero's journey’ described by Joseph Campbell7 that involves a testing and transformative journey of hard-won insights into knowledge and personal meaning.
Mental illness: why is this important?
Although we employ psychiatric terminology in describing mental health conditions for the purposes of clarity in this paper, the understanding that mental ill health per se is related to a combination of socio-environmental, psychological and biological factors (the ‘biopsychosocial model’) underlies our thinking. We admit to writing from a westernised biomedically focused culturally ethnocentric perspective and fully acknowledge that there is much variation in the interpretation of beliefs, symptoms and experiences that co-exist with the biomedical descriptions employed here.8–10
Most mental health conditions have been found to first emerge in childhood and adolescence, half by age 15 and 75% by age 2511 with 30% of mental ill health directly attributable to adversity in childhood such as abuse, neglect and domestic violence.12–14 For example, childhood adversity is associated with 45% of all childhood onset psychiatric disorders and with 26%–32% of adult onset disorders.15–17 The biological impact on the developing brain of such chronic stress in childhood results in cumulative vulnerability to a wide range of emotional and physical ill health conditions and harmful behaviours.18 ,19 This suggests an urgent need to prioritise social and environmental interventions alongside medical models of cause and cure. It also may help to set the context for understanding why stigma has remained a constant companion to mental health difficulties with Hinshaw noting:
Despite real progress in terms of scientific knowledge regarding causal factors for mental disorders, the development of empirically supported treatment strategies, and increased public knowledge of the concept of mental disorder, mental illness—particularly its most severe forms—continues to be engulfed in stereotype, prejudice, and stigma, promoting shame and silence and perpetuating a vicious cycle of ignorance, distancing, and punitive societal responses.20
For many individuals and families, seeking even advice or information on these topics is itself regarded as shameful or stigmatising with associated avoidance of help seeking. Corrigan21 describes how both public stigma—the local consensus view of mental illness—and self-stigma—the degree to which an individual internalises negative beliefs and stereotypes about mental illness—operate to keep those experiencing mental distress from seeking social support, employment or treatment.
In our efforts to find the linguistic roots of stigma (στίγμα in Greek) and understand the meaning of the word over the centuries, we found that it refers to the type of visible marking that was cut or burned into the skin of individuals identified as ‘morally polluted’, such as criminals and slaves, and thus forcing individuals to literally carry shame and disgrace as a ‘tattoo of dishonour’.22 ,23 Stigma and its components including knowledge (literacy), attitudes (prejudice) and behaviours (discrimination) are suggested as key targets in enabling improvements in mental health pathways to care and although some excellent work has been carried out by national programmes in the UK and other regions (eg, the ‘Time to Change’ campaign to reduce stigma in England5), there is still no mandatory training or awareness raising on these topics while up to 75% of people experiencing mental ill health receive no appropriate treatment.24 One avenue to challenge stigma and increase awareness and understanding we here explore is through drama and devised performance in theatre.
To challenge a theatre audience's thinking on these topics, we invited general public audiences to discuss and explore it within the theatre setting in postshow talks. Such methods can act as a catalyst for highlighting and transforming our personal views and behaviours, and thus can potentially be more effective than a news story or a film in engaging our critical faculty to digest and imagine ourselves within the scenario.
We were concerned with the ethics of inviting audiences to openly discuss sensitive issues such as their personal views on the experience of mental ill health with the risk of assumptions, heated misinterpretations and judgements about the play, the characters portraying mental illness and the artistic view of real-life phenomena. Thompson writes ‘When creating theatre with vulnerable or marginalised communities, the ethics of our practice must be a paramount concern’.25 Here the artist is engaged in the exploration of different questions, ideas, cultures and environments, trying to make sense of what it means to be human and what it means to be healthy and accepted. These questions are important as they may bring the artist's personal ignorance, bias and prejudices to the surface. There is always the risk of unintentional misinterpretations of the situation because the artist is a central figure, one who filters facts through personal experience and reflection on illness. Filtering stories is an ethical issue and places a great responsibility on the artist who requires real empathy to visualise how the person who experiences mental illness sees things.
We understand for instance that many mental health conditions such as bipolar disorder are often represented within narrow negative stereotypes as ‘difficult’ yet those with lived experience may value elements of their experience such as increased confidence, higher energy levels and a sense of increased connectedness with others which are a salutary reminder that labels of ‘ill health’ or ‘illness’ imposed as an attempt at diagnostic classification may encourage a very reductionist understanding of the actual lived experience and understanding of recovery.26–28 By this we do not imply that there is a ‘right’ or ‘wrong’ way to see mental illness but rather that people tend to employ judgements in polarised ways. There is no assumption that audience members share the same views about tolerance and acceptance of mental illness and stigma. We all carry around our personal experiences, values and ideological luggage and bring it with us to the theatre. We have unique histories, which are individually ‘marked’ by past experiences and our thinking is shaped by the ways that we have embodied these experiences. It follows that there is little we can promise about objectivity and transformation of attitudes about mental illness and stigma through artistic practice. However, we do feel justified in engaging in a theatrical experiment exploring pre-existing biases about mental illness in society and reflecting on the struggles and experience from dual perspectives, those of the individual and the caregiver.
We tell the story of a woman in her 30s who lives with bipolar disorder and her life partner who builds a protective environment around her to support her recovery. Through the characters' perspectives on the same story, we hoped to provoke some thinking about the interface of mental illness everyday life and how much theatre can reveal about attitudes and shame. To reduce individual bias, we took careful steps to justify the selection of ideas for representation of the characters by involving an advisory group of psychiatrists, psychologists and caregivers with experience of working and caring for people with mental illness. We also were inspired by a series of conversations with people with lived experience of bipolar that were made available on the UK Royal College of Psychiatry website.
We then devised two meaningful narratives in the form of monologues giving dramatic structure to the experience of mental illness and stigma presented from two independent perspectives: that of the person experiencing mental illness and that of the caregiver. In the play, the partners share their stories through independent lenses, not aiming to contradict each other but presenting with different viewpoints. We aimed to convey the message on stage that one character does not control the other and they are not subject to each other's authority choosing to remain in a caring partnership. The proposition in the drama is that the partners can be respectful to each other, self-sufficient and autonomous in real life as long as their relationship and their experience of illness allows it.
Shame and resolution
Erving Goffman, considered one of the most influential sociologists of the 20th century, described the impact of stigma on an individual as a spoiling of self-identity in relation to a perceived flaw or undesirable characteristic when judged against the norms or expectations of the society in which the person lives. The link of stigma with shame is a short step as Goffman describes:
Shame becomes a central possibility, arising from the individual's perception of one of his own attributes as being a defiling thing to possess, and one he can readily see himself as not possessing.29
This suggests that shame can involve a painful psychological alienation from an individual's peers and this can also have powerful motivational functions in social settings. Hence, the capacity to feel ‘shamed’ (and its lesser relative, embarrassment) appears to have developed as a boundary—a way of keeping individuals ‘in line’ and adhering to social norms under intense peer pressure and scrutiny,30 ,31 We will explore the crossing of this boundary in later sections of the paper. Stigma and its constituent shame is thus a dynamic, multifaceted social process that is associated with ‘outsider’ status and has been consistently implicated as a key contributor to poor outcomes for many people who live with stigmatised health conditions, such as mental illnesses.32
Early in the monologues, Simone shouts at the internal voices that would not leave her alone, constantly sitting in judgement and commenting on her. She describes that at first the ‘voices’ had been supportive and helpful until becoming dark and threatening and we learn that the ‘ups and downs’ of her symptoms have resulted in her losing her confidence, her florist business and her freedom for a time when hospitalised—blaming her family and partner for being complicit in these losses. Her partner Brian feels that he had been supportive and overwhelmed at the changes in his partner and personal struggles in coping with work and life. He now describes a pivotal moment—facing Simone about to tell her he is leaving her: ‘..we're not the same people we were..’. But as he speaks he experiences a revelation regarding how he really sees her and their situation for the first time in a new more expansive way. Brian has developed insight into what is really important in his life journey—to really connect with another human being: ‘.. all the colours were there..’ and later both acknowledge that although exhausted from the process they had learned a lot about life, about themselves, had faced down shame and humiliation together and were able to accommodate more as a result. They have routine, some local work, family and true friends that stuck by them—a tight supportive community—with new hopes and dreams for the future. Brian and Simone both realise their experience has intensified their relationship, they are closer, united and recognise joy in their acceptance of each other.
From a safe aesthetic distance and within a protected dramatic environment, the audience of the monologues could experience the shaming, self-blaming and the steps taken to reach towards reflective insight, acceptance and understanding. The audience was encouraged to see from the perspective of Simone and Brian, to feel the conflicting emotional states and to explore stigma and how it affects people's lives through the drama. In a previous paper, we describe this process planned to elicit an interactive response through provocative postperformance discussions and related activities across media and public settings. Importantly,
the monologues' significance lies in democratising mental illness: bringing mental illness into domestic situations as Ibsen did in his plays showing how mental illness is a contemporary event happening in families like it happens to members of the audience.. using the dramatic conventions to bring onstage what is often hidden behind closed doors..6
To democratise mental illness through depictions of reality, we first need to value the need for this discussion in public and the potential of raising awareness about stigma through this discussion. At the theatre, we can imagine the possible before acting to make it happen. We need to believe in equality between members of our society to discuss what troubles us at the theatre. What is democratic in this process is the right of speaking personal truth and listening to truth; addressing mental illness in the play, experiencing and expressing emotions about the hidden meanings of mental illness through the characters; exploring different perspectives of the same story from the individual and the caregiver's point of view; and questioning the attitude of individuals and society as a whole to the stigma that is related to mental illness. The ethics of representation of illness on stage is a major issue as it potentially contributes to the shaping of public opinion in relation to the image of individuals with lived experience either directly or indirectly. The communication of mental illness experience on stage can be difficult, its portrayal may appear unidimensional, lacking subtlety and lacking diversity or it may challenge the artist to face ethical questions about the educational role of the arts in health-related contexts. Questions of patient autonomy, privacy, the confidentiality of personal information and compulsory treatment are all powerful contemporary topics for debate. Indeed, we lack agreement across disciplines and cultures as to what mental illness actually is. However, the complexity of the topic should not prohibit reasoned debate as long as we respectfully admit the limits of our own understanding. We should remind ourselves that what is unexamined or under-represented often remains unenlightened offering no help for improving our attitudes, lives and communities.
In the monologues, we believe that we have portrayed different aspects of the individuals' experience. For instance, Simone describes Brian's protection as intimidating and restricting her personal freedom to practise her professional skills as a florist and accomplish her dreams despite her health condition. In contrast, Brian's priorities are to construct a safe and structured environment for his partner to help her deal with her loss of professional role, mood swings and poor concentration. This was one of the many reminders that truth is relative and in the eye of the beholder. Acknowledging that protection could have been interpreted as a point of conflict in the postshow discussion, we expected heated exchanges of views from the audiences as we were concerned about the potential of the drama to trigger raw personal experiences. However, the talks revealed the story had allowed the audience to relate the dramatic to personal experience safely—with the protection of fiction that happens in theatre ‘as if’ situations33—the story enabled the service users, caregivers and others who were present to reflect retrospectively with a focus on the story outcome. Thus, performance was intended as an enjoyable evening, and the one involving an experience of sharing between the artists and the audience. At the theatre, it can happen that the personal becomes universal and vice versa; however, we clearly accept that theatre is open to interpretation and there is no guarantee that audience members reached any new insightful understanding of bipolar disorder or that any would subsequently be galvanised to challenge mental health stigma. It is also understood that individuals experiencing mental ill health have differing backgrounds, cultures, class, race, sexuality, identities, histories and experiences and theatre can never portray a comprehensive representation of mental illness per se on stage, not even of bipolar disorder as a more narrowly defined condition. Nevertheless, we trust that the performance responsibly told a story of two people, whose lives were affected by mental illness directly and indirectly, with insightful care, sensitivity and attention to ethics.
Setting the monologues: the labyrinth and the hero's journey
The inspiration to create a ‘labyrinth’, as the key element of the set on stage, came from a Knossos coin from the third century BC34 (figure 1) which portrays the mythical Cretan Labyrinth constructed by Daedalus to contain the Minotaur, the half-man, half-bull creature. The historical labyrinth is a place of high danger where all is risked, and the dead ends, distractions and blind wandering can be fatal without a guide or help. The ‘return’ for those successful enough to have found their way to the centre, confronted primal fears and safely returned to the exterior or ‘real’ world with new insights may be equated with a broadening of world view that is often not easy to share with others.
The monologues set was designed as a representational space on a number of levels. Artistically, the labyrinth was constructed of pebbles that portray the landscape in the characters' back garden. Symbolically, the garden as physical space is a replica of the characters' personal and emotional space. It has to be symbolic because theatre aspires to rise above life—not merely repeat it, and because the human imagination feeds on symbolism.35 ,36 Through symbolism, the artist intends for the audience to see the potential, to accept the convention (a garden landscape that works as a pattern for the characters to tell their story) and by doing this, to accept the possibility that Brian and Simone are engaged on their own paths of personal development when we see them on stage pacing the coiled trails of the labyrinth. As they walk their story reveals their inner experience, their suffering as well as the celebration of being present, being fully alive through adversity on a metaphorical journey from ‘outside’ to deeper within their private selves. Inevitably, each member of the audience may find a different way of relating to the characters' journey. The symbolic feeds the imagination leaving the action open to interpretation.
To walk the labyrinth as installed onstage may seem to be a minor physical task, but it provided the audience with a major condition for drama: aesthetic distance. ‘Aesthetic drama’ is the term that Richard Schechner37 performance theorist and theatre director uses to describe the traditional performance, where audiences know that they are indeed audiences; they are there to watch a play, engage and respond, safe in the knowledge that what is unfolded on stage is not real life. The audience is seated at a distance from the theatre event, and they keep their distance both literally and metaphorically. The performance may look similar to reality, the correspondences may be close, but there is no confusion between real and fictional. Jackson38 describes this boundary line between art and life as central to the very business of art. The intention is that the audience believes the fictional as if it is real, but at the same time they are aware of the functionality.
No matter how engrossed in the lives or problems of the characters on stage we may feel, the fact that at the same time we know it's also a fiction […] enables us to see, reflect, perhaps understand more clearly than we normally might, beyond the noise and flux of everyday life38
The use of the labyrinth was intended to set the play beyond the noise of real life into a timeless ‘mythical zone’, which can be anywhere in the past, the present or future and aimed to provide the audience with a visual and metaphorical ‘safety net’ allowing for retreat from the intensity of the exchanges on stage.
As a physical and psychological motif, the labyrinth holds potential to provide a powerful metaphor for the journey seeking personal insight, truth and knowledge that has been explored and amplified by the mythologist Joseph Campbell as the ‘monomyth’ and ‘the hero's journey’7 Campbell suggests that key stages and elements of the journey form a template that most folkloric and adventure stories across cultures reference where the protagonist is faced with an urgent personal challenge that will involve stripping away ego and hubris, acceptance of vulnerability and developing intuition and wisdom in a deeper connection to life and nature (figure 2).
The parallels of imagery with the labyrinth theme are clear as both include the possibilities of avoidance, wrong turnings, frustrations and distractions, or places to linger if resolution wavers. Both guarantee some suffering in terms of anxiety, disconnect or despair and a clear message that an essential humility is vital to begin to hear and learn from good advice. Finally, both can suggest a positive transformative function and outcome of the experience as an expanded understanding of the world and of our individual and collective place in an ongoing journey. It must be acknowledged that although these were latent references in the performance setting and in the ‘journey’ of Simone and Brian, there is no evidence that audience members attended to or were influenced by these themes and metaphors.
Stigma and POST TRAUMATIC GROWTH
The belief that difficult life experiences that test human resilience can be motivational resulting in a change of attitude or behaviours increased perception psychological growth and insight has often been referenced through religious teaching, drama and through the traditional telling of folklore and fairy tale. The term ‘post-traumatic growth’ was first used by Richard Tedeschi40 to describe a change in thoughts and behaviours resulting from the experience of challenging life events or situations. PTG describes a change to an individual's way of understanding the world and their place in it, differing from other psychological constructs such as hardiness or resilience as it is not regarded as merely the ability to respond to stressful situations by ‘bouncing back’ to the prestress level of functioning but rather a shift beyond the previous level of functioning often embracing a new way of understanding the world and the place of hardship within it. The psychoanalyst Victor Frankl in his book describing the impact of incarceration for years in concentration camps during WWII wrote:
We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into triumph, to turn one's predicament into a human achievement. When we are no longer able to change a situation–just think of an incurable disease such as inoperable cancer–we are challenged to change ourselves…41
Although suffering for Frankl is not the only or even the desirable route to find meaning in life—the message he proclaims is that even when life seems most without present hope—meaning is still within the control of an individual.
Tedeschi and Calhoun40 describe five general outcome domains involved in PTG: a greater appreciation of life and new understanding of priorities; a greater sense of connectedness with others; increase in personal resilience; recognition of new possible directions in life and an embracing of spiritual development. These would appear to accord with the essential need to actively embrace meaning and purpose that Frankl describes. According to Tedeschi and Calhoun, PTG can be facilitated by the process of self-disclosure in the context of a supportive social environment. PTG has been described as a universal phenomenon with cultural variations but has also been criticised as arising from an illusory sense of change42 Although it is probably too early to make any definitive statements about PTG, research findings appear to suggest that there are real transformative life changes that are commonly reported in response to trauma that are empirically measurable and tend to fall into three categories: finding new abilities and strengths; improving connectedness and good relationships and a positive understanding of place in the world and direction.42–44 Engaging with the sequelae of trauma such as stigma and shame may indeed be key motivational factors eliciting a process of positive reengagement with life. In recent research, Lickel and colleagues45 have begun to examine shame as a motivational factor in eliciting positive change—but one that also carries a risk of getting stuck in a cycle of avoidance. They write:
Of course, an intriguing issue posed by our research is the question of why, if shame does motivate a desire for self-change, it sometimes predicts a recurring cycle of maladaptive behavior (Tangney et al, 1992). One possibility is that in addition to motivating a desire to change the self, shame may simultaneously elicit a motivation to suppress and deny that painful emotion and avoid situations where it is triggered. Indeed, people generally nominate shame as their most dreaded emotional experience. This motivation to avoid experiencing the pain of shame might rob people of the emotional experience that triggers specific actions and facilitates actual change. In other words, shame may be a paradoxical double-edged sword: It may both elicit a strong desire to change the self and simultaneously evoke avoidance-oriented responses that work at counter-purpose to that motivation for change.45
Much research over recent years has documented the negative impact of mental illness on individuals and families alongside attempts to unravel why such a common human experience remains so intricately bound up with shame, distancing and stigma. There still appears to be a great deal of work to do to both understand and overcome some of the barriers to a more generally empathic and reasoned understanding of the causes and consequences of mental ill health, and we present an example from the field of theatre that was intended to provide some reflection on these topics. One of the learning points from this experience for the authors has been of the importance of prioritising service user participation when planning activities related to education, training and awareness-raising on mental health issues leading to an increased appreciation of the expert by experience model in driving the quality of any approach taken.
In relation to service users and carers responses to potent elements of the mental illness experience such as shame and stigma, the PTG literature suggests that for some there is an active process that begins with adversity but can ultimately lead to a new and enhanced understanding of their individual place in the world. The hero's journey of Joseph Campbell offers another template for the transition from crisis to meaning, but acknowledges that insights are hard won, often highly subjective and difficult to share or explore with others.
It seems possible that the act of witnessing a microcosm of this journey within a devised performance setting with its protective ‘distance’ yet intimate relationship between actors, set and audience might encourage a reflective contemplation on our own vulnerabilities and fearful responses in relation to mental illness. We feel that similar media productions could have potential in helping to generate insight and facilitate the empathic responses that can reduce aspects of stigma and encourage a broader and more inclusive understanding of mental ill health and vulnerability.
The authors acknowledge the many individuals with lived experience of mental health difficulties alongside the carers staff and students who attended the performances and contributed to the discussions.
Contributors PS planned and produced the devised theatre performances. PP and PS planned and completed all aspects of the manuscript.
Funding PP was partly funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care-West Midlands (CLAHRC—WM).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.