When role-play comes alive : A Theory and Practice 978-981-10-5969-8, 9811059691, 978-981-10-5968-1

Table of contents :
Front Matter ....Pages i-xx
Front Matter ....Pages 1-1
Virtual Worlds (Paul Heinrich)....Pages 3-13
A Model of Performance (Paul Heinrich)....Pages 15-24
Role-Play as Performance (Paul Heinrich)....Pages 25-35
Role-Play as Rehearsal (Paul Heinrich)....Pages 37-47
Role-Play as Drama (Paul Heinrich)....Pages 49-63
Front Matter ....Pages 65-65
The Workshop Team (Paul Heinrich)....Pages 67-73
Designing Role-Play (Paul Heinrich)....Pages 75-88
Where to Hold a Role-Play Workshop (Paul Heinrich)....Pages 89-96
Working With Actors (Paul Heinrich)....Pages 97-116
Managing Performance Anxiety (Paul Heinrich)....Pages 117-131
Beginning the Role-play Workshop (Paul Heinrich)....Pages 133-139
Managing Aesthetic Distance (Paul Heinrich)....Pages 141-161
Effective Facilitation (Paul Heinrich)....Pages 163-174
Observation and Appreciation (Paul Heinrich)....Pages 175-184
Words, Words, Words (Paul Heinrich)....Pages 185-200
Body Language and Imagery (Paul Heinrich)....Pages 201-217
Managing Emotions (Paul Heinrich)....Pages 219-233
Facilitation Techniques (Paul Heinrich)....Pages 235-262
Workshop Formats (Paul Heinrich)....Pages 263-275
Composure (Paul Heinrich)....Pages 277-296
Observation Exercises (Paul Heinrich)....Pages 297-302
Back Matter ....Pages 303-307

Citation preview

PAUL HEINRICH

WHEN ROLE-PLAY COMES ALIVE A Theory and Practice

When role-play comes alive

Paul Heinrich

When role-play comes alive A Theory and Practice

Paul Heinrich Pam McLean Centre University of Sydney St Leonards, NSW, Australia

ISBN 978-981-10-5968-1    ISBN 978-981-10-5969-8 (eBook) DOI 10.1007/978-981-10-5969-8 Library of Congress Control Number: 2017952084 © The Editor(s) (if applicable) and The Author(s) 2018 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: moodboard / Alamy Stock Photo Printed on acid-free paper This Palgrave Macmillan imprint is published by Springer Nature The registered company is Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

I dedicate this book to my wife Chrissie.

Foreword

I am an academic. So, like all good academics, I begin with a definition. The Oxford English Dictionary defines role-playing as The acting out of the part of a particular person or character, for example as a technique in training or psychotherapy.

Most health professionals have experienced role-playing this way at some stage during their training. In the 1990s, the world of healthcare was increasingly assailed by the challenges of effective communication with patients and their families. Communication topped the charts for complaint and litigation, and role-playing seemed a good solution to getting a better match between how professionals communicated and what society expected. But it wasn’t working. Sadly, the exercise was often unproductive, and legions of wounded warriors described the experience as disappointing, amusing, boring, pointless, or, occasionally, traumatic. In the world of Psychology, role-playing becomes The unconscious acting out of a particular role in accordance with the perceived expectations of society. (OED)

It took me a while to appreciate how doctors, nurses, and other health professionals can play roles that are squeezed (sometimes mercilessly) vii

viii  Foreword

into some sort of perception of societal expectations: but roles that often constrain them personally and professionally—with occasionally disastrous consequences. It is precisely this conflict between what society expects of us, what health professionals expect of themselves and each other, and who we really are as authentic specimens of humanity that gives role-play its true potential. Effective role-play inhabits the virtual world between who we are, or who we think we are supposed to be, and who we are capable of being. And then came Heinrich. It was Paul Heinrich, a dramatist and thinker, who introduced me to the concept of Lazzi—not in sixteenth- and seventeenth-century Italy, when they first appeared as stock comedic routines traditionally associated with Commedia dell’arte, but a little later in the late twentieth century in the academic hothouse of a university teaching hospital. Commedia dell’arte translates to “theatre of the professional” and refers to improvised performance based on a set of standardised routines. Performers had stock lazzi (Italian for a “joke” or “witticism”) in their repertoire and would use improvisatory skills to weave them into the plot of dozens of different scenarios. The concept was compelling: that a doctor or nurse might adopt a role characterised by bits of well-rehearsed behaviour woven together through authentic, in-the-moment improvisation to achieve a goal that is right for the moment. To quote from Chap. 13 (“Effective Facilitation”): So how do you make sense of an interaction? You might be tempted simply to compare what the players are doing with what you think they should be doing, based on approved protocols, practice guidelines or on your own professional experience. The approach is quite appropriate for clearly defined procedures that need to be memorized and rehearsed. It directs your attention to shortfalls in performance, that is, to where further work needs to be done. However, that kind of template-based approach is less useful for most open-ended interaction. By directing your attention to mismatch, to what the learner is not doing, it takes your eye away from what is actually happening.

 Foreword    

ix

We need to recognize that there is no possibility of scientific certainty at any stage. Instead, you and the group must work your way forward through a shifting landscape of rolling hypotheses.

It was the beginning of a wonderful experiment in developing a powerful mix of clinical medicine, psychological research, and dramatic theory and practice that became the multiple award-winning Pam McLean Centre in the Sydney Medical School at Royal North Shore Hospital. In our case, things were very different. Paul, a dramatist, became an integral member of our clinical/research team and that changed the emphasis inexorably. The world of drama had things to offer that could not be supplied by clinical medicine or psychology. Drama didn’t tell us how to communicate, but it did provide effective means to find out and explore. Along the way, we all had to adjust to Paul Heinrich’s unique way of doing things, his exhausting attention to detail, his capacity for absorbing prodigious amounts of clinical and psychological information, and his enormous red glasses. And he had to adjust to the foibles of a team of academic researchers and clinicians in a world that was initially just as foreign to him as his was to us. At this point, any attempt to adhere to scientific inquiry becomes almost irrelevant. Each health professional, in their attempts to maintain authenticity in improvising responses to standard scenarios, constitutes an “n” of 1. We are not in the world of science here. And this book is not an academic survey of evidence for the effectiveness of role-play. Neither is it a description of the programme we developed, or a simple “how to” manual for trainers of standardised patients or preparation for OSCEs etc. The book attempts to rectify the imbalance in discussion of role-play and communication skills training by providing a voice for drama itself to describe role-play and, because role-play is a form of drama, it makes sense to talk about it as drama. Role-play is traditionally seen as an educational tool and often its nature as drama is overlooked completely. This book is an explanation of role-play as drama and this explanation is usually lacking. The insights contained in this book have the potential to imbue role-­ play with a magical quality, sometimes reflected in instant positive changes but, more importantly, leaving participants with the capacity to

x  Foreword

continue to think more deeply about their communication and how they can continue to grow. Professor of Psychological Medicine Sydney Medical School—Northern Associate Dean (Admissions) Director | Pam McLean Centre

Stewart Dunn

Preface

If you are an educator, a trainer in business or one of the professions, a workshop facilitator, a role-play actor, a manager looking for ways to improve the quality of communication in your workforce, or someone interested in role-play as performance, this book is written for you. Research over decades has convincingly demonstrated the superiority of role-play over older, didactic methods in teaching communication and social interaction. So much so that the use of educational role-play has become widespread in professions such as medicine and healthcare, policing, defence, law, and business. However, the experience of role-play is sometimes uneven. If you have ever taken part or been in charge of it, you have probably found that it is not always as effective as it might be. Sometimes we find it hard to lose ourselves in the make believe and just cannot buy into the situation. Sometimes an interaction will grind to a halt, and we are unsure how to proceed. Sometimes an approach that always works well, suddenly fails. This book shows you how to redress many of those shortcomings, rejuvenate your experience of role-play, and access many more of the resources that it offers. The most important consideration by far for successful role-play is that it comes alive. The interactions need to be so convincing that it is as if they are really happening. Everyone in the room, not only those on stage but also those watching on the sidelines, need to be caught up and xi

xii  Preface

t­ ransported into that world. We should routinely expect to see everyone’s eyes riveted on the action, and moments of high suspense when those watching forget to breathe. This total immersion is crucial, as it is only when that happens that we begin to access this kind of learning. “Aha” moments should be the rule and not the exception. Ultimately, we only discover how to communicate and perform by forgetting all else and stepping into action, not by thinking about it from outside. This book shows you how to make role-play come alive in this way. The chapters in Part I focus on theory, show how and why role-play works, and introduce the key factors that bring it alive. The chapters in Part II show how these ideas run through every aspect of role-play practice, and offer practical guidance on designing and running role-play scenarios, and dozens of techniques to handle situations that occur on a regular basis. You should expect the resulting interactions to be more dynamic and engaging, and on a good day, life-changing. You will quickly recognize that the approach of this book owes much to the world of drama. I came to educational role-play somewhat late in life, bringing with me 20 plus years of practical experience as a director, performer, and acting teacher, and a PhD in Theatre and Drama from Northwestern University in Evanston, Illinois. Both the practical and the academic were needed for the task I was given. The Sydney Medical School of the University of Sydney recognized that communication between doctors and patients left a lot to be desired, that there needed to be a new kind of training, and that that training needed to start early. It seemed that all they had for an answer was a blank sheet of paper. I was brought on board as a lateral “wild card” to think this training into being and to fill that page. Very soon, it became clear to me that the page was not at all blank. Half was already occupied by clinical medicine and research psychology which had got together, identified what good medical communication looked like, and had amassed a wealth of evidence to prove it. Missing on the page were concrete, practical ways to communicate it. Doctors often face demanding, complex situations that are difficult to understand and navigate. Drama cannot provide answers to any of those questions. However, it knows how to provide a platform to practitioners whatever their competence, and it knows how to upskill. It knows how to engage

 Preface    

xiii

with issues and make them come alive. It knows how to help young doctors take new understanding on board, make it their own, go places they’ve never been before, and to greater and lesser extents, end up with better relationships, conversations, and outcomes with patients. As well as knowing how to bring the world of clinical medicine alive, drama has insights of its own to offer young doctors and young professionals in general. An actor and a young doctor have something very basic in common. Both need to be able to walk into novel situations and quickly become situationally aware, asking “Who is this person? What is this situation? What do I need to do? How do I do it? How will I know if it’s working?” Both need to acquire professional use of their own sensorium: to know how to be present in the moment (mindfulness); how to maintain composure under stress; how to see and hear more acutely; how to interpret their own inner impulses; how to avoid false assumptions; how to read their partner and their situation; how to communicate clearly, and knowingly; and how to navigate challenging situations with confidence and professional competence. This skill set is what actors have studied, and they have an extensive resource kit of vocabulary and techniques to offer. When role-play accesses these resources, it comes alive in a new way. It becomes more dynamic, the interactions become more authentic, discussion becomes more focused, and people take risks and grow. Role-play done well is an exciting and moving experience that leaves participants altered in some way. It has been a common experience to witness even senior participants moved to tears over the reality of a role-play scene and the issues that it generate. “But this is not really role-play,” we have often heard, “this is something else.” That something else is simply well-crafted role-play. It is possible to build a communication skills programme which uses actors and role-play simply as teaching tools. But when you include drama in the mix at the very beginning—in our case, as a triumvirate of clinical medicine, psychological research, and dramatic theory and practice—with drama no longer just a utilitarian tool but an equal player, our experience is that the mix is very powerful and very effective. Many papers have been written on role-play from within the worlds of educational research and clinical practice, but to my knowledge this is the first

xiv  Preface

time that the drama called role-play has been explored so extensively as drama. Examples in this book reflect my experience in healthcare education, but the principles and approaches apply just as easily to other fields. Just like healthcare, the worlds of business, law, policing, and the armed forces have their own cultures and language, their own difficult situations and conversations to navigate, and their own important messages to communicate. Many of their trainees also have yet to develop communication skills which are up to the stringent demands of their workplace. I believe that these role-play techniques are readily transferable to those fields. A few words on housekeeping. One set of ideas runs through this book and produces a cohesive body of practice. Facilitation techniques work to the degree that they recognize and apply these ideas. Therefore, though you may be tempted to move straight onto the later, more practical chapters, I recommend that you spend at least some time on the early theory section. Later recommendations will then make greater sense because it will be easier to see how and why they work. You will notice that some topics appear with slightly different emphasis in more than one chapter. Many practices of role-play cannot be adequately explained once under one heading. No matter how and where you cut into a practice, parts of it escape elsewhere. As with any art or performance, to do it justice you have to circle around it and work your way somehow towards the centre. I have tried to present the material as economically and as logically as possible, but some circularity is inevitable. It is also crucial for this kind of work that we grasp the idea of what we are doing rather than learn a series of rules to follow. An important task has been to communicate central ideas, and that is often best done by metaphor and example. Metaphors are extremely effective but have one major failing. To work, they must make immediate sense to the reader, but no one metaphor has universal reach. The example that works for you may leave the next reader no wiser. Therefore, where a concept is important, I deliberately describe it in more than one way to make sure that the concept comes across to you.

Acknowledgements

This kind of education works only because of a relatively small but dedicated band of stalwarts who understand the importance of training in communication and are passionate to champion it and to see it passed on. I have been fortunate to have met and worked with more than a few of you, and to you I offer this book in the hope that it may invigorate your practice. Many people contributed to the content of this book. Some presented the vexing challenges that needed to be solved, and collaborated in setting up new workshops to test the approach in practice. Some grounded the work in reality by pointing the way to relevant research. Others opened my eyes to the rich complexity of clinical life. Many taught me much about care and compassion. In ways we shall never fully understand, that unique interplay of forces produced a programme that works well in our particular Australian context. That programme, known as the Pam McLean Centre, is now well established, and has won a reputation for exciting and transformative training in communication skills. To the countless clinicians, researchers, and educators who contributed in ways large and small; to close colleagues who grounded and finessed the programme through years of collaboration, conversation, debate, and suggestion; to the many wonderful facilitators and actors who joined this enterprise, and made it what it is today—I thank you all. xv

xvi  Acknowledgements

Dr Elyssebeth Leigh offered much encouragement and gave useful critique on the manuscript. My particular and very heartfelt thanks go to the two far-sighted clinicians who invited me to join them in their world all those years ago. Prof. Fran Boyle, medical oncologist and medical director of the Pam McLean Centre, taught me about the world of clinical medicine so that we could bring it convincingly alive on stage. Fran selflessly gave up many hours to read the entire manuscript including earlier, discarded drafts and gave thoughtful feedback and suggestions. Prof. Stewart Dunn, medical psychologist and director of the Pam McLean Centre, taught me respect for research and evidence so that our teaching would be grounded in world’s best practices. Most importantly, Stewart gave me the latitude I needed to explore the best ways forward, walked the road with me as we slowly put the programme together, gamely tested out new ideas of facilitation, and found the ways to make them work in practice. My deepest and sincerest thanks to you both. The tight fusion of the three worlds of clinical medicine, medical psychology, and dramatic theory and practice is a powerful mix, but this book is not primarily about our programme, however proud we may be of it. Every programme grows out of the contributions of a unique team and the demands of a unique context. What works for us might not always work for you. However, the same dramatic principles apply whatever our situation and whether we are aware of them or not. It is these dramatic ideas, principles, and practices that are the subject of this book. They are applicable in whatever society and whatever professional world you find yourself. Because of the particular focus of the book, there is obviously much more to the performance of role-play than can be covered here. I acknowledge the limitations to be mine, but it is my hope, like any author, that what the book has to offer far outweighs any failings.

Contents

Part I Theory

  1

1 Virtual Worlds   3 2 A Model of Performance  15 3 Role-Play as Performance  25 4 Role-Play as Rehearsal  37 5 Role-Play as Drama  49

Part II Practice

 65

6 The Workshop Team  67 7 Designing Role-Play  75 xvii

xviii  Contents

8 Where to Hold a Role-Play Workshop  89 9 Working With Actors  97 10 Managing Performance Anxiety 117 11 Beginning the Role-play Workshop 133 12 Managing Aesthetic Distance 141 13 Effective Facilitation 163 14 Observation and Appreciation 175 15 Words, Words, Words 185 16 Body Language and Imagery 201 17 Managing Emotions 219 18 Facilitation Techniques 235 19 Workshop Formats 263 20 Composure 277 21 Observation Exercises 297 Index 303

List of Figures

Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 2.1 Fig. 2.2 Fig. 3.1 Fig. 7.1 Fig. 8.1 Fig. 8.2 Fig. 8.3 Fig. 8.4 Fig. 9.1 Fig. 12.1 Fig. 12.2 Fig. 12.3 Fig. 12.4

Model of a virtual world 5 A framed virtual world whereby a frame draws focus to its content 8 Dynamics released by the use of a frame 12 Model of a performance space framing a virtual world 16 The stage in a virtual world, and its empathic wash into the auditorium 21 The Simulation Triad 31 Model of performance with frame, focus, and subjective virtual world 81 Room is too deep 91 Room is too wide 91 Room is too large 92 Example of effective room set up for role-play 92 Boundaries and projected stepping stones through an interaction106 The spectrum of aesthetic distance from over- to under distance142 Incomplete model of the relationship between the stage and observers 145 Interactive model of the relationship between the stage and observers 146 Crossing from area of observation fully into the virtual world 147 xix

xx 

List of Figures

Fig. 12.5 Moving the discussion to the more engaged end of the spectrum by calling “Pause” instead of “Timeout” Fig. 12.6 When to call “Timeout,” or “Pause” Fig. 12.7 Player arrives at possible timeout points Fig. 13.1 Four-part heuristic to determine focus Fig. 13.2 Four analogous cultures from the world of business Fig. 14.1 Viewing angles change the subjective nature of the perception. Objectivity is most intense at A and subjectivity at B Fig. 15.1 Active verbs implying objectives and specific outcomes Fig. 17.1 Play within a play as model for shifting to client’s agenda Fig. 17.2 Model indicating potential intervention points after expression of emotion

155 156 157 169 172 182 194 222 224

Part I Theory

1 Virtual Worlds The Riveting Scenarios Intrinsic to All Convincing Performance, and the Factors That Make Them Come Alive

Role-play works because it simulates, that is, creates an illusion of real life. A role-play simulation can be so convincing as to be virtually indistinguishable from the same thing in everyday life. Therefore, we could call this simulated action a “virtual world.” If such a world does not manage to come alive and to seem convincingly real, no learning is able to take place, as the watching group will not buy into its premise. Virtual worlds are not limited to role-play, but are a hallmark of performance in general. Therefore, before we dive into role-play itself, we take one step back to the larger world from which it springs and consider the nature of the virtual worlds that lie at the heart of performance everywhere.

Role-play is a dramatic subtype of performance in general. Human beings have an impressive capacity to perform. When we do so, we select particular behaviour and emphasize it. We say and do particular things in specific situations that we otherwise might not do. We sometimes reach into our potential and release capacities that surprise and amaze us and others. Wherever it occurs, performance is marked by heightened activity.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_1

3

4 

1  Virtual Worlds

We find performances spread all throughout human society. They include: • aesthetic performances, such as drama, dance, and music; • sporting performances of all kinds; • rites of passage, such as baptisms, birthdays, bar mitzvahs, weddings, awards ceremonies, and graduations; • social performances, such as dinner parties, trivia nights, and games of all kinds; • mini performances, such as telling a joke, or recounting a recent experience to friends or family; • professional performances in the law court, board room, and parliament; • clinical interactions in medicine, nursing, allied healthcare, and counselling. The dramatic form called role-play is performance in the educational domain. Performances are played out in the midst of what we call real life, the common round of actions that make up our working, social, and personal lives. Real life or reality is a fairly loose term. A professional consultation is real in that loose sense, and that understanding lies behind the complaint heard muttered from time to time in medical circles that one can only learn from real patients because simulation is not real and, therefore, not educationally useful. No matter if communication in a clinical interaction may sometimes remain safely on the surface, no matter if a clinician may work his or her way methodically down a checklist and the patient leave with questions unraised, and concerns unrecognized and unaddressed, the consultation is nevertheless considered real. From the viewpoint of interpersonal communication, however, it is perhaps more useful to think in terms of authenticity. Rated against that benchmark, there may sometimes be more authenticity in a simulation than in the consultation of a busy clinician, lawyer, or businessman, where heavy workload may crowd out opportunities for real connection. In role-play, participants are given time and opportunity to drop other competing demands to pay full attention to the phenomenon of an

1  Virtual Worlds 

  5

i­ nteraction, to become aware perhaps for the first time of questions, fears, and personal concerns, and to develop the courage and resources to begin to address them. Rather than reality, then, let us in this chapter refer to our usual round of behaviour as everyday life. Whenever we engage in any of these performances, it is as if we draw a circle in the midst of that everyday life and step into it. When we do so, it is almost as if we become someone else. We may find ourselves more confident, more focused, and our senses more heightened. This is the world of performance. Outside the circle lies everything that constitutes our usual behaviour during any given day. Inside the circle, temporarily quarantined from the everyday, is that separate, heightened reality of performance. Researchers in drama, drama therapy, and psychodrama have come up with various terms to try to define this different reality, such as imaginative reality, dramatic reality, surplus reality, playspace, fantastic reality, fictional present, liminal field, potential space, aesthetic space, possible world or hypothetical space (Pendzik 2006, 271–280). The different names reflect the differing purposes to which performance can be put. Whatever the term used, each experience of performance is a kind of virtual world, real but not real, a domain that is “both actual and hypothetical: it is the establishment of a world within a world.” In this book, I will refer to this heightened reality of performance as a virtual world (see Fig. 1.1). Everyday world

Virtual world “As if”

Fig. 1.1  Model of a virtual world

6 

1  Virtual Worlds

Stanislavsky, the father of modern acting, called this imaginative reality an as if world. The players act as if the situation were that of the real world. In all performance, we play it for real, as if for that moment ­nothing else in the world existed. Our decisions and actions become of paramount importance, and this concentration of attention releases a focus and an energy that enables superior performance.

The Inner Tension of a Virtual World The world of role-play, as of much performance, is characterized by unresolved inner conflict. Ambiguity over whether a virtual world is real or not is intrinsic to the nature of role-play as it is to any other form of performance. On the one hand, the interaction is not real, in the sense that it is an unashamed fiction, fiction in the sense of something that is fashioned for the purpose of heightening or shedding light on our everyday behaviour.1 On the other hand, we recognize the behaviour that takes place within this virtual world as actual. The audience knows that they are watching, and the players that they are performing, a fiction, but we agree to act as if it were actually happening. When done well, it is virtually impossible to tell the difference. For all practical purposes, the virtual world reflects life in the everyday world. Coleridge’s overused term suspended disbelief or suspension of disbelief is often trotted out to describe this transaction between performers and audience. Coleridge coined the term to explain how his contemporary audience, who no longer believed in ghosts and supernatural forces, would accept them in his poetry as if real (Coleridge 1817). The concept has since expanded to describe the convention by which we knowingly suspend our knowledge that we are watching a fiction and choose to accept it as real. This inner tension is integral and necessary to any virtual world, and its presence is critical if we are to enjoy the experience and learn from it. It enables us to live out experiences that in real life might paralyse us and make us unable to act. For instance, in a virtual role-play world, a trainee police officer may find himself faced with a gun aimed at his chest and the task of talking the gun down. The double awareness of being involved but not really creates safety for both the police officer and the audience. We take it as real, and hold our breath. How will he do it? Will he ­succeed,

  The Frame 

  7

or will the gun go off and certainly kill him? The same tension holds true if the task were to talk a would-be suicidal person down off the ledge of a hypothetical 20-storey building. The fact that we do not know what will happen creates suspense, maintains our interest, and holds our attention. The suspense triggers higher levels of energy and awareness than usual. At the same time, we remain aware that we are not really in the danger of that situation. We have willingly stepped into an alternative space where we can temporarily play with the elements in this fiction, yet remain unharmed. The fiction makes us safe. We return to being like small children who delight in being terrified because we know all along that the scary ghost story is only make-believe. The fiction, in other words, has the significant advantage of divorcing us from real-world concerns. We are thrown into the middle of the experience, but at the same time we are protected from unpleasant and even dire consequences. This intrinsic tension between the actual and the hypothetical in the virtual world is critical to an understanding of role-­ play. The unresolved tension acts like a coiled spring within the interaction and produces the energy of suspense, engagement, and enhanced awareness. In successful role-play, it holds us enthralled as we watch to see what will happen and drives the participants and audience towards discovery and new insights. There needs to be sufficient interest, of course, to provide a riveting focus for attention. The viewers need to be interested, and the action needs to be interesting. Receptive viewer plus interesting action creates satisfying performance. Take away the suspense, the unknown outcome, and heightened focus, and we are left with a cool, intellectual exercise. Without suspense, we can take it or leave it. We watch dispassionately from afar, but we do not experience the almost irresistible pull to forget everything else and pay close attention.

The Frame Because our mind is being tugged simultaneously in opposite directions, the two realities of the actual and the hypothetical need to be acknowledged, and to be separated formally from each other. This separation is enabled by the device of a frame (see Fig. 1.2).

8 

1  Virtual Worlds

Fig. 1.2  A framed virtual world whereby a frame draws focus to its content

This staged photograph represents a frozen moment in an interaction between two people. We could be looking at a businessman and client, or a clinician and patient. Both parties are focused on their own particular agenda, each more aware of their own preoccupations than of the other. The sheer act of capturing the moment in a still photograph already separates it from the seamless stream of moving experience that brought these two to this moment. Suddenly, the interaction is available to us in a way that was not possible a moment beforehand. The photograph now exists as an object separate from the interaction from which it was extracted. It comes packaged in a rectangular shape, which being unknown in nature, is already a contrived act and acts as an implicit frame. However, we ­usually heighten and formalize the separation still further by surrounding the image with an external frame. The convention of a frame is most recognizable from the world of visual art. Each painting in an art gallery is differentiated from the background wall and from the other paintings by its frame. The function of the frame is to separate out the object, and to focus our attention on it. As our eyes are drawn to the image, we are aware somewhere in our

  Aesthetic Distance 

  9

psyches of the tension intrinsic to the exercise. Yet, assuming sufficient interest, at a certain moment we forget the presence of the frame, and we step through it, as it were, into the painting. We move perceptually very close in and begin to see things that were not immediately obvious at first viewing. It is as if this image were the only thing that existed, as if it were really real, and we had stepped into that world. At the same time, another part of our mind remains aware of the frame and that we are in fact standing in a gallery looking at a painting. Depending on our interest, the day, the surroundings, the moment, the picture, and so on, our attention resides somewhere between total absorption in the world of the picture and the detached recognition of the existence of a framed painting. Our example is from visual art, but this device of the frame is used in all performance. It is a crucial factor in role-play.

Aesthetic Distance This push-me-pull-you tension of a virtual world may be couched in terms of aesthetic distance. The term was first coined by Edward Bullough in the early twentieth century (1912, 87–117). Bullough asks us to consider the phenomenon of fog at sea. For a sailor, fog might in most cases be seen as an unpleasant experience—cold, damp, and with dangers to shipping that make fog one of the terrors of the seas. Yet, extract the danger and any need to be on alert, and the fog can almost immediately become a pleasant experience. The same negative attributes take on pleasing aesthetic qualities as we consider fog from a totally different point of view. This transformed view is only possible because of the “insertion of distance,” “by putting the phenomenon, so to speak, out of gear with our practical, actual self; by allowing it to stand outside the context of our personal needs and ends—in short, by looking at it ‘objectively.’” This newly enabled aesthetic view “is not, and cannot be, our normal outlook.” It is precisely this transformation of our ability to perceive that enables heightened and hitherto unavailable insights. In Bullough’s words, “The sudden view of things from their reverse, usually

10 

1  Virtual Worlds

unnoticed, side, comes upon us as a revelation, and such revelations are precisely those of Art. In this general sense, Distance is a factor in all Art.” Consider again the painting hanging in the gallery in terms of aesthetic distance. A visitor to the gallery will tend to experience aesthetic distance in one of three ways: overdistance, engagement, or underdistance. If nothing in the painting spikes our interest, we will remain unengaged and detached and see only a framed picture hanging on a wall. In relation to the painting, we are not completely present in the moment. In this case, the viewer is overdistanced, and there is no possibility of fresh insight or personal transformation. In Bullough’s example, we see only the usual problem of fog. Alternatively, the painting may capture our attention. We step through the frame and become caught up in the aesthetic world. We forget time and all other practical considerations and see only this new world within the frame. All we are now aware of is an unexpected experience of fog, as if we had never seen it before. This heightened experience is aesthetic distance at work. Our stance here is one of engagement. We potentially come away with a transformed point of view. However, if we become too involved, we may forget that we are dealing with a fiction. In the case of a video game, for example, a player may become obsessed with the world of the game and cease to function in everyday life. Or we may become distressed by the events of a really convincing film, or completely identify with a character whose distressful situation mirrors our own. If this happens, the illusion is punctured, there is no protective distance, and we are left to deal with our own raw experience. In these cases, we have become underdistanced. Neither extreme of overdistance nor underdistance is conducive to fresh learning, and Bullough concluded that the “most desirable is the utmost decrease of Distance without its disappearance.” In role-play, the most obvious blockage to an interaction coming alive is when players and audience are overdistanced. All they see is the artifice of role-play. For whatever reason, they are not swept up into the world of the scenario, and the whole thing remains an intellectual exercise. They remain unengaged and detached, and no learning can take place. On the other hand, however, they do not need to become completely caught up

  Aesthetic Distance 

  11

in an interaction to get value from it. In fact, complete identification is not a good idea. If we become too caught up, that is, underdistanced, the situation may become too close for comfort, and we may lack protective distance to manage it. In this case, we may become emotionally overwhelmed, or alternatively we may back right off and attempt to dismiss its reality with nervous laughter or ridicule. Successful performance thrives in the middle ground of distance, where we are in that world but not of it. The most fruitful role-play interaction takes place when the players and the audience are swept up by events, and become engaged, sometimes despite themselves. Everyday concerns drop away, and we become attentive and alert. We pay attention to the performance, and begin to see things in it. We need the heightened perceptions of performance for fresh insight. In our everyday world, we develop habits that work, and we take the habitual for granted. Our behaviour becomes virtually invisible to us. It simply is, therefore holds no further interest, and we move on to other more pressing matters. In a virtual world, we need to catch a glimpse of our usual behaviour as if we had never seen it before. In order to do that, the familiar needs somehow to become interesting. Paradoxically, to become interesting, it needs to become unfamiliar. We need to walk through familiar terrain, as if we had become a stranger in a strange land. That is basically what aesthetic distance does; it distances the situation sufficiently to give us a new point of view. The world ceases to be completely predictable. This process is often referred to as defamiliarization, a term coined by Russian Formalist literary critic Viktor Shklovsky in 1917. Shklovsky wrote, “art exists that one may recover the sensation of life; it exists to make one feel things, to make the stone stony. The purpose of art is to impart the sensation of things as they are perceived and not as they are known (Lodge 1992, 53). The concept became well known in drama circles through its promotion by the German playwright Berthold Brecht, who recognized the need for adequate distance in drama so that the audience might reflect critically upon the events playing out on stage. Brecht used the term Verfremdungseffekt, which means “the effect of making strange or distant” (Brecht 1964). You may run across Brecht’s term translated as Alienation Effect, or A-Effect, though “alienation” is a little strong as a translation.

12 

1  Virtual Worlds

Summation Role-play works by first creating a virtual world, that is, a framed hypothetical reality that is virtually indistinguishable from the behaviour it replicates from everyday life. It is this fiction that lies at the heart of all compelling performance. The intrinsic tension between the real and the not real, the actual and the hypothetical, is essential to produce the simultaneous engagement and detachment that makes fresh insight possible. Convincing role-play is only possible through these key devices of framing, inner tension, aesthetic distance, and defamiliarization. The interplay of these elements is posited in Fig. 1.3. It is impossible to overemphasize the importance of this foundational concept. A virtual world is the sine qua non of simulation. Nothing further can happen without it. If players are not swept up into a living world, they will not buy into the scenario, and new insights and personal change are unlikely. The first and continuing task of any facilitator is to take this virtual world seriously, to bring it alive, and to keep it fresh and energized Frame Virtual world

Real / not real

Aesthetic distance

Inner tension Suspense

Defamiliarization Energy focus

Awareness Realization New understanding New behaviour

Fig. 1.3  Dynamics released by the use of a frame

 References 

  13

all the way through the role-play. Once you learn how to put these devices into practice, you should expect the role-play to come alive far more often, your facilitation to become far more proactive and focused, and discussion to become more lively and insightful.

Notes 1. It is important to recognize that fiction does not mean untrue or false. The term simply refers to the fact that the interaction is an artefact, something that we humans construct.

References Brecht, Bertolt. 1964. Brecht on Theatre: The Development of an Aesthetic. Edited and translated by John Willett. London: Methuen. Bullough, E. 1912. ‘Psychical Distance’ as a Factor in Art and as an Aesthetic Principle. British Journal of Psychology 5: 87–117. Coleridge, Samuel. 1817. Biographia Literaria: Biographical Sketches of My Literary Life & Opinions. Chap. XIV. Lodge, David. 1992. The Art of Fiction. London: Secker and Warburg. Pendzik, S. 2006. On Dramatic Reality and its Therapeutic Function in Drama Therapy. The Arts in Psychotherapy 33 (272): 271–280. Shklovsky, Viktor. 1998. Art as Technique. In Literary Theory: An Anthology, ed. Julie Rivkin and Michael Ryan. Malden: Blackwell Publishing Ltd. Referenced in David Lodge, 1992.

2 A Model of Performance A Model Showing How Framing, Focus, and Aesthetic Distance Work in Practice in all Performance

In the previous chapter we introduced the inner dynamics of the virtual world that make living role-play possible and that generate its energy and capacity to foster fresh insight. On a practical level, we need ways to encourage participants to become engaged so that discovery and learning can begin. The problem is more likely to be one of over-distance than for people to be too involved, and so organizers of all performances do everything they can to minimize detachment. Here we explore how we use framing, focus, and aesthetic distance to minimize distraction and encourage focused attention so that audiences are caught up in the virtual worlds on a stage or playing field. These same techniques are at work in role-play.

Performance realities of any kind depend for their existence on being separated from the everyday. They need to be framed for separation and focus. The frame acts as a buffer between the activities that take place within a virtual world and the demands and distractions of the everyday. The frame is always present whether we are talking about a football match, a theatre performance, or a role-play. In each case, the event is separated and cushioned from its surroundings by a buffer frame which exists in both space and time (see Fig. 2.1). © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_2

15

16 

2  A Model of Performance

Everyday world

Frame

Virtual world Entrance exit

Fig. 2.1  Model of a performance space framing a virtual world

Spatial Frames Society sets aside certain spaces and designates them as special places for performance. These performance spaces are given specific designations, such as stadiums, ovals, cinemas, theatres, auditoriums, halls, churches, seminar rooms, and so on. This naming of a venue—stadium, theatre, seminar room—itself acts as a frame and heightens our focus through expectation. When we go to a stadium, we know what to expect. Our choosing has taken us there, and that choosing motivates us to get engaged. And if that venue is itself set within the larger frame of a sporting complex, an entertainment district, or within an education centre, then our attention will become even more focused. The most immediate impact of a frame, however, is provided by the physical wall or fence that separates the outside world from the inside event. Outside, our attention is assaulted by the noise of competing demands, and one has to work hard to stay focused. Once inside, that fragmentation is replaced by a focus, an atmosphere, and an energized expectation. When we step through the doorway, we leave our concerns outside and walk through into another reality, albeit a hypothetical one, for a short time. That reality may be a play, a film, a sporting match, an awards ceremony, a birthday party or a role-play workshop. In each case, the world inside differs significantly from the world outside.

  Spatial Frames 

  17

The venue presupposes an attentive audience. We arrive wanting to be entertained, enlightened, or engaged in some way. The venue itself then does what it can to enhance and heighten those expectations. Most venues provide an intermediate space within the buffer wall. For instance, we do not step from traffic straight into a theatre, or cinema auditorium. Instead, we walk into the intermediate space of a theatre foyer. We cannot instantly adapt and put ourselves into a receptive frame of mind. We need time to adjust from one reality to another. We need time to cool down from the ruffled difficulty of finding a parking spot and the rush to arrive in time. We need to shed unfinished business and the turmoil of the day from our minds, to settle down, and to move our thoughts expectantly forward to pleasurable events up ahead. The foyer provides the time and the space to do precisely that. It functions as a warm up and socialization zone where we are able to transit between the two worlds. There is both space and time to grab a drink and wind down a little, to catch up with friends, and generally let the noise drain out of the system. Posters on the wall remind us of what will shortly be taking place in the inner sanctum of the theatre itself. Flashing lights or warnings over the PA system remind us when it is time to leave this intermediate zone and to proceed on into the protected area of the event itself. Dimmed house lights and selected lighting on stage begin to project our attention forward. The fade of lights to black out or the raising of a curtain signal that the special event is about to begin. The whole process is designed to manage our expectations and to lead us gently from outside distraction to eager and expectant focus. Meanwhile, out of sight of the audience, the players have themselves entered their own intermediate zone—the footballers’ locker room, the actors’ green room, the surgeons’ scrub room, the priest’s sacristy—their preparatory space. The players’ change room is a sanctum, a sacred space. There they shed their everyday clothing and put on the uniforms and costumes that designate their roles in performance. There their minds focus forward onto the challenges up ahead, and their bodies prepare for action. These spaces are usually protected from the public and provisioned with a conscientious guard.

18 

2  A Model of Performance

Temporal Frames Temporal boundaries also mark the event out from the rest of the day. We do not go to a football match not knowing when it will start, how long it will last, and when it might finish. We know that a football match will begin at a certain time, last for a designated duration, and finish at a particular time. Knowing how long the performance will last permits us to set this period aside. The finite period with its beginning and end allows us to give undivided attention to the special event for the duration, knowing that everyday concerns will return soon enough. The time of day and the day of the week colour the subjective quality of the temporal frame. Friday night and Saturday night at the theatre or cinema create expectations that are quite different from a Wednesday night or a Sunday matinee. Any actor will tell you how predictably different a Friday-night audience is from a Thursday-night or a Sunday-matinee audience. The desire to kick back at the end of the working week effectively buffers that event from the rest of the week, which is often joyously dispensed off into the past. Though both nights share the end-of-the-­ week advantage, Friday-night audiences are often quite different to those of a Saturday night. There is often a more light-hearted quality to a Friday night. A well-directed Chekhov play is a good example. Successful Chekhov performances are delicately poised between pathos and comedy. Chekhov was a medical practitioner. As an objective but compassionate doctor, Chekhov saw human frailty all too clearly. He felt for his characters and saw their weaknesses, yet did not judge them. I remember one Friday-night audience at a performance of Uncle Vanya who laughed at the smallest indication of the characters’ foibles and stunned the actors who were all too aware of the terrible things that were happening in their characters’ lives. The following night, the audience hardly made a sound, yet the hall was alive with a sense of their deep connection with the events on stage. They did not respond to the subtleties like the more quick-witted audience on the Friday, but instead quietly absorbed the tragicomedy of the characters’ lives. Time functioned as a frame in both cases, yet flavoured the experience in a different way for each audience. Role-play workshops are similarly affected by time. Scheduling a workshop during a working day, after work, or on a weekend will inevitably alter the subjective quality of the experience.

  A Preset Stage or Playing Field 

  19

Closing the Door When the time has come for the event to begin, someone closes the door. In intimate settings, patrons are reminded to turn off their mobiles. These acts seal off the last physical connection with the outside world. There are no windows to the outside, the door is now closed, communication channels are shut down, and there is only the reality of this here and this now. The audience and the players are now sealed together within a space and time devoted to the exploration of a heightened reality. They have passed through conventions of buffering all designed to minimize the possibility of over-distancing so that they might become engaged in the events before them. I am sure that we are all personally conscious of how effectively the closing of a door seals off outside distractions and allows us to focus on a task at hand, and of the converse, the tug of outside distraction when a door is left open. We have all spent time in modern corporatized shopping malls which consciously manipulate our focus by precisely these means. Once we are inside, we lose all view of the outside world. Usually there are no windows and no clocks to remind us how long we have been inside. Piped music, chosen through careful research, creates a new atmospheric reality conducive to lingering and further purchase. All these devices are designed to keep us inside shopping for as long as possible. In some cases, it may not be possible to close the door. Concealing the door from view will have much the same effect. Virtual worlds depend on at least the sensation of a closed door to reduce over-distancing. The outside world needs to be partitioned off in order to concentrate attention on the event in question.

A Preset Stage or Playing Field Inside this performance zone there is invariably a stage which functions as the major focus of attention. Usually it has been prepared beforehand to draw focus and expectation. In a theatre the stage is dressed with furniture, and lighting is carefully deployed to create expectation. Sporting fields are mowed, lined out, and preset for action. The emptiness itself of

20 

2  A Model of Performance

a large sporting field produces a magnetic expectation of what will soon fill it. Depending on the football code, there may be preliminary music, cheer squads, the testing of horns that signal the divisions of play, or prior matches as warm-up acts. There will be a traditional and formalized mode of entry for the two teams, referees, linesmen, and mascots.

Start of the Event Immediately before the start of play, the referees and players will engage in set behaviour known in advance to everyone concerned. Coins may be tossed, confabs held between referees and captains, hakas performed, and club songs or national anthems sung. The start of play itself is clearly signalled by means of devices known to the players and audience. Performers take their places on the field. A horn, siren, or whistle is blown. Lights in a cinema or theatre fade to black out. Music begins to play. Curtains are raised or lights fade up on the stage or screen. The audience is filled with expectation, and this engaged focus produces a charged atmosphere. The energy of the audience transfers to the players and provides an extra energy surge to fuel their performance. The actions of those on the field or stage will be the major focus of attention for the duration of the event.

Intense Subjectivity The whole area within the performance zone is characterized by intense subjectivity. The world of performance is not one of abstract, intellectual knowledge. The focus of attention is on the messy world of human behaviour along with the thought, emotion, and passion that combine to produce it. We go to the cinema or stadium primarily for an experience which refreshes us or enlightens us in some way. We inevitably learn from that experience. Theatre- and film-goers potentially take away far more than the momentary enjoyment of a good story. Art at its core is about opening up human experience so that we may vicariously look in upon it and learn from it. Sports fans learn a good deal about how to live their

  The Stage 

  21

lives from years of watching their favourite sports. We learn how we feel about things, what we really appreciate, which kind of behaviour is admirable, and which kind is not. We learn something of how other people think and live, and we learn to face our own inadequacies and fears, and hopefully begin to overcome them.

The Stage The action is most heavily concentrated on the playing field or stage (see Fig. 2.2). It is on the stage that life is experienced at its most intense and learning is most sharp. In general, the performers have more to cool down from afterwards than the audience, in that their actions have been actual while those of the audience have been mostly vicarious. The birthday boy or girl is likely to experience their party more strongly and in a very different way than most of those who attend. From the stage, the energy radiates out in what we might call an empathic wash. Because the experience is most intense on the stage, we could call this the hot spot. We see this regularly in role-play. Members of the audience interject that the solution is obvious from where they sit, and are utterly nonplussed when they come onto stage and try to play the scene themselves. “It is very different up here,” is a common response. Everyday world

Frame

Virtual world Empathic wash

Stage

Fig. 2.2  The stage in a virtual world, and its empathic wash into the auditorium

22 

2  A Model of Performance

The next most intense spot is the area nearest to the stage. Those who want to become engaged in a lecture will often head down to be close to the lectern, and the young know that the place to go for the action in a concert is the mosh pit. The overall principle is clear and well known: we push forward to become engaged and draw back to remain detached. As the distance increases from the stage, the intensity diminishes until it fades into cool detachment at the rear and in the far corners. At the opera or a concert we would rather our seats were not way back, high up in the “gods.” This phenomenon is well known to every lecturer, public speaker, or stage performer. The cool zones are where you expect to see behaviour disconnected from what is going on onstage: whispered conversations, checking one’s mobile, personal business, dozing, and so on. These zones are points of intrusion of the outside world. It is here that the audience is prone to over-distancing, which means it is hard for them to experience what is going on onstage and to profit from it. Performance spaces do what they can to minimize these cool zones by architectural design, placement of seating, lighting, heightened stage focus and action, and closed exits.

When Aesthetic Distance Is Lost Things can come unstuck when aesthetic distance is lost. A football match simulates a battle between two opposing tribes. Violence has been sublimated by rules and the knowledge that the match is ultimately only a game. However, in the heat of the moment, aesthetic distance can become lost. When the stakes are high—when winning becomes all important, when rivalries are unusually intense, when the outcome is disputed or intolerable—the contained event may explode into a riot. The problem is a severe loss of distance whereby players and fans forget that these serious events are in fact a fiction. The problem is not limited to the sporting fraternity. Even the art world, usually a more polite and controllable group, is not exempt from under-distancing. The history of theatre is well stocked with examples of plays that struck too rich a chord and resulted in riots spilling out into the streets. The mistake can be fatal. Male actors touring in the Wild

  Time to End 

  23

West of the United States occasionally found their careers cut short when a member of the audience would stand up, draw his gun, and save the beleaguered heroine from the villain of the melodrama by putting a bullet through his heart. These riots and misadventures fall into the category of occasional occupational hazard of performance. The players play for real, place great value in succeeding, and often subject themselves to astonishing sacrifice and hard work in order to shine at what they do. To do all this hard work, and yet at the same time to recognize that in the end all their efforts have been directed to what is merely a game, a play, a fiction—is a hard tension to maintain. Fact and fiction are not always easy to differentiate. From time to time breakouts happen.

Time to End The end of the event is usually clearly signalled. Because the time frame is known to the audience, the passage of time in itself lets us know how close we are to the end. Some performances such as closely fought sporting matches maintain their suspense right up to the final whistle or siren, at which point the spectators (on the winning side) explode into cheers and jump around and hug each other. This collision of climax and final moment has a lot to do with the occasional explosions of a quite different kind by the losing side. The buildup of tension has no time to dissipate and releases itself instantly in the stands to sometimes disastrous effect. Aesthetic performances such as drama usually do not combine climax and final moment but reach their climactic point shortly before the end. The period of time after the climax is called the dénouement, meaning the “unravelling” or “untying” of the complications of the story. The aim of the dénouement is to resolve the conflicts and tension that have built up during the performance. Sometimes the resolution is hackneyed as in an Agatha Christie final tell-all in the living room, or the final section in American TV drama in which the heroes lounge about, make jokes, and the screen drops into freeze frame and credits. We always recognize, on the other hand, when the resolution has been handled well. The ­resolution

24 

2  A Model of Performance

of tension is designed to resolve the problem safely within the frame of the virtual world, so that we may return unencumbered to the waiting world outside. When aesthetic performance withholds dénouement, it is usually as a conscious decision to make extra impact on the audience. The intention may be to playfully shock them by overthrowing their expectations, as in M. Night Shyamalan’s film The Sixth Sense, or to compel them to examine their own preconceptions and prejudices and to do something about them, as in Henrik Ibsen’s drama The Doll’s House. In these exceptional cases, the lack of dénouement produced by combining climax and final moment seeks to subvert the usual conventions of theatre, and to send the audience unresolved back into their everyday world. The hope of the exercise is that the audience will seek resolution either in enthusiastic conversation over coffee after the show, or even better, in changed understanding or behaviour in their own lives. When the virtual battles have been fought and won and the contrived conflict has found its way to a satisfying resolution, the members of the audience stir in their seats, stand, and begin to make their way out of their temporary world back into the messier world outside. They make their way out through the foyer, perhaps extend re-entry time by repairing to a café or pub, and then all too quickly become caught up in the busyness of life as they go back to the car, jostle into traffic, and negotiate the familiar way home.

Summary These dynamics are time honoured and intrinsic to virtually all kinds of social performance. Conventions of framing, management of expectations, aesthetic distance, the careful use of time, the focus of a stage and the conventions of play upon it, entry onto and exit from that stage, and the final resolution of tension are universal hallmarks of performance. They are all matters of interest for organizers of any performance event, whether that be as host of a birthday party, emcee of a wedding, director of a theatre company, organizer of a sporting match, or as the facilitator of a role-play workshop. In the next chapter, we consider how these factors apply to role-play itself.

3 Role-Play as Performance The Most Important Factors That Need to Be Managed Well to Produce Dynamic Role-Play

Having considered some of the major aspects of performance in general, we now turn our attention to role-play itself. We begin with the need for creativity throughout the process, and consider organization, the choice of location, the active management of aesthetic distance, the simulation triad of actor, player, and facilitator, and the intrinsic nature of role-play as rehearsal. Managed well, these factors produce dynamic role-plays and accomplished facilitation. These important aspects of role-play performance are introduced here in broad brush strokes and expanded in much greater detail in later chapters.

While other kinds of performance are designed to entertain, celebrate, or provide an outlet for competitive impulses, role-play is designed to educate. Role-play is the living virtual world at the heart of an educational workshop, and as the central activity needs to be done well. Like all performance, role-play has to be exciting to be successful. Something has to “happen.” Those who come to our role-plays need to walk out with something energized in their step and in their spine that was not there when they came in. If we want people to learn, and then to return and to bring others with them, their experience needs to be positive. © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_3

25

26 

3  Role-Play as Performance

The Importance of Creativity For role-play to trigger expectation, excitement, and new insight, creativity needs to make its presence felt at each stage of the process. Creativity energizes and releases new life in those who are involved. Routine and formula tend to deaden performance. We become bored with routine role-play, just as we do with formulaic comedies and action movies and uninspired play on the sporting field. Overreliance on presentation of data and research findings in a workshop may make logical sense, but it might not inspire and challenge. The modern world is outrageously demanding, and there are many competing demands for the attention of our audience. We sometimes only have one shot at a group of trainees. Therefore, our workshops need to make an impact and to leave a significant impression on the minds and psyches of those who attend. For anyone who values the importance of logic and reason, there is often a temptation to assume that one constructs workshops and role-­ plays primarily through those same faculties. That is, we take out the laptop and type out a logical list: our learning objectives, hoped-for outcomes, information we want to communicate in order of importance, relevant research findings, concepts and ideas that seem central, and approaches and techniques that have worked in the past. And, of course, we need to do these things. However, they are only the very beginning of the process: in fact, more of a prelude than a beginning. The success of the role-play will depend upon what comes next. That next process of designing a vibrant role-play workshop is not so much a logical task of constructing and assembling, of engineering something into existence, as it is a process of “dreaming it up.” The use of a word like “dreaming” may sound hopelessly unscientific, and it is. The process by which we generate an inspiring workshop has more to do with imagination than with reason. Of course, facts and research findings come into the equation but not as the main drivers. A role-play workshop is not an academic paper to be constructed in a cool and dispassionate manner. Role-play belongs to another world entirely. The world of role-play, like that of the interactions it simulates, is anything but cool and dispassionate. The interactions of role-play are always

  Composition and Performance 

  27

challenging and important, which is why they have been chosen. The stakes are high, and we must solve tricky situations in real time with no certainty of success. Uncertainty is intrinsic to the process of confronting new situations. Because we have to stretch to deal with challenge, we shall sometimes feel that we have come to the end of our resources and have no idea how to proceed. It is then we start to learn. These psychological forces, the stresses and feelings they generate and the resulting thoughts we must work through, are just as important as the actions we carry out on stage. We access this living world more effectively through imagination than reason. Please do not baulk at this prospect. The imagination I refer to is not some rarefied artistic faculty limited to the few. It is a basic human imagination that most of us can access. We consider how to “dream up” a role-play in Chapter 7 “Designing Role-Play.”

Composition and Performance A role-play workshop is the culmination of two separate, creative processes and a third process of management. It begins as a blank slate— whether blank paper, whiteboard, or computer screen—upon which appears an idea for a workshop. The idea opens out into a concept and an outline, and then expands further into a script and a plan of action. Then, in an entirely different creative process, we take that idea and translate it into concrete words and actions performed in a particular place and time with a specific group of people. These two processes are the universal twin phases of creativity known as composition and performance. Composition and performance are creative acts both of which are intrinsically imaginative enterprises. The nature of the creativity is quite different in each case. Composition draws upon inner reserves and energies, which have a quality that we might call introverted energy. Performance, on the other hand, is outward looking and draws upon knowledge of past and potential social interaction. This more restless creativity has the character of extroverted energy. These two creative acts are in one sense complementary and in another diametrically opposed, which is why writers are not always natural performers and vice versa.

28 

3  Role-Play as Performance

As a facilitator, you may be called upon both to compose and to perform, that is, to design the workshop that you will facilitate. This is analogous to a singer-songwriter who must resort to a private, introverted world in order to come up with a new song, but then switch gears into active, extrovert mode in order to go out on stage and put the song across to an audience. This double-sided act of composition and performance is difficult to pull off. We often tend to favour one pole over the other. For instance, you may be naturally reflective and find it relatively easy to design a workshop but find facilitation a messy affair. Or you may be a natural performer and rely on your experience and ability to improvise on the day and may underestimate the need for the initial journey into reflection.

Organization Yet again, your natural centre of gravity may be that of an organizer. Any performance depends upon this third ability, namely, the capacity to organize and to manage an event into existence. Someone needs to make it happen. People need to be contacted, rooms booked, parking arranged, handouts prepared and copied, refreshments ordered, technical equipment organized, lists of attendees drawn up, and signs printed which advertise the location of the workshop. It is the rare person indeed who is equally at home in these three domains of composition, facilitation, and organization, yet all three must come together to produce an effective role-play workshop. A good solution is to be part of a small team that together covers those bases. This issue of dividing up these functions is discussed in Chapter 6 “The Workshop Team.”

Where Do You Hold a Workshop? Like all performance, role-play takes place in a space and time that are buffered from the outside world. Sporting and artistic events have the advantage of buildings exclusively devoted to their activities. In role-play, we have no such advantage. Unless we have access to a well-designed

  Aesthetic Distance 

  29

simulation or education centre, we must run our workshops wherever we can find a space, and those spaces are sometimes only marginally suited to the purpose. However, if we understand such notions as framing and aesthetic distance, and how space and time affect the outcome, we are less likely to fall prey to circumstance, where sometimes things work well and sometimes they don’t, and we really don’t understand why. There are at least three things we can do to make spaces work for us. Firstly, choose the best spaces available. Secondly, apply principles of framing and focus to optimize the space we select. Thirdly, actively counter expectations of didactic teaching, and foster anticipation of exploration and experiment. Information on how to do this is in Chapter 8 “Where to Hold a Role-Play Workshop.”

Aesthetic Distance As in all social performance, aesthetic distance is a key factor in the success of role-play. Because of the presence of aesthetic distance, role-play offers us experiences distinctly different from those of real life. This is one of the great gifts of drama. It enables us to see ourselves in action in a very novel way. Normally, we see life from an insider point of view, from inside our own skin, and through our own eyes. We go out into our days, we look, we listen, we speak, and we decide as active players from within our interactions. As Shakespeare said, we live our lives as players on a stage. But we cannot see ourselves as others see us. In role-play, however, we are granted the opportunity to experience what we normally do from a completely different perspective. We watch as someone else carries out familiar tasks in ways that are more or less similar to our own. The person on stage could very well be us. Over time, we internalize that detached viewpoint. Then as we ourselves step up on stage, we find that we both act and observe ourselves act. We are fully involved, yet not. The situation is real, yet not. This is aesthetic distance in action. Critics who disparage role-play in favour only of interaction with actual clients or patients fail to grasp the opportunities for insight and personal growth that are afforded by these multiple points of view.

30 

3  Role-Play as Performance

The role-play stage is in fact a close facsimile of any number of professional workplaces where heightened, effective interaction is called for. This double act both of acting and of being aware of our actions is in fact the same faculty of split focus that all proficient performers and communicators employ in real life. As a new interaction begins, we split our forces into two as one half of our self speaks and acts and the other half monitors our actions and their impact on others. Role-play can teach young trainees how to get in touch with and heighten that dual sensibility and to transfer that renewed sensibility into real life. Effective role-play generates heightened awareness. Those who interact become far more aware of their usual behaviour and of new possibilities. Those who observe see things they usually do not notice. Often we see something in ourselves or in others to which we had been effectively blind. The Aha moment is an expected and hoped-for moment in role-­ play. After a well-run session, it is possible for many to leave transformed in some way through what they have experienced. As facilitators, it is part of our job to manage this process of attention, awareness, and insight. We must elicit this enhanced awareness, and encourage the rolling series of realizations that it produces. This is a far cry from the idea of simply practising new skills, or applying research findings to practice, assuming that the latter is even possible. The aesthetic distance that lies at the heart of all art and performance has a transformative potential that far transcends the simple transfer of intellectual information from one mind to another. These skills are discussed in Chapter 12 “Managing Aesthetic Distance.” We need to know how to create and maintain the virtual world of role-­ play that provides this stimulus for new experiences and learning. To do this, we need to learn how to work with actors and how to relate to them as characters in a virtual world, as we negotiate between that world and the world of the audience. We need to learn how to help role-players manage their anxiety and step into the virtual world, explore it, and identify new things that they can take back into their everyday lives, both personal and professional. We need to know how to help the audience observe with greater clarity and intensity and to process their insights and realizations. At the end, we need to know how to help participants step out of the world of the role-play, debrief, and bundle their experience to take back home. All of these areas are covered in the chapters listed under Practice in Part 2.

  The Simulation Triad 

  31

The Simulation Triad Virtually all models of role-play involve a nexus of three players. We might call this nexus the Simulation Triad. The three players of the triad are the actor, the role-player, and the facilitator (Heinrich 2011, p. 608) (see Fig. 3.1). 1. The Actor One person in a role-play is invariably called upon to act. “Acting” here is used in the commonly used sense, that is, to play a part that is distinctly not oneself, like an actor on stage or screen. The one who acts, the actor, most often plays the role of a member of the public—a patient, a client, a customer—though in an interaction that explores communication among colleagues it may be the role of a superior, a difficult colleague, or a colleague in difficulty. Whatever the role, this part requires a conceptual leap away from one’s own circumstances into those of another. This is an acting role, whether it is played by a professional actor or by a colleague with facility and comfort in performance, or whether it is quickly sketched or portrayed with photographic fidelity. Not everyone has a facility for this kind of performance, and it is best to recruit a ­natural performer, whether amateur or professional. The acting role is critical in that it recreates the desired scenario and generates the focus for the virtual world.

Facilitator

Actor

Fig. 3.1  The Simulation Triad

Role-player

32 

3  Role-Play as Performance

2. The Role-Player The second person of the triad is a role-player. Role-players usually need only to behave as they would in real life. A student acts as a student, a trainee as a trainee, a junior doctor as a junior doctor, and a nurse as a nurse. The role-player is aware that their partner is an actor and that they are performing within a hypothetical situation. Practical training, accumulated knowledge, and past experience are generally sufficient to carry out the designated task. Sometimes role-players become confused, and wrongly assume that they are being asked to act. “I can’t pretend,” they might say, “I’m not an actor.” Quite apart from the fact that actors do not pretend, to role-play is not to “act,” at least in the vernacular understanding of the term. Role-­ play does, however, require a modicum of imagination. It asks us to get in touch with how we behave in life, by accessing memory, or might behave in a hypothetical situation, by accessing imagination. This is the faculty we instinctively call upon on the day of an interview, first date, or any other situation where we desire success. In our minds, we entertain various possible scenarios, weed out those least likely to work, and settle on the best potential courses of action. We do this regularly with little conscious awareness that what we have chosen to do is to rehearse upon a stage in our imagination. Experience suggests that most people can access this basic level of imagination, though some of the more factually minded do continue to struggle. More crucially, role-play does require a certain level of comfort in performing in front of one’s peers, and the difficulty is more likely to be this one of performance anxiety, which we deal with in Chapter 10 “Managing Performance Anxiety.” The role would only become acting should players be asked to pretend to experience and knowledge beyond their present capacities. If, for instance, a medical student were instructed to leap forward in time and play a doctor, an intern to play a specialist, or a police trainee to play a senior constable, in each case, they would lack the professional e­ xperience and knowledge to do so. In these cases, they would, in fact, have been called upon to “act” rather than to role-play. The resulting performance would be very hit-and-miss.

  The Simulation Triad 

  33

However, a role-player is usually able to imagine one step ahead, which means that we can ask someone to play a professional role one level ahead of where they are now, provided they are very near to that level. For example, final-year medical students are already starting to project imaginatively forward to their next incarnation as interns and are able to imagine how they might behave in several months’ time. Specialist trainees preparing for their college examinations can imagine life as a consultant and respond to playing that role. Police trainees towards the end of training can imagine life as a probationary constable. 3. The Facilitator The third person in the triad is the educator whose job is to facilitate the role-play and to tease out the learning. The success of the workshop rests heavily upon the shoulders of the facilitator. A number of factors determine the scope and success of a workshop: your specific understanding of the learning process; your experience and comfort in the role of facilitator; your comfort with ambiguity and uncertain outcome, in that no two learners will come up with exactly the same solution to any situation; your ability to improvise within clearly defined boundaries; and your ability to respond authentically to someone else’s words and actions. Your concept of facilitation will determine how actively or how passively you interpret the role. That concept is partially determined by experience. Facilitation is a complex skill set, and inexperienced facilitators are mostly focused on getting the hang of the basics. Attention is largely absorbed by mechanistic issues of dispensing rules, watching the clock, and making sure that every member of the group has an opportunity to have their say. With greater experience, the rules and clock recede and tick quietly in the background, and facilitators become more proactive. Some lack understanding of adult learning and tend to offer instructions on what to do or say based on their own experience and point of view. This kind of advice may be useful where the focus is on training or procedural ­processes. Otherwise, it can inhibit the process, by moving the onus for learning away from the learners.

34 

3  Role-Play as Performance

However, as facilitators gain greater experience and feel more secure within themselves, the role takes on the colouration of fair-minded refereeing with elements of coaching. They confidently canvas opinions, weigh up how things are going, and make judgement calls on how and when to intervene. Their most useful tool is the apt question. Focused questions guide the group into the most fruitful territory for productive problem-solving. The solutions are those of the group, not of the facilitator, who personally might solve the issue quite differently. Experience and greater understanding steer us towards this latter kind of proactive facilitation. Chapters listed in Part 2  under Practice provide many of the resources to help you achieve this goal.

Role-Play as Rehearsal Role-play differs from other performance in one significant way, and it is important to recognize this fact. Most performances, whether they be stage, film, sporting, public speaking, or professional practice, take place at the end of a long process of practice. By the time of public performance, the wrinkles have been ironed out, and trial and error is largely relegated to the past. Role-play, on the other hand, is by its very nature rehearsal and practice. It is all about wrinkles and trial and error. Players should not be expected to produce polished performance. On the contrary, everyone should be encouraged to “play,” play seriously, but play nevertheless, and to explore and find new ways to accomplish professional demands. The laws of the rehearsal room are very different from those of the public or professional stage. The doors are shut to outside eyes and ears; confidences are confidential; personal safety and mutual respect are axiomatic; mistake and error lose their terrorizing power; exploration is encouraged; nothing can be mastered at once. Let me emphasize this point, because all too frequently trainees agonize when they fail to grasp a new concept or master a new skill at first attempt. I usually try to defuse this anxiety by reminding them that even the simplest skill requires at least three attempts to even commit the steps to memory. The focus, at least in the beginning, has to be on process rather than outcome. These issues are fleshed out in Chapter 4 “Role-play as Rehearsal.”

 Reference 

  35

Summary All art and performance have the capacity to generate insight and new understanding. Sports buffs analyse games and extract nuggets that inform their thinking and world view. Teams of artists labour long and hard to present elaborate case studies in their TV dramas, in the hope that their audiences will see through the surface action to the themes and arguments beneath that gave them the motivation to produce the show in the first place. Role-play does its job in a more direct and conscious way. The aim is unambiguously educational, and facilitators put in the effort in the hope of changing attitudes and behaviour. However, to make impact and achieve real outcomes, role-play needs to come alive. When this happens, the audience will engage with the virtual world, enter it either actually or vicariously, and take seriously the issues and dilemmas that it raises. There they can explore and practice scenarios they will soon meet in their professional life. For all of this to happen, role-play needs to be done well, and the elements that comprise it need to be taken seriously. The following chapters take you through ways to saturate the process with creativity, to organize, to allocate roles, to make locations work for you, and to actively manage aesthetic distance and the simulation triad of actor, player, and facilitator.

Reference Heinrich, Paul. 2011. The Role of the Actor in Medical Education. In Handbook of Communication in Oncology and Palliative Care, ed. D.W.  Kissane, B.D.  Bultz, P.N.  Butow, and I.G.  Finlay, 607–617. New  York: Oxford University Press.

4 Role-Play as Rehearsal How a Focus on Process Rather Than Outcome Shapes the Way We Run Role-Play Workshops

In contrast to other types of performance, role-play precedes performance proper. Role-play is all about practice and takes place within the safety of the rehearsal room where the rules and conventions that govern behaviour are quite different to those of professional life. It is very easy to overlook this basic distinction which informs the practice of role-play. Role-play that makes use of the resources of the rehearsal process produces greater insights and opportunities for personal growth.

Role-play differs from other performance in one very specific way, and it is imperative that we recognize this distinction up front. Most performance takes place at the end of a long process of practice. The practice sessions build up necessary skills, explore options, shape the clearest course of action, iron out the wrinkles, and polish till it sparkles. By the time we see such performance, the period of trial and error has largely come and gone. Role-play, on the other hand, takes place in this messy trial-and-error period. It is practice for the real thing, rather than the thing itself. Role-­ play is akin to actors in the rehearsal room, sportsmen and women in practice sessions, and the public speaker working up a new presentation. © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_4

37

38 

4  Role-Play as Rehearsal

Interactions are played for process rather than for outcome. Players throw themselves into the midst of a scenario so that it will reveal its secrets. This is a truism, but one we can easily forget, that competent or polished behaviour only occurs at the end of a period of exploration. If we forget this fact, and attempt to carry out a new task correctly the first time, all we will achieve is to realize a picture that we already carry in our mind. This means that we will not discover anything new. The answers we seek do not exist on paper or in our minds. They are as yet unknown, and only to be found within the interaction, and every interaction carries its secrets within itself. Players must walk into the middle of a scenario to discover what is there. Every discovery is gain. Nothing can be guaranteed at any stage. Players need to know from the outset that they are free to learn. Therefore, unless role-play occurs in an examination setting, nothing whatsoever in this environment can or should be assessed, and given a grade. This crucial distinction between rehearsal and performance proper carries implications for how we run role-play sessions, what kind of learning we aim for, what we happily allow to take place, and how we safeguard these moments. Let us begin with the last.

The Sanctity and Safety of Rehearsal Space The rehearsal room is virtually sacred space. The same principles tend to apply in all fields, but I will draw from the world of theatre and drama, as it is what I understand best. In the world of drama, rehearsals are closed sessions. Rehearsal is very vulnerable for those involved. People put themselves on the line, take chances, perhaps do things they have never done before, and push themselves and their limits to find out what they are really capable of. In the solving of any new play, they must venture into unknown territory, accept what they find on its own terms, and find ways to flourish within that world. By definition, things do not always work beautifully the first time, and occasionally there will be beautiful catastrophes. For these and other reasons, actors and directors prefer to have rehearsals closed to others beyond immediate cast members. No public is allowed, which means no ­audience,

  The Sanctity and Safety of Rehearsal Space 

  39

no critics, not even family, only the director and the cast. Cast members need to develop a confident trust in each other. This trust will enable them to explore their own vulnerabilities safe in the knowledge that those around them will not take advantage of them. It is an obvious maxim of rehearsals that one has not yet mastered the role. The laws of the rehearsal room, therefore, are very different from those of the workplace, the stage, or the playing field. The doors are shut to outside eyes and ears; confidences are confidential; mistake and error lose their terrorizing power; exploration is encouraged; fun is to be expected; nothing can be mastered at once; and personal safety and mutual respect are axiomatic. There is no audience as such in rehearsal. Everyone who attends is in some way a member of the team. If actors sit and watch colleagues rehearsing scenes, they do not primarily do so as an audience. They are of course interested in seeing what is going on while they are back stage, but their primary concern is to absorb the totality of the performance, so that their own contributions form a seamless part of the whole. When the technical team attend, they watch to see how the actors’ movements on the stage feed into their own decisions on lighting, set design, and sound. The same principles apply in role-play workshops. Students and trainees need to know that they are learning in a safe environment. They need to know that in their small group they are safe to learn and grow, safe from humiliation, safe to take risks, safe from unfriendly scrutiny, and safe from the eyes of seniors who may have forgotten what it is like to be back at the beginning of their professional lives. Therefore, the door is closed to scrutiny of competitive colleagues and more knowledgeable superiors, examiners, and those who will open or close the gates to their futures. Only learners, trainers, and actors are present, and everything that takes place is confidential. Any senior clinician or manager in attendance needs to be there first and foremost as a sympathetic teacher. Rehearsal requires the freedom to try out the untried and end up in the occasional cul de sac, before finding a way to win through. Therefore, it requires sensitive and open teachers who are in touch with the learning process and who see themselves as learning as much as the students. Unless the focus is on procedural training, any tendency by a facilitator to push a student to perform according

40 

4  Role-Play as Rehearsal

to a blueprint or guideline only blocks the learning process. Learners would find themselves forced to conform to stereotypical notions of how they should act, which produces at best performance of a stilted kind and which is unlikely to be authentic human interaction. As facilitators, we need to remember that we work within the special domain of the rehearsal room and to do what we can to safeguard the creative opportunities of the learning space. To help students to take risks, you will probably need to model this willingness yourself and to make the group consciously aware of the special nature of the rehearsal space and the very different rules that apply within it. Emphasise the safety of the workshop, the focus on process and exploration, and collect an agreement on confidentiality. Emphasize the collective nature of the learning. Work to create a sense of team cohesion. Make it clear that there is no summative assessment of any kind attached to anything that takes place in this time and space. You are not primarily interested in how well or how badly any one person performs. The focus is on the role-play scenario itself, the intrinsic interest that it holds, the challenges that it poses, and the insights that they will experience as they all combine their knowledge and abilities to make the scenario release its secrets. Remind them that there is no audience. When someone else takes the floor for a time in role-play, they should not think of themselves as an audience but as colleagues working together to explore the scene. Encourage those watching to become active observers because at any time their insight may be that which is most needed for the group to move forward. The role-play will hopefully come alive and, for a time, become indistinguishable from everyday behaviour in the workplace. Interactions sometimes become intense, so develop a light touch. When all is said and done, role-play reality is not real. The learning mode in rehearsal is one of play, serious play, but play nonetheless. Real-life consequences are parked outside the door, and this freedom from actual consequence is what generates the aesthetic distance that makes learning possible. Play should be fun at least occasionally, and you should expect laughter from time to time. The greatest freedom from consequence, of course, lies in the fact that you have not brought a real patient or client into the room. Players can-

  Streaming and Layering 

  41

not harm the actor, who will bounce back from the interactions no matter what might happen. You know that. The actor knows that. Make sure that the group knows that.

Streaming and Layering When actors rehearse, they explore their roles from as many angles as time allows, and slowly—repeat, slowly—build their understanding one layer upon another. They understand that many different streams run through any interaction—the clarity or obscurity of language, explanations and growth in understanding, words spoken for the first time or dragged out for the umpteenth time, realizations sudden or dawning, a shifting emotional landscape, a sense of connection or of being held at bay, anxiety provoked or allayed. So many factors are at play at any one moment that no one is able to pay attention to them all simultaneously, let alone master them. The concept of layers or streams is common currency in acting circles. The principle is very simple. We cannot produce polished performance if we have not in some way identified at least several of the major strands that comprise it. Most clinicians, for instance, have had to work towards accomplished consultation skills through trial and error with patients. It is the same with any profession. We learn as we go, and sometimes it takes a very long time. Rehearsal with role-play enhances and potentially speeds up this natural process. It does this in several ways. Each person has the opportunity to watch others handle familiar situations. Some will have a similar approach to our own. Seeing our own approach in action and successful, we feel affirmed, and the skill consolidates. Others will have a very different approach or style. Their approach may work, but we may still sense that it is something we could not do. Unless it is fear talking, we may be right. On the other hand, if we sense, “I could probably do that,” even though it is something we had not thought of before, we are already tucking it into our bag of tricks (everyone has a bag of tricks), and again, we are probably right. Our imagination is that part of our mind that goes ahead as a scout, checking out possible ways forward. I have found, as a basic rule of thumb, that if you can imagine yourself doing something, whether

42 

4  Role-Play as Rehearsal

you see it in others or come up with the idea on your own, the likelihood is that you can actually do it. On the other hand, if you cannot see yourself doing it, you probably cannot. There are things that other people can get away with that do not work if you try them, and things you can do that elude others. Communication is partly a matter of style. Things remain invisible until we see them, and one way of seeing things is to name them. By naming, we realize them. That is, something that has been operating unseen in the background is spotted on the radar and is now real, where before it was not. We might, for instance, become aware that we know what to do and do not fall apart if someone is distressed, or the converse. As we notice and pay attention, we start to discover how we do it, and what was once a native but unconscious skill now comes within our conscious control. Or, we may recognize that the same words asked by a patient, “So, what do you think it is?” can mean different things depending on how the patient is sitting, the angle of the head, the focus of the eyes, the tone of voice, or a hesitation or a directness in the enquiry. We realize that each version prompts a different response from us. Our ability to differentiate makes us more flexible, more focused, more apposite in our reply. Facilitation takes on a midwifery role as we tease these insights into the open. For the group, it doesn’t matter if the behaviour is their own or that of one of their colleagues. They are now aware of something that was hitherto unrecognized. You are able to use streaming or layering in the way you prompt the role-player. If the interaction is likely to be richly layered, you might narrow the focus by having players focus on one particular aspect. You might ask them to pay particular attention to how well their partner in role-play is taking in their explanation, or to monitor their partner’s anxiety levels, or their own anxiety, or to be aware of the way they use language, any number of things. The role-player then concentrates on one of the significant layers of a conversation and becomes much more aware of that strand, as do the members of the watching group. Sometimes one layer takes on greater prominence at a particular point in an interaction. For instance, emphases shift as a medical consultation moves from initial ­rapport and rule-setting through history-taking, answering of questions, discussion of side effects, or explanation of treatment or disease path-

  Distinguish Among Training, Workshop, and Rehearsal 

  43

ways. The consultant’s mind will change tack whether he or she is aware of that fact or not. If role-play is facilitated well, these unconscious shifts come to the fore.

 istinguish Among Training, Workshop, D and Rehearsal Rehearsal is an umbrella term for the process of preparation leading up to performance proper. However, preparation for performance is a complex matter, and it is useful to fine-tune the overall concept of rehearsal into its constituent parts. Role-play will change its shape according to the precise kind of preparation envisaged. Does the group need to acquire and practise new skills, explore and expand repertoire, or polish behaviour till it glistens ready for actual performance? These different points of focus correspond to three aspects of rehearsal which are commonly known as training, workshopping, and rehearsal (Schechner 1985, pp. 16–21).

Training Training refers to the process of skill acquisition. In learning music, we go over and over scales, learn to read musical notation, practise fingering, chord shapes, and progressions, and learn how to care for our instrument, whether that instrument be a clarinet, guitar, or our voice. In sport, we learn such skills as ball handling, goal kicking, line outs, set pieces, dribbling, and shooting, depending on the specific sport. Medical students learn physical examination skills, how to take a pulse or blood pressure, how to insert a catheter, how to suture, and so on. For clinical communication, they learn to introduce themselves, obtain basic consent for interaction, take different kinds of history, identify the value of different kinds of questions, listen and hear, observe and see, give information, and check understanding. The aim of a role-play may be to teach specific micro skills or a protocol for a particular kind of conversation, for instance SPIKES as a way to keep on track when you break bad news. In this case, an external grid is

44 

4  Role-Play as Rehearsal

imposed on the interaction, and the student needs to consciously think and act in the non-intuitive, abstract terms of Setting, Preparation, Invitation, Knowledge, Empathy, and Summary (Baile et al. 2000). When you teach these skills, you engage in training. Your facilitation adjusts accordingly and inevitably works through a process of demonstration, practice, correction, repetition, and drill until behaviour becomes second nature. Individual variation is relatively minimal, and formative assessment is implicit in that behaviour needs to nudge closer and closer to an established standard. Any communication of a more procedural nature usually carries strong overtones of training.

Workshopping Workshopping usually assumes prior training. When role-play focuses on workshop mode, players walk into new or familiar situations, learn to recognize and analyse the nature of those scenarios, develop their capacity to think on their feet, become more at ease in interacting with someone else, and build a clearer sense of the possibilities available to them. They learn to become social actors in the sense of becoming active agents of their own actions. The dominant mode of learning here is improvisation. Through improvisation, players expand their repertoire of behaviour, identify new options, consciously become aware of their actions and critique them, affirm successes, identify shortfalls, make necessary distinctions, and hypothesize and test potential courses of action. Individuals vary tremendously in the way they tackle situations and interact with others. Young players need to be encouraged to find their own style which may be quite different to your own. Professional demands provide an overall guide to the way forward, but the most useful answers are to be found within the intrinsic logic of the situation itself.

Rehearsal Rehearsal proper is directed forward to the pressing demands of actual performance. Rehearsal assumes prior training and ideally prior opportunities for workshop. It also assumes the existence of a specific script for action in written or scenario form. In professional communication, the script will

  The Place of Emotions 

  45

almost always be scenario based and include options for various eventualities. Once basic skills have been acquired through training and possibilities canvassed through workshopping, players kick back into tunnel-vision mode, make considered choices, and lock them in. Rehearsal proper is practice for the real thing. This is when players “block” their action, that is, make definite choices on what they will do and say when and where and how, internalize their lines and actions, go over and over them, and find the appropriate pitch or level of performance. Rehearsal proper is about eliminating noise or polishing performance, whichever metaphor works for you. Though these three activities are covered by the umbrella term rehearsal, the emphases are distinct and call for different kinds of facilitation. Training calls for emphasis on acquiring micro skills, workshopping for open-ended exploration, and rehearsal for focused attention on impending professional performance. Our own workshops are mostly designed around exploration of specific scenarios, which is of course why they are called role-play workshops. Because clinicians have so few opportunities for this kind of learning, we rarely get to rehearsal proper. You will find a fuller discussion of these modes of rehearsal in Chapter 19 “Workshop Formats.”

The Place of Emotions Emotional expression also works by different rules within rehearsal. Rehearsals for a new play are often marked by moments of laughter and tears, the traditional twin faces of drama. In rehearsing comedies, for instance, actors may fall about laughing at the silliness of their lines. In actual performance, such behaviour would be regarded as unprofessional, as it sabotages the performance by puncturing the build-up of tension that leads to audience laughter. In rehearsal, however, different rules apply. For comedy to succeed, the audience must sense a comic sensibility at work, no matter how straight the faces on stage. For this to happen, the actors must get in touch with the silliness of their words and actions. When actors crack up in rehearsals, they acknowledge and succumb to the comedy. Each time, it gets the temptation to laugh out of the system and builds immunity for later when they need to keep a straight face. One laughs now so as not to laugh later. Here, as in all else, the rules of performance and the rules of rehearsal are entirely different.

46 

4  Role-Play as Rehearsal

The same thing happens in serious drama. At a particularly poignant part in the rehearsal, the eyes of an actor may suddenly well up in tears. The events may be too close for comfort, the reality too raw, but, most importantly, in rehearsal actors tap into the emotional truth of a moment and allow themselves to be moved by it. During the actual performance, this would not be appropriate behaviour, but by that stage the actors are in control. By having tapped into the emotional truth during rehearsal, they have acknowledged and accepted the pain and the pathos. In performance, this receptivity transfers to the audience. Such sad events should evoke tears. In rehearsal, the tears appear on stage. In actual performance, they appear empathically in the eyes of the audience. In a similar way, interactions in role-play sometimes trigger emotional responses in some players. Their first response is often to despair over their “lack of professionalism” in becoming emotional. The distress may have been triggered by an analogous situation in their recent past, or it may be something they are now going through. In either case, they have yet to process the experience and develop a degree of detachment from it. In terms of aesthetic distance, they are too close to the virtual world. They need greater distance. Or it may simply be that they have been unexpectedly moved by the pain or distress of the situation. If they are distressed, offer to remove them from active interaction, so they might recover their equanimity. Some may wish to return and try again. Others may not be ready. If players have issues left unresolved from experiences in their own lives, you might offer debriefing. In some cases, professional counselling may be of benefit so that past trauma does not block open interaction in their professional future. Most students and trainees, from our experience, are able to navigate emotional scenes in role-play without too much difficulty. However, the reality is that for those with strong empathic abilities, distress in someone else evokes distress in them. The important consideration is that players permit themselves to identify and experience the emotional reality of the scene. In time, that emotional understanding will become internalized, and they can experience the emotion of such situations in the future without succumbing to it. Rehearsal is the place where these reality checks take place. If players allow themselves to experience the emotionality of a situation at least once in rehearsal, the memory of that experience remains in muscle memory. In

 References 

  47

future situations where patients or clients experience intense emotion, they understand something of what it means because they have allowed themselves to do so during role-play rehearsal. In one sense, they no longer need to become overwhelmed by the emotion because they have already done so.

Summary 1. Role-play is all about rehearsal, the learning that takes place in the period of trial and error that precedes polished professional performance. It is practice for the real thing rather than the thing itself. 2. Therefore, mastery can never be assumed. 3. Role-play learning depends on sympathetic teachers and a focus on process rather than outcome. 4. The rules of role-play are those of the rehearsal room and emphasize safety, trust, confidentiality, group learning, and the freedom to explore and take risks. 5. Because professional interactions are so complex, learners cannot focus on everything at once. It pays, therefore, to pay attention to specific aspects or levels of communication. Over time, learners become more aware and expand their repertoire. 6. Three different modes of rehearsal imply different emphases of role-­play. Training imparts new skills, workshopping opens the mind and expands repertoire, and rehearsal proper polishes for professional performance. 7. The rehearsal nature of role-play provides opportunity for young professionals to get in touch with their feelings and emotional responses, acknowledge them, and develop greater empathy.

References Baile, W.F., R. Buckman, R. Lenzi, G. Glober, E.A. Beale, and A.P. Kudelka. 2000. SPIKES—A Six-step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 5 (4): 302–311. Schechner, Richard. 1985. Between Theater and Anthropology. Philadelphia: University of Pennsylvania Press.

5 Role-Play as Drama How Drama Resources Invigorate the Practice of Role-Play and Transform Players into Active, Adult Learners

Role-play drama offers far more than simply the capacity to recreate professional interactions. The field of drama offers an array of insights, approaches, and techniques to help players buy into the world of role-play and addresses a wide range of specific issues faced by players and facilitators. Just as importantly, these techniques go a long way in giving players real access to the findings of the research literature which otherwise remain almost impossible to put into practice. The examples are here drawn from the world of medicine, but the same principles apply to healthcare, law, policing, and business.

Let us begin with a truism. Role-play is a particular form of drama. In a workshop setting, a group sits around a small space designated as a stage. One party on the stage acts as a patient or client. The other interacts as him- or herself in a professional scenario. A third watches, facilitates, and uses whatever resources are available to generate profitable learning out of what takes place. A group of peers observe, discuss ways to take the interaction productively forward, and take turns on stage as the role-player. The usefulness of role-play drama as an educational tool that simulates real life is now widely recognized. Often, however, the concept of r­ ole-­play © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_5

49

50 

5  Role-Play as Drama

as drama goes no further than that. For example, in the medical world, once role-play is set in motion, a group may tend to critique what happens and work out what to do by recourse to research literature. The literature will suggest particular approaches, and the group will attempt to put those approaches into practice. There are at least three difficulties with this approach. Firstly, the literature is based on an extensive sample size, which means that it identifies how best to behave in general. The clinician, however, is faced with a situation of n = 1—an anxious Mrs Gupta, or a stoic Mr Anderson—and needs to know which behaviour is appropriate in this one specific, idiosyncratic case. On this point, the literature is mostly silent. Secondly, the questions pertinent to the clinician are often not those of the researchers. The latter mostly observe interactions from an outside viewpoint. They describe what outsiders see when clinicians talk to patients. The clinician, on the other hand, experiences the interaction from within it. A clock ticks, and the clinician must find a way forward to a satisfying solution. “What is going on here?” the clinician may ask. “What am I seeing? What is most important here? Am I getting through? What am I missing? How should I proceed?” They will mostly search the literature in vain for answers to these questions. The researchers were tackling other issues. Thirdly, the findings of the literature are theoretical and abstract, and hover several levels above the ground, as it were. This means that, even if the first two difficulties did not exist, it is extremely difficult, if not impossible, to apply these findings, to move from library to stage in one move. Theory rarely leads directly to practice. Drama can do much to bridge library and stage and to address these problems. Role-play is more than just a useful educational tool. It is also a kind of lens, another way of looking at everyday interactions, and a very effective one. This is because role-play is drama all the way through. Its interactions, like the consultations it simulates, are intrinsically dramatic. People enter, greet, sit, open their hearts, speak, listen, fail to speak, fail to hear, lean forward, draw back, become anxious, distressed or angry, come to agreement or appear to, and leave hopeful, confused, or devastated. This is all the stuff of human drama. Many of the techniques that explore interactions such as these and open them up for scrutiny are

5  Role-Play as Drama 

  51

­ ramatic techniques. Most of the behaviour itself is intelligible in drad matic terms, including the important knowledge of what to do when you don’t know what’s going on, or what to do. Drama, after all, centres on the knowledge required by performers to find their forward within an interaction. This is the same kind of knowledge required by professionals in the workforce. The benefit of dramatic insights is that any understanding gleaned from drama can be put into practice. Drama is practical, and insights from drama are never further than one theoretical step above the ground. The language of drama is flexible enough to absorb insights from many other domains of knowledge, and to transform it into performable action. This does not mean that drama itself can tell us the best ways to communicate and interact. Only ongoing exploration and research can do that. Drama, however, provides a means to find those answers. Unfortunately, these extensive resources from drama are often overlooked in role-play practice. Useful insights and techniques from drama appear all through this book. They address the challenging kinds of issues faced by a facilitator: how to make the most use of a workshop space; how to prepare yourself for action; how to reduce performance anxiety; how to manage aesthetic distance; how to help a group buy into the reality of the role-play world; how to halt or pause the action; how to relate to the actor; how to know the best place to intervene; what to do when a player is too detached, or stiff, constrained, blunt, or unfocused; what to do when a player is too focused on self, is oblivious to their impact on others, is unaware of their use of language, or is blind to non-verbal communication; what to do when a player sees only surface behaviour and cannot see what is going on underneath, or hears only factual cues, and misses personal concerns. In this chapter, I propose three fundamental insights from dramatic practice that open many doors to a facilitator. The first describes a common difficulty faced by young performers, that is, they have mostly accumulated what they know in an ad hoc manner and are largely oblivious to their own actions. The principle is called the Centipede’s Dilemma. When players become aware of their actions, they learn to become present in an interaction and to work their way forward from within it, rather than trying to impose recommendations from without.

52 

5  Role-Play as Drama

The second insight has to do with the universal ability of performers to perform a role, and, at the same time, to stand back from it to critique and direct their own behaviour. This dual awareness is well known to all proficient communicators but is rarely recognized by young professionals. I call this principle Split Focus. By drawing attention to this phenomenon, you validate and give trainees conscious control over a crucial element of their clinical thought processes. The third insight addresses the problem of how to break the impasse between library and stage, and to bridge theory and practice. The usual approach chosen by medical education is to identify appropriate behaviours and require young clinicians to put them into practice. The result is often uncomfortable and stilted behaviour. This is the problem I call the Creep Principle, and the solution is the time-honoured dramatic technique called Objectives.

The Centipede’s Dilemma Perhaps the most common phenomenon among novice actors is what seems to be a strange inability to perform on stage something well within their capacity. I remember young acting students going up on stage to perform a simple scenario, and their dismay when they struggle and fail to carry it off with conviction. “But I know I can do it,” they say mystified. “I know I can do this kind of thing. Why can’t I do it here?” If you are an educator, you have probably seen the same thing with students or trainees. For instance, a student is asked to interact with an actor lying in bed as a patient, find out what has brought the patient into hospital, and do what he can to address her issues. He walks into the scene and begins to ask questions. The patient seems preoccupied and agitated and asks a stream of unconnected questions. The student tries to answer them one by one, but after three “I don’t knows,” feels his temperature begin to rise, his pulse quicken, and an overwhelming urge to escape. He reacts in frustration and shame. “Why can’t I do this?” he asks bewildered. Let us assume for a moment that the student is able to handle this kind of situation to some degree in real life. His problem is that of the

  The Centipede’s Dilemma 

  53

novice acting student. He can more or less do it as himself in life, but not in role on stage. In role, his performance collapses because he doesn’t know what he is doing. When I say, he doesn’t know what he is doing, that does not necessarily mean that he can’t do it. Sometimes, someone will in fact carry out a task with great aplomb, and yet have no idea what they did, or how they did it. The problem is that they don’t consciously know what it is that they are doing. They do things but are effectively asleep as to their actions. As a result, they cannot necessarily reproduce appropriate behaviour at will. Until this fact is pointed out, they often don’t even know that they don’t know what they are doing. They are doubly asleep. The student is grappling with what is known as the Centipede’s Dilemma.1 The story of the centipede first appeared in print as a short poem by Katherine Craster in 1871 and quickly spread through other publications. In subsequent retellings, a large centipede cornered a small spider (originally a toad) and was about to finish him off. The spider asked for a last favour. “What do you want?” asked the centipede, feeling magnanimous. “I have a question,” said the spider. “How do you coordinate all those legs? Which leg moves first?”

As the centipede stopped in confusion, the spider slipped from his grasp and escaped. The centipede set out to give chase but fell in a jumble of uncoordinated legs. We pick up much of what we know in life in an ad hoc, mostly unconscious way, and much of our behaviour is inevitably automatic. The process is entirely natural and causes no problems until our attention is directed to it. Start to think too much about a complex activity that you normally carry out without thought, and you may find yourself in the throes of the Centipede’s Dilemma, suddenly unable to tie a Windsor knot, finger pick a banjo, or swing a golf club. Drive for the first time on the other side of the road, and your automatic skills may suddenly become problematic. We see this phenomenon in workshops all the time. Students have picked up ways of managing situations in life. However, when asked to

54 

5  Role-Play as Drama

assume a clinical role, and engage in the same activity on the heightened plane of a clinical interaction, they suddenly are at sea. An ability to address anxiety or distress, or give clear directions to a friend or acquaintance, may not automatically transfer to the professional stage. To address the dilemma, the facilitator teases the student’s self-­ knowledge out into the open. The student may recognize that he is more or less able to sit down and talk with an anxious friend in life, but not yet on stage. So, how does he do it in life? What does he already know? As he and the group identify the elements of the scene, they move forward into his conscious mind. He gives a name to factors operating in the scene and, as he does so, he gains potential control over them. Gradually he is able to take what he already knows in life and to do likewise in the artificial environment of the stage, whether that of role-play or professional practice. At first students may feel frustrated, as their behaviour is now a little mechanical. This is because their focus is on the skill. There is no way around this process. The more time one spends on practising a skill, the stronger and more flexible it becomes, and the greater the eventual mastery. In time, the knowledge drops back into second nature. The process is sometimes referred to as the acquisition of competence from a starting point of unconscious incompetence.2 Training programmes throughout the world teach that competence moves through four stages, from unconscious incompetence, through conscious incompetence (the centipede), to conscious competence (focus on skill) to unconscious competence (second nature). If you think back to how you learned to drive a car and the way you drive it now, you have the idea. Young actors usually spend their first year of training becoming aware of themselves, their strengths, weaknesses, style, and range. They learn to see, hear, and reason in a professional manner; to observe behaviour, recognize, and understand it; to develop situational awareness so that they can identify the nature of a situation, what they are to do, and how they might do it. They gain control over their sensorium and their learning apparatus, so that they become trained, autonomous, adult learners. Then they start to focus on the roles that they will be called upon to play. Skip this first stage with actors, and you have performers who remain insecure, because they are not in touch with their own reality and have

  The Centipede’s Dilemma 

  55

not accepted it. Their basic posture in performance remains one of anxiety, which they try to allay by putting on what is effectively a mask, and resorting to short cuts, scripts, and tricks of various kinds. In acting terms, they are “cheating” and producing inauthentic behaviour. It fools only the indiscriminate audience. It does not fool many patients or clients. In medicine, some students prefer to skip this initial phase, particularly those for whom clinical interaction is secondary to their scientific interest in disease and research. They may fear any process that directs attention to their inner being, because it is not something that they naturally spend time on. However, they lose out in two significant ways. Firstly, they will end up much of the time with stilted performance, which is not satisfying either to them or to patients. Secondly, their desire for instant answers in communication is diametrically opposite to the way they learn everything else in medicine. They learn medicine by struggle, by facing tough problems, asking questions again and again, and building their understanding up from the basics. It is an intrinsically satisfying process that demands their full attention and intellect. They are not told the solutions as they want to be told for communication. In this latter case, both the way they learn how to communicate and the end results they achieve are intrinsically undemanding and boring. The basic problem with rushing straight into “the good stuff” is that the student may not have learned how to enter any given moment, and to be present in an interaction. Yet this is the essential first requirement of performance and communication. Communication begins from within an interaction. Performance that does not spring from presence in the moment tends to be superficial and perfunctory. Early training that confronts the Centipede’s Dilemma activates emotional intelligence, and over time develops this habit of presence. A doctor with presence is the man or a woman who makes patients feel that they have the doctor’s full and undivided attention. The doctor somehow is right there in the moment with them, and patients leave with a sense that the doctor cares and is on top of their case. The same principle of course applies in all healthcare, law, policing, and business.

56 

5  Role-Play as Drama

Split Focus All professional communicators have a faculty of dual awareness, one part of the mind clinical and detached, the other engaged and interactive. I call this faculty split focus. If you are a clinician, you are presumably aware of your natural capacity for split focus. As you begin to interact with a patient, one part of you smiles, reaches forward to shake hands, offers a chair, and engages in preliminary banter to break the ice. This first part of you interacts and asks questions, listens, sees, hears, writes, looks up, and makes encouraging noises to the patient to go on. Meanwhile, the other part of you sits back and monitors the action. This second part coolly watches the interaction, notices and notes, wonders, quietly suggests questions to yourself to ask, weighs up possible ways forward, sets a course, and bides time. This natural capacity for split focus is something that all professional communicators share with actors and performers of all kinds. The actor playing Hamlet is not delusional and knows that he is not Hamlet. The Hamlet part of himself moves around the stage, speaks, listens, reacts, gets frustrated, plots and schemes, and finally gets to pull out his sword. The actor within quietly makes sure that his voice can be heard, that he stands in the assigned place on stage, monitors his breathing, focuses his attention, reenergizes and prepares for his next moves, and adjusts his position on the stage to counter an unexpected move by Horatio. The two realities operate concurrently, the performance as Hamlet and the inner direction of the actor. The performance is warm, in the sense that it is subjective, interactive, experiential, and engaged. The inner direction is cool, in that it is distant, analytical, dispassionate, and observing. The inner voice directs and tells Hamlet what to say and do. This means that the actor in a sense has two voices, two ways of thinking and speaking. Hamlet follows his script and speaks in public the lines that he has internalized. The actor, meanwhile, thinks in code and in shorthand, makes diagnostic judgements, and says things to himself that no one else is meant to hear. Both sides of his mind work in tandem: the objective mind considers, and the subjective mind engages. Needless to say, the audience sees only Hamlet. Professional communicators do exactly the same thing. If you are a clinician, a cool streak in your mind objectively monitors your i­ nteraction

  Split Focus 

  57

with the patient and directs your behaviour. The you-in-role, the doctor, leans forward, warmly engages with the patient and, like Hamlet, follows what is in fact a script, though in your case, a clinical pathway of an improvisational nature. Your doctor plays the required clinical role, speaks vernacular where possible, and paraphrases medical terms when they come up. You, invisible behind the role and responsible for what is going on, meanwhile figuratively lean back, think in code, make diagnostic judgements, and say things to yourself that no one else need hear. “Looks like back pain,” your cool objective mind thinks as you watch and listen. “What has brought you to see me today?” the patient hears you ask. “We need to discuss prognosis,” you think as a clinician. “Do you want to talk about what these results mean?” the patient hears. “Sounds depressed,” you think. “How are things going since I last saw you?” the patient hears. “You look a little down, how are you going with the tablets?”

Unless, of course, you are oblivious to the split focus, in which case, the inner you and outer clinician share the same voice. “Sounds depressed,” your cool objective mind thinks. “You sound depressed,” your clinician says.

Telling patients that they are depressed may be a good judgement call in some situations, but your thoughts about what is going on are not always appropriate for public airing. Unfortunately, the following comments by doctors have been drawn from real life. “You have a very strange colour.” “I wouldn’t start War and Peace, if I were you.” “Uh-oh!” “That’s the smoking!” “So, what are we going to do with this cancer, then?” introducing utterly unexpected news while waving a CT scan in the air.

58 

5  Role-Play as Drama

You may notice a natural tendency in the first stage of an interaction, particularly with someone new, to favour the cool observer in you over the warm interlocutor. Observation needs some distance, and it inevitably first treats the newcomer as an object to be scrutinized. A patient walks in awkwardly, and sits down. What does the patient’s gait tell you? The way she lowers herself into the chair and guards a certain part of her body suggests pain. Her flat affect suggests depression or depletion. Meanwhile, the other part of you has entered into conversation and interacts warmly with the patient. Both modes of action run more or less simultaneously, and on separate tracks, until you have gathered enough information to relate in an integrated way. This double action is not equally comfortable for all clinicians. At one extreme, the more actively minded prefer to jump right into the conversation, and to work things out as they go. They are natural clinical performers. They immediately treat the patient as a fellow subject like themselves and handle the simultaneity with relative ease. At the other extreme, the naturally observant or the socially reticent prefer to sit back until they have gathered enough information to proceed. They are reluctant to engage immediately with the patient as subject because they realize that they have insufficient understanding of whom and what they are dealing with. That is, they do not understand the patient as an object, and need to. At a certain point, they experience an impulse to lean forward and engage. The former group may be tempted to foreclose too early and may miss more important cues. The latter group may be tempted to remain within the safety of their observation post and not to interact personally at all. Young people often find it difficult to manage the two tasks simultaneously. Leaning forward and backward at the same time, as it were, takes time to master. If you consider that this skill needs practice, draw the group’s attention to this faculty of split focus, and focus on one or the other strand. If players have warm interactive skills but need to tighten up their objectivity, have them focus on their cool, clinical streak and thus treat their role-play partner as object, a clinical problem to be solved. If they have no problem with objective detachment but are low in relational skills, have them develop their capacity for engagement by treating their partner as another subject, that is, a fellow human being. Because

  The Creep Principle and Objectives 

  59

the focus is so specific in each case, the practice interaction will inevitably lack the balance of accomplished performance. The point of the exercise, however, is not to achieve balance but to work towards it by strengthening a weaker side. By separating them, each of these two layers is made explicit, and learners are able to perceive with greater intensity than if they try to do both at once. Just as importantly, by drawing attention to the phenomenon of split focus, you validate and give them conscious control over a major element of their clinical thought processes. You will probably find that players will feel considerably less stressed, as they are often confused about this dual aspect in themselves, but have had no way of naming and accepting it.

The Creep Principle and Objectives Extensive research has been carried out worldwide to find out what patients demand and expect, and what doctors might do in response to provide compassionate and effective healthcare. The research continues, but we now have extensive lists of behaviours that are seen as effective and compassionate, and other behaviours that are regarded as unsatisfactory and ineffective. To put this information into practice, medical educators routinely identify appropriate behaviours, combine them into lists, and require young clinicians to put them into practice. The result, however, is often uncomfortable and stilted behaviour accompanied with lots of uncertainty and anxiety. Why should this be so? And if this is not the way, how do we produce authentic and effective behaviour? Much of the research into medical communication tends to identify and analyse specific behaviours. Do doctors have open, or closed posture? Are their questions open, focused, closed, leading, double, or complex? Do they smile, nod, acknowledge with uh-huh, right, and so on? Do they use blocking tactics, or do they facilitate discussion? How long does a doctor wait to interrupt the patient? Do they respond to emotional cues or stick to the facts? Do they share ownership of the consultation or play it in the traditional me-doctor, you-patient mode? These factors are mostly external behaviours visible to an outside observer. They are

60 

5  Role-Play as Drama

i­nvisible to the clinicians who produce them because they are focused on their clinical task and are largely oblivious to how they look to others. If you overly direct the attention of young clinicians to inappropriate external behaviours, they will assume that they simply need to change them. For instance, we may show students what they look like on video. They suddenly see their behaviour from a new, outside point of view and are genuinely surprised and shocked because they were unaware of how they look from the outside. It is not their usual viewpoint, which is from inside their own skin. Most people who see themselves on video are not only surprised but anxious. They all too quickly see shortcomings. This means that the changes they will make will be made from a baseline of anxiety, which is not a helpful starting point. If they try to change the behaviour, for instance, by leaning forward more, nodding more, or maintaining better eye contact, the new behaviour is unlikely to be authentic or effective, and the student is unlikely to feel comfortable with the changes. The illusion that we can simply pass in one step from objective observation of ourselves to accomplished performance is simply that, an illusion. It may indeed produce more head nods or less interruptions, or more queries of “how do you feel about that?” It is a common sight in medical students and young doctors—a stiff clinical spine, detached demeanour, professional tone in the voice, conventionalized behaviour, and medical language—all acquired in an attempt to win acceptance and become the real thing as soon as possible. Dramatic theory has a number of terms for this surface approach: demonstrating, playing the emotion, playing the outcome, or end gaining (used by practitioners of the Alexander Technique). Whatever you choose to call it, the approach consists in trying to anticipate what the behaviour should look like, and then jumping across to reproduce it. If you look at it from one angle, it is a kind of forgery. At the very least, it is mimicry, that is, producing a copy, or working from a mould. It can never be an original expression, or be satisfying to clinician or patient. Stanislavsky called this approach “imitation.” He wrote: Imitation is the most deadly sin of all. It is something that is completely devoid of any creative principle. And by imitation I mean teaching ­someone

  The Creep Principle and Objectives 

  61

to imitate someone else’s voice, or manner, or results, or to give an exact copy of the deportment of a well-known actor [for our purposes, read ‘professional model’ ]. (Stanislavsky 1961, p. 162)

I call this phenomenon the Creep Principle. If you want an inexperienced acting student to creep across the stage, you would think that the simplest thing to do would be to tell him to “creep across the stage.” However, as an acting coach, this is the last thing you would do. If you tell him to creep, he is likely to focus his attention on the task, lift his feet carefully, and mimic as best he can the impression of creeping. The result will probably look slightly cartoon-like, even a little shifty, as he sneaks across the stage on tippy toe. The student is copying behaviour rather than recreating the real thing from scratch. Instead, you instruct the student to “cross the stage without anyone hearing you.” As the student sets out to accomplish this task, a focused look comes into the eyes, a sense of purpose infuses the spine, and we see him creep across the stage. In other words, creeping is the outcome, the end product of something else, and that something else is the objective of getting across the stage without being heard. Putting it another way, creeping is the phenomenon as observed by an outside, objective viewer. Crossing without being heard is the same phenomenon as experienced subjectively by the performer. Good communication between doctors and patients, as in any field, works in the same way. For example, some clinicians smile, are not rushed, engage with you, do not talk down to you, actually listen, hear, adjust what they say to your ability to understand, invite questions, and seem happy to answer them. These clusters of external behaviours are what we see when clinicians are actually interested in you as a person and are intent on identifying your problem, and helping you to a solution. On the other hand, clinicians who hardly look at you, interrupt almost as soon as you begin to speak, who do not hear your tentative questions, and who make you feel that you need to play good patient and not waste the good doctor’s time, have other objectives completely. They have a lot to do with getting you, the problem, sorted and out of the way as soon as possible. In other words, the behaviours do not have

62 

5  Role-Play as Drama

intrinsic meaning in themselves but are the external signs of motivations and objectives underneath. In role-play, when an interaction lacks lustre, that is, lacks focus and energy, the temptation is strong to focus on external behaviours. More is often achieved by remembering the Creep Principle, and directing conversation to the player’s objectives beneath. Players may discover, to their surprise, that they don’t have one, or it is poorly defined and easily swayed, or that they do have an objective, but it is not entirely appropriate. In any event, send the player back into the interaction with a well-chosen objective expressed in simple, bold, and active terms: “I need to find out exactly what is going on. I need to get to a conclusion.” “This time I need to make sure that she understands what I am saying. Feedback suggests that she didn’t before.” “I need to capture his full attention as I have something unwelcome and unexpected to say.”

The shift in focus from surface behaviour to the desired objective changes the entire interaction. Players pay closer attention because they now have something specific to achieve. The questions they ask are no longer perfunctory, but are active and searching, because they now need specific information in order to act. Eye contact is no longer a surface behaviour that they must remember to do but occurs automatically as a result of paying attention. They listen actively in order to hear and discover. They become more committed to the task, more focused, more dedicated to finding the solution. A well-chosen objective transforms the encounter from inert painting by numbers to active engagement and makes genuine interaction possible. It is a simple dramatic way to take proficient behaviour down from the library shelf, and place it in the players’ hands. The players immerse themselves within the scenarios to solve their intrinsic challenges, and the research literature directs them, and confirms the degree to which they are on the right track. Further ­discussion in Chapter 15 “Words, Words, Words” explores this technique of Objectives at greater depth.

 Reference 

  63

Summary The field of drama is able to help you become more accomplished and resourceful as a facilitator. It does this by providing you with techniques of all kinds to create an atmosphere conducive to learning, bring the role-­ play world alive, and help students and trainees overcome obstacles and become more confident and competent as communicators. These interventions appear all through this book. Drama also can help to address the difficult problem of transferring knowledge from research to practice. The three insights of the Centipede’s Dilemma, Split Focus, and Creep Principle and Objectives are particularly helpful in this regard. Together, they encourage self-awareness, even mindfulness, in the players as to their actions and enable them to be present in the moment so that they can work their way forward in real time; to identify within themselves the clinical mind that is both engaged in an interaction and at the same time detached and watchful; and to find their way to the motivations and objectives of proficient communicators that produce the kind of behaviours that we regard as good communication, thereby enabling them to make use of the findings of the research literature. I cannot commend these three techniques highly enough.

Notes 1. http://en.wikipedia.org/wiki/The_Centipede’s_Dilemma. The psychological effect is also known as the centipede effect, centipede syndrome, hyperreflection, or Humphrey’s law. 2. Origin unknown, sometimes attributed to the organization Gordon Training International.

Reference Stanislavsky, Konstantin. 1961. Stanislavsky on the Art of the Stage. Translated by David Magarshack. New York: Hill and Wang.

Part II Practice

6 The Workshop Team The Different Functions of Organizer, Front of House, Facilitator, the Optional Specialist Co-facilitator, and Observer, and What to Do If You Must Play More Than One Role Yourself

A role-play workshop is a relatively complex performance which requires the facilitator or facilitation team to carry out a number of varied tasks. Effectively, the team is being asked to play a number of roles. Each of these roles is characterized by a distinctive rhythm, pace, and mental focus. In this chapter, we consider the differing challenges of organization, front of house, facilitation, specialist co-facilitation, and observation, and what is needed if one person is required to fill more than one role. The actor is also a member of the team, but it is not practically possible or desirable for you to play that role as well as facilitate. A separate chapter covers the special case of the actor.

When you take on facilitation of a workshop you may need to do more than just facilitate the role-play. You may need to liaise with the actor beforehand and discuss final performance choices. There may be no one else to set up the room beforehand, and you may have to sort out the technical equipment yourself. You may have to meet and greet participants and simultaneously get yourself prepared to run the workshop. Unexpected problems may occur, and you may be the only one available to address them. You gallantly attempt to do all these things under the

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_6

67

68 

6  The Workshop Team

understanding that this is part of the job. When the time arrives for you to stand up to start the workshop, you may wonder why you feel disoriented and nervous. The ideal, of course, is to have a small team around you so that you can concentrate on your role as facilitator. In reality, however, resources are often limited. One or two people are often the driving forces behind a workshop, and they have to play roles on the day apart from facilitation. A facilitator who is aware of the particular nature of these different roles, and knows how to move among them, will be less anxious and have greater focus on the day. This is no routine task, as each of these roles generates and depends upon a specific rhythm, pace, and mental focus. Before the day of the workshop, you need to allocate roles to others, if that is possible, or plan how to switch among those roles yourself if it is not. The major roles are those of organization, front of house, facilitation, the option of co-­ facilitation, and critical observation. Let us first consider the different qualities of each of these roles and then the issues raised if one person has to play multiple parts.

Organization Someone needs to make sure that • • • • • •

a suitable room has been booked; refreshments have been organized; people contacted; call times notified; parking details and so on worked out; handout materials, attendee list, and evaluations prepared and copied; • technical equipment confirmed as available; • signs made up for the day which advertise the location of the workshop.

 Organization 

  69

On the day, someone needs to be there an hour beforehand to make sure that • the room is set up according to plan; • signs are put up in strategic places to direct participants to the workshop; • any audio-visual slideshow has been loaded, tested, and is ready to roll; • the facilitator and actor have arrived and have somewhere to acclimatize and prepare; • refreshments have been delivered and are laid out ready for the first arrivals or for morning tea; • sign-in sheets, name tags, and handouts are in place. When the event is finished, someone needs to check that • • • • •

the room is left in good order; the technical equipment is turned off; any audio-visual slideshow is removed; evaluations and surplus handouts are collected; the local signs have been taken down.

The task of organization is directly analogous to that of stage management in theatre. The task presumes a busy and practical frame of mind, whether that is your natural mode or not. It requires physical energy and a disciplined mind to switch into organizational mode if that is not your natural bent. Many establishments nowadays have technical people employed full-­ time to manage their audio-visual equipment. Technical problems should in general not be the last task tackled before beginning the workshop. As anyone with experience in performance knows, the devil is in the wiring, and if something can go wrong with the technical side of things, it will. Focus: practical, busy, physical activity, problem-solving, deadlines, checklists, black-and-white thinking, fast heartbeat, multiple focus, goal oriented, factual, sometimes relatively oblivious to the emotional needs of others.

70 

6  The Workshop Team

Front of House Someone needs to welcome the participants as they arrive, direct them to sign-in sheets, name tags, handouts, refreshments, washrooms, and places to sit or mingle. This time before the workshop gives participants time to refocus, meet new people, and touch base with old acquaintances. The idea is to incorporate a sense of a transitional space, like a theatre foyer, to ease the passage from everyday world preoccupations and distractions to the focused role-play world. If you have a specialist expert to co-­ facilitate with you, they will probably know many of those coming and would be ideally suited to handle this task. Focus: people-oriented, welcoming, adaptive to each person, facilitative of people meeting others and adapting to a new environment, a sense of quiet excitement and expectation.

Facilitation Whoever is facilitating needs to arrive 30–60 minutes beforehand, depending upon the demands of the specific workshop. More time rather than less is needed if you are dealing with a new workshop, a new location, computer presentations, actor briefing, or last-minute team meetings. The facilitator needs enough time to find their way to the location without rush and anxiety, then to acclimatize and feel at home in the space, and finally to reconnect imaginatively with the virtual world of the role-play. This last task is crucial, as the participants of the workshop will take the facilitator’s state of mind as their cue for how to respond. When it is time to begin, the facilitator needs to walk to the centre of the performance space, proactively capture the attention of those present, and draw them into the world of the workshop. From then on, the facilitator must remain in top gear without loss of focus for the duration of the workshop, and during social interaction later on. Focus: focused on the impending workshop and interactions, high levels of concentration, not distracted, mentally and emotionally alert, ­energized and excited but not overexcited, calm and not anxious. If anx-

  Observer (Optional) 

  71

ious or pressured by time, the facilitator is less likely to be open to interaction and instead may fall back on preplanned scripts or a priori solutions.

Specialist Co-facilitator (Optional) Complex role-play workshops benefit from the input of an expert in the field. Such a person can assist in the design of the workshop, direct the team to relevant research, provide an apt scenario for role-play, identify the most pressing educational needs, and even influence trainees to attend a workshop. On the day, they can provide an invaluable service as a “specialist co-facilitator.” While the facilitator carries responsibility for the running of the workshop, the specialist co-facilitator can provide specialist experience as required, and recommend effective clinical approaches. Focus: relevant research findings, provision of supporting audio-visual material, the voice of professional realism. Could assist in organization of front of house.

Observer (Optional) Many workshops are run as lean affairs and must rely for evaluation on handouts filled in at the end, feedback from the actor, and notes taken on the side by the facilitator. Where personnel are available, someone can be allocated to take notes of the proceedings in the role of observer. Observation can never be scientifically objective. There is always an implied objective and a point of view. For instance, if the observer is the person who designed the workshop, one eye will always be on how well the workshop matches their intentions. The notes will tend to record the flow of events and will determine the shape of future workshops. If the observer is a researcher in the field, the questions currently being explored by the researcher will flavour the observations. The co-facilitator will inevitably be deeply involved in watching how well the encounters mirror actual professional  life. This makes it difficult to cover observation as

72 

6  The Workshop Team

well, demanding as it does significant aesthetic distance and the ability to assess the mechanisms of the workshop itself. A camera cannot take clear pictures unless you hold it still, and it is the same with observation. The stiller and calmer the observer, the clearer and more valuable will be the resulting observations. Any other requirement during the workshop itself beyond observation complicates the issue for the observer, and it is better for an observer to be unencumbered by any other task. Focus: calm, reflective, non-judgemental, confident observer, not pressured by time or outside duties.

Switching Between Roles These roles represent quite distinct worlds with very specific tasks to accomplish. Their preoccupations are so focused that it is difficult to switch immediately from role to role. It takes time to cool down from one and to warm up to another. This cool-down factor has to be taken into account if you are called upon to play more than one role. For instance, assume that you need to do all the organizational work to set up as well as facilitate the workshop. A transition from a busy, practical, business-like frame of mind over to the calm, imaginatively engaged focus required by the facilitator is quite a jump. You might reason that all you need to do is give yourself a couple of minutes and that should do it. If you really want to be on the ball as a facilitator so that the group receives all you have to offer, that would be a risky move. You need sufficient time to pull aside from everyone else so that you can slow down, let go all practical considerations, and really drop them from your mind. Then you need to concentrate all your creative energies and focus them on to the task ahead. You need to find your way into the fictional world of the workshop before it begins so that you already stand immersed in it as you utter your first words. If you must play both roles, allocate sufficient time to making the switch, and find somewhere where you will not be disturbed. Find your way back into the zone. Determine from experience how long it takes for you to actually do this, and give yourself that time. If you are still fairly

  Switching Between Roles 

  73

new to facilitation, I would suggest you allow a good 15 minutes. Do everything possible to avoid time pressure before a workshop. It is probably wise to come with a preplanned strategy to enable the process. The same issue applies if you have no one else to handle the welcoming tasks of front of house. Not everyone is temperamentally suited to assume the extrovert and interactive tone of front of house, and simultaneously to enter imaginatively into the fictional world of the workshop. Better to have someone else such as a co-facilitator handle this task, and if you wish to welcome people to be only peripherally involved. If the organizer is given the job of observation and note-taking, allow time to move from the bustling mode of organizer to the calm, reflective mode of observer. If the co-facilitator is asked to take notes, remember that note-taking will necessarily be a secondary consideration, as their primary task is to be actively involved in the workshop.

7 Designing Role-Play How to Design a Role-Play Workshop from Scratch

Role-play works best when members of the group find themselves transported into the virtual role-play world. The art of role-play design, therefore, is a creative exercise and follows conventions of composition and editing common to all art forms. This chapter discusses how we can enhance the quality of our role-plays through creative design while ensuring workplace accuracy. The first part considers notions of creativity, leading in the second part to practical suggestions for creative role-play design.

As in any art, dramatization of human encounter in role-play is potentially complex and subtle. We could, of course, treat the whole exercise simply as a logical problem to be solved: that is, we jot ideas down, follow some simple rules, and come up with an interaction that could technically be designated as role-play. There is no shortage of such role-plays out there in the corporate world, as I am frequently told by actors who are employed to do them. The interactions, however, often tend to be formulaic. The role-player is encouraged to put recommended strategies and algorithms into practice, and the actor obligingly rewards “good” behaviour and punishes “bad.” The process, however, is unsatisfying to the actors who are locked into superficial responses and to the players © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_7

75

76 

7  Designing Role-Play

who are unable to get in touch with the real insights and motivations that drive their behaviour but instead simply learn to conform to expected dictates. Effective role-play is an art with all of art’s transformative potential. When done well, role-play challenges and changes understanding and behaviour. To liberate that potential, we need to drop down below the surface noise and find our way to the inner life of professional interaction. This fact needs to be emphasized, as the best role-play always hovers in an unresolved tension between educational intent and revelatory storytelling. Its dramatic world lives in the zone between the two poles of aesthetic distance. At one pole sit the specific educational aims of the workshop. This is the pole of high distance whereby we watch for take-­ home lessons. At the other pole, we are caught up in the convincing illusion of life unfolding before us. This is the pole of low distance. The best role-plays exploit the tension between these poles and come to life in the tense region halfway between. A logically produced, “educationally appropriate” role-play rarely produces this tension with its capacity for fresh insight because it keeps the group overly distanced. How do you create quality role-play from scratch? I would argue that you create the virtual world of role-play in the same way that you compose any work of art. You first have to enter the fictional world and discover something yourself so that you have something to present to others. If you don’t discover something new and become excited yourself, you can hardly expect the group to do so. Once you allow yourself to imagine what that world might look like, what you as facilitator might be doing and saying, what might be happening on stage, and what kind of responses there might be from the group, words and interactions begin to surface in your mind, and the role-play starts to come alive. A number of models and theories have been developed over the last 100 years to explain the birth of fresh ideas. Many of them build on a model of creativity by George Wallas (1926), which posits a four-part process of Preparation, Incubation, Illumination, and Verification (Plsek 2013). Incubation describes the common experience whereby we struggle to solve a problem and finally put it aside, only to wake up the next day with the solution appearing as if out of the blue, often while we are doing something else. The problem has gestated deep within, as it were,

7  Designing Role-Play 

  77

before suddenly springing to life “solved,” virtually fully formed. One model in fact describes the process as Conception, Gestation, Parturition, and Bringing up baby (Barron 1988). This model pays heed to the experience of many artists who describe their experience of creativity as of giving birth and who sometimes refer to their works as their children. Older models of creativity such as these two recognize the unconscious aspects of the process. Sometimes you work on a problem, put it aside and come back to it, and the answer appears with no apparent effort. At other times, the problem resists all your efforts and usual strategies. Sometimes, the mood comes suddenly and unexpectedly upon you. You can’t sleep because your head is filled with jumbled thoughts that won’t let you rest. You are compelled to get up and get it all down on paper or laptop. The experience is mysterious so much of the time. We might conclude that people who work in these fields are either naturally comfortable with uncertainty and ambiguity, or eventually learn to be so. Artists and writers early in our cultural history could not explain this sudden, demanding intrusion of novel ideas into their minds and the experience of an inner voice engaged in dialogue with them. The concept of the bicameral brain was as yet unknown. We are a species that can recognize itself in the mirror and our Self is anything but a unified entity. Anyone who has written a journal has, I am sure, been writing along in the first person as I, only to find that the writing style suddenly switches across to second person, and you are now writing to you. Is you someone else, or are you the you? If so, who is writing to you? This emergence of what seems to be another voice could only be explained in ancient times as the presence of an unseen being, obviously supernatural, who desires to communicate with us. The ancient Greeks explained this phenomenon as the intervention of the Muses, all female, of which there were three or nine, depending upon the current theory. By the time of Socrates, the muses had presumably gone into retirement, and Socrates spent time each day engaged in satisfying conversation with his personal daemon. With the advent of Christianity, the daemon was converted into a guardian angel or the quiet voice of God within. Whatever the name, the experience was the same, and the only explanation that appeared to make sense was that of some outside agency.

78 

7  Designing Role-Play

More modern theories ignore these kinds of subjective experiences, interpret life as prose rather than poetry, and tend to emphasize the conscious aspects of the process. They sensibly recognize that ideas do not spring fully formed out of a vacuum. Most commonly, they appear as the result of considerable prior mental activity as we analyse and pull together the disparate elements that comprise a problem, minus, of course, the solution. None of the theories can hope to explain all aspects of the processes involved which are complex; are unpredictable, in that they are never quite the same twice running; comprise a large, unconscious component; and whose mechanisms are perhaps ultimately unknowable. Knowing the theories may not help much in the end. Vinacke, for instance, doubts that any model explains creativity in the arts (1953). He is probably right. Of all the people I have known who work in creative fields, I can recall none who consciously follows a model of creativity to do their work. Instead, they find their way to practices that foster creative output and to ways of life that support those practices. Natural diagnosticians I have met seem to do the same thing. Some people slide naturally into those practices like a duck into water. On the other hand, you may be more comfortable with facilitation or organization than with the elusive process of composition and design. My hope is that this chapter may help you to understand more of what is involved so that you can be happier with the process, or else organize for someone else with these abilities to help with the design that you will later facilitate or organize. None of this argument denies in any way the need for the role-play to be factually appropriate and accurate. Educationally, specific learning objectives need to be identified in advance and factored into the planning. Factually, the scenarios need to be a close fit, accurate, and marked by detail that is specific to the daily experience of those attending. To achieve this rigorous match, we need to do our homework and to make sure we have access to the latest and most appropriate research. If you are designing role-play within your area of expertise, you will have the content covered and know where to go for any missing research. You may, however, be too close to your subject and may miss some of the more obvious problems faced by someone many years more junior. You

  Practices That Foster Creative Thinking 

  79

would probably benefit from the assistance and naive questions of someone not from your area. On the other hand, if you are designing role-play outside your area of professional expertise, it would pay to include a specialist expert from the very beginning. In medical workshops, we look for a clinician who is both a champion for the particular issue at the heart of the workshop and a passionate advocate for the need to mentor young clinicians. Such people are invariably in touch with latest research, can guide you to the difficulties likely to be experienced by the group, and are willing to co-facilitate on the day. As “specialist co-facilitator,” they are invaluable as an expert resource on the day and can provide the voice of experience, recommend effective approaches, and point to relevant research as the need arises. Once the homework is done and once a specialist expert is on board, the issue now becomes how to make it all come alive. How do you take all this information and turn it into role-play scenarios that will potentially change people’s minds and behaviour and send them out with expanded repertoire and renewed motivation?

Practices That Foster Creative Thinking If artists develop practices that foster creative output, what are those practices, and how might we apply the same approach to role-play? My suggestion is that we keep it simple and practical. If the ideas come flooding in upon you, there is no issue, as you are already in a creative space. You write them down and tease them into shape. But what do you do if this does not happen, as more commonly it does not? In one important aspect, composition follows the same principles as performance. We have seen that performance takes place within a space framed by a physical buffer. Within that creative space, there is a clear and intense focus and a heightened sense both of doing and of being aware of doing, released by what we call aesthetic distance. Composition follows the same principles, only in this case the field of action is not the auditorium or the seminar room, but the study. When I say study, I don’t necessarily mean the room in your house or at work that is your office, though it well may be. By study, I mean a place

80 

7  Designing Role-Play

where you feel comfortable and free to be yourself: to think, to speak aloud, and to move around without restraint, free from outside scrutiny. You may think well alone, or you may work more effectively by brainstorming with others. What is important is that you choose what works for you. The space needs to be conducive. For many people, that means uncluttered and without unwanted distraction. On the other hand, if you prefer clutter, it helps if it is your clutter and thus familiar and unremarkable, so that it won’t attract your attention. Past associations often help. For instance, you may have a favourite chair or desk that has been the launch site of many previous good ideas. A familiar route where you walk the dog may get you started. First task then is to make sure that you feel happy with your surroundings. Now, to focus your attention on the task at hand, consciously strengthen the spatial buffer around you to block out distraction. Eliminate outside distractions: take the phone off the hook, turn off the mobile, ask not to be disturbed. Check to see if there is any nagging, unfinished business in your mind. Perhaps there is something that will need to be done later today. Perhaps you had a temporary falling out with someone that you need to do something about. Whatever it is, do something about it, or put it on the shelf. That is, remove the competing demand from your mind. Either address it now before you begin, or type it into your diary or smartphone so that you can deal with it later. Consciously create a temporal frame, that is, allow yourself sufficient time for thinking, make sure that you are happy with the time available, and commit to that period of time so that your attention remains within the room and focused on the task. Most importantly of all, shut the door, and block out the rest of the world (see Fig. 7.1). You will recognize the familiar model of performance: a heightened space within separated by a frame both spatial and temporal from outside distractions. Your aim: to find your way into the same virtual world that you will recreate in the workshop. That world consists both of the workshop and of the role-play at its heart. Run a personal stocktake of your levels of physical tension and the resulting state of mind. You are more likely to have a productive time if your body is not locked in physical tension, and your mind is not anxiously rushing ahead to the answers that you do not yet have. This does

  Find Your Way into the Zone 

  81

Everyday world

Frame

Virtual world Entrance exit

Fig. 7.1  Model of performance with frame, focus, and subjective virtual world

not mean that you have to be utterly relaxed to be creative. In fact, creativity requires a certain energy and tension associated with the intense inner work of creative thought. Obviously, everyone is different, and you have to find your own approach. My own mantra is to be calm, focused, and alert. If you are unfocused and distracted, do some stretches, and loosen your shoulders and intercostal muscles (between the ribs) so that you are able to breathe freely. Bring your breathing down to a calm level, breathing deeply in the abdomen rather than shallowly and high in the chest. Confirm that the actions you take do in fact result in a greater sense of calm and focus. Once this has happened, you are ready to begin.

Find Your Way into the Zone You have found a good space, made it conducive for thought, and have paid attention to your own state of mind. Now you need to find your way into the zone. That is, you need to find your way into a creative frame of mind. Performers repair to a preparatory space to prepare themselves for action, and designers need to do the same thing. You cannot expect to simply waltz in, close the door, and instantly design a role-play workshop. You haven’t given yourself enough time to settle into creative space and time. Not unless the idea has already surfaced fully formed in your

82 

7  Designing Role-Play

mind as you were busy doing something else, and you repaired to the study merely to write it down. How do you get into the zone? Unfortunately perhaps, the process is neither mechanistic, linear, nor guaranteed to occur. However, certain things do tend to work much of the time. Remember, this first task is not about confronting the issue and starting to hunt for a solution. The task is to generate a creative frame of mind. Intention and motivation help. A closed door helps. Knowing that you have consciously created a spatial and temporal frame helps. Consciously generating a creative atmosphere helps. Develop your own creative opening rituals to focus your attention where you need it to be. Talk yourself into it. Move around. Listen to music. Meditate. Follow a familiar routine. Read over the brief. Sit in your favourite chair. Remember back to a previous workshop that worked particularly well. Think about who will be coming as your group. You may perhaps remind yourself of what you have done so far. You may start to put words down on your laptop, or on paper, or a whiteboard as they occur to you. This is a situation where it is appropriate to ask, “what do I feel like doing?” In other words, what do you usually do to put yourself in a creative mood? In summary, whatever you do, your task is to limit your circle of concentration, warm up your imagination, and find your way into a creative space where creative thinking is possible. This is an important skill. Find out how to do it. You will know when you are making progress.

Working With Ideas The models all remind us that creative solutions occur as a result of activity that is both analytical and imaginative. Much of the earlier and later phases of design have a strong analytical bent, that is, the initial phase where you identify your aims and consciously tease out the problem and the later phase where you tidy up your creative ideas into a working plan. In between, new ideas and creative synthesis tend to surface through the imagination. You may have noticed that the imagination works somewhat differently than the logical parts of your mind. It responds better if you take

  Working With Ideas 

  83

your time and allow your imaginative mind to work at its own pace, almost as if it were not part of you. Think aloud. Let the flow of ideas determine the pace and not your own sense of needing to exercise control. Allocate enough time. Be aware that your natural tendency may be to underestimate how much time is actually needed. I have found, for instance, that video clients virtually always underestimate how long is needed for this first, creative phase. Invariably, the tendency is to want to get the script down and then move straight on to the business of rehearsing and shooting the footage. In fact, script ideas tend naturally to remain in a state of flux for a time. New ideas continue to occur to the clients themselves who ring up with new elements that need to be included. Once you move onto rehearsals and shooting, changes become progressively harder to incorporate. It is a good rule of thumb to allow more time for design and planning than you first think necessary. The imagination appears to have its own life independently of ourselves. We know that our own mind generates the ideas, but that is not necessarily how we experience it. Thoughts often appear unexpectedly or ready formed, and we feel that we weren’t involved in the process of patching them together. The impression is that there is a line somewhere that separates us from our imagination which functions quite well without our assistance. Early acting teachers such as Michael Chekhov developed exercises to strengthen the imagination (Chekhov 1993). All of these exercises work on the principle of treating our imagination as if it had an independent existence. Artists of all stripes have learned to externalize their imagination and to treat it as if it were not part of them. Doing so makes the imagination easier to work with and renders it more malleable. Try it yourself. Allow thoughts to come, work with a light touch, and wait for them to take on a life of their own. Consciously ask questions of them, “interrogate” them, as we say in modern parlance, and see what comes up. Prod and nudge an idea and see where it goes. “What if …” is a very productive question. Push ideas forward as if you were working with materials outside yourself. Remember that you are imagining a role-play world. Therefore, you are not looking primarily for theoretical ideas, but for actions and words, that is, people doing things, things happening, you doing things, or others

84 

7  Designing Role-Play

doing things. Role-play is activity, so feel free to move and talk out loud as the ideas come. You may catch glimpses of the possible layout of the stage, interactions happening on the stage, or a possible title for the day. A theme may appear. You may see a different way of introducing the workshop and an opening exercise that you haven’t considered before. You may hesitate and be unsure if you can pull it off. Learn to become confident about what you can imagine—we are all capable of far more than we think. Jot everything down. Do not foreclose, censor, or veto thoughts as they come, or the flow may dry up. The thoughts will sort themselves out. Peripheral ideas will drop away, and fruitful ones will generate others. If you are brainstorming with others, make sure that they do not lock down every new idea as it appears, and try to include it whether it fits or not. Keep an eye out for similarity, for patterns, analogies, examples, anecdotes, images, and hooks to hang things on. Do not reject the lateral; your imagination is trying to pull things together that your conscious mind may not necessarily connect as significant. Your conscious mind at this stage is not necessarily your greatest asset, in that it knows more about what already is than about what might be possible. You have become part of a process that is larger than your usual view of yourself. Embrace it, and go with the flow. Be careful of assumptions. Assumptions are, after all, residue of what we have learned so far. Some of what you now assume may need to be revised as a result of new ideas, so wear your assumptions lightly. You may have a clear idea of where you think the workshop will go but, once you set about actual composition, completely new thoughts may come flooding in that shake your carefully designed structure. You may have to amend it, add to it, subtract from it, or discard it completely. Novelists and playwrights create characters they think they understand and control, only to find their characters taking on a life of their own and choosing their own plot lines over those of their author. The fact is, your mind has already done a lot of good creative work behind the scenes. Now is the time to find out what it has been doing and to jump on board. You have potentially been thinking about some of these things for a long time. I suggest that you ignore practicalities for a time. Utility is a function of implementation not of primary design. There will be time later to order and shape.

  Edit Mode 

  85

Maintain the sense of flow by recording what you do in a provisional way: the computer screen is intrinsically provisional—anything can be changed; words on a whiteboard are easily erased, and rearranged; mind maps are works in progress; on paper, ideas often flow more easily with a pencil than with a pen. Order and solutions come at the very end of the process, not before. Recognize that this flow of ideas has an intrinsic patterning quality to it. The ideas do not just tumble out in a random way, though it may seem that way because the patterning may not be immediately obvious. Ultimately, your mind is predisposed to make sense out of the apparent chaos and to organize it into meaningful pattern and order. Know this, let go of unhelpful controlling tendencies, and let your mind do its work without interfering. Simply encourage it, direct it, and help it along. Do not interrupt your imaginative mind when it is working. You will probably have noticed that your imagination follows your interests and your deeper passions. These deep preoccupations are like an inner compass that steers you forward towards your own magnetic north. Follow those promptings in your imagining, and your workshops will prosper as a result. We all have very different compass settings. Some people are fascinated by dramatic interactions between people. Some are intrigued by emotions, and the way people cope with the trials of life. Some are interested in clear communication of important information, or by people authentically communicating in a meaningful way. Others are compelled by safety, by justice and fair dealing, or by making sure that patients get the best possible treatments for what ails them. You can be fairly sure that you won’t be engaged by all of these preoccupations. Your passions and interests, should you follow them, will determine the focus and the nature of your workshops and will differentiate them clearly from others who have other concerns.

Edit Mode You will probably discover that your mind naturally switches to another mode once you have come up with a satisfying concept and design for your workshop and role-play. Artists and writers regularly move between

86 

7  Designing Role-Play

two different creative modes. One is the highly subjective, imaginative mode that we have described above. When in the heat of inspiration and ideas are flowing, it is mostly best to encourage the flow, avoid censor, and let your creative mind do its work. We might call this mode warm or creative in reference to its subjective, engaged quality. There is little aesthetic distance in this mode. We are immersed within the contours of an imaginative world, and accept whatever comes with minimal critique, because there is always more than we expect, and we do not want to staunch the flow. Then, once the flow has largely run its course, and we step back to look at what we have come up with, our mind automatically drops back into a more objective frame. This mode is analytical and emotionally cool in contrast to the emotional warmth of the purely creative mode. This mode is characterized by its greater aesthetic distance. It is within this mode that we critique, edit, and move the ideas around in a more practical and utilitarian manner. Here we are aware of practicalities, such as constraints of budget, personnel, resources, time, and the need to convert the concept into the linear shape familiar to the analytical mind. Activities need to be ordered from a beginning through a middle to an end. Sometimes we order thoughts as they appear and thus blend these modes in real time. If you are new to the process, it is probably a good idea to separate the two processes as much as possible, as each mode presupposes an entirely different standpoint and quality of thinking. It is very difficult at the beginning to position yourself both in close and far back at the same time. A professional writer will often produce new material in the morning (warm mode), take a break, and then edit previous writing in the afternoon (cool mode). Even in the editing phase, however, it is common for further creative ideas to come to mind. Usually, these ideas are elaborations and refinements as your mind continues to fill in details and to resolve the concept to greater satisfaction. This flow may continue for several days. Jot additions down as they occur to you. Some people become impatient or even upset when ideas continue to appear. They feel that they had nailed it and cannot understand how they could have missed anything. If this happens, recognize that the process commonly takes longer than you estimate, and go with the flow. It takes as long as it takes.

 Summary 

  87

It is important to distinguish between these two modes because they will reappear at various times and in various ways in role-play performance. As facilitators, we constantly have to navigate our way between these two poles of aesthetic distance, as we lean in to empathize with the players and pull back to check the time and make cool-headed decisions as to how best to proceed. We will deal with these matters in later chapters.

Summary We do not need to understand exactly how creativity works in order to learn how to navigate the process. It is not a logical puzzle, where you work out what you want to happen, systematically list it down, and then go out and do it. It is human, organic, messy, unpredictable, sometimes lightning fast, and other times painstakingly slow. But it is something that can be learned. The following hallmarks of creativity usually come into play. 1. Find a space that encourages creative problem-solving. 2. Consciously strengthen the spatial frame around you to block out outside distraction. 3. Create a temporal frame, and allow sufficient time. 4. Eradicate surplus physical tension, and breathe calmly. 5. Develop rituals or practices that enable you to get into the zone, that is, to move into creative space. 6. Recall that imagination appears to have a life of its own—work with that conceit. 7. Forego theory. Look for concrete ideas, words, and actions. Imagine yourself and others in action. 8. Trust in the mind’s natural compulsion to create order out of chaos, and do not get in the way. Let ideas come, and do not staunch the flow. Beware of any tendency to critique unnecessarily. 9. Learn to identify your personal passions and inner compass, and use that knowledge to guide you to future subject matter. 10. Distinguish between the warm compositional and the cool editing modes of creative thought.

88 

7  Designing Role-Play

It is important, I would say, essential, when we design a workshop, to touch into new discovery and the excitement of that discovery. It is not only insight but also the excitement of insight which will motivate the workshop. Both when we first get in touch with the world of the role-­ play, and later when we facilitate it into being, it needs to come alive. Life attracts and draws people in. On the day of the workshop, we will need to tap back into this prior experience, and the excitement of discovery, so that our own experience can come alive again for others.

References Barron, F. 1988. Putting Creativity to Work. In The Nature of Creativity, ed. R.J. Sternberg. Cambridge, England: Cambridge University Press. Chekhov, Michael. 1993. On the Technique of Acting. New York: Harper Collins. Plsek, Paul E. 2013. Working Paper: Models for the Creative Process. http://www. directedcreativity.com/pages/WPModels.html Vinacke, W. Edgar. 1953. The Psychology of Thinking. New York: McGraw Hill. Wallas, Graham. 1926. The Art of Thought. New York: Harcourt Brace.

8 Where to Hold a Role-Play Workshop How to Make Locations Work for You to Enhance, Rather Than Inhibit, the Experience

Space is not just another practical matter to organize and tick off your list. The location of your venue and the arrangement of the space are dynamic factors that determine much of the success of the event. This chapter considers how to select and arrange spaces to optimize the quality of interactions in the role-play. It applies to role-play the spatial elements introduced in Chapter 2 Model of Performance. It is probably more meaningful if read after that chapter.

When we are asked to run a workshop, one of our first jobs is to find somewhere suitable to hold it. Our decision may end up having to be made on the basis of availability. However, the choice of location for a workshop should not be regarded as a perfunctory matter. A physical location is never an emotionally or physically neutral entity. By this I mean that we do not enter a space and remain untouched, or uninfluenced, by it. We respond very differently to different spaces. In some environments, we feel comfortable and at home, and we relax and act casually and informally. In others, we are much less at ease. We stiffen and find ourselves acting in a formal, constrained manner that is not conducive to spontaneity and creative learning.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_8

89

90 

8  Where to Hold a Role-Play Workshop

Some spaces are purpose built and prod us to act according to those purposes. The furnishings and layout may direct our attention to one end of the room, as is the case for rooms devoted to lectures and presentations. Other spaces are much more open-ended and give us greater latitude of use. Some rooms have an inviting atmosphere. The proportions are pleasing, the atmosphere is welcoming, the temperature is neither stuffy nor arctic, there is good lighting and sufficient flow of oxygen, and altogether the room offers a sense of possibility for something different to happen. Other rooms tell you very quickly that there is virtually nothing you can do to make the space work for you. We may not always be conscious of exactly what it is that evokes our response, but we respond anyway. Michael Chekhov encouraged young performers to explore how the atmosphere of a space changes their behaviour so that they could become conscious of those effects (1993). Unless we have access to a simulation centre, we must use spaces that have been designed for other purposes such as meetings, seminars, or video conferences. Two issues arise from this opportunistic use of space. Firstly, they may be only marginally suited to role-play. Rooms are sometimes badly designed for interaction: they are too long, too wide, too large, or too small. Many are crowded with chairs and tables. The air conditioning may be too cold, too warm, or too noisy. Secondly, they often come with entrenched associations that do little to foster experimentation and everything to inhibit it. Seminar rooms are seminar rooms when all is said and done. Young professionals have learned to think and act in constrained ways in these spaces. The familiar rooms convey the message of business as usual. The content of the workshop often does little to counter these expectations of business as usual. After all, the scenarios are designed to be as close to the real thing as possible. Therefore, trainees will tend to tackle the scenarios in their usual way, unless cued strongly in another direction. The rooms provide no such cues. All the associations of place will urge the group to be clinical and business-like, so it should come as no surprise if participants find it hard to think and act outside the box. To add to the problem, periods of training are spasmodic and infrequent, so there are few cues from past experience to override the overwhelming, normative dictates of place.

  Choose the Best Space Available 

  91

How do we solve this problem? Firstly, choose the best spaces available. Secondly, apply principles of framing and focus to optimize the space you select. Thirdly, actively counter expectations of didactic teaching, and foster anticipation of exploration and experiment.

Choose the Best Space Available Choose a space that is conducive to role-play. Consider factors introduced above, and pay particular attention to the size and shape of the room. Spaces with satisfying proportions that approximate the golden mean1 usually produce a better atmosphere than more elongated rooms. Consider the following examples. In Fig. 8.1, the facilitator will struggle to reach down to the back of the room. Several of the back rows are well beyond empathic reach and remain resolutely within the cold zone. In Fig. 8.2, the facilitator will

Fig. 8.1  Room is too deep

Fig. 8.2  Room is too wide

92 

8  Where to Hold a Role-Play Workshop

Fig. 8.3  Room is too large

Screen

Fig. 8.4  Example of effective room set up for role-play

have difficulty scanning from side to side and finding ways to keep the flanks engaged. In Fig. 8.3, the room is far larger than is needed, and the empty space will remain an active and impeding presence that threatens to distract attention away from the focus of the workshop. Figures 8.1 and 8.2 would be more sympathetic if the rectangle were less elongated and Fig.  8.3 if it were smaller. Figure  8.4 illustrates a more conducive layout.

  Use Framing and Focus to Optimize the Space 

  93

Use Framing and Focus to Optimize the Space Adjust the space so that it serves your purposes. Use principles of framing and focus to make the space work for you instead of against you. Sometimes someone will put out chairs in straight lines and hope for the best. Move them around to suit. Mark out a defined space with sufficient room for the role-play and the group. Use your kinaesthetic judgement to determine how large or how small the space should be. The aim is to create a self-contained world in which the group fills the space and is seated comfortably close to the action with a good view of the proceedings. Identify which part of the room is most conducive to role-play and which wall provides the best back drop. As a general rule, avoid walls with distracting details. Windows are best behind or to the side of the group, unless they come equipped with effective blinds or curtains. Otherwise, backlighting will turn the role-players into silhouettes. Allow room for a playing space (the stage), and place the front row of seats close to the stage with just enough distance to differentiate the two spaces of stage and group seating. Preset the stage with chairs and a table or desk for role-play. You do not necessarily need to set up the furniture exactly as you will use them during role-play. Sometimes the first player finds it helpful to rearrange the seating to adjust the virtual world to their own conceptions of how they would like it to be. As a general rule, face the role-player’s chair so that his or her attention will be directed towards the actor and away from the group. In this way, the actor will fill the player’s field of vision, and the group will tend to melt back into peripheral vision and memory, thus reducing performance anxiety. It is a good idea to test-sit chairs at the extremities and rear to check for sight lines and empathic connection to the stage. If the space is too large or of cumbersome dimensions, reduce the areas of cool zone, so that everyone will feel engaged in what is going on. We have found that the best solution for our purposes is to arrange the chairs in a semicircle around a playing area, with the chairs one or two rows deep. If at all possible, remove all unnecessary clutter from the room to minimize distraction. If that is not possible, move the clutter to the periphery

94 

8  Where to Hold a Role-Play Workshop

or to the rear, and if possible obscure from view by the use of screens. Check the lighting in the room. Usually institutional lighting leaves a lot to be desired. Only rarely are you able to create extra focus by dimming rear lights and highlighting the front area. Do what you can. If you do find yourself in a space that does allow control of lighting in different parts of the room, you have the option of highlighting the playing space and dimming down the “auditorium.” The dramatic use of lighting will increase the draw of attention onto the stage and role-play.

Counteract Everyday Expectations Simple framing, focus, and lighting in themselves create a sense of novelty and suspense to counter expectations of business as usual. Heighten that effect by adding colour, props, or other furnishings. Add a telephone, computer, or test results to the desk. If you are using a PowerPoint screen or a white board, preset the title of the session, or display a striking illustrative graphic. No matter where the workshop takes place, create expectations of the enjoyable and the unexpected.

Further Suggestions for Proactive Use of Space 1. Create a “foyer.” Place your welcome table with name tags, pens, paper, and handouts, and that with coffee, tea, and refreshments well away from the action of the workshop. Either set up the tables outside the room with space enough for people to gather, chat, and wind down or, if that is not possible, at the back of the room so that the space around it becomes effectively another room. This way, when the time comes to begin, and everyone troops down and takes a seat in the “auditorium,” they have effectively entered another space, the world of the workshop. 2. Except for emergency situations, try to have pagers and mobiles turned off for the duration of the workshop activities. Provide regular breaks for refreshments and bathroom visits during which people can check their mobiles.

  Further Suggestions for Proactive Use of Space 

  95

3. Close the door to the room when you are ready to begin. A closed door physically shuts out access to the outside world. 4. Find a way to manage time without drawing attention to that fact. When things are going well in the workshop, time will seem to stop as everyone’s attention becomes totally absorbed in what is happening around them. This is exactly what we want to happen. However, you, almost alone in the room, need to stay aware of time and to time-­ manage events from beginning to end. A handy tool is a portable wall clock placed towards the back or side of the room, so that you are always aware of the passage of time without anyone else noticing that fact. If you look at your watch, others will notice. You are likely to puncture the atmosphere by reminding the group of life outside the room, thereby creating greater aesthetic distance. 5. Become aware that you in your role as facilitator are also a significant environmental factor. If you prepare yourself well, when you step forward to lead the group you do so as a magnet of attention, drawing everyone into the virtual world of the workshop. Your commitment to the virtual world acts as a focal device. 6. Provide early opportunity for physical activity and interaction. As members of the group begin to talk and act, the world of the workshop assumes a self-evident quality. That world alone is now real, and life outside recedes into theory and memory. 7. A sense of hurry will puncture the reality of the virtual world by reminding the group of the presence of learning objectives. Eliminate any sense of rush. Limit the number of activities so that the group has time to immerse itself in interaction and forget outside demands. This may require you to dispense with a favourite topic for the sake of the workshop as a whole. Less here is definitely more. In summary, space is not just another practical matter to organize and tick off your list. The location of your venue and the arrangement of space are dynamic factors that determine much of the success of the event. They actively inhibit, or foster, the virtual world you need to create. Choose the space well, arrange it well, and use it well. As a facilitator, step forward knowing that the space is actively working for you.

96 

8  Where to Hold a Role-Play Workshop

Notes 1. Traditional Chinese lore proposes that some spaces exhibit more conducive feng shui than others and Western artists and architects have long argued for the supremacy of spaces that match the proportions of the golden mean, whereby the length of the sides are in the ratio 1:φ (phi), that is, 1:1.618. The ratio of the golden mean is widespread throughout nature and determines the proportions of such things as sea shells, flowers, pine cones, seeds, and the human body, and has a 2500-year application in Western architecture, art, and design. To this point, scientific evidence that the golden mean has widespread appeal to untutored sensibilities is mixed at best. Nevertheless, the principle remains that some shapes are more conducive and useful to our purposes than others.

Reference Chekhov, Michael. 1993. On the Technique of Acting. New York: Harper Collins.

9 Working With Actors How to Recruit, Rehearse, and Get the Most Value Out of Working With Actors

The actor is your greatest ally. It is the actor who most makes the scenario believable and brings the virtual world to life. In this chapter, we discuss ways to make the best use of your collaboration with an actor. Discussion includes recruitment, scripting, rehearsal, preparation for feedback, interaction during role-play, and debriefing afterwards.

Many people may help you to set up and run a role-play workshop, but your greatest ally in a workshop is undoubtedly the actor. It is the actor who provides the strongest stimulus to draw everyone into the reality of the virtual world. Publicity may create expectation and interest, props may suggest an office or consulting room, and your preparation may make the fiction plausible, but the actor embodies the central living force, the patient or client who makes that world come alive. It is the actor who most transports the player and the group into the world of the workshop. It is the actor who draws and holds focus, compels belief by his or her utter commitment to the part, and demands engagement from the player. Players may remain intellectually aware that the person on stage with them is an actor, but every message from their senses insists “patient” or “client.” © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_9

97

98 

9  Working With Actors

You and the actor, therefore, need very much to be on the same page. As colleagues, you both guide the interaction forward into fruitful territory. The actor prods and guides the players from within the action, you from the watching margins. The actor, in fact, potentially works with you as co-tutor. Your role as tutor is perhaps more obvious in that you overtly guide the group towards consciously articulated, educational goals. The actor’s role as tutor may appear to be slightly more oblique, in that his or her major task is after all to portray a character in the virtual world. Nevertheless, the actor rarely plays this part completely objectively. By this I mean that actors cannot afford to lock their characters into fixed courses of action, reasoning that, in order to be psychologically consistent, their character must behave in such and such a manner. For any interaction to be fruitful, their partner, the learner, needs to be stimulated sufficiently to become engaged, but not so much as to become overwhelmed, threatened, and anxious. Learners need to navigate safely in that middle zone of aesthetic distance between under- and overdistance. Actors, therefore, should pitch their performance to suit your educational objectives. As they play their part, they watch their stage partner for signs on the one hand of disinterest and on the other of distress, ready either to increase the pressure or to pull back. They perform in a dual capacity as actor and educator. They also remain alert to the messages and feelings experienced by their character and store these impressions in short-term memory should they be sought during discussion. They work on many fronts. Despite your common focus, each of you approaches the workshop from a different angle. Your point of view is akin to that of a theatre director, in that you must step back and take into account all the factors that work together to produce a successful workshop. Actors, on the other hand, must see the interaction entirely from their character’s point of view and apply all their insight and energy to inhabit that role. This means that the actor starts from a different place, views the world through a differently tinted lens, speaks what is effectively a different language, and does a different job. For those with little experience of actors, it may not be immediately evident how you should proceed when working with them.

 Recruitment 

  99

There is a caveat here. In this chapter, we consider the actor in role-­play dedicated to exploratory learning. None of this discussion should be taken as normative for all kinds of performance. As discussed in Chapter 3 “Roleplay as Performance,” actors, role-players, and facilitators all work tightly together as members of a Simulation Triad. Issues such as recruitment, scripting, training, and performance are managed differently where roleplay is in the service of assessment or demonstration (Heinrich 2011, 608).

Recruitment Howard Barrows, who championed the use of “programmed patients” in the 1960s, considered that the person called upon to act needed only to be intelligent and motivated (1987, 1993). This may be the case for simple assessment scenarios, but when we recreate realistic interactions in order to play with them and tease them apart, a little more is required. The one who acts as a patient or client needs to be comfortable with performance. If not a professional actor, they need to have had experience in performance, and preferably some training. They need to be skilled at authentic interaction with a partner. They need to be able to identify and differentiate various factors at play as they perform. At the very least, they need to analyse their part and identify the most significant elements of their character. They need to see the world of the role-play through their character’s eyes and remain aware that their character’s grasp of the situation is distinct from their own. They need to know how to analyse the shape of a scene so that they can reproduce their behaviour at will. They need to be able to concentrate on their role, their trajectory through the scene, their role-playing partner, their partner’s comfort in the interaction, the impact of that partner’s behaviour on their character, and the intelligibility and impact of language. They need to tailor their behaviour and cater to their partner, understand the educational goals of the scenes, and store away information most likely to be of use in subsequent discussion. They need to know what to hang onto and what to relinquish. They need to be flexible and fluent in improvisation. Not all actors are equally at home in improvisation, and some actors have had only minimal ­exposure to it. It is, moreover, important that they do not bring with

100 

9  Working With Actors

them any axe to grind over the profession with whom they are working. Conversely, it is an advantage if they respect the people they work with and enjoy an educational milieu. A professional such as a doctor or a nurse who volunteers to play the acting role comes with the significant advantage of an extensive library of patient types they have met over the years, which they can trot out as needed. That advantage alone is often not enough. A patient from their personal library may not exist as a person in his or her own right, but only as perceived by the doctor or nurse: that is, they come prepackaged and preinterpreted. Doctors and nurses may also significantly underrate the degree of their own medicalization. They may recognize overtly medical terminology as jargon but fail to identify the many ways that their very thought processes (which to them are neutral) are heavily medicalized. Experience and training in performance helps to reveal and liberate them from these biases. The same issues apply to senior practitioners in law, the police, or business. In our work, it is usually best to typecast. Actors pride themselves on being able to find their way into many different kinds of roles, and the challenge of playing against type provides one of the deep satisfactions of the profession. It does, however, require time and effort in rehearsal to create a convincing character against type. It also requires performances of sufficient duration to convince us of the portrayal. We provide neither of these requirements in our workshops. Rehearsal is brief, and restricted to the essentials, and role-play scenes are short. The members of the watching group sit close, and the role-player very close indeed. For the workshop to succeed, the role-player must immediately buy into the fiction and engage in interaction as soon as possible. The actor is the strongest stimulus to transport the role-player into the fiction, so he or she needs to offer the maximum of credibility and the minimum of discordance. A 40-year-old actor playing a 20-something member of the public is a tough sell. I suggest that you identify the necessary hallmarks of the character—sex, age, body build, ethnicity, and essential physical findings—and cast accordingly. There is no simple answer to accessing actors. The supply of actors will depend upon your circumstances. Professional actors and acting students naturally gravitate to large urban centres. Otherwise, you may

  The Script or Scenario Brief 

  101

have access to a local amateur theatre company, and it is surprising how often someone knows someone who does a bit of acting. Try them out with simpler material first to see how they manage this type of performance. Acting students are often competent enough, but mostly cannot fill your need for older characters. Performers from amateur musical theatre groups may be more interested in song or dance, and may find improvisation daunting. Some professional actors find role-play a little beneath them. Others tell us that it is the most challenging work they do: the audience is seated very close, they must remain at all times completely in the moment, and have the rare opportunity in many ways to direct their own performance choices. They also clearly see the social utility of their craft in awakened minds and changed lives. In our case, it took us some time to build up a company of actors committed to role-play. After a number of workshops, many have developed high levels of improvisatory skill and sensitivity. We could not do it without them.

The Script or Scenario Brief Because there is so little time to workshop or rehearse the role into being, the onus falls on the script to provide most of what is necessary for the actors to imagine their way into the role. By script, of course, we do not mean a verbatim text to be learned by heart. Script in the context of role-­ play is a scenario brief. It may provide an opening gambit to get the ball rolling, some wording that you want the character to volunteer, or questions you want them to ask. However, these are details. Looking at the big picture, the script provides the information necessary for an actor to create a realistic and plausible portrayal. It also tells the actor where you want to focus educationally, how the trainees see their professional role, how experienced they are, where you anticipate that the role-players might stumble, and what kinds of particular things you want the actor to focus on for subsequent feedback. The simulation triad is visible in the background in that the actor’s role is not absolute but depends in its colouration on how you see the role-players and what you want them to learn. The script summarizes these understandings.

102 

9  Working With Actors

Stylistically, I recommend that whoever writes the script does so in plain language, and from the point of view of the patient or client. You may need to actively counter your own blind spots. For instance, if you have a medical background or have inherited a clinical case from a medical specialist, you will need to make a conscious effort to abandon the medical view of the events. A patient lives in a different world entirely, and the actor needs to access this world as quickly as possible. The script speeds, or inhibits, this process in the choice of point of view. Put aside the factual style that you use for writing academic papers or business reports. You will probably begin writing in the third person— “Lisa Camilleri is a 55-year-old woman who was diagnosed with breast cancer three weeks ago.” You might continue in third person or switch across to second person, that is, using “you”—“this is the last thing that you had expected.” An advantage of a switch to second person is that you can introduce what is called the voice of the part. Don’t be afraid to be subjective. Prompt the actor in their choices by the way you describe events. If you want the actor to play an anxious patient, introduce anxiety into the way you describe events. If you want the patient to have seen an overly positive surgeon as part of their medical history, incorporate the doctor’s own words into the writing. If the patient has heard a term for the first time, identify it by italics or inverted commas. Dr Farren was very professional. He was happy with the way the operation went, the ‘margins’ were clear, which is very good apparently, and he managed to get all of the cancer. Things have gone well. He just wants you to see an ‘oncologist’—that’s a cancer doctor—as insurance, just to be sure.

Note the lack of reference to the fact that the cancer in this case statistically has a 30% risk of return within five years. When the oncology trainee sits down with the patient in role-play, the patient will encounter an unexpected twist in the conversation. Make sure that the actor knows both what the patient heard and understood, and the actual clinical reality as understood by the trainees. The patient may be medically naive, but it is important that the actor is not. Like you, the actor needs to know what is going on. The actor wants to make sure that their character heads in the most productive direction. To do that, they need to know what

  The Script or Scenario Brief 

  103

their characters know, and what they don’t know. The more professional the actors, the more likely they can internalize this knowledge and direct their performance while still having their characters respond in ignorance of these facts. Actors also need to know how most patients behave so that they can avoid an idiosyncratic performance. If doctors regularly struggle in certain areas or tend to respond in particular ways, it also helps the actors to know this in advance. In the script, begin to incorporate some level of experience with the profession, if this is the case. For instance, patients gradually become medicalized through experience with the medical system. The patient may have picked up knowledge of medications, tests, scans, anaesthesia or operations, may have researched on the internet, or read booklets on medical procedures. The actor needs this information in order to play the part with any conviction and credence. You will save the actor a lot of preparation time by providing the required information yourself. Provide specific clinical detail sufficient to create plausibility for the role-players. Each professional group needs to recognize minutiae of its own world. If there is insufficient detail in the writing and portrayal, a group may say, “well, that’s more or less so, but our particular work situation is different.” The group will not buy fully into the fiction, and learning will remain limited. There is probably no best way to prepare a script. Scripts are works of art not science, scriptwriters improve over time, different interactions suggest different approaches and styles, and scripts do not exist independently of the rehearsal which fleshes them out. However, over time we have found that actors need to know four things in order to walk confidently into a complex role-play interaction: 1 . Who am I? 2. What has brought me to this moment? 3. What am I walking into? 4. What are we hoping educationally to achieve through this interaction? The first two questions provide information on what actors call their back story. The second two questions focus forward onto the drama of

104 

9  Working With Actors

the interaction and anticipate fruitful outcomes. Let us call these four sections as follows: characterization, history, anticipated shape of the drama, and educational considerations. 1. Characterization: Who Am I? Section one introduces the character, family relationships, occupation, and general personal information relevant to the particular scenario. Typical headings are name and age, name and age of partner, number and age of children, occupation, ethnicity if relevant, relevant social history, and background history. The actor uses this information to build up a back story for their character. Include here, or discuss in rehearsal, what their character will wear, whether there will need to be a costume change should there be more than one role-play scene, and how their character presents in the consultation. Be aware that the aim is not to produce a completely three-­dimensional character but a characterization that is of interest to the group in question. Novice scriptwriters may become overenthused and flesh out the script with all manner of background detail—the name and breed of their dog and cat, the colour of their house, their children’s hobbies, and so on. One of the major virtues of drama is economy. To remain economical, consciously separate the essential from the desirable from the insignificant. Forget the insignificant, include the desirable where possible, and focus on the essentials. Ask yourself, which information is absolutely necessary for this role-play? For example, you may have chosen a case that calls for a 30-year-old woman. Do you have a 30-year-old actor? Would an age range of 25–50 do equally well? Cast the actor, and script the character’s age to match. If profession, number of children, their ages, marital harmony or disharmony, social history, or personal preoccupations are significant for the interaction, specify them in the brief. If they are not essential, you might choose to leave them to the actor’s discretion, as long as the actor’s choices do not lead the interaction in a direction counter to the purpose of the exercise. Sort out any mismatches in rehearsal. There is positive value in allowing the actor latitude in fleshing out details of the characterization. As actors imagine their way into the

  The Script or Scenario Brief 

  105

c­ haracter’s life, they invest of themselves, increase their commitment to the character, and thereby create imaginative depth in their characterization. This personal investment and commitment stand them in good stead for the improvisatory uncertainty of the role-play. 2. History: What Has Brought Me to This Moment? The events which lead to the moment of role-play provide the second part of the actor’s back story. They also suggest the prescene, the specific moment immediately before the role-play begins. The rationale for the concept of prescene is that actors walk onto stage from somewhere specific, having just done, thought, or felt something in particular, and they carry the muscle memory of this previous action with them onto the stage. Their performance begins before they walk on and before the role-­ player meets them. The history comprises those specific events leading up to the role-play that are of interest to the role-players. In a healthcare setting, the history section represents the patient’s illness narrative. The term “illness narrative” refers to the story that more often than not begins with presenting symptoms and proceeds step by step through significant medical events up to the role-play consultation. It includes any tests and prior interactions with other health professionals; any relevant medical or genetic history; and medications, treatments, and any side effects. It needs to be written in story form from the patient’s point of view and should incorporate events as the patient remembers and interprets them. If the experience of an earlier consultation was important to the patient, include that information. The aim is to provide the actor as much as possible with a vicarious experience of a medical history. The story is a platform that provides not only facts but also experience and memories for their portrayal. Even with all this preparation, there is always the possibility of an unexpected question, in which case the actor will have to read the moment as well as possible and improvise as best they can. Aim to keep these moments to a minimum. 3. Anticipated Shape of the Drama: What Is My Character Walking Into?

106 

9  Working With Actors

Whereas the first two sections focus on the patient’s back story, the latter two are directed to the actors as performers. Actors always know more than their characters. Actors work with the same split focus of all professional communicators where one half of the mind engages and interacts, and the other half coolly considers and directs. This third section of the brief addresses the cool mind of the actor, rather than the warm mind of the character. I tend to think of the script as providing tram lines and nodes (see Fig. 9.1). The tram lines are the boundaries that designate no-go areas. Inside the tram lines are where, say, 80% of relevant cases are to be found. The research literature gives us this territory. Outside the lines live the outlier and the idiosyncratic, where time constraints usually don’t allow us to go. The script describes the world within the lines. Within the lines also lie a number of nodes spaced throughout the consultation. They represent anticipated or necessary stepping stones through the interaction, sticking points, points of divergence, and specific things to be investigated. This third section of the brief makes these issues explicit. The actor would prefer not to walk into the interaction blind. If there are expected sticking points, usual ranges of responses, and main points of business to attend to, let the actor know. If actors know the important issues up ahead, they can make sure that early interaction does not stall in minor territory. For instance, a trainee may respond early on in an inappropriate way. The trainee may have been too blunt or insensitive or inept. The patient’s natural response would be to focus on the slight and react to it, thereby stalling the action on the inappropriate behaviour. However, if the actor knows that more important business lies up ahead, he or she can give the trainee a symbolic “slap on the wrist” with a quick X

X Fig. 9.1  Boundaries and projected stepping stones through an interaction

  The Script or Scenario Brief 

  107

response, then ignore it, and push on. The role-player and group are given instant feedback, but the action does not bog down as it might were the actor not in the know. You are free to pick up on that moment in later discussion, if that is appropriate. If you can describe the usual shape of an interaction, do so. In this particular type of interaction, how do most members of the public respond? What do they want, understand, or fail to understand? What would be considered a good outcome? If bad news is to be given, that news may be expected, or unexpected. Which one do you want? The actors will adjust their response accordingly. If past trainees have had difficulties with this situation, where did these occur, and what form did they take? How tough or how reasonably do you want the actor to pitch his performance? Is there likely to be a significant turning point in the scene? This section makes sure that your colleague, the actor, is on the same page as yourself, and working towards the same ends. If the surgeon mentioned previously did not volunteer a 30% risk of the cancer returning within five years, include that information for the actor here, or in the next section. 4. Educational Considerations: What are We Hoping to Achieve? In this section, you give the actor access to information on the major educational concerns of the workshop. When actors prepare for a demanding role-play, they undertake background research to understand as much as possible. The information is this section is designed to fast track that research. If the focus of a workshop is breaking bad news, either of a sudden death or of unwelcome test results, this section gives the actor information on breaking bad news. You might include information on shock, the typical responses of disbelief, anxiety, anger, and distress. You would include the most relevant findings from the research literature, with practical applications such as confirming what the actor will learn through experience, that the mind may shut down on hearing the word “died” or “cancer.” In role-play, if the character’s mind does shut down, the conscious actor remains aware of that fact. If the workshop explores conversations about clinical trials, this section would entail a condensed tutorial on key issues of communicating about trials:

108 

9  Working With Actors

What are trials? How do they work? What is randomization and equipoise? What do patients find easy to understand, and what do they find difficult? How do doctors unwittingly coerce by choice of language? Provide good questions to ask—“If I was your wife/mother, what would you advise?” If the patient underwent complex procedures as part of their prior medical history, this section might include more detailed information such as the patient would acquire through personal experience.

Rehearsals Rehearsals are inevitably brief. However, with a well-written script, a three-hour rehearsal is usually sufficient to prepare an experienced actor for a three-hour workshop, with one proviso. An actor doing this work for the first time will need orientation in the basics of this kind of performance: how it is organized; how long they will perform; what they are to do during timeout and discussion; what kind of feedback they are to give, and not give; how they are to relate to the role-players; how to pitch their performance; when they are to turn up on the day; how they will be paid, and so on. Once actors gain experience through previous workshops, you can jump straight into issues of performance. No two actors or two facilitators rehearse in exactly the same way, so you must find your own style. If there is a lot of material to cover, you may need to stay technical. Give the actor the big picture of the workshop: what you hope to achieve; who they will be working with; what kind of clinical standards you are expecting; practical issues of when, where, how long, parking, and the like. Then zero in to the workshop: the overall shape; the sequence of scenes; when, and how they will enter in the role. Then work through the script. Discuss the character and back story. Some actors prefer to remain a little distanced, and to talk about their character in third person. Most prefer to enter role and speak at least partially in first person from their character’s point of view. If the actor has made creative choices in characterization or back story, listen c­ arefully, and confirm that their choices will aid, and not hinder, your plan for the workshop.

 Feedback 

  109

Then work chronologically through the history. Involve the actor as much as possible. Encourage them to flesh out the story with details as their character remembers it. In medical scenarios, if there are symptoms, make sure that their descriptions match the facts. If there is time, dramatize interactions with previous doctors to make them come alive and to give the actor a vicarious medical history. Take the part of each significant doctor or nurse whom they have seen. If a doctor had been aloof, you may choose to play that role and let them experience something of that aloofness. Use the wording of the doctor as suggested in the script. Let the actor savour the emotional impact of each interaction. Talk about it before you move on. If they underwent any procedures, make sure that they build a picture in their mind so that they have that experience to draw on in the role-play. If they have had relevant personal experience, they can use that. Make sure that their own experience matches that of their scripted character. It doesn’t ultimately matter whether the picture in their mind is from memory or the imagination. Both will be equally real to them in the role-play. Go over the anticipated shape of the drama, and clarify the central issues. Listen for the feedback that tells you that you are both in sync. If you have time at the end of this session or the luxury of a later rehearsal, it helps to do a dry run with a senior practitioner standing in for the role-­ players. In this dress rehearsal, check to see if the actor needs to pitch their performance slightly differently. They may need to be more or less anxious, more or less assertive, or quicker or slower on the uptake. The run through may reveal things to be changed, added, or omitted. Did the practitioner ask an unexpected question? Incorporate the desired answer in the scripting.

Feedback Training also needs to include discussion of feedback. Feedback from actors is important in that it represents a source of information not normally available to professionals. A clinician may handle situations in one particular way, assume that it works, but never actually hear back from patients as to whether that is true or not. Role-players are often stunned

110 

9  Working With Actors

in workshops to find that cherished chestnuts may leave a patient or client confused, disheartened, or even angry. Feedback from the actor is important because sometimes an entire group may approve an interaction, and through professional group-think remain oblivious to the fact that an explanation has completely missed the mark. Feedback can include any number of factors such as the impact of manner and language, whether their character feels blocked or encouraged to ask questions, whether the player acknowledges their personal concern, and the extent to which they share ownership of the consultation. Work out with the actor beforehand the kinds of behaviours you want to focus on in this workshop. Do not assume that the actor is omniscient. Especially in an intense interaction, actors concentrate all their attention on responding authentically to what their partner gives them. They notice certain things and are oblivious of others. If you want focused feedback, discuss with the actors the kinds of behaviours that you would like them to pay attention to. Make sure that both you and the actor are aware that feedback takes place in three ways. 1. Feedback of the Actor’s Performance Itself The actor’s responses within the interaction through words and body language provide immediate feedback on the impact of the role-player’s actions. Exact wording, hesitations, silences, and sudden changes of tack, posture, gestures, and tone of voice all speak volumes. These responses communicate the character’s needs and general state of mind and also signal how well or how badly things are going from their point of view. In this way, the actor provides you with a steady stream of realtime feedback on the experience of their character. This form of feedback is the most immediate and the most direct, yet is most often left out of discussions on feedback, possibly because it does not occur during sessions of timeout allocated to discussion and formal feedback. 2. Feedback from the Character During Timeout The actor needs to be ready to give feedback during timeout breaks. Actors instinctively understand that they remain in character until the

 Feedback 

  111

play, in this case, the role-play, is over. When you call timeout, they do not drop out of the virtual world and relinquish their role. They remain as their character in the world of the role-play but cease to interact. However, if an actor has not done this kind of work before, coach them on timeout conventions. Some actors might understand timeout as a freeze, which is all right as long as they do not stiffen: tensing physically will remove important subjective information from their system. Actors see it as pulling back psychologically into their character’s personal space or dropping into a shadow zone. Whatever the metaphor, the movement is a holding pattern of inner retreat while rebuilding energy to resume the role-play. The actor sits quietly, perhaps sits back in the chair, relaxes excess muscle tension unless that tension holds important emotional information, drops the eyes so as to cut off any possible interaction with the group, and remains firmly within the virtual world of the role-play. Only their ears stay attuned to life outside that world. These actions reinforce the impression that the role-play world has temporarily paused. The members of the group will still retain emotional echoes of the interaction, which hopefully give an empathic flavour to their discussion. However, they momentarily need some distance to discuss what they have just been through, and to imagine a way ahead, so the character needs to recede from prominence for a moment. While the group engages in discussion, the actor can listen unobtrusively and plan adjustments to their performance based on the feedback they hear in the group. If you have previously cued the actor to watch for specific issues, the actor recollects those impressions and waits for your prompting to give feedback. Cue actors on how you will elicit feedback. Remember that they will have their eyes down and thus have only their hearing to pick up cues. You can address them indirectly or directly. Once you have worked with an actor and developed a degree of comfort and shared understanding, you can be more confident that the actor is actively listening to the drift of the conversation. The actor might hear you ask the role-player, “what if the patient were to ask about prognosis?” or “but we don’t know if there is something behind that question.” If you have discussed possibilities of feedback in rehearsal, both of you will be in the know: you will know that the actor will hear and respond to your indirect prompts, and the actor will know that you are consciously cuing the next step.

112 

9  Working With Actors

When you do address the actor directly, speak the character’s name first. If not, the actor might assume that you are still talking to the group. It goes without saying that you use the name of the character and not the actor. The actor will hear their character’s name and look up. At that moment, their character comes back to life. You speak into the virtual world from where you sit on the margin, address the character as if he or she were real, and ask your question. The character replies from within the role-play world. The feedback carries strong credence with its illusion of objective reality. Be careful of hypothetical questions such as “if the trainee had said such and such, would that have been better?” Any conversation at that point moves into speculation. Stick to specifics. Look for actual responses to actual behaviour. What did your character actually notice, feel, or understand? Our experience suggests that participants take this specific feedback very seriously indeed and in fact may even grant it an assumed objectivity it cannot have. Emphasize to the actor that feedback is given in character. Both the actor and the character will have their own take on the proceedings, and any actor will always be more aware than their character. Remind the actor that there will be things that they will see, and not be able to say. It is the same for you. The group will want to know what the patient or client thinks, feels, and understands about what happened. As far as they are concerned, the actor is not even there. If you find yourself with a group who may question the objective validity of feedback from the actor, you might send the actor outside while the group plans a course of action. When they then test their strategy on the actor, the actor’s feedback will be interpreted as without particular bias. I suggest that you keep this tactic for special occasions. It is usually not necessary, takes extra time, and fragments something of the reality of the role-play world which you and the actor have worked so hard to create. 3. Feedback from the actor at the end At the end of the workshop, you may want to provide an opportunity for the actor to give some feedback. After all, everyone else has had their

  On the Day 

  113

say—the group, you, the character—the only one who has been mute is the actor. In our situation, we treat these comments as reinforcement of what has gone before rather than an opportunity to add anything new. The virtual world is now fast receding into the past, and the actor speaks of things which cannot now be rectified, changed, or improved. We u ­ sually keep this feedback fairly brief with some positive comments and one or two uncontroversial, specific pieces of feedback to add to what has gone before.

On the Day Arrival On performance days, actors arrive early so that they have time to clear their minds, costume up, and assume their role so they are ready to perform. This arrival time is usually called their Call, and their changeroom is traditionally called the green room. You may want to incorporate these terms into your own vocabulary. Call should be about an hour before the actor performs. Make arrangements to meet the actor before the start of the workshop. Show the actor where they can change. This is your opportunity to connect personally, finalize any last-minute changes, clarify points of focus, and sort out any practical issues.

Decide Whether to Introduce Actor or Character Decide whether the group will meet the actor or the character. You may be working with a group for two or three hours and be particularly aware that you want everyone to be prepared to try new things in an atmosphere of safe exploration. In this case, you might want to introduce the actor in person at the beginning, overtly draw attention to the coming illusion of role-play, and make it clear that the actor will be playing a part and will not be harmed by any of their actions. Once the role-play begins, the illusion will quickly take hold, and the group will be drawn into the

114 

9  Working With Actors

interaction safe in the knowledge that the whole exercise is a sophisticated game and that they can do no harm. You may wish, however, to have the patient appear in role to minimize aesthetic distance. This strategy is the one we use when students rotate through a number of stations centred on interactions with different patients. Each interaction is necessarily brief and requires high and ­immediate impact. Therefore, we hide the actors until afterwards, and each group must confront the reality of an unknown patient.

Manage Feedback During Role-play Remember that the actor will have unique feedback on what has transpired that is inaccessible to anyone else in the room. A group can easily discuss what has happened and unconsciously make all kinds of assumptions about the character. The actor’s feedback will confirm, refine, or contradict the opinion of the group. Don’t leave the actor too long in their suspended state before asking for feedback. Immediate impressions, particularly of an emotional kind, are ephemeral and quickly dissipate. If you anticipate lengthy discussion, immediately upon calling timeout, let the actor know what kind of feedback you will ask for, for example: “could you hang onto your understanding of the treatment?” or, “could you keep in touch with how you’re feeling at the moment, I’ll get back to you in a bit.” If the role-play is stopped in the midst of high emotion, the actor will attempt to retain the emotion, but the stimulus will have disappeared, and the emotion will inevitably change colour. Should you want feedback from within that emotion, ask for it earlier rather than later. Also, be aware that most of the time it is not possible to simply rewind back to before the emotional release and run it again. High emotion demands a lot from the actor, and it will not be exactly the same. Be judicious and selective at these points.

Maintain the Dramatic Fiction Maintain the fiction of the role-play in the way that you relate to the actor. Some facilitators find this conceit easier to manage than others.

  On the Day 

  115

Remember that it is the actor who generates the reality of the world of the role-play, and that the actor is in the role at all times. Without this virtual world, there is no basis for interaction and learning. It is important, therefore, that you do nothing to puncture that illusion and everything to foster it. For instance, when you ask characters for feedback, do not treat your interaction as a factual exchange. They may be anxious, confused, or preoccupied. When you speak to them, model empathic behaviour for the benefit of the group. Be aware of the character’s feelings. Speak kindly, politely, and calmly as if they were completely real and not a fiction. Do not address the actor because there is no actor in that world.

Bring the Actor Out of Role Actors are trained to take on and shed roles without assistance. However, role-play is a very personal kind of performance for both actors and role-­ players, and we have found that actors often enjoy some kind of ritual debriefing at the end of a long workshop. As facilitators, we sometimes drop into a lighter mood at the end of the workshop, and invite the group to effect a miracle cure, remove the hypothetical ailment, and return the actor to life. The sudden shift in mood signals the end of the hypothetical world and the return to normality. As the actor emerges from the character, the group can interact for the first time, no longer with the fictional character, but with the actor, the real person. This deroling is usually therapeutic for both the actor and the group. The actor often has experienced intense emotions during the role-play and is relieved to shed whatever physical tension has built up during the interactions. The greater benefit is probably for the group. Health professionals frequently find it hard to distinguish the actors from the patients they portray. Obstetricians, for example, may be so taken by the illusion that they will check during a break that the “pregnant” actor is seated comfortably, will ask how her health has been, and compare her condition with that of themselves or their wife when she was pregnant. They often come to the end of a role-play very concerned for the patient. Members of a group will often gather around the actor, asking questions, and making physical contact. They are, after all, members of a caring profession, and they need to make sure that the patient is in fact all right

116 

9  Working With Actors

before they feel comfortable in leaving the workshop. Oncology trainees may want to confirm that the actor has not been drawing on a personal experience of cancer. Rather than demonstrating naivety, these examples show just how powerfully virtual worlds seize our imaginations, draw us in, and convince us of the truth of their reality.

Debriefing Bringing the actor out of the role is not the same thing as debriefing. In general, professional actors know how to debrief from their roles. After all, the cool-down after acting is an intrinsic part of the performance process. Actors have time-honoured ways to let the adrenalin fade after a show. Oftentimes, they do so by surrounding themselves with other members of the cast, eating, drinking, talking, and laughing, until they feel the energy start to drain and know it is time to leave. In the case of role-play, many actors appreciate the opportunity for a drink and nibbles afterwards with the other key cast members, namely, you and the workshop team, along with the chance for informal chatter about what has just happened. Serious post-performance analysis is usually best left till another time when everyone has cooled down, and psyches are more protected and not so vulnerable.

References Barrows, H. 1987. Simulated (Standardized) Patients and Other Human Simulations. Chapel Hill, NC: Health Sciences Consortium. ———. 1993. An Overview of the Uses of Standardized Patients for Teaching and Evaluating Clinical Skills. Academic Medicine 68: 446–451. Heinrich, Paul. 2011. The Role of the Actor in Medical Education. In Handbook of Communication in Oncology and Palliative Care, ed. D.W.  Kissane, B.D. Bultz, P.N. Butow, and I.G. Finlay, 607–617. Oxford University Press.

10 Managing Performance Anxiety How to Manage the Major Obstacle to Role-­play Engagement in Yourself and in the Group

Performance anxiety is an inevitable by-product of any kind of performance. It tempts us to remain safely overdistanced and uninvolved and makes us reluctant to get up and have a go for fear of failure or ridicule. This chapter offers ways to manage this anxiety in members of the group, and in yourself.

Probably most of us experience some measure of performance anxiety when faced with the prospect of standing up and performing in front of others. The simple act of separating oneself from the mob, of walking forward, and then turning to present oneself to one’s peers and superiors, is guaranteed to produce a significant measure of performance anxiety. This act of confronting the group releases a barrage of psychological forces that together activate a fight-flight-freeze response. When these forces become sufficiently overwhelming that we are no longer able to function, we experience what is popularly known as stage fright. Usually, the anxiety dissipates once we begin to perform. Occasionally, however, the stresses generated by public performance are too severe and are only discharged by leaving the stage. These less common, but severe, cases may require outside intervention by a performance coach or mental health professional. As a facilitator, you need to be aware of the lurking © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_10

117

118 

10  Managing Performance Anxiety

ubiquity of performance anxiety, and learn a handful of techniques to reduce it to manageable proportions. All those involved in role-play are potentially prone to anxiety, and that includes the role-players, the facilitator, and even occasionally, the actor.

Why Would You Be Anxious? Even seasoned performers succumb at times to performance anxiety. Why is this? Basically, performance presupposes a stressful environment. When you walk onto a sporting field or a stage to perform a role, you do not walk onto neutral terrain but into a complex grid of intersecting lines of tension that permeate the playing space. As you become aware of the assault of tension, you may be tempted to assume that the fault is your own, and that you are in some way not up to the simple task of standing up and addressing a group. You may underestimate completely the scale of the psychological forces that surround a performer in a public space. This reality is the first important concept to grasp: performance implies action within a stressful environment. Tensions abound. In role-play, I would suggest that these lines of tension tend to radiate from four sources: from the group; from the workshop situation; from the actor (occasionally); and from within you. All four affect each other in multiple ways so that the individual lines may be hard to distinguish. As a facilitator, you walk into a messy central zone where all these forces collide. The stresses released by these clashing forces express themselves as anxiety.

The Group The group who have come to the workshop bring a complex web of stresses with them. First of all, though they may superficially present themselves as a group, some of them may not know the others at all, may have only superficial relations, or may recognize people who are important players in their future careers. Each case generates its own kind of tension.

  Why Would You Be Anxious? 

  119

They may not know you. They do not know what you will ask them to do, or what kind of unprepared situation they may find themselves in. They are likely to feel apprehensive over the potential danger of exposing themselves in role-play to the scrutiny of their peers. Their attitude to role-play may be negative, as some may have had prior, unsatisfying experiences. Those role-plays may have been cobbled together without any real understanding of performance or of insightful and supportive feedback. Some members of a group may accordingly not look forward to the experience or expect much from it. Their expectation may be one of endurance rather than of enjoyment. They bring unresolved stresses from work and home. They bring their uncertainty, their insecurities, their fear of vulnerability, their aversion to risk and error, and a massive need for safety in a strange environment with strangers of varying degrees. They may not be consciously aware of these personal factors. This lack of awareness makes these inner fault lines especially fragile: the tensions operate freely in the background, unknown and unharnessed. They will communicate themselves to you at some level.

The World of Role-play The virtual world of a workshop generates its own tensions. Its bipartite nature of being at one and the same time both real and not real is never completely resolved. We saw earlier how intrinsic and integral this tension is to a virtual world such as role-play, and how necessary it is as the engine of the aesthetic distance needed for fresh insight and learning. This irresolution is compounded by the exploratory nature of the exercise. Except in the case of procedural training, role-play does not primarily exist to practise known routines or scripts. It is most satisfying when it opens up new or supposedly familiar scenarios to discover what is really at stake and how to find the way to satisfying solutions. Improvisation, unknown pathways, and open outcomes are by nature stressful. The potential for danger and failure is obvious. This danger is exacerbated by the importance of the subject matter for the careers of those who have

120 

10  Managing Performance Anxiety

come and the felt need to achieve some degree of success within the limited time frame of the workshop.

Actors One would think that professional actors and other stage performers would be exempt from performance anxiety. In reality, however, performers sometimes report problems with performance anxiety that last in some cases for decades. These problems are not limited to young performers, and some actors have been struck down by debilitating anxiety in mid-career. Triggers can be forgetting lines, negative reviews, build-up of stress, factors in their personal lives, or may remain unknown. That list is said to include such luminaries as Barbra Streisand, Andrea Bocelli, Glenn Gould, Ian Holm, Meryl Streep, Ian McKellen, Rod Stewart, Carly Simon, and Laurence Olivier.1 Most of the actors who work with us in medical role-play have not found anxiety to present a significant problem. They have all learned in different ways how to handle anxiety, have developed techniques to maintain equanimity and focus, and perform their roles without debilitating stress. The stresses of role-play performance are usually quite manageable for a professional actor. There are a couple of caveats here. Actors vary tremendously in their capacity for role-play. Some are at a difficult time in their career or personal lives, and role-play may not be the best choice at this time. Some are comfortable only within the security of prewritten scripts and find improvisation threatening. Others, in contrast, are natural improvisers, and if anything find written scripts more difficult to master, because of their natural inclination to make things up. We make every effort to cast well and recruit actors who are in a good place in their lives, are comfortable with improvisation, and have had some satisfying experience with it. Those actors who do not come with an extensive history of improvisation, and yet express an interest in role-play, we first cast in more routine and less demanding roles, and give them time to settle in while we watch their progress. Performance anxiety is most likely to be an issue for those first few times of role-play as they summon up extra levels of concentration under the pressure of the unaccustomed style of play.

  Managing Performance Anxiety 

  121

The Facilitator You add your own tensions to the mix. However experienced you may be, you need to step up in front of the mob and perform. You recognize the blunt fact that you are only ever as good as this current challenge. You too do not want to look foolish or stupid. You bring your own fracture lines and insecurities. You too may have brought unresolved tensions from home or the office. You may arrive sleepless after a 12-hour flight. The improvisational and open-ended nature of the exercise affects you as well. Though the workshop may have an overall shape and an expected through-line, no one can completely anticipate how any one role-play will go. If you are inexperienced, you are still enmeshed in mastering the mechanisms of role-play. “Have I left something undone? I should have organized the slides earlier, now I’m running late. I feel flustered. What do I do next? What did the manual say? Remember to keep an eye on the clock! When do I call timeout?” All along there is a nagging awareness that this is a new workshop for you. The situation is fraught with possible things that might not go according to plan, or that might go wrong. With inexperience, you may interpret these two possibilities as being the same. Whatever your level of experience, you are acutely aware of the responsibilities that rest on your shoulders. There is added stress on you, in that anyone else can seek sanctuary in the anonymity of the group at any time. You do not have that luxury. At any given moment, you need to know what to do or to at least look as if you do. You are overly aware that the success of the exercise will largely depend on your leadership, but that there are far too many things that might go wrong and drive the whole venture onto the rocks.

Managing Performance Anxiety Anxiety, therefore, is a factor that potentially affects all of us. Left unaddressed, this anxiety will hamper the task of creating a safe and non-­ judgemental environment in which members of the group are free to explore and make the mistakes they have been conditioned not to make

122 

10  Managing Performance Anxiety

in their working lives. Trepidation will have them shrink from venturing out from the safety of their fortified positions, block them from entering into the hypothetical world of the role-play, and hamper spontaneous and creative responses to the problems they encounter there. Management of performance anxiety is thus a key skill to learn. Because of the pivotal role of the facilitator in role-play, it is important that you learn how to master your own nerves first in order to communicate calm and control to everyone else. Professional performers utilize a number of techniques which they have discovered to work for them personally. You doubtless do the same. Most of these approaches presuppose a working, practical knowledge of relaxation skills. For that reason, I have included Chapter 20 “Composure” should you not have considered this issue so far. Performers also learn different ways to accept the fact of stress chemicals in the body, and to use them as the energy for their performance, rather than succumbing to their power and becoming overwhelmed by them. As facilitator, you have access to the same energy that is provided by the adrenalin-noradrenalin surge prior to performance. The trick is to harness the power rather than have it run riot. The answer has to do with attitude and will (“I will harness this power”) and practical skills to handle a range of likely situations.

Ways to Reduce Performance Anxiety Reduce Your Own Anxiety Choose to harness your stress response for use in the workshop. Knowing that you are facing a challenge, your autonomic nervous system is ­readying itself for action. Your adrenal glands have begun to release significant quantities of adrenaline and noradrenaline into the blood stream to prepare for action. Your digestive system is shutting down, and blood is being diverted away from the gut to strategic areas where it is more needed. We experience this disquieting change and interpret it as “butterflies” (Palmer 2000).

  Ways to Reduce Performance Anxiety 

  123

Most of us don’t like the experience of butterflies, view it negatively, and wish it would go away. By doing so, of course, we unwittingly double our anxiety. Now we have both a daunting prospect and a sense of not being in control. Why not reframe the situation? Treat butterflies in the stomach as a positive sign, namely, that your body is on your side, and on its own initiative is generating the energy you will need. However, your body is taking bets both ways as it doesn’t yet know which way you are going to go: will you need more adrenalin for flight or noradrenalin to stand and take action? Your body is awaiting further instructions, and you need to take charge. Now is the time to choose to ready yourself for action rather than for flight or the more paralysing option of frozen fear. Convert the surplus chemicals into useful energy rather than debilitating anxiety. Support that decision with practical techniques that reduce triggers for anxiety: 1. Allow ample time for you or a colleague to handle all organizational issues, and have them resolved well before start time. 2. Allow time to switch your focus from organization to facilitation. Allow 10–15 minutes to “enter the zone” as facilitator and become ready to work. 3. Take steps to become calm before you begin. Breathe deeply, release excess physical tension, focus away from organizational issues onto the performance ahead, and imagine yourself into the event that you have prepared. 4. Become quietly confident in the process itself and in the capacity of the participants to enjoy and handle the role-play. The group will ride in on your calm and confident belief. 5. Become aware of the growing extrovert energy within you that readies itself for action. Channel your stress chemicals into useful energy. 6. Have notes prepared so that you do not try to remember everything you have to do. Calmly scan them to remind yourself of your first steps. 7. Do not hurry. 8. When it is time to begin, steady your nerves and decide to really enjoy the experience. Wait for the impulse to get up and begin. Start when you are ready.

124 

10  Managing Performance Anxiety

Diminish Tensions Around the Actor The presence of an actor may create tensions in a group. The actor is probably unknown to them and is therefore a stranger and a source of potential stress rather than comfort. They know they are to treat this person as a client, patient, colleague, or senior officer, but simultaneously they must deal with their knowledge that this is, in fact, an actor. If you were watching merely as a member of an audience, this suspension of disbelief is easier to carry off. After all, you are not called upon to do anything but watch. The participants, however, know that they may be called upon to step onto stage and interact with  the actor, which is another step-up entirely. You might choose to reduce tension by introducing the actor at the beginning of the workshop as an integral member of the team. The group thus recognizes that the actor is not a fictional character but a real person like themselves. Have them realize that the actor is indestructible. Actors bounce. There is nothing that anyone can say in the role-play that will cause harm to the actor. They are free, therefore, to explore in a way that is impossible in their actual practice. You may, on the other hand, desire the heightened dramatic value in the appearance ex nihilo of an unknown character. If so, keep the actor out of sight till the time of performance, at which time the actor appears in the role. The raised dramatic tension can add real educative value, but remain aware that it comes at the cost of elevated anxiety.

Strategic Placement of the Role-player’s Chair When the role-play begins, the actor will draw the focus of the role-­ player so that after a relatively short period of time (probably less than a minute), the role-player will become increasingly aware of the aliveness and the reality of the character. At the same time, their intellectual awareness of the character-as-actor will recede into the background. Simultaneously, the watching group will also naturally tend to recede into their peripheral vision. Enhance this natural process. Arrange the seating so that the role-player is looking away from most of the group.

  Ways to Reduce Performance Anxiety 

  125

 mphasize Group Learning over Individual E Performance Even in a workshop where assessment is not on the table, the fear of negative scrutiny and of the judgement of peers lingers on. This is common for role-play in general and certainly in competitive professional cultures such as medicine, business, and law. Explicitly make it clear right up front that the aim of the exercise is group learning. The focus is not on how well or how poorly any specific person communicates and performs. Be sure that this is what you yourself really believe, lest your unconscious actions contradict and undermine your reassuring words. Discuss progress in terms of “we” and “us.” Make it clear that these scenarios are complex, and that the aim of the exercise is to tease them apart in role-play, and to investigate them as if for the first time, as a group. In other words, the focus is the challenging scenario itself with its intrinsic issues and not the performance of any one participant. In discussion, encourage the group to come up with potential strategies and approaches. By so doing, the role-player becomes the de facto representative of the group as he or she attempts to put the group’s plans into action. Credit and shortcomings are thus shared around the group, and anxiety is diluted.

Opportunity for Safe Exploration Emphasize that this is an opportunity to experiment. This distinction needs to be communicated early and clearly. The workplace is not always the best place to try out novel approaches to see how they go. However, here in the workshop, the rules are reversed. The group is now free to explore, and discover, new approaches. They are all safe. The patient or client is “not real,” which means he or she cannot be harmed. Actions and decisions are hypothetical, which means they are without harmful consequence. The workshop is the world of rehearsal rather than the real thing. You might point out that we do not expect to see solutions at the start of the workshop. The point of the workshop is to identify significant

126 

10  Managing Performance Anxiety

e­ lements and try out possibilities which will come together by the end of the time together. No one at any stage has to be right, which can be a welcome relief.

Use Techniques to Ease People into Role-Play These techniques might include ice-breakers of various kinds, which might be social games, dyadic conversations, or intellectual games. Workshops might also begin with covert role-play activities that do not draw attention to themselves. For instance, we often open a workshop with an exercise that we call Open Chair. The actor enters as the patient and sits in a chair facing the group. The participants curve around the chair in a semicircle. Each person in turn asks a question of the patient, as they would if they were to take a history. The task of taking a history is second nature and thus provides a sense of security. As each person asks and listens, the others take in the information as if they themselves had asked the question, process the answer, and formulate in their minds the next question. By the end of the exercise, the group has built up a picture of the patient and the clinical problem and has begun to develop a relationship with the patient. Without drawing attention to it, they have already engaged in role-play, and now find it easier to continue on, and to interact with the patient individually on their own. You might think of the technique as similar to priming a pump.

Choose the First Player Well Choose the first player well so that there will be a good experience for all. There is nothing more detrimental than an initial role-play that goes horribly wrong. Exercises such as Open Chair provide an opportunity for you to watch the interactions unfold between the group and the actor. Very quickly you will identify two or three people who would be good candidates to begin the role-play interactions. How do you recognize who would be a good person to start? Everyone has their own bag of tricks. One way is to screen by temperament. Some

  Ways to Reduce Performance Anxiety 

  127

in the group will be naturally more outgoing and activist by nature and will prefer to learn by doing. Another approach is to identify someone who verbally proposes a hypothetical course of action. If they describe how they would tackle the situation, and the approach offers a good chance of success, they are very likely to be able to carry it off to some degree of satisfaction. A confident first role-play is an encouragement to others to volunteer.

Perhaps Avoid the Use of the Term “Role-play” There is one school of thought that attempts to reduce anxiety by drawing attention to the fact of role-play and spelling out all the rules and conventions in great depth before beginning. Sometimes, however, this approach can increase stress in the group by emphasizing the impending role-play. You can get an interaction up and running with less stress by not referring to role-play at all but by simply easing people in. For example, after the group has warmed up and begun to discuss a course of action, and you recognize a potential candidate, you could simply say, “why don’t we try that out?” or “what would you do in that situation?” Allow people time to move imaginatively into the scene by thinking and hypothesizing aloud. As soon as you can see that a ­participant can hypothesize a course of action, get them up and into role-play mode: “Good, good, why don’t you try it. Start whenever you are ready.”

Keep the First Role-play Positive Tone the first discussion towards the positive for the same reason. Place the major focus on what the role-player has discovered and achieved rather than on shortcomings. Medical people are not alone in being very self-critical and will quickly overleap their accomplishments and focus on where they think they failed, or went wrong. Students might be aware only that they are uncertain how to proceed and completely overlook how much information they have collected. Consciously circumvent this process by asking for the positives, and keep bringing a straying discussion back to positive territory. Once the group has recognized what they

128 

10  Managing Performance Anxiety

have already accomplished, direct discussion onto where we should go from here. Once the group settles down and becomes comfortable with the exercise, subsequent discussion can become more flexible.

Involve Participants in Setting the Scene Have the first player move the furniture to match what they are used to. Ask them, “where would you normally have the chairs?” or “is this how you would set up your office? Change it around till you’re happy with it.” As the role-player shifts the chair or table to suit, they have begun to actively engage in the hypothetical reality of the scene. It takes their mind off possibility and theory onto specific, active problem-solving. They commit themselves to choices of action, and that commitment to act is their most potent spring board for performance. A focus for action can reduce excess anxiety.

Establish Clear Boundaries Successful role-play depends upon setting up a playing space that is defined in space and time. Close the door to the outside world to block outside distractions and to increase the focus of the playing space. Make sure that participants know the role-play does not go on forever but has a beginning and an end. In most cases, each person will spend at the most five minutes in interaction before breaking for discussion. Make sure that they know that they have not lost control of their lives and can call timeout as needed to halt the role-play. Due to anxiety, we can sometimes feel obliged to move or speak before we are ready. Assure them that they are perfectly free to wait until they feel ready to walk in and engage in role-play.

Include Appropriate Humour Psychologists such as Mihaly Csikszentmihalyi remind us that the best learning takes place when everyone forgets the passage of time because

  Ways to Reduce Performance Anxiety 

  129

they are having what he calls “serious fun” (1990). As children, we discover that learning new things can be fun and effortless. A light-hearted attitude on your part removes the sting from potential glitches by reminding the group that ultimately we are engaged in something that is not real and without real-world consequence, and are therefore free to enjoy ourselves as we learn. Don’t worry if role-players occasionally break out of the fiction, and laugh, or make a joke. These nervous breakouts simply puncture the tension to deflate it and make it bearable. In our immersion in the all-too-­ serious adult world, many of us have quite forgotten how to play. In the nervous laughter or commentary, they remind themselves that this is in fact fiction and not real. Mostly, these brief moments are sufficient to bring the tension back to manageable proportions, and people settle more comfortably into the hypothetical world. The actor’s utter commitment to that world is usually sufficient stimulus to keep the interaction moving forward.

Be Gentle on Yourself Facilitation is a complex skill set to master. It takes time and many experiences till things become second nature. You will pass through the same phases as the learning of any new skill. Remember back to when you learned to drive. In the beginning, you will inevitably spend some time feeling that you are “facilitating by numbers.” You will be aware that you are not operating in your usual “natural” manner and will feel somewhat mechanical. In the beginning, you may find it almost impossible to balance the twin dictates of becoming absorbed in the interaction while remaining detached enough to decide what to do next. Then comes a period when you are comfortable with the basics. You feel much more at home and feel that you know what you are doing. Time management has ceased to be a problem, you have worked out good ways to start the ball rolling, recognize when to call timeout, and lead groups to satisfying resolutions. Anxiety has ceased to be a major issue. Then, out of the blue, something new or unexpected happens, and your mind rushes back into technical mode to work out what to do. Even

130 

10  Managing Performance Anxiety

worse, a player may plunge into real difficulties which he cannot manage, or the discussion may wander into a cul de sac with no obvious way out. You do not know what to do, you panic, and your anxiety soars. You feel yourself revert to becoming technical, and you interpret this negatively as reversal, or failure. Reframe the situation. Recognize that nothing is out of control, these moments will almost certainly occur from time to time. This is where you learn something new, and this is precisely where a technical approach is called for. Your stress surge will heighten your perceptions and give you added energy to tackle this new challenge. Harness and access that energy. Consciously manage your anxiety. Take four or more slow, deep breaths, and inwardly monitor the return of a sense of control. Then, use whatever techniques you have access to, and calmly work your way forward. Find out how to help the group solve the problem. You are all in this together. No lives will be lost. By remaining calm, you will all work towards some kind of resolution.

Summary Performance implies action within a stressful environment. Tensions abound, and performance anxiety is to be expected. To manage performance anxiety, adopt the following strategies: 1. Reduce your own anxiety 2. Diminish tensions around the actor 3. Artfully adjust the placement of the role-player’s chair 4. Emphasise group learning over individual performance 5. Emphasise the opportunity for safe exploration 6. Use non-threatening techniques to ease people into role-play 7. Choose the first player well 8. Perhaps avoid the use of the term “role-play” 9. Keep the first role-play positive 10. Involve participants in setting the scene 11. Establish clear boundaries

 References 

  131

1 2. Include appropriate humour 13. Be gentle on yourself

Notes 1. http://tvnz.co.nz/view/page/411319/696544, http://www.mckellen.com/ writings/9602fry.htm, http://www.msnbc.msn.com/id/20727420/

References Csikszentmihalyi, Mihaly. 1990. Flow: The Psychology of Optimal Experience. New York: Harper and Row. Palmer, Stephen. 2000. Physiology of the Stress Response. London: Centre for Stress Management and City University. http://www.managingstress.com/ articles/physiology.htm.

11 Beginning the Role-play Workshop How to Compose Yourself on the Day So That You Can Confidently Lead the Group into the Virtual World of Role-play

If you have no difficulties with public speaking and are comfortable leading a group, this material will probably already be known to you. If these are issues you have yet to master, this chapter discusses how to prepare yourself on the day, so that you can stand calmly and confidently and introduce yourself and the workshop. You do this by reestablishing imaginative contact with the world of the role-play, introducing yourself from within that imaginative space, and inviting the group into the virtual world.

The day of the workshop has finally arrived. You have come up with a good workshop design and are looking forward to seeing how it goes in practice. You or your team wrote a scenario brief, rehearsed with the actor, found a good location, came early to set up the room, greeted the actor, attended to any sound and audio-visual technical requirements, and made sure someone was covering front of house. There is nothing ahead of you now but the workshop.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_11

133

134 

11  Beginning the Role-play Workshop

Stocktake and Self-Preparation Be aware that you are not yet quite ready to facilitate. All of these prior activities have put you into a busy frame of mind. Your focus is likely to have become as fragmented as the number of tasks you have had to address. In facilitation, however, you will need to forget all else and to focus on the present moment. That mindful attitude will transfer across to the group. Basically, you need to make the same shift that you are going to ask of the group, that is, to put the day on hold and enter the world of the workshop. The difference is that you have to make that transition before the workshop begins so that you already inhabit that world when you step up to take charge. You will then have a world to invite others into. I would suggest you pull aside, and give yourself a good 10–15 minutes alone to prepare. Run a brief stocktake on your physical readiness and your state of mind. At the very least, have a long, satisfying, slow stretch. Excess muscular tension will inhibit natural breathing and drive it high and shallow. Your body’s internal systems will interpret the shallow breathing as anxiety and respond accordingly. Spend a few minutes allowing your breathing to become slow, deep, and steady. The value of this exercise is enhanced if you pay attention to how the breathing improves your state of mind. That attentive awareness will be your single greatest asset during the workshop. Your calm awareness will enable you to be in the moment, which is the creative space needed by every performer in order to think and respond creatively to each new challenge. Particularly if the workshop takes place early in the day, it might be a good idea to warm up your voice, if you did not already do so at home. You will be using your voice all day. It will be the major instrument by which you direct activities and keep the ball rolling throughout the workshop.1 Many of you have very busy lives and may consider this preparatory time as something of a luxury you cannot afford. Please reconsider the importance of this preparatory time in view of the immense value of you becoming grounded.

  Get Back in the Zone 

  135

Get Back in the Zone Thoughts will slide into your mind. Some are thoughts that have to do with practical tasks just completed. Calmly tick them off a mental list, and move on. If the thought represents something you need to do after the workshop, place it on an imaginary shelf or actual list to pick up at the end of the day. A second group of thoughts represents the upcoming workshop. A new idea may come to you as to what you might say as introduction or as a different way to run an exercise. Your mind is now warming up and rehearsing for what lies ahead. Useful and applicable words, phrases, and ideas for action often appear like this at the last moment. Consider it perhaps as the mind’s economy, not bothering you with tactical details until you really need them. These last-minute words and ideas arrive hot out of the oven and warmed up ready for use, so to speak, and usually work well in practice. They may perhaps be intended for this time only, or they may also be applicable for future workshops. Allow yourself to move imaginatively into the virtual world. In one sense, you are moving forward to what is to come. In another, you are returning to the virtual world that you first imagined. Fill your mind with the world of the workshop. Let there be no other outside considerations. Speak words as they come to you. Physically move around as you recreate that world. If you have trouble imagining what you will say or do, start with the concrete realities of the setting. What does the stage look like? Where will you stand? What will you do? Use hypotheses to trigger your imagination. For example, you might say to yourself, “I think I’ll say something like …” and then try out some words; “and then I’ll introduce this or that person, or this or that exercise …” You have two major goals for this period of preparation. The first is to bring you to a place where you are calm, focused, and alert. The second goal is to get back in the zone. You will know when you have done this. You will feel ready, and the world of the workshop will feel close, accessible, and alive. You are now imaginatively where you need to be. You have revived the memory of the virtual world so that it feels real and alive once more. You are now ready to walk out in front of the group and introduce yourself.

136 

11  Beginning the Role-play Workshop

Walk Out and Introduce Yourself Some of you have no problem with this task at all. Many of us, however, experience some apprehension and anxiety right at this point. I would suggest that you think in terms of simple stagecraft. A technique that many people find helpful is that of double objectives. When it is time to get up and walk to the front, divide that simple act into two. Tell yourself, I have two tasks to do. The first is more important: maintain the sense of calm focus that I have reached. The second is much simpler: get up and walk to the front. You might perhaps codify this concept by simply telling yourself to be calm and walk to the front. You may have this part already under control. Experience, however, suggests that more people experience nerves at this juncture than not. People commonly experience difficulty in these first moments when they stand to introduce themselves and the workshop. Those difficulties are often of two kinds. The first is the temptation to feel that you have to speak and act before you are ready, so you begin off balance and have to work to regain equilibrium. The second has to do with not being clear what your immediate objective is.

Speak and Act When You are Ready When people are asked what they most hate or fear to do, one of the top contenders for the crown is public speaking. When you stand to speak, your inner being is rapidly making an important security assessment, often beneath your conscious radar. The thinking goes something like this. “It doesn’t feel safe with everyone’s eyes fastened upon me waiting to see what I am going to do. Am I in safe company, or do I need to protect myself?” There is a strong impulse to hide behind some kind of protective barrier, whether that barrier be a rostrum, or microphone, the mask of a persona, or a prepared script. However, you stand there with the consent and approval of the group. As a species, we are predisposed to novelty and new knowledge. This means that the group wants something good to happen. If you

  Your Immediate Objective: Lead the Group into the Zone 

  137

choose to believe and act as if you have something interesting to offer, all your internal energies will line up and work for you. By choosing to engage and throw yourself into the task, you send a loud and clear signal down to your waiting psyche that you have assessed the situation and found it to be safe. There is therefore no need for any protective barrier, physical or psychological, between you and the group. Instead, you have effectively dissolved any barriers and drawn all of you together into the same space. Whatever techniques you discover and use to do this, your aim is to realize a sense of safety and potential in your role. With that safety, you will be able to breathe calmly and freely throughout the workshop, and you will be able to think and decide creatively, and without anxiety. Therefore, in those first few seconds, before you open your mouth to speak, cast your eyes around the group, and register their presence. Consciously take in the panorama of expectant faces. Your eyes will do this anyway, but by consciously choosing to do so without anxiety, you commit to being there. This slight delay also creates a sense of anticipation as to what you are about to say and do. This may take only a matter of two or three seconds, but in those seconds, you will have done something to ground yourself. You will sense the impulse to speak. When you do open your mouth, the group will have a sense that you are talking to them, not at them, and will relax and feel no concern on your behalf. You will all immediately feel much more at ease.

 our Immediate Objective: Lead the Group Y into the Zone When asked to make a public presentation, people often nervously ask, “what should I do with my hands?” Awkward hands are simply a sign that we don’t know what we are doing. The solution is simple. Forget about the hands, and instead think about what you are going to say, and your hands will follow. Your first objective is to capture the attention of the group, convey a sense of an interesting time ahead, and begin to lead them into the world you have prepared.

138 

11  Beginning the Role-play Workshop

I suggest you avoid too much talk, and get the group moving as early as possible. Initial activities are sometimes called warm-ups or ice-­breakers, but those terms do not really convey what they are meant to do. Certainly, an early exercise or game does warm up the group and does break the social ice, but the primary objective of the exercise is far more dynamic than that. The objective of this first activity is to lead the group into the zone and into the world of the workshop. Your prior preparation makes this task easier to do. As a result of your personal preparation, you already stand in that world, so it is not a theoretical construct for you but a tangible reality. The opening activity, whatever it is, is like a kind of bridge from the everyday over into the world of the workshop. Judge the effectiveness of the opening activity by how well it does that job. When choosing an opening activity, consider where you would like the group to be at its culmination. If the focus of the workshop is to enhance observational skills, you need to warm up the group’s capacities for observation and reflection. The activity may be a mind game or a creative self-­ presentation exercise.2 If the workshop is designed to have people role-playing with an actor, get everyone physically moving, interacting, and focusing hard on an enjoyable task that demands their full ­attention.3 By the end of the activity everyone will be focused on the here and now and will hopefully have put the rest of the day completely out of their minds. If you want to jump straight into the business of the workshop, make sure that the opening role-play activity is intriguing, draws focus, demands their full attention, and requires the participants to interact (such as Open Chair). By doing so, you build a platform upon which the role-play can proceed. The workshop proper is then ready to begin.

Summary Your first primary task as facilitator on the day is to move the group through the frame into the virtual world of role-play. Major steps include: 1. Step back from last-minute organizational issues, and take time to prepare yourself for performance. 2. Do what is needed to become calm, focused, and alert.

 Notes 

  139

3 . Focus on your breathing, and allow it to become deep and steady. 4. Get in the zone, that is, reenter imaginatively into the virtual world of the workshop. 5. Have a simple strategy to acknowledge to yourself that the workshop is in fact a safe exercise, so that you can function calmly. 6. Find effective ways to manage the first moments of standing to address the group and to capture their attention. 7. Have in readiness a creative opening activity that will convincingly lead the group into the virtual world.

Notes 1. To warm up the voice, simply sing quietly in the shower or hum forward onto the lips. When warmed up, the voice loses its “sticky” quality and sounds smooth. The water vapour helps to lubricate the voice. Hum or sing up and down through your vocal range. The voice should slide smoothly up and down its range without jumps. If you discover a break, hum up and down over the break. Then test to see that the voice has become smooth. 2. For example, ask everyone to write down one fact about themselves that is improbable but true, collect the slips of paper, read out the entries, and see if the group can identify the writers. Or ask everyone to introduce themselves to the person next to them in one minute in the most interesting way possible. Or involve them in a game where the group must work out how many objects, verbs, or adjectives begin with a specific letter of the alphabet. For instance, suggest that their state of mind on being asked to break bad news begins with the letter D. How many words can they find? 3. Chairs is an enjoyable team-building game. Scatter chairs randomly around the room. Everyone but a volunteer occupies a chair leaving one chair free. The volunteer simply needs to sit on the free chair. However, anyone can stop this happening by vacating their own chair and occupying the free one. Someone else needs then to occupy the empty chair. The group needs to work together to keep the volunteer on their feet. How long does it take before the volunteer manages to sit? Whoever loses their chair becomes the next volunteer. The game is surprisingly absorbing and generates considerable interactivity.

12 Managing Aesthetic Distance How to Manage the All-Important Element of Aesthetic Distance Without Which Role-play and Simulations of Any Kind Cannot Exist

Because of the centrality of aesthetic distance to role-play, this chapter is devoted to a practical consideration of how it works in practice. Many of the techniques and practices of facilitation have a lot to do with knowing how to manage this one factor.

The dynamic of aesthetic distance undergirds the entire experience of role-play. Because our minds hold in tension an experience of reality with an awareness of artifice, there remains a deep sense of irresolution at the heart of role-play performance. The result is rarely a perfectly balanced state. One side of the equation will tend at any given moment to come to the fore and the other to recede into the background. Aesthetic distance can profitably be thought of as a spectrum (see Fig. 12.1). At one end of the scale we have greater detachment and at the other greater involvement, yet wherever we sit on the scale, we experience what has been called in the psychological literature balance of attention (Jackins 1965), that is, we remain aware that the virtual world is real but at the same time not. Aesthetic distance is intrinsic to role-play as it is to all performance. Remove it, and role-play immediately ceases to exist. If we fall off the scale at what we might call the cooler end, we become overdistanced and © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_12

141

142 

12  Managing Aesthetic Distance

High

Aesthetic distance

Low

OVER

UNDER Cool Dispassionate observation

Warm Involved interaction

Fig. 12.1  The spectrum of aesthetic distance from over- to under distance

see only artifice. The role-play world ceases to exist; we see only pretence, and it holds no interest for us. If we fall off the scale at the warmer end, we become underdistanced, mistake the fiction for reality, and become overwhelmed. Role-play takes place when we agree to the conventions that govern all art and performance, and act for a time as if the fiction were real. We are caught up but not too much. We are detached but not too much. It is in that aesthetic zone between both extremes that the world of role-play comes alive, whereby we act and simultaneously are aware of acting in ways that are not possible in everyday life. Many of the common mistakes in facilitation occur because a facilitator is unaware of aesthetic distance. Aesthetic distance is at work at all times: when we create an environment conducive to role-play, bring the virtual world to life, help others to enter and navigate safely within it, discuss their experience, and juggle the simultaneous demands on us as facilitators to be empathic observers and objective managers.

The Fragility of a Virtual World The virtual role-play world is the single indispensable sine qua non of this kind of learning. Without it, we are left with mere theoretical discussion. Theory and intellectualization are the modalities of choice in academic discussion but are relatively unhelpful in experiential learning. Only the felt reality of the interaction and the thoughts and feelings that it arouses generate the experience and the insights that make this kind of learning possible. However, the role-play world is very fragile. It is like a bubble. It shimmers before us as if it had all the stability in the world, yet that stability is

  The Fragility of a Virtual World 

  143

an illusion. The world inside the bubble is unstable because it is ultimately not real. It requires energy to bring a virtual world into existence, and energy to sustain it, and keep it alive. It is very easy to puncture, very easy to deflate, and very easy for the contrived interaction to splutter and die. We must never forget the fragility of the world of role-play. It requires constant tending to remain intact and alive.

Creating an Environment Conducive to Role-play Without a sympathetic physical environment, it is extremely difficult to bring that world to life in the first place. As with all performance, the workshop space will influence the atmosphere and will enhance or inhibit interactions within the room. We have considered the selection and set up of a space in Chapter 8 Where to hold a role-play workshop.

Bringing the Virtual World to Life A living role-play world depends upon the three strong stimuli of a well-­ devised scenario, a committed actor, and an accomplished facilitator. Firstly, the scenario needs to be recognizable, sufficiently challenging to generate interest, and of uncertain outcome to maintain suspense. In other words, the group quickly recognizes that they have work to do if they are to resolve the intrinsic tensions within the scenario. Secondly, the actor through rehearsal commits to play the role of patient or client and maintains that intense commitment for the duration of the workshop. This commitment provides the role-players a powerful stimulus for interaction and helps to send the role-play in productive directions. This commitment is probably what Darius Razavi was sensing when he found that emotional intensity in role-play produced greater learning (2000). Actors, in fact however, do not focus on playing emotions such as anger or distress, but embark on strong courses of action which produce a shifting landscape of emotion as a by-product. Razavi is undoubtedly correct in his observations, though the relevant factor is more likely to be utter commitment on the part of the actor, demanding an equally strong response by the player.

144 

12  Managing Aesthetic Distance

Before the group meets the stimulus of the committed actor, they are confronted by the equally strong presence of an engaged facilitator. The preparation on your self immediately before the workshop is not just to reduce your own performance anxiety and to ready yourself for action but also to ensure that you become a strong stimulus to draw the group into the world of the role-play. From the very first moment, the ­combination of strong scenario, committed actor, and engaged facilitator capture the attention of the group. We have found that specificity and detail help the group to buy into the reality of the scenario. By making sure that we provide relevant detail wherever the player may turn, it is as if the scaffolding that holds up the artifice disappears, and all that remains in view is the virtual world. Research into transportation theory supports this practice. Transportation theory explains our experience as readers of fiction wherein we are transported, that is, drawn imaginatively into the world of a novel. As we do so, we temporarily forget everything around us, an experience analogous to that of role-play and of all absorbing art and performance. Research shows that we are more likely to be transported when we are supplied with a lot of physical detail and are put in touch with the feelings and thoughts of those in the world of the novel, in our case, of those on stage (Green et al. 2004a, b). A group is more likely to be transported into a virtual world when they identify and sympathize with the protagonist (Green 2004), in our case, the role-player and are familiar with the fictional situation, that is, the client or patient, and the scenario. The familiarity and identification with the scenario and those playing within it create an enjoyable experience that has a lot to do with the intrinsic safety of the exercise. Though it looks and feels real, we know that it is not, and that there is no danger of causing harm, so that we are free to abandon ourselves to the conceit of the fiction (Green et al. 2004a, Nell 2002). The experience of being transported into another world is akin to the all-absorbing experience known as flow, whereby time seems to stop as we immerse ourselves in “serious fun” (Csikszentmihalyi 1982). These findings also find support in research in the field of computerized virtual reality. As we sympathetically identify with the protagonist and the action, we automatically pay closer attention and become more involved. This immersion in the virtual world produces what these researchers call

  The Fragility of a Virtual World 

  145

presence, that is, “the subjective experience of being in one place or environment, even when one is physically situated in another” (Witmer and Singer 1998). This experience is enhanced when you provide “scene realism,” namely, a rich sensory environment, consistency of information, and natural interactions that mirror our experience in real life. The implication of a virtual world is that it is located somewhere else, outside the training room, wherever the players conceive it to be. What is most important is that everyone buys into the fiction and joins in the game. The ideal is that of universal transportation, that is, everyone to be caught up in the reality of the role-play encounter, whether as actor, role-­player, onlooker, or facilitator. We don’t need to be reminded of the artifice; we all bring our sense of distance with us. We do need the combination of a strong stimulus to capture and hold our attention and freedom from outside distraction, in order to be transported into the alternative reality. At first glance, it may appear that the role-play “bubble” is confined to the stage (see Fig. 12.2). According to this way of seeing it, the character and role-player interact in the virtual world inside the bubble while the facilitator and group sit safely outside and peer in. When we then call timeout, the interaction ceases and the patient remains inside while the player steps out to talk with the group. If this is our tacit model of role-play, the discussion may tend to be cool and detached, almost as if we had never been part of the experience. The player will reflect and discuss in the cool, neutral zone, then step back into the warm bubble to resume the interaction with the

Cool objectivity

Stage Intense subjectivity

Observers

Fig. 12.2  Incomplete model of the relationship between the stage and observers

146 

12  Managing Aesthetic Distance

actor. While the character is assumed to live in that other world, the player is a foreigner to it, and merely comes and goes as a visitor. In reality, however, the virtual world of the role-play fills the entire room or at least is meant to do so. The stage area is indeed the hottest zone in terms of subjective experience. The player takes an active role and steps fully into that world. There, he or she experiences the world as if it were truly real. The player’s senses are saturated with sight, sound, and feeling. The flooded senses transport and keep the player engaged in that world. Only the mind remains aware that this reality is ultimately a contrivance. The player’s experience as a whole is that of near-complete immersion at the warm end of the spectrum of aesthetic distance. However, an empathic wash flows out from the stage to envelop the watching group, and all are caught up in some measure in the fictional world. In the group, we experience the interaction vicariously. To the degree that we identify with the situation and with the player, our own senses fill with sight, sound, and feeling and transport us into that world. Because we sit at a greater distance, and because we observe rather than act, our mind is likely to send stronger signals to remind us of the fact of role-play. Nevertheless, we do not sit unaffected in some safe, neutral zone but are also caught up in the aesthetic illusion. Compared with the player, we may sit closer to the more distanced end of the aesthetic scale, but we sit nevertheless within the ambit of the virtual world, not outside it. The situation is closer to Fig. 12.3.

Cool objectivity

Stage Intense subjectivity

Observers Empathic wash

Fig. 12.3  Interactive model of the relationship between the stage and observers

  Entering the Virtual World 

  147

This distinction is anything but idle. When things are working well, we watch in an engaged manner and discuss from within the emotional warmth of the experience. When we go back onto stage, we are swept back into the moment. Discussions are far less likely to drop back into intellectual theorization once we become conscious that everything we do in a workshop is carried out within this aesthetic zone.

Entering the Virtual World For role-play to begin, someone must commit to get up from the safety of their seat and step into the virtual world on the stage (see Fig. 12.4). This process tends to work more smoothly if we operate within this latter view that the virtual world at least vicariously fills the entire room. Initial conversation is less likely to remain entirely dispassionate because imaginations in the room will have begun to engage with the world of the roleplay. Nevertheless, the shift from auditorium to stage does involve an act of the will, and of the imagination. The major task here for the facilitator is to reduce aesthetic distance by making the role-play world more real, or at least, more plausible. Several techniques help this process along. It is important first of all to lower performance anxiety wherever possible. An anxious individual is likely to have difficulties in being transported somewhere else, as anxiety

Stage

Observers

Fig. 12.4  Crossing from area of observation fully into the virtual world

148 

12  Managing Aesthetic Distance

leads to overdistancing. We may seek refuge in the coolest part of the room and pull back into the safety of non-involvement. We may lean back in our chair, and assume a posture that both reflects and produces passivity. We will be less likely to volunteer for role-play and will have difficulty imagining ourselves in the scenario. Once on stage, such a player might simply go through the paces. Alternatively, he or she may suddenly become overwhelmed by the intensity of the experience and be unable to continue. Therefore, early efforts to reduce anxiety pay great dividends. A group which finds a way to relax into a sense of relative safety is more likely to engage with the role-play and to provide emotional support for any individual who finds himself in difficulty. Players may need assistance in overcoming their natural sense of distance, expressed as diffidence in stepping forward. Make the virtual world more plausible. If someone hesitates, and is unsure about how to buy into the scenario, have them talk their way in. That is, get them to voice aloud a hypothetical approach. Once they begin to voice an appropriate course of action, nudge them towards the stage by saying something like, “that sounds good, let’s give that a try!” When someone is naturally distanced like this, they need to focus their attention on the virtual world so as to be transported into it. Sometimes the mention of role-play is counterproductive because it draws attention away from the scenario to the artifice, which reinforces the natural tendency to remain distanced. Experience shows that some people do have trouble buying into hypothetical realities, though little research has been done on this. Two studies did find that readers who tended to limit themselves to reading non-­ fiction performed less well on empathy tasks and were less able to infer the mental states of those in a novel (Mar et al. 2006, 2009). Though the jury is still out on how to identify those who are most likely to have difficulty, we might conjecture that people of a more factual cast of mind naturally maintain greater personal distance so as not to contaminate their objectivity with subjective noise. In this case, acknowledge the fact of artifice up front, emphasize that pretence is not called for, but that they are simply to act as they would in real life, and to take things as they come. As mentioned in Chapter 10, a good strategy in any case is to invite the player to adjust the stage furniture to suit their purposes before they

  Entering the Virtual World 

  149

begin the scene. The moment they begin to shift the furniture to match a preconception in their mind, they commit themselves to act, and in so doing move imaginatively forward into the scene. Once role-play has begun, aesthetic distance is at work in at least four separate domains: your facilitation, the action on stage, observation from the sidelines, and discussion and feedback. Even a brief understanding of each domain enables you to modulate the distance in each case to optimize the experience for all.

Aesthetic Distance and Facilitation During role-play, the facilitator will naturally move back and forth along the spectrum of aesthetic distance. When role-play begins, we are drawn empathically forward into the action, and our sense of distance is ­automatically reduced. We need this low distance to put ourselves into the player’s shoes, to feel something of the emotion, to grasp the specific intellectual challenge, and kinaesthetically to sense the inner flow and tensions of the interaction. However, to complicate matters, while we are doing this we also regularly distance ourselves. We pull back to keep an eye on the time, decide upon viable courses of action, and look for ways to steer the discussion profitably forward, all high-distance activities. It is easier to manage this movement to and fro if we are aware of its presence and the way that it affects us. A constant task for the facilitator is to maintain the dramatic fiction, to keep the bubble intact, as it were. Take the lead in how to relate to the world on stage. If we want the group to be transported into the life on stage, then we must take the virtual world seriously ourselves and treat it as if it were real. To do this, we need to pay close attention, allow our senses to become saturated with the interaction, and thereby involve ourselves vicariously in the world on the stage so that it becomes alive for us. Remember that there is no actor in this virtual world, only a fictional character, so never refer to the actor by name. Instead, reinforce the reality of the virtual world by relating to the character as if he or she were real. Use the character’s name when asking questions. In manner, tone of

150 

12  Managing Aesthetic Distance

voice, and choice of wording, model how you want the group to relate to the character. Avoid asking hypothetical questions of the character, such as “if the trainee had done such and such, would you have felt differently?” The resulting conversation would drop into speculation and conjecture. It also draws attention to the artifice and thereby diminishes the reality of the virtual world. If you wish to send instructions or updates to the actor, do so indirectly, knowing that the actor is listening at all times for cues as to how to proceed. When resuming role-play after discussion, reenergize the dramatic fiction by making sure that the player reenters with a strong goal to be achieved. You may find it useful to have the character restart the action by repeating a previously used phrase, or by introducing a new concern.

Aesthetic Distance and Action on Stage The role-players likewise operate in the complex zone between total immersion in the fiction and detached awareness of playing a role. Sometimes a player will be drawn fully into an interaction and engage with it as if it were real. Another player will find it hard to move from a position of cool detachment and to see the role-play as anything other than artificial. Usually, however, aesthetic distance is lower on stage than in the auditorium, and the player will be sufficiently engaged to interact as if the situation were real. This engagement is due to a number of factors: • a good script and a well-prepared actor that provide a strong stimulus for engagement; • a recognizable and relevant task for the player; • consistency and coherence of response that signal authentic interaction; and • sufficient relevant detail to reinforce the reality of the illusion.

  Entering the Virtual World 

  151

Nevertheless, even with thorough preparation, you may notice a player about to fall off either end of the scale. If the player expresses difficulty with engagement, and is in danger of losing contact with the virtual world, there are a number of interventions you might offer during timeout (for fuller listing, see Chapter 18 “Facilitation Techniques”). • If you sense that the stimulus may not be bold or demanding enough, have the character become more concerned, or ask more questions. • Make sure that the player goes back into role-play with a clear and relevant objective. • If the player displays a factual and theoretical cast of mind, have him work with his strengths and reason his way forward, even if the issue at hand is the character’s personal concerns. • Enhance the relationship of the player with the character in some way. Have the player interact as if the character were an acquaintance; change the physical relationship by sitting if standing, sitting closer if far away, or changing the arrangement of the chairs to a more engaged angle; use role reversal, and have the player and character change places for a minute or so to enhance empathic connection. • Shift discussion during timeout towards the more engaged end of the scale. Focus on the player’s perceptions, feelings, and thoughts in the moment. Avoid intellectualization and abstract thought. On the other hand, a role-play may become too intense for a player, and heightened emotion may make it difficult to continue. The fictional situation may have triggered unresolved personal issues, or provided too strong a stimulus for a naturally empathic player. Whatever the reason, the player has lost necessary distance and is in danger of becoming emotionally overwhelmed. Increase the distance in some way, and find a way to move the player back towards the cooler zone of the scale in order to restore balance. • Call timeout earlier to reduce the duration of contact. • Remind the player of the artifice. Emphasize the fact of role-play, the rules of engagement, and that they can call timeout at any time, thus remaining in control of the situation.

152 

12  Managing Aesthetic Distance

• Reduce the intensity of the stimulus, that is, the stakes of the scenario. Have the actor pitch the performance downwards by reducing the intensity of emotion, concern, or challenge. • Increase objectivity by having the player think through the situation before reengagement in order to develop a more detached point of view. • If the player is sitting physically too close, or at an angle that encourages close empathic connection, move the chair back, or change the angle to a more objective position. • If you notice that a player’s torso leans forward, coach the player to slowly pull back to an upright position. The change of posture is often enough to provide needed detachment (see Antenna exercise in Chapter 18 “Facilitation Techniques”). • If you sense that the player has been bombarded with stimulation, and simply needs time to process what is happening, have him or her physically step back towards the margin, or just outside the stage area. This simple act of physical distancing often provides the needed ­perspective. The situation may look much clearer from this new viewpoint, and after discussion the player may be very happy to step back in and continue. • If the issue is an unresolved personal situation, remove the player from the stage. Have the player resume their place among the group, and allow time to come to terms with what is happening. The player may then want to resume the interaction or may not be ready to confront the situation. Provide empathic support, validate their choice, follow up later to check their well-being, and offer the opportunity to discuss the matter if they wish. If you have the luxury of a co-facilitator, your colleague can invite the player outside the room for support and debriefing.

Aesthetic Distance and Observation When role-play is done well, the action comes alive for the audience in the same way as does a riveting play, film, or sporting match. Those on the stage are obviously the most deeply and actively involved, but no one can deny the feelings aroused in those who watch with great interest from

  Entering the Virtual World 

  153

the sidelines. Theirs is a slightly cooler engagement, but it is engagement nonetheless. By means of aesthetic distance, they too have become part of the virtual world. As long as the action on stage is strong, and as long as the group identifies with the player and responds to the challenge of the scenario, the group members are likely to be transported into the world of the role-­ play, to side with the player, and to collaborate in finding an effective way forward. The default setting for their experience is that of shared awareness with the player on stage (Scheff 1976–77; Evans 1979). That is, they have approximately the same levels of knowledge, and will watch, discover, and experience much as the player will. As new information surfaces, they, like the player, will ponder and hypothesize their way forward. If something unexpected occurs, they, like the player, will be surprised. However, as Sir Alfred Hitchcock insisted, if you had to choose between surprise and suspense, then suspense would win out every time. With surprise, the audience has a moment of enjoyment, and then it is over. Suspense, on the other hand, can last for an entire performance. And, more importantly, with suspense we are granted extra insights through aesthetic processes such as dramatic irony. That is, we begin to see what the player cannot see, we sense implications and potential consequences and therefore anticipate and watch with bated breath to see what will happen. With suspense, we are elevated above the action and above the level of knowledge of the player. We watch with heightened senses and deeper understanding. With suspense, the experience of the player and that of the group may be equally intense but quite different in nature. The group may not know how to get to this level of observation by themselves. This is not in any way unusual. In a Hitchcock film, the director cues us strongly and grants us this exciting point of view. As facilitators, we can do the same. The secret is to provide direction to the group on what to look for and how to observe. Many in a group will watch with an undifferentiated gaze and wait for loud signals to catch their attention. Meanwhile, much of what transpires in the interaction may slip quietly by. By providing direction in observation, we elevate the watchers above the action. As they pay attention to one specific factor, they become more observant than the player, if only in that one respect.

154 

12  Managing Aesthetic Distance

Nevertheless, that one change is enough to shift the group from shared to discrepant awareness (Scheff 1976–77). The group will focus their attention rather than wait for loud signals. Say, for instance, in the first discussion or timeout break we posit the possibility that the patient may have brought personal concerns that they haven’t raised. Or we wonder aloud just how well the patient is absorbing the doctor’s explanation. By being forewarned that this factor may exist, we watch for it and, if it is there, we see it, no matter how subtly expressed. We observe on a higher level, and later we have a lot more to discuss. Suggestions on ways to do this are included in Chapter 14 “Observation and Appreciation.” You may feel concern that watching for a specific behaviour might overly distance the group. However, by providing direction and sharpening the gaze, we increase commitment to the task of observation. Research on transportation found that prior framing and instructions that threw focus onto specific aspects of behaviour had only minor and ultimately negligible effects on transportation (Green and Brock 2000).

Aesthetic Distance in Discussion Like observation, discussion is a relatively high-distance activity. Usually, the player experiences the immersion of low distance in the interaction and pulls back into reflective high distance during discussion afterwards. However, if we recognize that the virtual world is not limited to the stage but permeates the room and envelops the group, the discussion can still potentially retain warm, empathic echoes from the interaction. In both the player and the group, feelings have been aroused, emotional buttons pressed, memories activated, and minds engaged in active problem-­ solving. In discussion, we take one step back to gain a measure of perspective before reengaging. However, the discussion ideally stays in touch with the experience on stage and avoids retreat into intellectualization. “What did we see, hear, and feel? What does that mean? How did we go? Where do we go from here? What are we learning?” All these questions are those we ask as engaged players from within an interaction, not as disinterested researchers looking in objectively from the outside.

  Entering the Virtual World 

  155

Even feedback from the character is slightly more distanced than his or her portrayal during role-play. It is as if the character has slipped back into a kind of timeless space, where he or she retains the experience of the interaction but adds a measure of considered thought on what has taken place. When you ask the character for feedback, it is as if both of you communicate through an invisible curtain. You speak through the curtain into the virtual world, and the character speaks from that world back through the curtain to where you all sit and consider. This invisible curtain that separates the world of the stage and that of the group is called in drama the fourth wall (Jacobsen et al. 2006). Normally in stage performance the actors imagine that they are completely cut off from the audience by a solid, fourth wall. The audience effectively does not exist from the point of view of the stage. There is only the reality of the virtual world. In role-play feedback, however, this convention changes. The boundary that separates the world of the stage from the auditorium blurs, the wall becomes as if transparent, and the character can now see you and converse with you. This is a subtle convention, so remember to maintain the dramatic fiction of the virtual world in the way that you relate to and communicate with the character. Though the default position in discussion lies somewhere towards the cooler, distanced end of the spectrum, even here there is a way to modulate the aesthetic distance  (see Fig.  12.5). If you find that discussion becomes too detached, and threatens to become overly distanced, move the conversation back towards the more engaged end of the spectrum by switching to the device of Pause rather than Timeout (see also Chapter 18 “Facilitation Techniques”).

Timeout

Pause

OVER

UNDER High Cool

Low Warm

Fig. 12.5  Moving the discussion to the more engaged end of the spectrum by calling “Pause” instead of “Timeout”

156 

12  Managing Aesthetic Distance

By calling “Pause,” the character and player pause like the picture on a screen when you hit the DVD Pause button. By staying within the interaction rather than dropping out, the player remains in touch with important subjective data such as emotions, sensations, and observations. Be aware that the player is still within the interaction, and in manner, tone of voice, and choice of wording, guide the player in processing what is happening to him or her. Don’t let the experience fade by talking for too long. As soon as you see that the player has a way forward, release the pause button, and let the interaction continue. The quality of the discussion and the nature of the insights will be quite different: much more engaged, more specific, and more in touch with the experience.

When Do You Call Timeout or Pause? One of the most important considerations is working out when there has been enough interaction to call “Timeout” or “Pause.” This is a complex question and one that facilitators ask themselves for many years. Timeout is a judgement call. Like all such calls, it is sometimes perfect, more often workman-like, while occasionally, in hindsight, you shake your head and wonder how you could possibly have made the call you did. You make the call, you run with it, and over time, you improve. Finessing this decision comes only with experience. We gradually hone that call by learning to avoid two fruitless, opposing tendencies, that is, to intervene too late or too early (see Fig. 12.6). If we wait too long, the group will forget what they have seen. Their attention will pull back from a moment-by-moment focus on the interaction to a

Role-play begins

Too early Not enough to discuss

Too late Optimal intervention

Fig. 12.6  When to call “Timeout,” or “Pause”

Too much to process

  When Do You Call Timeout or Pause? 

  157

more distant narrative interest in what might happen next, and the interaction will all become a blur. There will be far too much information to process. Interactions that are too long tend to produce generalized discussion. As a rule of thumb, never wait longer than four or five minutes. The major exception to this principle occurs if the role-play simulates complex team work, or an action that must continue till resolution. Here, you are unlikely to be watching for micro skills or detail but will be scrutinizing broader issues of strategy and tactics. In this case, make sure that those who observe do so proactively and preferably take notes to remind themselves of what they have seen. On the other hand, if there has not been enough interaction, there will be nothing to discuss. Do not, I repeat, do not micromanage, and stop and start every few seconds! For role-play to work, it must generate an alternative, believable reality to draw us in and transport us. The only valid learning is what we discover within that world. If we micromanage, we inhibit the interaction and kill it at birth. Player and group never make it into the role-play world but stay firmly fixed in their everyday reality, thoroughly overdistanced and unmoved. Responses and discussion can then be nothing but theoretical and abstract. We must allow enough time for the role-player and character to interact and arrive ­somewhere, whether that somewhere be a pause to reenergise, a decision point, or an impasse (see Fig. 12.7).

Impasse Pause to reenergise

Role-play begins

Decision point

?

Fig. 12.7  Player arrives at possible timeout points

158 

12  Managing Aesthetic Distance

Have the interaction begin, and watch the player’s behaviour. You will know when the new reality kicks in, and the role-player begins to respond as if it were real. Now let your clock start. The issue now is, when do we get to a point where we have something meaty to discuss? Has the player worked out an awareness of the situation? Do they need more time in role-play, or do they need timeout to talk it over? Does the player know what to do? Are they working their way towards it or showing signs of stalling? Most importantly, do you have a tentative hypothesis in mind as to where the role-player is at, so you know what kind of questions to ask. Learn to trust your impulses. They will improve over time. Make a decision, and call “Timeout” or “Pause,” and leave evaluation on how you went for later on.

Aha Moments When things go well, when the virtual world comes alive, when players and observers treat it as if real, and are transported into that world, there inevitably will occur moments in which something changes in all of us— in the role-player, the actor, the watching group, and the facilitator. Peter Brook, English theatre director, described this phenomenon in a television interview on the BBC. When theatre is true, there is an actual ‘moment of truth,’ and when that happens there is a change of perception. Every one of us, most of the time, is blind to reality; but when life, or some aspect of life, is perceived more intensely, then there is real food for the soul. (Roose-Evans 1984, 168)

This experience may differ for every person in the room in its nature, its intensity, and its significance. For one person, it may provide only a moment of brief interest. For another, that same moment may have become life changing, the kind of event that we refer to in the vernacular as an Aha moment. Sometimes a player finds it easy to describe what they have discovered. Words are not a problem when an insight is simple. However, when discovery is deeper, realization takes longer than a moment. The relevant axiom seems to be, the more profound the insight,

 Summary 

  159

then the longer the process of realization, and the longer it takes for the “pennies to drop.” If words don’t come easily, that does not mean that we are not learning. Significant realization sometimes struggles to enter thought and to find expression. Beware not to block incoming insight. Allow people time to take in the full realization of what they have discovered. These moments of insight are where new understanding breaks in from which new behaviour is possible. Nurture these moments. It is why we do role-play.

Summary To ensure that role-play is convincing, a facilitator needs to manage the device of aesthetic distance at all stages of a role-play workshop. Many of the difficulties experienced by facilitators are due to ignorance of the need for this foundational skill. 1. Use framing and focus to create an environment conducive to roleplay by reducing overdistancing as much as possible. 2. Work from a well-devised scenario that provides the plausibility, consistency, and convincing detail to ensure that the members of the group are transported into the virtual world. 3. Rely on the power of a committed actor to provide the strong stimulus for interaction. 4. Be aware of the positive impact on a group of a confident, engaged facilitator who has already bought into the reality of the virtual world; 5. Remain aware of your own shifting experience of aesthetic distance throughout the role-play as you lean forward to engage and pull back to manage affairs. 6. Assist the players to buy into the illusion so that they can cross over into the role-play world. 7. Nurture, maintain, and reenergize the fragile virtual world so that the group does not fall back into overdistance. 8. Guide players safely back towards the central, creative zone of aesthetic distance if they succumb either to over- or underdistance; 9. Energize the group’s experience of observation by producing discrepant awareness to counter any tendency to remain distanced.

160 

12  Managing Aesthetic Distance

10. Substitute the command “Pause” for the usual “Timeout” to reduce distance if discussion becomes too intellectual and detached. 11. Nurture moments of realization and new insight as perhaps the most valuable payoff of role-play.

References Csikszentmihalyi, Mihaly. 1982. Toward a Psychology of Optimal Experience. In Review of Personality and Social Psychology, ed. L. Wheeler, vol. 3, 13–36. Beverly Hills, CA: Sage. Evans, Bertrand. 1979. Shakespeare’s Tragic Practice. Oxford and New  York: Clarendon Press/Oxford University Press. Green, Melanie C. 2004. Transportation into Narrative Worlds: The Role of Prior Knowledge and Perceived Realism. Discourse Processes 38 (2): 247–266. Green, Melanie C., and T.C. Brock. 2000. The Role of Transportation in the Persuasiveness of Public Narratives. Journal of Personality and Social Psychology 79 (5): 701–721. Green, Melanie C., T.C.  Brock, and G.F.  Kaufman. 2004a. Understanding Media Enjoyment: The Role of Transportation into Narrative Worlds. Communication Theory 14 (4): 311–327. Green, Melanie C., P. Rozin, A. Aldao, B. Pollack, and A. Small. 2004b. Effect of Story Details on Transportation into Narrative Worlds and Identification with Characters. Presented at IGEL, Edmonton, August. Jackins, Harvey. 1965. The Human Side of Human Beings. Seattle: Rational Island Press. Jacobsen, T., A. Baerheim, M.R. Lepp, and E. Schei. 2006. Analysis of Role-play in Medical Communication Training using a Theatrical Device the Fourth Wall. BMC Medical Education 6: 51. Mar, Raymond A., K.  Oatley, J.  Hirsh, J.  dela Paz, and J.B.  Peterson. 2006. Bookworms Versus Nerds: Exposure to Fiction Versus Non-fiction, Divergent Associations with Social Ability, and the Simulation of Fictional Social Worlds. Journal of Research in Personality 40: 694–712. Mar, Raymond A., K.  Oatley, and J.B.  Peterson. 2009. Exploring the Link Between Fiction and Empathy: Ruling out Individual Differences and Examining Outcomes. Communications 34: 407–428.

 References 

  161

Nell, V. 2002. Mythic Structures in Narrative: The Domestication of Immortality. In Narrative Impact: Social and Cognitive Foundations, ed. Melanie C. Green, J.J. Strange, and T.C. Brock, 17–37. Mahwah, NJ: Erlbaum. Razavi, Darius, Nicole Delvaux, Serge Marchal, Michel De Cock, Christine Farvacques, and Jean-Louis Slachmuylder. 2000. Testing Health Care Professionals’ Communication Skills: The Usefulness of Highly Emotional Standardised Role-playing Sessions with Simulators. Psycho-Oncology 9 (4): 293–302. Roose-Evans, James. 1984. Experimental theatre from Stanislavsky to Peter Brook. London: Routledge. Scheff, Thomas J.  1976–77. Audience Awareness and Catharsis in Drama. Psychoanalytic Review 63 (4): 529–554. Witmer, Bob G., and M.J.  Singer. 1998. Measuring Presence in Virtual Environments: A Presence Questionnaire. Presence 7 (3): 225–240.

13 Effective Facilitation How to Intervene in Role-play in an Effective Way

How do we decide how to halt role-play and lead a group into productive discussion and further experimentation? One effective solution is to work from a four-part heuristic that follows a player’s questions from initial reading of the scenario, through knowledge and strategy, to successful implementation.

Let us begin with the simple and the obvious. If we strip away all the scaffolding around role-play for a moment, we are left with a small group of people watching an interaction that looks for all the world like the real thing. We see two people take turns as they talk, listen, interact, and come to some sort of resolution. Like all human interaction, if you look at it closely, it sometimes becomes very puzzling. How do we penetrate the smokescreen of words and actions and make sense of what we are seeing? We come to this task in a way that is neither neutral nor objective. We may not even consider ourselves to be particularly perceptive. This being so, how do we find our way past our personal blind spots, predilections, and hobby horses to make sense of what is happening? Constant spontaneity is hard work, and so we have all developed shorthand, routinized © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_13

163

164 

13  Effective Facilitation

ways of looking at the world. Knowing this to be true, how do we avoid presumption and comfortable, standardized lines of enquiry? How do we find our way to the most fruitful lines of questioning? Even if we come to an interaction with specified learning goals, how do we nevertheless give every interaction its due weight as a unique event and find a way to view it as openly and clearly as possible?

Analogue of the Detective Imagine for a moment that you are a detective. A man has been brought in for questioning over a crime. He is your classic, hard-bitten type. He is unkempt, unshaven, and unhappy to be here, and sports tattoos down both arms and a surly look on his face. He presses all your stereotype buttons, and you find it all too easy to imagine him guilty, if not of this crime at least of something significant. However, the evidence is all circumstantial. He was mostly in the wrong place at the wrong time. There is no hard evidence as yet to implicate him in wrongdoing. He is conceivably entirely innocent, and you are being tested on your objectivity. His story is entirely plausible. Is that plausibility because he is telling the truth, or is he spinning a very convincing yarn? Is his behaviour a reflection of genuine innocence, or is it a clever act? Is the innocent face you see the real thing, or is it an assumed mask? Can you tell the difference? The situation depends on your ability to read human behaviour to work it out. How do you approach it? Do you decide to err on the side of trust, or of suspicion? In other words, do you remember that he is innocent until proven guilty and give him the benefit of the doubt? Do you therefore watch and listen as good cop and presume innocence until indications suggest otherwise? Or, on the other hand, do you take on the devil’s advocate role of bad cop, presume guilt until proven otherwise, and leave questions of innocence to the jury? In medical terms, do you set your index of suspicion low (assume innocence), or high (assume guilt)? Or are you able to find a neutral position halfway between both positions and simultaneously watch for innocence and guilt? How do you do that?

  Making Sense of Sensations 

  165

Making Sense of Sensations Your task as facilitator is similar. Your issues are not those of distinguishing innocence and guilt, but a successful outcome depends on your ability to read human behaviour sufficiently to work out what is going on. All you have to work with are your background knowledge and your sensory impressions moment by moment. Firstly, we need to recognize that there is no possibility of scientific certainty at any stage. Instead, you and the group must work your way forward through a shifting landscape of rolling hypotheses. At first, you may feel that you are faced with a stream of words and actions that could mean anything and lead you anywhere. Nevertheless, when it is time for discussion, you will need to know why you are asking the group this question, and not that one. You will need to know what you are doing or at least make a good show of looking as if you do. Some courage is required as there is always an element of risk. What you are looking for is not a scientific conclusion but a working hypothesis that is good enough for you to act on. So how do you make sense of an interaction? You might be tempted simply to compare what the players are doing with what you think they should be doing, based on approved protocols, practice guidelines, or on your own professional experience. The approach is quite appropriate for clearly defined procedures that need to be memorized and rehearsed. It directs your attention to shortfalls in performance, that is, to where further work needs to be done. However, that kind of template-based approach is less useful for most open-ended interaction. By directing your attention to mismatch, to what the learner is not doing, it takes your eye away from what is actually happening. When an interaction is open-ended, recognize up front the unavoidable fact that you have no real idea what is going to happen. While this admission of personal ignorance may at first stir feelings of vulnerability and anxiety, it does produce awareness that this interaction is indeed truly unique and as such is happening for the first and only time. It reminds you how much you have to rely on your senses. Imagine back to the detective. As detective, you pay close attention to everything that you can. You cannot rely on the surface message that you

166 

13  Effective Facilitation

are being given. Words can mislead you, either by accident, or by design. The suspect may provide an entirely plausible story. Yet in response to one of your questions there was a momentary hesitation, a certain brief look in the eye, something in the tone of the voice, some little niggling sensation that did not fit the picture. His lawyer declares that you have no evidence of any kind and therefore must let his client go, and you know that legally you must. Are you going to let him go and forget about it, simply because of his plausible story? I doubt it. As any detective worth his salt, you will remain intensely aware of the questions seeded in your mind by that moment, and you will follow them up in whatever way possible. The suspect may choose to believe that you believed his story, but you know otherwise. In the same way, as a facilitator you rely on paying close attention to the sensations that arise as a result of the interaction. The evidence of your senses, however, tends to lead, not to conclusions, but to a baffling stream of questions. These questions are your greatest asset as a facilitator, as they lead you through the surface noise into the inner workings of the interaction. For example, observing a male medical student in conversation with an anxious female patient, you might experience some of the following. What is going on here? Is the player engaged in the interaction? Has he bought into the fiction, or is he too aware of being in a role-play? How anxious is he? Is that due to the scrutiny of his peers, or is it because the clinical situation is difficult? Is he rushing? Is his breathing steady, or is he forgetting to breathe? Does he need help to settle down? How perceptive and aware is he? Does he only pick up cues that are overt and factual and miss the rest? Does he act as if he is on top of things, but you sense this may not be true? If he is floundering, does he know this, or does he seem oblivious? How open is he, or conversely, how self-protected? In discussion and feedback, will we need to tread carefully, or will we need to be overt and unambiguous to get through? Does he listen? Does he block the patient or encourage questions? Does he consider what was said before responding, or does he already have the next question in mind? Does he adapt his language to the patient? Does he r­ ecognize that a doctor thinks about medical things in code and far more quickly than do most patients and therefore consciously slows his delivery of information? Is he aware of the impact of his choice of words on the patient, either positively

  Making Sense of Sensations 

  167

or negatively? How aware is he of the patient in general? Does he pick up on or miss that complex stream of messages we send each other that we summarize with the single term “body language”? Is he comfortable in human interaction or stilted and uncertain? Is he pushing on with his agenda when it might be more sensible to drop it and deal with the patient’s concerns? If he is doing really well, is he aware of that fact. If things are going unevenly, is the issue lack of awareness, lack of knowledge, lack of experience, or lack of confidence? You notice that the patient is very anxious, and yet the student pushes on. Does he recognize the anxiety? What does he understand about the impact of anxiety? Does he know how to manage the situation in an effective way? We could continue on and amass all the questions that might theoretically arise as you try to make sense of the interaction. Such a list might last for several pages. The questions are all valid, and the combined answers would produce a comprehensive view of what was taking place. Such a list would be at the same time both helpful and off-putting. It would be helpful in that it conveys something of the richness of what takes place when two people sit down and interact. However, the sheer volume of insights would likely overwhelm us and induce paralysis. Becoming aware of all this stuff that is going on, where in the world would you start? As we begin to identify the details of a conversation, it helps at the same time to zoom out and look at it as a whole. From this more distant viewpoint, rather than details, we see a big picture. We see someone walk into a novel situation, tentatively feel his way forward, relax into a sense of recognition of what he is dealing with, come up with a plan of action, and then carry it out as best as he is able. We see this done well, poorly, or somewhere in the messy in between. Mostly it is the last. No heuristic model can handle every instance, but in many cases interactions do seem to work as a four-step process. When things go well, it is because the successful communicator has known how to: • • • •

grasp the nature of the situation; factually understand the main issue and its implications; manage the issue by identifying the most potent course of action; confidently and competently carry it through to completion.

168 

13  Effective Facilitation

These four steps could be designated in many ways, but for the moment, let us recognize the steps as the objective categories of situational awareness, knowledge base, management plan, and actual performance. For example: 1. Situational awareness. Does the medical student (let us call him Brendan) grasp the nature of the situation? Does Brendan, for instance, recognize an emotional presentation of anxiety that suggests he drop his clinical agenda and address the patient’s concerns? Or does he not recognize the anxiety and instead gamely try to answer each of the patient’s questions, only to be asked another? In acting terms, does Brendan know what scene he is in? How well does Brendan read and interpret what is happening in front of him? If you sense that there are significant deficits here, this is where you would profitably direct the discussion. There is no point Brendan trying out suggestions by others on what to do or simply having another go if he has not first tackled the need for situational awareness. He needs first to know where he is and what is going on and to be given the tools to do so more effectively in the future. 2. Knowledge base. Brendan may recognize that the patient is anxious but has no real grasp of its significance. From personal experience or from study, what does he know about anxiety? What does the patient need most at this moment? If Brendan does not have sufficient knowledge base, group discussion may need to fill it out. Has he learned, when a patient’s concern is strong enough, that it may pay to drop his own agenda and pay attention, address the patient’s concerns, and go back to his own agenda later if that is still appropriate? Does he know that such a course of action is not only effective but also more likely than not will add no extra time to his consultation? 3. Management plan. Assuming that Brendan recognizes the issue of anxiety, and understands its significance, does he know what to do? Does he know that he can respond appropriately and be accomplished in this situation, even as a student? Does he recognize that the patient feels temporarily out of control and would benefit if he could somehow return that control to her. How might he do this? Of what tactics is he already aware? Discussion would here centre on an effective and appropriate strategy to manage the situation.

  Making Sense of Sensations 

  169

4. Actual performance. Brendan may have wrapped his head around the issue, and know in theory what needs to be done, but may struggle in carrying it out. The reason may be lack of experience, or lack of personal resources. With inexperience, he may have had only one string to his bow, that is, one way to tackle the problem, and it didn’t work. This being so, he may confuse strategy with tactics and conclude that he doesn’t know how to do it. He may not recognize the high probability that no one tactic is universally applicable. Group discussion might produce another tactic to try, which, if successful, extends Brendan’s repertoire of behaviour and the number of situations he can manage in the future. Alternatively, we might designate these four steps from the players’ point of view as therapeutic actions they need to carry out (see Fig. 13.1). In this case, we would ask ourselves: does Brendan know how to read the situation, understand it, manage it, and carry it out? In general, later actions are dependent on the player successfully handling earlier ones. It is difficult for Brendan to carry out the task with confidence and competence if he does not know what his strategic objective is, that is, to return a sense of control to the patient. He cannot come up with this appropriate objective if he doesn’t sufficiently understand what anxiety is and what the patient needs. And he cannot begin to access his knowledge 4

1

I have the confidence and competence to carry this task through to completion

I discern and grasp the nature of this situation

Carry out

Read and interpret

3

2

I can solve this problem and know what my most potent course of action would be

I have sufficient factual knowledge to understand the nature of this situation

Manage

Understand

Fig. 13.1  Four-part heuristic to determine focus

170 

13  Effective Facilitation

about anxiety if he hasn’t recognized it as the major issue in the first place and instead has his attention focused on his need to take a history. At a certain point, you need to take a punt. “Everything I’m seeing suggests that x is the issue. I have no hard and fast proof, but it’s a good working hypothesis. I’ll test it out with my first questions and go from there.”

Four Differing Modes of Discussion Notice that each quadrant tends to produce a different kind of discussion.

Situational Awareness: Reading and Interpreting If the player has difficulty in reading and interpreting the situation, you might want to direct discussion to sensory information. “What did you see? What did the patient say? What does that mean? How were you feeling yourself? What does that tell you?” It is important to get to these questions promptly while the experience still lingers in the air. Otherwise, the group will drop back into theorizing, and the specific stimuli of the interaction will be lost. This kind of discussion will have a personal and reflective quality with an unmistakably subjective stamp. This subjectivity is entirely appropriate, as the only data available rose out of subjective, personal interaction. Reflection should not be rushed because players are often searching to put words to wordless experience, and may need to think, and be tentative, and to shuffle thoughts around in order to come up with a good description. Use the opportunity as a practice session in active reflection. Discussion converges around the central question “What does all this mean? What is the most important issue here?”

Knowledge Base: Understanding If the issue is that of generating factual understanding (in this case, of anxiety), the tone will probably be more dispassionate and objective. It

  Four Differing Modes of Discussion 

  171

may even take the form of a mini tutorial on anxiety. What do they know about anxiety? What has been the personal experience of the group? What does research say? These discussions invariably have a more focused quality. The group may want to list and sort the information. Have them look for applications of this knowledge. For instance, they may not have considered what the anxiety suggests about the patient’s needs right now, that is, for order somehow to be restored so that she might regain a sense of personal control over her life. The clearer and more focused their understanding becomes, the more likely they are to come up with an effective plan of action. Discussions here tend to revolve around the issue “Do we understand what is happening and what we need to do here?”

Management Plan: Managing If the issue is how to manage the situation, the group will likely drop into business-like mode as they identify the problem to be solved and line up their resources. They will inevitably look around for a plan of action. They will want to make a decision. Do they pick an appropriate goal? Do they mistake tactics (for instance, help the patient write a list of questions to ask the surgeon) for strategy (find a way to return a sense of control to the patient)? Their plan needs to be a strategy that can be carried out in more than one way, and it may help to have a couple of tactics up their sleeve in case the first one proves inappropriate. How will they know if they succeed? What would be an outcome that they would recognize as success? The central questions have to do with “How do I manage this situation?”

Actual Performance: Carrying It Out If the issue is how to carry out the task, the tone in discussion changes again. This time, the discussion is a practical one, about words, actions, and tactics, all in the service of effective personal interaction. There is usually more than one way to handle a situation, but all of them are tested against a practical bottom line: “Does it work?” In this discussion, conversation invariably responds to such questions as “What worked? What was effective? How do you know? What else might we try?”

172 

13  Effective Facilitation

Discussions Vary in Tone As we have just seen, the discussion and the feedback to the player vary in tone according to the nature of the issue that is being addressed. Hard and fast rules about feedback tend to assume that all discussions are of an identical nature, and that reflection and management can be tackled with the same armoury of questions. A moment’s consideration would put that idea quickly to rest. Anyone with some experience with business, for example, will recognize the vastly different cultures that exist in the different domains of a big company. Take for instance these divisions (see Fig. 13.2). In the design area, the focus is on future possibility. Discussions are therefore highly subjective, and the thinking is changeable, unpredictable, lateral, and time-consuming. In research and technology, conversation is lengthy and detailed, and endless shades of grey are carefully calibrated. Error is studiously avoided. The tone is objective and unemotional. Reason and evidence are the final arbiters. Discussions in management and production are focused, practical, time-aware, and geared towards decision. Ambiguity is forfeited by the need to embark upon a course of action. Conversation is geared to concerns over goals, tasks, evaluation, budgets, and timelines. In sales and marketing, the atmosphere is extroverted, interactive, interruptive, anecdotal, and very much geared to trial and error. Emphasis is on human interaction and on realistic solutions to unique situations. 4 Sales & Marketing 3 Management & Production

1 Design 2 Research & Technology

Fig. 13.2  Four analogous cultures from the world of business

 Summary 

  173

It is not hard to see why management types baulk at time-consuming, reflective discussions about possibility, and reflective types cringe at what they see as the black-and-white simplicities of practical decisionmaking. Nevertheless, any discussion over a two- or three-hour period about human interaction is likely to move among several of these domains, and the conversation will shift into different modes as it does so. To remain academically objective and scientifically factual, come what may, will prove to be unhelpful outside its proper domain, that is, the development of factual understanding. To be pragmatic and business-like when the issue is to discover what is actually taking place will lead to decisions leading off in the wrong direction. To stay too long in reflection when a decision needs to be made will mean that the group runs out of time to try out possible solutions. An impatient demand to jump in and simply give it a go may lead to unexpected conflict or superficial behaviour.

Summary 1. Discussions around situational awareness are best done subjectively, as reflection on observations is the natural mode for establishing an accurate reading of a situation. The central question is—are we reading this correctly? Have we hit the nail on the head? 2. Discussions on factual knowledge are the natural home of academic objectivity, where the evidence is to be found outside the interaction in the professional library and in the primary research of one’s own experience. The central question is—do we understand this clearly enough? 3. Management decisions work best in a business-like manner leading to a plan, strategy, or objective with probable tactics spelt out. The central issue is—do we know how to manage it? What are our resources? 4. Questions of actual performance need to cut to the chase. When all is said and done, the central question is—what worked, what didn’t? If it didn’t work, was it because it was the wrong tactic, or the right tactic poorly executed? How do we improve?

174 

13  Effective Facilitation

Questions to Consider Most of us are not equally at home in every situation. From experience over many years of running workshops, most people report that they are most at home in one area, have facility in another one or two, and find one area uncomfortable. Only a few individuals are comfortable in all situations. In which of these areas are you most at home? Your answer will help you to identify the kinds of discussions that you most enjoy and relate to. It will also show you where and when you need to move beyond your favoured approach, so that discussion will more effectively target the specific issue at hand.

14 Observation and Appreciation How to Develop Greater Powers of Observation in Yourself and in the Group

In this chapter, we discuss ways for the watching group to become more proactive. We consider the importance of paying attention and active observation and suggest ways to enhance these important faculties in a workshop.

Several times people have said to me, “I don’t have any difficulty with positive feedback. My difficulty is about how to give negative feedback.” By negative feedback, they mean criticism and correction. This always surprises me. I remember from my time as an acting coach how much harder it was to give constructive or positive feedback. To give positive feedback on a particular performance, you needed to have a good idea of what the actor usually did and the exact nature of this particular challenge. I needed to recognize where they had begun, what changes they had made, how much distance they had travelled, and how effective the changes were. Otherwise, I would fall back on my own ideas of how the performance should look and use my own experience as a benchmark for the actor’s performance. They may get a tick here or there for where their performance matched my idea of how it should look and a cross or question mark for where it differed.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_14

175

176 

14  Observation and Appreciation

Appreciation To critique constructively, we need to perceive clearly the performance being played out before us. To do this, we need to trust our eyes, ears, and kinaesthetic senses and the messages that they are sending us. We need to be able to make sense of those messages. This process is primarily that of appreciation. This is an important issue. I would argue that learning begins not with analysis but with appreciation. Unless we first are attracted to something outside ourselves, unless it grabs our interest, we do not pay attention and make the effort to process it further. Appreciation denotes that we have found something of sufficient value to spend time on. Unless scientific researchers are first gripped with a deep passion and appreciation for a particular topic, they will not have the motivation and energy needed to keep going for the long haul. Unless health clinicians have a deep fascination for their field, they may fall back into subsidiary concerns such as financial betterment or professional status in order to keep their interest alive. Unless artists find a way to appreciate the humanity of their subjects, they cannot paint insightful portraits but must fall back on technical proficiency, or superficial trickery. This act of paying close attention, of asking the basic questions “what am I really seeing?” and “what does this really mean?” all have to do with appreciation. Appreciation culminates in a description of what we see. That description is important. It suggests the next step, namely, what do we do about this new thing that has presented itself. Observation needs, therefore, to be keen and the description clear and accurate. None of this process can be taken for granted. As a former acting teacher, I become aware with the passing of every year just how little I still see and how much I must miss of what is going on around me. The learning task for a facilitator is thus endless. To really enjoy facilitation, that prospect needs to be exhilarating rather than daunting. Anything we see has never happened before. Perhaps this is an obvious comment, but in the busyness of life it is a fact that we often forget. No two performances and no two critiques can ever be the same. We cannot immediately know what something is until we first pay due attention to it as something that we have never seen before. We may have seen

 Appreciation 

  177

s­ omething that looks just like it, but this particular interaction has never occurred before and will never occur in this exact configuration again. If the surface behaviour or words happen to be familiar, we may erroneously assume that we know what is going on and that we do not need to pay such close attention this time. In fact, it is when things appear similar that we can make simple mistakes of judgement. We make assumptions as to what is happening and may completely misread a simple situation. The fact that an interaction only ever occurs once poses a potential intellectual problem. Scientific knowledge is expressed primarily in theoretical and factual terms and applies without prejudice to all situations and to all populations within its ambit. Human communication, therefore, presents a problem. Each encounter is unique. It will occur only once, and it may be of an idiosyncratic nature replete with statistical anomalies. Yet the universal knowledge must be applied to this single, idiosyncratic event. How do you do that? This is perhaps the major grand question underlying role-play. How do you make sense of the individual and the unique, when the only available and agreed-upon scientific evidence relates to the group and the general? We may fall into a conceptual fallacy here and assume that the question being a question must have an answer that can be spelt out on the page. In fact, this is one of those questions that can only be answered by engaging with life, diving into it, and piecing the elements together bit by bit yourself. The question is one that must be solved by you as facilitator, by the role-player within the interaction, and by the observers watching on the margins. Observation, therefore, is a prime concern for any facilitator, both in tightening up one’s own observational skills and in tutoring the observational skills of others. Though for all concerned—facilitator, role-player, and group—the answers are unknown in advance, we do know something of how to find our way to them. Simply, we need to put distraction aside, pay close attention, trust our senses and the messages they send us, and learn to improve the way we describe what we perceive. Clear observation also demands a certain courage in hypothesizing what you see without hard evidence to back you up. Once you have come up with a hypothesis, it can be tested in role-play.

178 

14  Observation and Appreciation

How Do We Facilitate Observation? How do we facilitate observation in the group? We start by paying close attention. This is particularly important if this is the first time that we have worked with a scenario. We and the group are then basically on the same page and are learning together from moment to moment. With experience over time, we develop an advantage over the group which we can use for their benefit. Often, we will have seen similar scenarios in the past. The workshop scenario may be a stock one that we have worked with several times before. We may have seen a dozen people play with this situation over the years. Some of them have struggled, some have muddled their way through, and some have known exactly what to do. Even when done well, no two interactions were exactly the same, and we have seen different ways to handle the same situation. Put together, these past performances build in our mind a library of possible approaches, sticking points, and solutions. We still identify the individuality of this current response but are not restricted to it because we have a larger context within which to interpret what we see. These past experiences give greater clarity to our perceptions by enabling us to compare and contrast this performance to a larger class of previous interactions. We start to bundle performances. For instance, a trainee may feel awkward when a patient becomes distressed and does not know what to do. We have a bank of past interventions, some successful, some less so. Every one of them has taught us something. We may be able to use a previous approach again here, but then again, we may need to work from the ground up. By recognizing the unique quality of each interaction, we are saved from falling back into stereotypical response. The advantages of working with familiar scenarios are obvious. Revisiting familiar scenes over time generates refined experience that we can then use. I once sat in with some wonderful acting teachers in Chicago over a three-year period and watched how they taught. Each year, a new group of fresh-faced, young actors would choose among a batch of scenes that were new to them but familiar to the teachers. A couple of new scenes were tossed in to keep the experience fresh for the teachers. Each year, the teachers became more adept and more subtle in

  How Do We Facilitate Observation? 

  179

their ability to help the actors solve the scenes for themselves. Over time, there was little the teachers had not seen before. Each time, however, it was as if they were working for the first time as they brought everything to bear to the scene for these particular actors attempting to solve the situation for themselves. As facilitators, we work in a similar way. The group may not be conscious of the importance of observation. They may settle into a chair and lean back to watch the role-play unwind, glad that they are not the first cab off the rank. They may actively scrutinize and search the interaction for new insights, or they may simply wait for something of interest to leap out at them. Many people, especially when they are young, are relatively unaware of their own thought processes. Many are unaware that they can control the intensity and focus of their attention. They may not be aware of how our perceptions become more acute as we lean forward in our chair and become actively engaged, and conversely, how our minds kick back into a more passive mode as we lean back. They may not be aware that we pick up different information depending on our distance from the action. The players on the stage have a unique viewpoint. Because they have been thrown into the action, and because the actor provides strong stimulus, they are more likely to be caught up in the interaction. They are extremely close to the actor-­ character and, once they get over their initial nerves, have nothing else but the character in their field of vision. Assuming sensitivity, they are close enough to pick up the most minute signals. Theirs is the most intense of all the experiences in the room. Most likely, they will be aware of their thoughts and decision-making processes. They might not be as in touch with their feelings or those of their client, unless this information is teased out in discussion. They might, moreover, not know how to read the interaction because they are swamped with a deluge of detail, and may therefore have trouble finding their way to the big picture. The watching group is usually close enough to pick up subjective information, though they will not do this as keenly as the player. After all, they can see what the player says and does from an outside viewpoint, and they are free of the responsibility for the encounter. We could postulate that to some extent the player and the group divvy up the classic clinician’s mind. The player experiences more of the interactive ­component

180 

14  Observation and Appreciation

of the professional mind, the group, the detached, objective section. By teasing out these differing perceptions of player and group, the insights combine into a complex, practical understanding of the situation and its resolution. If members of the audience are too far back, they are probably sitting in a cool zone of the room, and the danger is that they will tend to become overly distanced. They will lose access to important empathic information only available close to the action and will be too aware of the artifice and mechanisms of role-play, thus making it hard to become personally involved. The information they do pick up is likely to be obvious to all and potentially skewed to the negative. Avoid seating people too far to the rear and to the sides and try to bring everyone into the warm empathic zone close to the action. How might we enhance the group’s ability to pick up information? There are a number of different ways to do this. Encourage proactive observation. Ask each member of the group to move their chair to where they can get the best and most engaged view of what is going on. The aim of this exercise is to encourage proactivity and to increase their motivation and commitment to the task of observation. It draws people out of the cool zones into warm areas of empathic connection. The act of moving one’s chair shifts the group into a more active mode. Lean forward. Encourage the group to lean forward and to watch as closely as they can. By leaning forward, they will almost certainly become more proactive. Take notes. Suggest that they take out pen and paper and jot down whatever leaps out during the interaction. The idea is not to take extensive notes, just the briefest note as a reminder for discussion. By jotting down a word or phrase, they commit to personal response and are still able to keep their attention on the action. Provide objectives. Provide an objective rather than relying on chance. For instance, you may ask them to direct their attention to the patient and assess the patient’s experience or comprehension; to the role-player’s strategy and its effectiveness; to the language that is passing between them; or to the patient’s concerns and anxiety. You might decide at one

  How Do We Facilitate Observation? 

  181

point to divide the group in two, have half observe one aspect and half another, and then combine insights in discussion. By making them aware of a significant factor at play in an interaction, you increase their commitment to the task of observation. The resulting heightened awareness gives them access to insights not possible for the player. Effectively you move them from shared to discrepant awareness as discussed in Chapter 12 “Managing Aesthetic Distance” (Scheff 1976–77; Evans 1979; Brönniman 1986). Encourage nuanced description. At all times, encourage the group to find their way to words that describe what they see, hear, and sense. It doesn’t matter if someone struggles to find the right words. In fact, some struggle is to be expected when we attempt to describe something perhaps for the first time. Assert nuance and encourage finer use of language. Prod the group to make important new distinctions. Help them move beyond stock, or generalized responses which do not give due weight to the specifics of what has taken place. As a general rule, it is easier to work out what to do next when you know exactly what you are dealing with. Use angle of vision. Exploit the impact upon perception of angle of vision  (see Fig.  14.1). The angle we take relative to a line drawn between the player and the actor affects the way we relate to and perceive the interaction. You have probably noticed on film that cameras capture the action from different angles, and that each angle produces its own effect on you as the viewer. (A) An angle of 90 degrees captures the interaction as a whole in profile. As you see little of their faces, the angle effectively forces you into the role of detached onlooker. This vantage point favours big-picture objectivity. (B) Camera angles directly facing an actor (“down the barrel”) are either confronting or intimate. This placement almost forces you to relate empathically with the character by bringing you in close, and enabling you to see shifting impulses across the face, and to hear undercurrents in the voice. This angle is used for heightened effect in film and is the intense viewpoint experienced by both the

182 

14  Observation and Appreciation

Actor

B

C

Role player

C

Dr. Cam

Pat. Cam A Objective profile view

Fig. 14.1  Viewing angles change the subjective nature of the perception. Objectivity is most intense at A and subjectivity at B

actor and role-player on stage. This angle produces unique responses and insights which can be elicited during discussion. (C) The most usual viewpoint for a film audience is halfway between, where the camera takes a position at an angle from 30 to 60 degrees. The placement is sometimes called “over the shoulder.” The benefit of this angle is that we can see a character’s face and movements, and thus engage empathically while retaining some objectivity. The terms we use in our workshops for this placement, Patient-Cam and Doctor-Cam, betray their origins in medical role-play. Each of these positions colours the interpretation of a role-play interaction. None is more accurate in the sense of giving an overall reading. If you feel that the group is being too factual, and needs to pay more attention to the experiences of either the client, or the role-player, you could try the arrangement we call Patient-cam/Doctor-cam which makes conscious use of position C. One or two of the group sit close at an angle where they can clearly see the actor’s face, and one or two others where they can pay close attention to the role-player. Do this only once the role-­ player is comfortable in the role, otherwise the close scrutiny might send

 Summary 

  183

their anxiety levels through the roof. The feedback will usually give a more focused reading than otherwise. This understanding of camera angle has a long history in the world of film. Scientific support can be found in an unexpected quarter, in research done on police interviews. The studies provide strong evidence that different camera angles produce very different readings of the same situation. Interviews are often recorded with the camera focused exclusively on the suspect, the idea being that jurors can make up their own minds as to whether there has been any coercion in a confession. However, focus on the suspect was in fact least conducive to revealing coercion and most likely to conclude that a confession was entirely voluntary. The most revealing angle for coercion was a camera focused on the police officer, so that you saw what the suspect saw (Lassiter et  al. 2002). Predictably enough, focus on both parties in profile increased objectivity and made the viewers more watchful for coercion.1 The results were so compelling that the Police Executive Committee of New Zealand in the 1990s approved a national policy of videotaping police interviews with the cameras set up to capture the side profile of both the police officer and the suspect.

Summary The necessary faculty at the beginning of the process leading to feedback is the ability to pay attention, to observe, and to notice. 1 . Learning begins with appreciation. 2. Remind yourself that every interaction is a unique event and that the group needs to pay close attention. 3. Find ways to turn observation into a conscious and focused activity. Cue your group towards sharper observation. The precise approach is probably less important than the fact that you have taken steps to enhance observation, rather than simply assume that the group knows how to do it. This latter assumption should not be taken for granted. 4. Move people to where they will be most involved. 5. Encourage them to take brief notes.

184 

14  Observation and Appreciation

6 . Provide objectives to sharpen focus and produce discrepant awareness. 7. Encourage nuanced description. 8. Rearrange seating to shift the angle of vision if the group needs to become more engaged. Chapter 21 “Observation Exercises” provides suggestions on ways to strengthen powers of observation.

Notes 1. Lassiter and Irvine (1986). The investigations all studied cases where the suspect had been strongly presumed to be innocent. It is unclear how accurate the reading of a camera aimed at the officer would be in cases where the suspect is in fact guilty.

References Brönniman, Werner. 1986. Shakespeare’s Tragic Practice. English Studies 3: 211–215. Evans, Bertrand. 1979. Shakespeare’s Tragic Practice. Oxford and New  York: Clarendon Press/Oxford University Press. Lassiter, G. Daniel, and A.A. Irvine. 1986. Videotaped Confessions: The Impact of Camera Point of View on Judgments of Coercion. Journal of Applied Social Psychology 16: 268–276. Lassiter, G. Daniel, A.A. Irvine, I.M. Handley, P.E. Weiland, and P.J. Munhall. 2002. Videotaped Interrogations and Confessions: A Simple Change in Camera Perspective Alters Verdicts in Simulated Trials. Journal of Applied Psychology 87: 867–874. Scheff, Thomas J.  1976–77. Audience Awareness and Catharsis in Drama. Psychoanalytic Review 63 (4): 529–554.

15 Words, Words, Words How to Develop Greater Awareness of Language in yourself, and the Group

In this chapter, we focus on the use of language. We are often relatively unaware of the ways we use words to build relationships, elicit information, and communicate important messages. This chapter considers ways to encourage greater awareness and proficiency with language. Examples refer to the world of clinical medicine, but I am sure that most of the issues are relevant to other professions which similarly generate their own culture and language.

Let us look at the clinical consultation from the point of view of language. When a clinician and a patient sit down, what do they do? They talk. It is with words that patients must convey what is happening to them, how an unwanted intrusion of illness affects them, wondering if the doctor knows what it is, and if there is something that can be done. It is with words that the clinician must burrow down into unknown terrain, ferret out a sometimes-elusive quarry, identify it, and communicate what can be done to rectify the situation. There may be physical signs for the clinician to see or discover, but many times the answers are hidden in the words.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_15

185

186 

15  Words, Words, Words

Words are at the heart of what makes us special as a species. It is words that form our common currency. They are what most pass among us every day. We walk out in the morning into a veritable forest of words, and we hack our way through them all day. We use them to accomplish our purposes and to maintain our relationships. When we get home at night they may taper off but may not in fact stop until we go to sleep. We are a noisy species. Words have made us that way. Yet many of us remain unaware of the impact of what we say, and how we say it. When the ancient Greeks, the Athenians and Ionians above all, woke up to how language worked, they went delirious. They pulled out a minor deity called Peitho from an obscure corner in the Pantheon, dusted her off, and canonized her as the Goddess of Persuasion in gratitude for the almost limitless intellectual scope she had given them. Many were quick to recognize the potential power in understanding how words worked. On the positive side, those discoveries led to the creation of numerous fields of intellectual endeavour that have lasted to this day. Other aristocratic young bloods studied with Socrates himself and then went on to overthrow the democracy. They had discovered that you could overthrow a government by controlling the language by which everyone thought, backed up at the right time with judicious swords. Words were power. Back here in the modern world 2500 years later, it is as if we have forgotten what the fuss was all about. In school, we were taught merely to ask, “What does this or that figure of speech mean?” Faithfully we memorized the definition of simile and metaphor and learned to recognize them when needed. The Greeks, however, excitedly collected and pondered how to use this knowledge. How do we regain the interest and excitement of the founders of our Western civilization? How do we become more aware and use language with greater acumen and satisfaction? At the very least, I suggest, find a way to become interested in language, any way. That growing interest will sensitize you to the many permutations of language in the workplace so that you can bring that awareness to your facilitation. The mind of the facilitator can have a significant impact upon others. Our own mental horizons either permit others to remain where they are or challenge them to rise to new levels.

15  Words, Words, Words 

  187

People vary tremendously in their abilities with language. Some are naturally gifted with verbal skills and use language confidently and adroitly. They know how to ask good questions, present information clearly and systematically, make important distinctions, clarify uncertainty, and summarize for understanding and emphasis. Their words settle and soothe with little apparent effort. They deploy clarifying figures of speech, yet surprisingly may remain blissfully unaware of having done so. Their natural talent does not necessarily mean that they are awake to their own behaviour. They may communicate well but some have no idea that they are doing so. Others are gifted in domains other than the verbal, for instance, in mathematics, or in scientific problem-solving. These people when they become clinicians often happily saturate themselves in medical culture and language. Medical language expresses a complete world view with its own grammar, vocabulary, idioms, abbreviations, and slang. It is impressively comprehensive, accurate, detailed, abstract, and daunting. These people quickly learn to master this new language, become thoroughly medicalized in vocabulary and thought, and jargon slips unnoticed into their word banks. Their natural predilection to abstraction and theory will utterly mystify their patients, and sometimes, some of their colleagues as well. They may inadvertently alarm patients with frightening phrases or may bombard them with too much information too quickly. Because they live in a world of fact, those are the only kinds of words they recognize, and the patient’s tentative signals of concern pass by unnoticed. Studies show this to be extensively so (Butow et al. 2002). Health professionals learn thousands of words for the workings of the physical body, down to the most minute detail. These specialized words enable them to make distinctions impossible for the rest of us, which gives them great power over disease and trauma. However, when it comes to the human condition in general, it is often a different story. There, a much smaller stock of multipurpose words is called upon to cover all exigencies. Upset patients tend to be difficult, angry, or distressed. Often, a clinician will figuratively pull out a label, marked for instance Denial, affix it to the patient’s forehead, and believe that the label has somehow explained what is going on.

188 

15  Words, Words, Words

However, our species has identified hundreds of different emotional states. Each one has been given a different name because no two are the same. The human experience is different in each case, the world looks different in each case, and the appropriate response is different in each case. To respond to 20 entirely different situations with one label (Denial) means a generalized response to a specific situation. In performance, generalized response equates to generalized success. Anyone who performs in a general way has not engaged and entered into the specific interaction but hovers on the outskirts and tries to solve it from outside. Much human interaction takes place in this shorthand way. This type of interaction may be unavoidable in many social situations, but professional communication at its best requires conscious deployment of language. This limited command of everyday language is really not surprising. You don’t need to be dextrous with language to pass medical exams and write scientific papers. The only real requirement is that your language be factually accurate. Stylistic considerations do not come into play. Nuance and shading are completely unnecessary, and satisfying turns of phrase do not add anything of substance to a scientific argument. In fact, a scientific paper can be expressed in the most rudimentary way. It can even be clumsy, as long as the data are correct and the methodology rigorous. Even lines of argument are largely  predetermined. The format of your research paper usually begins with the Problem, and proceeds with utter predictability through Background, Methodology, Results, all culminating in Discussion. The case in the humanities is very different. Problems are of many kinds, and they don’t all give up their secrets to the same kind of scrutiny and the same kind of argument. It is much harder to throw a multipurpose template over human experience and hope to capture much of significance. Language itself has the power to generate understanding. The turn of phrase, the modulation of nuance and distinction, and the careful deployment of rhetoric all combine with argument to produce insights and conclusions. Style is part of substance outside the scientific world. Why do I bring up the humanities? Because human interaction is closer to the world of the humanities than to that of science. In science, we need to know what we intend to say before we put pen to paper. In life, however, we mostly open our mouths and improvise. We work our way hesitantly forward, adjusting, correcting, patching understanding together, and check-

  Professional Communicators Need to Be Able… 

  189

ing to see if we are getting through. Very few of us naturally communicate by abstract analysis, bullet points, statistics, and reference to authoritative research as clinicians must do in their research and conference presentations. Once the world of medicine closes in around young clinicians, it is very easy for them to forget that human interaction follows very different rules and conventions, especially if they have not studied it, or are not that way inclined. Because they have studied the rigorous thought processes of medical science and not those of everyday interaction, they may mistakenly conclude that intellectual rigour does not exist outside of science.

Awareness of Language in Role-play When we engage in role-play we recreate behaviour that we use in life. Yet, when we speak we may not actually grasp the import of our own words. We may listen, but not hear anything but the most obvious of the surface flow. How aware is your group of language in general? Do they consciously hand over new information, or simply open their mouth and let it gush out? Are they aware that the same information can be communicated in a number of different ways, depending on what the patient needs and the clinician wishes to achieve? Is a player’s language exclusively factual? Are they aware of the impact of their words? Are they aware of their own level of medicalization in thought and language as a whole? The study of language is the pursuit of a lifetime, and I make no pretence in this chapter to provide anything but encouragement to greater awareness. The following examples are intended as pointers for more effective choices in role-play.

 rofessional Communicators Need to Be Able P Translators Several studies in the United States tested out medical vocabulary on the general public. Predictably, large numbers of people could not understand terms such as diastolic, fracture, diaphragm, trauma, fistula, lesion, cerebral, respiratory, secretions, appendectomy, malignant or terminal

190 

15  Words, Words, Words

(Samora et al. 1961; Hadlow and Pitts 1991). This is no surprise. The terms are purely medical and are clear examples of medical jargon. However, the researchers were somewhat surprised to learn that a large proportion of the public were equally perplexed by intermittent, stomach, abdomen, artery, cardiac, nutrition, nausea, hypertension, depression, hysteria and nerve. Mention alleviate, ventilate, titrate, palpate, radiate, rotate, isolate or flex, and many patients have no idea what you mean. This is the case in the United States. Probably it is not much different in other English-speaking countries. To address this disparity, one hospital actually compiled a dictionary called Patientspeak with 279 entries, so that medical staff and students could make themselves more intelligible (Scott and Weiner 1984). Meanwhile, patients often make attempts to add some of these new words to their vocabulary, but doctors tend not to recognize that they are doing so (Bourhis et al. 1989). After all, lay attempts at medicalese are but a drop in their ocean. How aware are the members of the group that they need to become accomplished translators from specialized language to the vernacular to be a good communicator? Do they still remember that a positive test result for a patient is a negative one? Do they realize that they may say treat and a patient hears cure? Do they recognize that a clinical category in their mind prompts them to discuss test results while a patient may be hearing bad news? How able are they to communicate the same diagnosis to different kinds of people? Find opportunities for a group to consciously put on their translator’s hats and translate diagnoses and explanations.

Beware of Speed and Volume It is not only knowledge and language that differentiates the professional from the lay person. When clinicians talk about familiar medical matters, their minds operate at a far faster rate than the mind of the average patient. Even an educated lay patient is not educated in medical knowledge and is hearing medical terms and explanations perhaps for the first time. This means that the patient’s mind cannot process the information at anywhere near the rate that the clinician can deliver it. The patient’s

  Does It Make Sense to the Patient? 

  191

mind is potentially like a very old-fashioned computer, perhaps even a typewriter, while the trainees have developed a high-speed computerized mind with super-fast processing and broadband download speeds. It is easy for trainee clinicians to forget that they have been initiated into a world where information is characterized by its vast volume and hair-­ splitting detail. Whoever the patient and whatever their background, the implication is the same. Slow down! Slow your breathing, slow your mind, slow your words! Take your time!

Does It Make Sense to the Patient? The only good information is that which arrives intelligible in your listener’s mind. I realize this is obvious, but in the heat of the moment the obvious is often hard to see in the glare of the urgent and the important. The player may have communicated well, spoken slowly and clearly, packaged the information, and avoided jargon, and yet the patient may have heard something entirely different. The problem may be that the patient has no helpful model in mind by which to interpret incoming detail. The patient is forced to collect the details and shuffle them around to find something that holds them all together. The group may not realize that all the details rotate around a unifying model in their own mind which makes sense of them all. They probably do not recognize that they have to communicate the model along with the detail if it is to make sense to someone else. They may need to reach for a helpful model or metaphor or draw a diagram. Perhaps the patient has in mind a picture of what is going on that is entirely at odds with what the clinician is telling her. We saw a beautiful example of this in action in a student exercise. Students sat in pairs, one facing a white board, the other facing away with pen and paper. The first student described a diagram on the board so that the second could reproduce it on paper. In one pair, a student was obviously struggling with her drawing task. Her partner was very clear in her communication, and the student followed her every detail to the letter to growing confusion. She had done everything according to instruction, knew that something did not add up, but could not work out what was wrong.

192 

15  Words, Words, Words

Her problem was due to one simple fact right at the very beginning. Her partner had told her that she was describing a house plan. She, however, heard house plant and had faithfully attempted to glue all subsequent information onto that paradigm. Make sure role-players check what the patient knows and understands about the subject before they launch into an explanation. If there is a mismatch up front, they need to correct it before adding detail to the picture.

Become Aware How Attitude Affects Delivery Notice how our attitude and motivation affect the way we speak. A trainee may want to tell a patient that a needle is tiny. Needle size is not purely a matter of identifying the factually correct dimensions and saying so. Whether we are aware of it or not, our motivation will affect the way we communicate size. If we want to reassure the patient, and reach for needle size as a way to do that, that objective is discernible in the way we say the word tiny. If we at the same time really believe the needle to be tiny, there will be added emphasis and a sense of conviction. If we recognize how frightening the thought of the needle may be for the patient, that empathic understanding will be expressed in the way we perhaps even physically shrink as we hold our fingers very close together, and make the word tiny sound as tiny as we can. Everything we bring to that moment pours into the expression of the word and is clearly discernible to a perceptive patient and facilitator. The actual size of the needle, our personal attitude to it, our comfort or anxiety with the exchange, and the presence or absence of fellow feeling are all communicated in the way we say the word tiny.

Objectives Language mostly works best and is most powerful when it is in the service of an objective on our part. Do players have clear and appropriate objectives in an interaction, or are they responding in an unconscious, generalized way? For example, young doctors are all taught the concept of active

 Objectives 

  193

listening, but does your group really know what it is? Do they describe it in terms of surface behaviour, as open posture, leaning forward, appropriate eye contact, asking questions, nodding your head, listening? Or do they recognize that all of these surface behaviours are the result of something else much deeper? That is, that they do not know what is going on, and that they need to engage, pay close attention, and listen really carefully in order to find out. Active listening is this latter dynamic action of ferreting out something unknown and not the former of reproducing the surface behaviours that someone else would notice as we do so. Objectives are usually best expressed as active verbs, that is, well-­chosen actions that effect outcomes. When the task is to reassure a patient, do learners assume that this task is accomplished simply by reassuring words pouring from their mouths, such as “Don’t worry!” or “Nothing to worry about!” Or do they instead focus on the patient and watch for signs of reduced anxiety and release of tension that indicate that the patient is feeling safer and reassured because of their words and actions? To reassure a patient is an action that ends with a reassured patient. Effective actions presume outcomes because without an outcome we cannot tell whether we have been effective or not. When a young clinician says, “I have some bad news,” is he just mouthing appropriate wording according to instruction, or do his words have power? That is, is he communicating to the patient, “Brace yourself, there is bad news coming?” and does the patient hear this message and physically do so? That is a successful moment of interaction. The player’s words have power because they have intention and, being well chosen, they achieve what they set out to do. When young doctors are instructed to preface bad news with a warning shot, they are effectively being asked to cue the patient. However, if they introduce the notion of bad news, but patients do not brace themselves or prepare themselves in some way, then no act of cueing has taken place. No matter how well expressed the words, without intention they were powerless and did not achieve what they were meant to do. Communication is effective when active. Some clinical tasks commonly referred to as discuss, take a history, ask, explain, listen, tell, or give (test results) are difficult if not impossible to actually perform. What exactly is discuss or ask or tell? How do you do it? It helps players if they

194 

15  Words, Words, Words

Active verbs implying objectives Welcome, put at ease, reassure, allay, establish rapport, elicit, discover, tease out, watch for, identify, deduce, check for understanding, double check, correct, acknowledge, validate, broach, cue, describe, clarify, define, simplify, instil, compare, contrast, illustrate, differentiate, suggest, offer, propose, affirm, reaffirm, confirm, emphasise, insist, specify, summarize.

Fig. 15.1  Active verbs implying objectives and specific outcomes

become more explicit in what they are trying to achieve. Look for active verbs that describe actions that they can actually carry out. Figure 15.1 gives examples of active verbs that cover the same territory as above though with greater intention. Notice how they give precision and direction to a player and how each choice significantly alters the focus and shape of an interaction. They represent some of the actions regularly carried out by proficient communicators.

Subtext A member of the public may mistakenly assume that the major part of acting on stage or screen is learning how to say the words in your script. Student-actors, however, quickly learn that the words of the script arise out of the life experience of their characters and ultimately only make sense when they and their audience grasp something of that life. Actors develop what they call a back story for their character, that is, the events and people that have led their character to this point in time. Once they have done their homework to realize their back story, the words almost speak themselves without effort. Translated into the professional realm, half a dozen patients could speak exactly the same words, yet mean half a dozen different things. The temptation is strong to simply take words at face value and to forget that the meaning of the words depends on the back story out of which they emerge. A well-taken medical history elicits important elements of a patient’s back story which gives the needed context for how best to relate to and

  Distinguish Factual Understanding from Intent 

  195

c­ ommunicate with this particular patient, suggesting how much information they will need, and of what kind, what they are expecting, how they are likely to cope, and what kind of support they are likely to need. To access subtext, actors also analyse the words of a script and ask themselves, “Why does my character not stop after one sentence? What is still left unsaid? Why does she continue? What is she trying to communicate?” The aim of these questions is to discover the underlying motivations for speech. We mostly do not talk for the sake of it. Our words may grope their way clumsily forward, but they are trying to achieve something, whether that be to seek confirmation or to give it, to understand or to grant understanding, to clarify, check one’s words have been understood, correct a false understanding, and so on. Realizing this, we might ask ourselves, why is the client or the role-­ player still talking? What are they trying to communicate here? What is still left unsaid? Why did the player not respond to an obvious cue? Was it intentional in order to come back to it later, was it not heard at all, or was it thrown into the too-hard basket? Actors are trained to listen to exact wording. What was the first thing the client said? In response to a query, what did they say exactly? Why these words, and not others? What does that suggest? Did they respond instantly, or did they hesitate before replying? If they hesitated, did they reply with their first thought, or did they change their mind and provide another answer? Did they actually answer the question? Do the intonation, body language, and words all line up, or is there something in the tone of voice or body language that suggests another, unspoken message? Feedback from the actor during timeout is often a catalyst for a change in direction in the thinking of the group by providing subtextual information mostly inaccessible in everyday life (see Thought Bubble in Chapter 18 “Facilitation Techniques”).

Distinguish Factual Understanding from Intent Stanislavsky referred to words of dialogue as thought-emotion-actions in that they comprise words laden with emotional connotations implying intention (1961, 116). Here is an example of thought-emotion-actions taken from a workshop situation.

196 

15  Words, Words, Words

A group of trainee oncologists discuss cancer prognosis with a patient. The first player explains the statistics of the patient’s prognosis very clearly: if 100 women with exactly these pathology results underwent chemotherapy, in 40 cases the cancer would return within five years. In those cases, further treatment could slow down the progress of the cancer, but there would be no possibility of cure. For 60 of the 100, however, the cancer would not return, and they would be effectively cured. The patient listens carefully, takes a breath, then leans forward, and says to the trainee, “I’m going to be in that sixty percent!”

The six young clinicians, one after the other, responded to the patient’s statement. The six answers, though differently worded, can all be paraphrased as follows: Okay, that’s good. Studies show that a positive attitude is helpful, and that fighting spirit does lead to better health outcomes. However, when you say that you will be in the sixty percent group, as long as you simultaneously remember that you could just as easily be in the forty percent, then I’ll be happy.

The patient’s spine sags and face drops. The group discusses the answers and feels that the clinicians have answered appropriately and accurately. What happened? The trainees considered that in their discussion of prognosis they had clearly communicated the fact that the patient might be in either group. They interpreted the patient’s assertion that she would be in the “good group” as failure on their part to put the factual message across. None of the group saw the obvious, namely, that the patient had heard what they had said, had rallied herself to face the future, and gamely was hoping for the best. To the trainees, her answer was a mistaken statement of fact. They did not see that, for the patient, it was a statement of intent. In fact, a more appropriate response would have been to affirm the patient’s desire to face the treatment with confidence: “And that’s exactly what we’re going to go for!” The trainees were safely practising in the context of a training workshop. In actual clinical practice, their answers would have robbed the patient of hope.

  Ask Three Questions 

  197

Ask Three Questions A simple technique to uncover subtext is to encourage players to ask three questions. Many times, we leap into action before identifying what the situation really is. For example, during role-play a young clinician informs a patient that she will need to have chemotherapy. “Do I have to have chemotherapy?” the woman asks. Below the sightline of the desktop, her hands nervously twist a handkerchief in her lap.

“Chemotherapy is the first line of treatment for this type of cancer,” the trainee replies and does not see significance in the fact that the patient asks no further questions. In discussion, the group discovers that the patient was left anxious and uncertain as to whether she will actually go through with the treatment. You direct them back to the question, “Do I have to have chemotherapy?” Do we know what she meant by that? Suggest that they ask at least three questions. “What kind of questions?” they may ask, thinking that they need to have the three questions in mind before they begin. “Ask three questions, one after the other, any three questions. Simply ask a question, listen to the answer. Another question will come to mind, ask it, listen, ask the next question, and listen. Wait for the penny to drop, you will sense something like, ‘Oh, I see,’ then respond.” The chemotherapy discussion above might then go as follows. “Do I have to have chemotherapy?” the woman asks. Below the sightline of the desktop, her hands nervously twist a handkerchief in her lap. I’m not sure what that question means, the player realizes. “Are you worried about the chemotherapy?” he asks (Question 1). “It sounds pretty toxic,” the patient replies. “What do you know about chemotherapy?” the player continues (Question 2). “Not a lot,” the patient replies, “it can make you sick, I know that much.” “Do you know anyone who’s had chemotherapy?” the player persists (Question 3).

“My Aunt Jessie had chemo for breast cancer. She was only 44. Her hair all fell out, and she was really sick. I’ve never seen anyone look so ill.

198 

15  Words, Words, Words

And it was all for nothing. The cancer came back, and they gave her more chemo. She was gaunt like a scarecrow, her face went all sallow, and she died.” The player senses a physical impulse within as things settle into place in the mind, which we sometimes refer to as “the penny drops.” He leans forward to answer, far more purposefully than before, because he is responding to a very specific reality. He now has a sense of what the question means to the patient, and his answer now potentially addresses the patient’s real concerns about treatment. Previously, the player’s understanding of the patient was far too shallow, and he hoped that insight might strike as he talked, rather than waiting to speak from a position of insight. On the whole, medical students seem to attribute more value to statements than questions. “I don’t know what to do,” they say and mean that they do not have an answer. Guide them to recognize the power of a well-­ chosen question.

Affirming Effective Communication Lastly, does a player use language well, but convey the impression that he or she is unconscious of that fact? We have all seen many players handle a difficult situation in role-play with great aplomb, yet remain completely unaware of just how well they communicated. As facilitators, I believe we need to recognize these moments and respond by drawing attention to accomplished communication. The feedback needs to be specific and descriptive: this is what you did, this is the technique or approach that you used, and this is the effect it produced. In summation, this is good practice. Feedback needs to identify exactly what was done well, and to name the elements of effective communication so that learners become aware of their own behaviour. By not being aware if we communicate well, we remain insecure and uncertain. We hope that we are doing a good job, but have not been given honest, objective feedback from outside to affirm that fact. The uncertainty maintains a certain level of unneeded anxiety, especially as trainees find themselves at the bottom of a very impressive and daunting professional totem pole. This is a significant issue in the busy medical world, which as a rule does not affirm young clinicians

 Summary 

  199

nearly enough, and far too many young doctors arrive insecure at college exams and perform poorly due to performance anxiety.

Summary Language is the primary currency of communication, yet there is no guarantee that young professionals have the same awareness for everyday language that they have for the terminology of their profession. If you yourself have not consciously considered the issue of language, discussion in a workshop may remain locked within the limited parameters of that group. For profitable discussion and enhanced future interactions, focus on: 1. Translation: the need for professionals to become able translators from specialist language into the vernacular; 2. Speed and volume: the general tendency to speak too quickly and with excessive detail, and the need to slow down and select detail; 3. The primacy of reception: the need to check for reception of information, to make sure that the message makes sense to the listener; 4. The need to communicate a unifying model along with detail; 5. Attitude affecting delivery: to become aware of how one’s words reveal intention, personal beliefs, and fellow feeling, or its lack; 6. Objectives: effective courses of action presuppose a communicator with a clear and appropriate objective; 7. Subtext: surface appearances can be deceiving in that the same words may mean different things according to what they mean to the speaker. Learn to pay greater attention to the back story, the world behind the words; 8. Distinguishing factual understanding from intent; 9. Asking three questions: an effective exercise to elicit understanding; 10. Awareness of language: no matter how accomplished we are as communicators, there are many aspects of language of which we are unconscious. Make a point of helping your group to develop greater awareness of language in general and of their own language use, especially when they do well.

200 

15  Words, Words, Words

References Bourhis, R.Y., S.  Roth, and G.  MacQueen. 1989. Communication in the Hospital Setting: A Survey of Medical and Everyday Language Use Amongst Patients, Nurses and Doctors. Social Science and Medicine 28 (4): 339–346. Butow, Phyllis, R.F. Brown, S. Cogar, M.H. Tattersall, and S.M. Dunn. 2002. Oncologists’ Reactions to Cancer Patients’ Verbal Cues. Psychooncology 11 (1): 47–58. Hadlow, J., and M. Pitts. 1991. The Understanding of Common Health Terms by Doctors, Nurses and Patients. Social Science and Medicine 32 (2): 193–196. Samora, J., L. Saunders, and R.F. Larson. 1961. Medical Vocabulary Knowledge Among Hospital Patients. Journal of Health and Human Behavior 2 (2): 83–92. Scott, N., and M.F. Weiner. 1984. ‘Patientspeak’: An Exercise in Communication. Journal of Medical Education 59: 890–893. Stanislavsky, Konstantin. 1961. Stanislavsky on the Art of the Stage. Translated by David Magarshack. New York: Hill and Wang.

16 Body Language and Imagery How to Develop Greater Awareness of the Use of Imagery in Communication

In this chapter, we explore the importance of story and imagery as expressed in language, physical gesture, and diagrams on paper. The approach suggested here is to draw attention in workshops to the ways that we all naturally resort to imagery so that players might better access their own existing resources and expand them by borrowing from the practice of others.

We have all heard the old chestnut “a picture is worth a thousand words.” Far too often a member of the public will leave a consultation unenlightened or confused because words alone were the primary currency of communication. There were perhaps too many of them, or they were unknown, foreign, or excessively polysyllabic. Perhaps an image had surfaced in the stream of words, but unrecognized by both parties it floated past, and opportunity for clarification was lost. You have probably noticed, when we want to communicate a significant concept, how we automatically reach for an image, story, or a literary device such as metaphor, simile, or analogy to explain it. Often we dramatize our explanations with supportive hand gesture and imitation. Some of us instinctively reach for pen and paper to draw diagrams.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_16

201

202 

16  Body Language and Imagery

Workshops provide opportunity to discuss any of these uses of imagery as they appear naturally in role-play interaction.

Images in Language Imagery occurs naturally in language in at least three ways: stories, concrete descriptions, and symbolic images, usually in the form of analogies and metaphors.

The Client or Patient’s Story Story is the universal means by which we communicate our lives to one another. Encourage players to listen to the client, or patient’s words as storytelling. What kind of story are you hearing? Where is it going? Has it been told before, or is this the first time? How at home is the speaker in their understanding of what is happening? For example, when we first come across a new term or piece of information, we often quote the person who used it as we try it out ourselves. You can almost see the inverted commas around it. When a patient uses a medical term, says she has seen an “oncologist,” is she quoting a word novel and still strange to her, or has this word become absorbed into her personal vocabulary through multiple visits? When the patient says the “margins are clear,” can we hear the surgeon’s voice, and what does this suggest about the tenor of that previous consultation? Is a story simple and organized, which suggests multiple retellings? Or is it complicated and uneven and suggestive of an early work in progress? Is the story well resolved, or does it indicate unanswered questions and issues yet to be sorted?

The Role-player’s Story How aware are trainees that the way they speak and the words they use will tell a story to their patients about their condition, how serious it is, what can be done for them, and how hopeful they might realistically be?

  Images in Language 

  203

Most patients ultimately rely on doctors, nurses, and allied health professionals for their understanding of what is happening. How aware are young clinicians that their words will lodge happily, or unhappily, in the memories of their patients, and will clarify, or muddy their understanding of what is happening to them? How aware are they that words are but a small fraction of human interaction, that we “speak” in everything we do and say, and that the way we relate one-on-one will either support patients or abandon them to their own resources? If we accept that our clinical interactions will form significant chapters in our patients’ stories, what kind of characters will we become in those stories? What kind of characters do we want to become? What might we do to achieve that? If you consider that the group would benefit from greater awareness in this area, encourage them in downtime to reflectively observe friends and family as they tell stories and to begin to apply what they discover. If you have workshop time, set up an exercise of reflective observation of each other as storytellers (see Chapter 21 “Observation Exercises”).

Word Pictures Clinicians describe all manner of things to patients: diseases, symptoms, prognoses, procedures, treatments, side effects, risks, and so on. The assumption might be that one simply says it like it is and names what one sees. However, not all descriptions are equally felicitous, and some are downright threatening. Many young professionals appear relatively unaware of word choice and its impact on a client or patient. They may have a clear idea of what they want to communicate, but may mistakenly assume that their words will automatically convey that picture. In discussing a colonoscopy, the following fictitious student combines delicious examples that colleagues and I have heard over the years. The doctor will push a camera, or a scope, up your rear passage on the end of a hose. From within the hose will appear a claw which will take samples from the wall of the bowel, and a metal noose or a lasso that will burn off any pre-cancerous or suspicious-looking growths that it may find. You do not need to worry, however, because there are no sharp edges, and the process is not

204 

16  Body Language and Imagery

dangerous. If the probe does accidentally puncture the bowel wall and perforate it, you don’t have to worry—they will rush you into surgery straightaway, and anyway, you won’t know anything about it because you will be out of it.

This patched-together student is surprised to discover that the patient’s anxiety levels have gone through the roof. He has no idea that when he uses the word camera, the patient sees an SLR with zoom lens, or a video camera. The only scope the patient knows is the microscope or telescope (both of them long, hard and metal), and a hose may be as thick and as inflexible as a garden hose (add in the rigidity of age and winter). Whatever the image conjured up in the mind of the patient, it is far from the actual reality of the colonoscope. Verbs with emotive connotations such as push, jab, prod, insert, burn, zap, destroy, irradiate, prick, puncture, escape, or run riot create unhelpful images in the mind. Beware the unintended impact of your confident offer of aggressive treatment. After describing radiation therapy, a trainee helpfully asked a patient, “Do you have any burning questions?” while the group sat with open mouths. The trainee remained oblivious of having done so until incredulous feedback from the rest of the group. Adjectives and adverbs do not figure large in the writing of scientific papers or the discussion of diagnosis and treatment. A group may need to be encouraged to recognize the value of using well-chosen adjectives— thin, flexible, tiny, brief, little, microscopic, painless, temporary (hair loss), normal, safe, rare—and adverbs to soften and modify the experience— pretty, fairly, quite, rarely, usually, a bit, seldom. Emotive terms tend to remain alarming even when theoretically neutralized with a negative. The word no seems to have far less impact on our minds than the word that comes immediately after it. A colonoscope may have no sharp edges, but sharp edges had not entered the patient’s mind till placed there by the student. A procedure that is not very dangerous is quite different in an anxious mind to one that is safe. Distinguish between not permanent and temporary, not risky and safe, and so on. It is possibly doubly important to draw attention to these distinctions to my fellow Australians who love to express themselves with negatives:

  Images in Language 

  205

“How are you?” “Oh, not too bad.” “How much further to go?” “Not far.” “How much is it?” “Not cheap,” or “not expensive.”

Figures of Speech As images become more abstract, we find ourselves in the world of rhetorical figures of speech. These figures arise naturally in our thought and speech, often unconsciously, and they have a strong visual component which we can use to heighten their effect. In conversation, we regularly employ devices such as comparison and contrast, understatement, overstatement, analogy, metaphor, simile, antithesis, parallelism, listing, truisms, repetition, euphemisms and summation, to name some of the more common. While these schemes and tropes remain unconscious, they have a hit-­and-­ miss effect. On the other hand, when we consciously decide to deploy a common figure of speech to clarify an explanation, the figure takes on added rhetorical power. Simple contrast is elevated into the artfulness of the stronger  antithesis  because, being self-aware, we automatically heighten the intrinsic parallelism of contrast, and thereby more effectively overturn false assumptions in the client and bring greater clarity.

Example of Conscious Use of Antithesis For example, a patient may express distress because she assumes that her clinical situation mirrors that of a friend which ended badly. Her doctor, however, sees clear differences that suggest at least the possibility of a better outcome. If the doctor simply responds to his own anxiety, he may jump in too early, deprecate the concern, and attempt to dismiss it with such words as “no, no, there’s no need to be anxious,” and leave the patient untouched. The intention is worthy, the execution less so. Consciously deploying antithesis, on the other hand, he might say, “I can see your concern. Your situation and your friend’s situation do look similar. However, they are quite different. This was your friend’s situation,” and he describes it in simple and bold terms. “Your situation, on the other hand, is quite different,” and he proceeds to clarify the distinctions.

206 

16  Body Language and Imagery

This clinician’s awareness of what he is doing injects clarity into the communication at every stage. First and necessarily, he is able to grasp the patient’s starting point that her case and that of her friend look the same. At the same time, he recognizes that this view is inaccurate and unhelpful, that good communication is called for and decides to respond. He recognizes that antithesis is intrinsic to this issue and its solution. He consciously sets out to let the patient know that he can see it from her point of view, that is, the two cases do look similar and concerning. In so doing, he has created common ground. He then consciously separates the two cases verbally—“but they are different.” At the same time, he likely will find himself using his hands because antithesis is intrinsically linked to the fact that we have two hands. On the one hand, we have the friend, and the doctor gestures with the left hand; on the other hand, as he indicates with his right hand, we have your case. The two cases are thus separated, not only verbally but now also in space, no longer together but separated to the left and to the right. The allocation of patient and friend to each of the doctor’s hands translates to an image of separation in the patient’s mind. Then, the doctor describes the friend’s case in a way that sets up the distinctions that can be used to positive effect as he describes the patient’s case. By being aware that he is using antithesis, his mind automatically sorts, partitions off, emphasizes, repeats to make the point clear, and comes to rest on the inevitable conclusion: your case is different, so you have real grounds for hope. In their practice, clinicians deploy these figures to the degree that they are consciously aware of doing so. Help players to discover them arising naturally from within their role-play interactions. Encourage them to take control of what they discover and, perhaps for the first time, to deploy them consciously in their practice.

The Specific Case of Metaphor The most common figures of speech are the related pair of simile and metaphor. Simile compares two different objects using words such as like, as, or a kind of: for example, chemotherapy is a kind of insurance. The figure usually recognizes that the comparison is not exact but close enough to be useful. Metaphor is the stronger figure, as it equates

  Images in Language 

  207

­ henomena from two separate domains. In a significant way A is B: for p example, cancer treatment is a battle against cancer. For the sake of this discussion, however, I’ll use the term metaphor to cover both figures. Metaphor can be addressed in many ways in role-play. For instance, we all routinely introduce metaphors into our explanations and often are oblivious of doing so. We may not realize how abstract thought is mostly built on metaphor as we attempt to explain something new in terms of something already understood (Lakoff and Johnson 1980). Metaphor is a powerful communication tool. Any suitable metaphor arising in role-­ play provides opportunity for profitable discussion. The issue of applicability provides a second level of discussion. The metaphor chosen by a player may or may not have been appropriate, or effective. Here is a tiny selection of metaphors that have done the rounds in recent student workshops. They are offered as examples, not exemplars. An MRI machine is like a big donut; its sound is like a jackhammer; the radiotherapy machine looks like a spaceship; adjuvant therapy is a kind of insurance; radiation is like shining a torchlight with a narrow beam, or like a heavy duty x-ray; the stomach is a storage sack; polyps look like little punching bags; the doctor has no trouble finding his way through the bowel because it is like driving home along a very familiar route, you know exactly when and where to turn; chemotherapy is not the first toxic chemical the patient has experienced, antibiotics and alcohol are toxic; an ulcer is like a graze on the arm only inside the stomach; cancer cells breed like rabbits; they are workaholics, and don’t have a life apart from work, and they collapse if you get them when they are dividing. What makes one metaphor more appropriate than another? Do role-­ players recognize potentially alarming imagery? Do they recognize that metaphors are most effective when they relate to the experience of the other person rather than to their own? Metaphor needs to lead someone from existing to new understanding, so the example must be self-evident to the other person. A metaphor discussing chemotherapy in terms of ridding a garden of onion weed presumes someone who has a garden infested with onion weed. Sporting metaphors are more likely to work if a patient is interested in sport. The axiomatic principle is that one should not have to explain the metaphor as it needs to be already part of the other person’s understanding.

208 

16  Body Language and Imagery

Patients themselves may use metaphor to describe their understanding of their illness. What kind of metaphors and images appear in the patient’s language? The pictures suggest underlying paradigms by which the patient understands the world. Are they helpful and explanatory, or do they lead the patient in unhelpful directions? How do you respond effectively in each case? Discussion might sometimes lead to more abstract levels. For instance, what are the impacts, positive and negative, of the widespread use of military metaphors in medicine itself—for example, the battle or fight against cancer? (Hodgkin 1985; Reisfield and Wilson 2004). Death comes to all and can hardly be seen as failure, but how do we maintain equanimity if treatment is unsuccessful in our case, and we lose the battle? The best we can do is to go down fighting. Should we redirect the metaphor to a more achievable battle for quality of life or drop military imagery completely?

Imagery in Gesture The wealth of expression available to the human voice and body is often undervalued in medical circles, the vast range of potential behaviour reduced in the textbooks to references to body language, or non verbals. It is easy to assume that our words alone carry the major burden of communication and to forget that we speak with our entire body and voice. We speak in the way we choose to interact with patients. Our smile or expressionless face conveys the overall nature of our interaction. Our tone of voice and its intonation conveys as much information or maybe more than the actual words we use. We speak even in our silences. Changes in body posture either reinforce or undermine our message. For example, a respiratory physician may look up from test results diagnosing lung cancer, make a decision to be as positive as possible, yet be unaware that his shoulders have slumped and communicate his real message, that there is nothing he can do. How aware are players of just how much information they communicate before they speak a word? And how their voices, eyes, shoulders, backs, and hands reinforce or contradict their words?

  Imagery in Gesture 

  209

Simple Illustrative Gesture Most of us gesture at key moments with our hands to add clarity to our words. This illustrative use of the hands is usually as unconscious as the impulse to reach for metaphor. Players are often surprised when observers bring it to their attention. They are mostly unaware that we naturally resort to hand gestures when we wish to emphasize or clarify an important point, and that these hand pictures possess great potency of communication. As we know from experience, when a friend is relating a story to us over dinner and the story comes to an important turning point or climax, the hands tend to come out and summarize the important moment in gesture. The impulse to use our hands runs very deep. In medical settings, I have seen clinicians put their hand on their heart as they mention cardiac symptoms or on their wrist if mentioning a cannula. They draw the route of a gastroscope or colonoscope on their body to show the position of the stomach or the intestines and use their hands to portray a chemo molecule docking onto a cancer cell, the shape of the MRI machine, and for radiotherapy, the horizontal table and the radiation machine moving around the patient. This expressivity is an element of their natural communication style and marks them out as expressive communicators. Not all clinicians are as physically expressive nor need to be. There is definitely a spectrum of expressiveness. Sadly, from time to time we come across young clinicians who sit unhappily upon their natural expressiveness because they have been instructed not to use their hands, but to be “professional.” It is true that speakers who are more factually minded are often less physically expressive and rely more heavily on the clarity of their thought to get their messages across. However, individual style is usually not a good basis for universal dictates.

Speeches, Set Pieces, Stories, Lines, Tricks Workshops time and again confront us with the potency of dramatic gesture. In a memorable encounter, a trainee anaesthetist described an epidural to a patient.

210 

16  Body Language and Imagery

“Now, I’m going to ask you in a minute to lean forward something like this.” The trainee leaned forward, and brought her head down towards her knees. Then she straightened up, brought up one hand, and put the index and middle fingers together. “When we do that, the vertebrae, the bones in your spine, will open up like this,” and she opened her fingers into the shape of a V. “I’ll then take a needle,” and here she raised the index finger of her other hand, “and slip it into the space between the bones.” The trainee slipped the index finger into the fork of the V. “Do you see that?” she repeated, “the vertebrae open up like this, and I slip in the needle like this. Does that make sense?” The patient indicated that it made perfect sense. In dramatic terms, the trainee put herself in the place of the patient and curved her back. Cinematographically, she had produced what is called a Long Shot (LS), where the camera is some distance away, and we can see the whole scene. When she raised her hands, opened her fingers, and slipped the index finger of the other hand into the fork between index and middle fingers, the trainee shifted her camera angle to Close Up (CU). Then she performed an Action Replay. She brought the index finger out and reinserted it twice. She even slowed down the action for the replay and performed the action in Slow Motion (Slo Mo). Her explanation was simple and clear and had probably been given already several times. It had become a set performance piece. Nevertheless, the trainee could not dissect her performance, was unaware of what she had done, and was astonished when others told her how effective it had been. As they started to reproduce her words, they too bent over, then raised their hands, and without hesitation accurately reproduced her actions. Set performance pieces like this are widespread in human interaction. Sports teams develop set pieces as effective routines for specific situations in a game. Actors have recognized their existence for centuries and codified them for use in improvisational drama. Over the years they have been variously called stage business, routines, set pieces, shtik, or lazzi. Most of the clinicians who have discussed this subject with me worked them out themselves. Most of them were unaware that their colleagues also did this. Intriguingly they all came up with the same names for the practice, referring to them as a speech, story, line or trick. When I mention

  Imagery in Gesture 

  211

them to clinicians, they commonly reply, “it would have been good to know this earlier. It took me twenty years to figure a lot of this out. If I’d been told as a student, the process could have been shortened by many years.” It took so long because speeches do not appear in books on health communication. However, once a player recognizes the extensive use of speeches in professional communication, the invisible becomes visible, and this time lag can be significantly reduced as effective speeches become common property. By means of these speeches, clinicians are able to communicate difficult concepts to patients in the language that we can understand. Speeches are effective because they come into life through struggle, as a creative solution to a difficult communication challenge. Each piece is built around a central unifying image. The words may change according to the situation and the patient, but the image itself remains constant. The words swirl around this image to bring it alive for the patient while the clear image maintains focus and prevents confusion. It is fixed, yet flexible. Almost always, the doctor’s hands begin to move as they access the image, and they illustrate it economically and simply. The use of the hands increases the strength of the image and creates extra focus, drawing the patient’s attention to the hand image and to the central explanation. Because the concept has been crystallized into an image, it is always available and on call. Its nature as an image makes for ease of recall. The image has instant transferability to a patient and to other clinicians. It is easy for the patient to understand, retain for a long period of time, and repeat later at home.

The Speech as Dramatized Metaphor Clinicians also develop speeches based, not on concrete image, but on metaphor. Take this example used by medical oncologist Professor Fran Boyle. Fran recognized very quickly that many patients became alarmed the moment that the conversation turned to pain relief via morphine or other opiates. As in the epidural example, Fran battled to find a way to address this concern and ended up with a dramatized metaphor which

212 

16  Body Language and Imagery

she called her morphine speech. In what seems to be a common pattern, Fran developed the speech in isolation and without input from other clinicians. Her speech goes along these lines, the words changing according to the situation. Opiates are the best pain relief we have. We use them for broken bones, for surgical pain such as for appendicitis, or if there is pain from cancer (the actual case in point).

Here the doctor raises her hands as if she is holding a large sponge between them. This is the central image. Think of the pain as a large sponge. We take some medication and pour it carefully into the sponge, the pain.

Here the doctor maintains the image with one hand, and with the other “pours” medication into the sponge. We don’t want to use too much, otherwise you might get woozy, so we use only what we need. We call this “titration.”

With facial expression, the doctor subtly suggests feeling woozy. If the patient’s prognosis may lead to reduced opiate use, she says: Now, once the pain is under control, we eliminate what is causing the pain so that it shrinks. Once the pain becomes lighter, we can stop using opiates altogether, and go onto something less powerful.

The doctor’s hands move together as the sponge shrinks, and finally pull away so that the sponge, the pain, disappears. On the other hand, more pain relief may be needed, and the patient may fear that she will develop a tolerance to the opiates, and they will no longer work. In this case the speech goes another way. The good thing about opiates is that there is no top dose. That means if the pain increases (the sponge grows), we can add more medication, and still get rid of the pain.

  Imagery in Gesture 

  213

If the doctor senses, or if the patient raises, concern about possible addiction, the doctor recreates the sponge with her hands to emphasize the presence of pain. People are often concerned that they may become addicted. However, experience says that when there is pain that is usually not a problem. The pain seems to soak it up, and addiction is not a problem, not unless there is a history of addiction already.

There are presumably as many speeches as there are creative communicators to produce them. Each time, a speech grows out of the need to explain a particularly difficult issue within their specialty. The speeches are instantly transferable from one doctor to another, and from doctor to student, but to this point, doctors seem relatively oblivious to them, or deprecate them as “a little trick I have.”

The Speech as Argument by Analogy Many speeches work as argument by analogy. The structure is often tripartite: Think of a sentinel node as like Central Station (Thesis). Every train has to pass through it on its way to the other stations/glands (Justification and clarification).

So, if we know what’s happening in the sentinel node, we can make a bit of a prediction about what might be happening with the other lymph glands (Application). Cancer cells are like workaholics (Thesis). All they do is work at growing; they have unbalanced lives, and lack the restorative abilities of other cells (Justification and clarification).

Therefore, chemotherapy can polish them off when they are feverishly dividing, and they can’t come back. Normal cells, on the other hand, have balanced lives, and they come back (Application). The utility of any particular speech depends upon several factors. Because the reasoning depends upon argument by analogy, the simile

214 

16  Body Language and Imagery

needs to be a good match for the subject to be conveyed. The analogy needs to be appropriate for the listener and match his or her life experience. The effectiveness of the speech will also depend for its appeal and intelligibility upon the doctor’s ability as a communicator, especially their capacity for spontaneity and creativity to block the natural tendency to fall back into rote performance. A speech needs to feel fresh, as if given for the first time.

Imagery on Paper: The Diagram We have already seen that clinicians often use their body as a canvas upon which to indicate the location of internal organs or the site of a lesion. Shift the canvas from body to paper, and imagery is introduced into a consultation in the form of a diagram. Encourage your group never to underestimate the power of a diagram. Players may regard a diagram as a mere accessory within a consultation and fail to see its potential power. A diagram can very often cut through confusion when a concept is difficult or complex. In drama terms, it is a very useful prop. Many young clinicians attach undue importance to the fact that they are not gifted artistically and preface discussion around a diagram with apologies for not being Picasso. However, you do not have to be an artist to produce a diagram. The human body, for example, can be portrayed as a rough sketch, a stick figure, or as lines, squares, and circles. It doesn’t so much matter what it looks like as long as it communicates the gist of your argument. What is more important is to be confident in the way that you present it. An effective approach here is to consider the diagram in terms of performance analysis. Notice how our relationship with a patient changes when we simply produce a blank piece of paper and place it confidently on the desk. The patient’s eyes are almost inexorably drawn to the page. Even before we have made one mark, the patient’s attention is captured and focused in expectation of what will appear on the blank page. You may need to heighten the focus because you have something very important to convey, and you need the patient’s full attention. Strengthen the effect with a piece of fanfare, and create an expectation that something is

  Imagery on Paper: The Diagram 

  215

going to happen. The fanfare could be as simple as, “Would you like me to draw you a diagram?” “Yes,” the patient is likely to reply, and become just that little more committed to look and listen. You have now drawn the patient’s attention, though the pen has as yet made no stroke on the paper. Before we draw the diagram, notice how the location of the paper alters the nature of the interaction. Option one: place the paper on the desk directly in front of you and facing you. The patient sits opposite you and can see the diagram, though, of course, it will be upside down. The arrangement tells a story: the diagram belongs to you. It represents you and the world of medicine, and you are inviting the patient to peer for a moment into your world as you tell them what they need to know. Option two: the interaction is quite different if the patient sits beside the desk at an acute angle to you. Consciously move your chair closer, and place the paper between yourself and the patient so that both of you look down on it from the same side. In this case, you both share the experience. Both of you see the diagram the right way up. It does not belong exclusively in your domain but is equally the property of the patient. You and the patient are now on the same side, and have, through a simple but judicious physical movement, become allies. The discussion of a diagram is itself a piece of performance which can be done unthinkingly, or masterfully. A diagram acts as a powerful focal point for attention whether you draw it yourself or produce a preprinted illustration. A preprinted illustration may be more accomplished art but is not always more effective. We can take in information only one piece at a time, and a complete diagram that contains all the elements of the story can easily overwhelm us if we try to take it in all at once. It is tantamount to expecting someone to absorb an entire story-line instantaneously. Start by drawing a line, circle, or square, explain it, check that the significance has been absorbed, and then draw the next element, and so on. Remember that conversations are more satisfying than monologues. Engage the patient, keep the communication channels open, and actively welcome questions and comments. The patient will then feel free to point to parts of the diagram that are unclear and ask for clarification. The diagram thus becomes an animated illustration that grows through time,

216 

16  Body Language and Imagery

and your explanation drops into a more compelling storytelling mode. The listener follows the unfolding story element by element and absorbs each new piece of information as it appears. The act of explaining the diagram is arguably more important than the actual diagram itself. As you speak, jot down important terms, numbers, and dates on the paper. When later you give it to the patient to take away, the diagram acts as an aide-memoir, not only to the information but also to you and the interaction itself. Occasionally in role-play, a player produces a diagram for the patient that pleases their audience of fellow clinicians but completely mystifies the patient. When this occurs, the bafflement in the patient is usually less to do with the quality of the drawing than with the subject of the diagram. For example, the patient may ask, “How does the chemotherapy get rid of the cancer?” The player, a second-year medical student, answers with a detailed drawing of the life cycle of a cell. His fellow students recognize in the diagram a beautiful summation of what they themselves have learned so far. However, they are completely oblivious of the fact that the explanation had gone straight over the patient’s head. After two years, the students have already become medicalized and fail to distinguish the patient’s need for different information. The patient simply needs to hear that the medication kills the cancer cells as they divide. The diagram does not answer the patient’s question and leaves her feeling that she needs a degree in biology in order to understand what is happening to her.

Summary 1. A picture is worth a thousand words. 2. We all naturally use imagery in our language, in gesture, or with pen and paper. 3. The way we tell a story gives us so much more information than a collection of facts. Learn to read the way we all give information as stories. 4. Learn to read the stories of clients and patients with greater finesse.

 References 

  217

5. Encourage trainees to recognize the part they play in the stories of their clients, or patients. 6. Sensitize the group to their choice of nouns, verbs, adjectives, and adverbs. 7. We often use figures of speech such as metaphor, simile, and ­antithesis in an unconscious manner. Conscious awareness and deployment of these rhetorical devices significantly enhance the power and clarity of communication. 8. Physical gesture is a natural and potentially potent factor in communication. 9. Clinicians develop set pieces as effective ways of expressing complex issues. Draw attention to this practice in general and to specific examples. 10. Encourage your group never to underestimate the power of a ­diagram. Run a small tutorial on diagrams when a diagram appears as a natural part of a conversation.

References Hodgkin, P. 1985. Medicine is War: And Other Medical Metaphors. British Medical Journal 291: 1820–1821. Lakoff, George, and M.  Johnson. 1980. Metaphors We Live By. Chicago and London: The University of Chicago Press. Reisfield, Gary M., and G.R. Wilson. 2004. Use of Metaphor in the Discourse of Cancer. Journal of Clinical Oncology 22 (19): 4024–4027.

17 Managing Emotions How to Manage Heightened Emotion When It Arises in Role-play

Many clinicians are more comfortable dealing with factual communication rather than with the personal concerns of patients. This chapter considers ways to help players address the personal concerns and emotional responses of patients. Role-play is a rehearsal process, and emotions may arise in role-­ players as well. These emotional responses are natural and beneficial in that future interactions are likely to be more empathic and authentic.

The medical world, like most professional worlds, is mostly a world of fact accessed through reasoned hypothesis and the careful checking of evidence. There is no place in this world for clever argument, or beguiling theory. Disease and the human body live their lives according to their own rules. We discover those rules and work with them, or else we achieve nothing. Disease can only be combated with fact; those facts must be discovered, and facts are hard to come by. Men and women who work as clinicians either inherit this natural propensity to factual thinking or internalize it as part of their rigorous training. Yet when we as patients walk into the doctor’s surgery to find out what is going wrong in our body, we do not do so in this reasoned and dispassionate manner. Our mind is not focused on understanding impersonal © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_17

219

220 

17  Managing Emotions

disease mechanisms but on countering a threat to our well-being and our very existence. That sense of threat evokes deep inner responses that we designate by such terms as fear, dread, anxiety, sadness, guilt, disbelief, denial, distress, anger, frustration, rage, depression, resignation, ambivalence, confusion, and all the other sensations and emotions that are the human lot. Even as we absorb factual information, our understanding is highly coloured by emotion because the problem is not distant but lurks dangerously within our being. As patients, emotions permeate all our thoughts, words, and deeds, colour our decisions, and decide the flavour of our hopefulness. As a general rule, the medical world is not very comfortable in dealing with this emotional world for which there are neither hard evidence nor algorithms for knowing how best to proceed. Many young doctors in particular find it hard to know what to do when emotional situations occur. As long as a patient’s emotions remain relatively contained and do not interfere with discussion or treatment, they tend to prefer to leave sleeping emotions lie. After all, most clinicians are not by disposition or training inclined to open up a patient’s inner world when there is already so much to do in terms of managing disease or trauma. We know from numerous studies that doctors deal quite comfortably with discussion of fact, but that when discussion turns towards the personal lives of their patients, as a profession they do less well. One study, for instance, showed how doctors were very capable of recognizing and addressing prompts from patients for factual information. However, they fared much less well when patients tentatively flagged personal concerns, and mostly ignored, or did not see, the cues (Butow et al. 2002). Hospitals and medical waiting rooms are suffused with emotion. Some of these emotions are of a chronic nature and simmer under the surface for a long period of time. Probably the most common presentations in medicine are of this kind. Doctors must learn to navigate through a world that is frequently sad and anxious without succumbing to the negative atmosphere themselves. Other emotions burst at inconvenient times out of the subterrain and into life. We become overwhelmed with distress at the shock of devastating test results or flare up in anger from any number of final straws. When emotion bursts into life, many clinicians become alarmed, and fear that the situation may get out of hand. They address the concern but

  Play Within a Play 

  221

leap into action far too quickly. For example, one doctor sees the first signs of tears and produces a box of tissues, but far too quickly. The patient gets the covert message and manages to control her distress, thus avoiding a distressing scene for her and the doctor. A patient may blow his stack at perceived neglect or delay, and the doctor or nurse immediately moves into self-protective mode in an attempt to nip the inappropriate emotion in the bud. The exhausted wife of a patient in a hospital ward may go home to rest only to receive a phone call that her husband has unexpectedly died in her absence. She expresses guilt that she had abandoned her husband. The doctor or nurse tries to dismiss the guilt the moment it is expressed. In each case, the motivation in the clinician is completely understandable. Health professionals are highly motivated to fix problems. At some deep level, expressions of distress, anger, or guilt are perhaps seen as something gone wrong, like disease, and the automatic fix response kicks in. To complicate the matter, many seem to be unaware that their own motivation is split, and half of their anxiety is for themselves. Will they be able to manage the situation? Will it go totally pear shaped and out of control? How will they manage the negative feelings that it arouses within themselves? The first impulse is to leap into action and nip the negativity in the bud. If they leap at all, that is, because they are just as likely to ignore it. The more unaware they are of their underlying motivation of self-preservation, the more likely it is that most of their inner reserves are silently directed to still the anxiety within themselves. This leaves only residual reserves to manage the patient’s emotional distress. Doctors may be taught as students “to take their own pulse first,” but it is easy to forget it in the heat of the moment (Shem 1979). There are two insights from the world of drama that are useful here: the notions of a play within a play and of optimal moments of response.

Play Within a Play You are probably acquainted with the dramatic device of a play within a play. Most of us have read or seen Shakespeare’s A Midsummer Night’s Dream and remember Ovid’s story of Pyramus and Thisbe as performed by Bottom and his hearty band of rustic “mechanicals.” Their tiny play

222 

17  Managing Emotions

within a play dramatizes in a comic vein the tragic events that might have overtaken the young lovers of the play had not their problems been resolved to everyone’s satisfaction. The story told within the frame of a larger story is an ancient storytelling device from many cultures. It reflects the fact that human life and thought do not travel in straight lines like logic but frequently wander off track and find themselves caught between novel and interesting parentheses. Emotions in a medical consultation, acute and chronic, can often be addressed as a play within a play. Let us assume a role-play scenario discussing poor test results, or from the patient’s point of view, the receiving of bad news. During the consultation, you the facilitator notice signs of agitation or anxiety in the patient as she struggles to come to terms with the enormity of her situation. The player may or may not acknowledge the patient’s concerns. Whether he does or not, he still keeps to his agenda because there are other patients waiting outside, and there is too little time to get off message. The patient struggles to maintain self-control, and at the same time to focus on what the clinician is saying, and her ability to take in information seems significantly impaired. If you estimate the patient’s emotional level in numerical terms as greater than four or five out of ten, or judge that it interferes with the patient’s ability to proceed, it may pay to guide the player to drop their main agenda temporarily and move into a play within the play. The consultation as a whole is the frame story, in this case, the discussion of poor test results. The play within a play addresses the patient’s anxiety or distress (see Fig. 17.1). Prompt the player to address the concern head on in a kindly manner, and make that the focus of their attention. In most circumstances, the patient will shortly find her way back to a solid footing, you can pick up the main story-line again and continue with the consultation. Main play

Blockage

Resolution

Breaking bad news Giving test results

“Anxiety”

Continue consultation

Play within a play

Fig. 17.1  Play within a play as model for shifting to client’s agenda

  Timing: Optimal Moments of Response 

  223

In discussion, you can refer to studies which show that, contrary to the player’s fears, a clinician who addresses a patient’s concerns up front is unlikely to end up with a longer consultation and may even shorten it (Brown et  al. 2001). The logic of these findings is not hard to work through. If patients are allowed to bring their concerns out into the open, and doctors acknowledge how valid those concerns are, patients frequently become much less anxious. Once the emotion has been ventilated and addressed, the patients’ arousal levels drop, and they find it easier to concentrate. The result often is a shorter consultation (Levinson and Roter 1995; Roter et al. 1995). Sometimes where a patient is overly distressed, it may not be possible to resume the consultation, and the clinician may need to reschedule another appointment. While it might have been possible to get through the consultation by pushing doggedly ahead, one might question how authentic the interaction would have been and how much information the patient would have retained. On the other hand, many studies confirm how much patients love it when doctors are willing to treat them as people and acknowledge their concerns and regularly report how satisfying it is when doctors show that they care (Roter et al. 1987; Anderson and Zimmerman 1993; Stewart 1984).

Timing: Optimal Moments of Response One of the great skills of performance is the mastery of timing, which includes learning to identify optimal moments to respond to emotional concern. It doesn’t matter whether the emotion is positive or negative, the points of intervention are the same. For instance, imagine you are an actor playing a comic role in a play with many funny moments. The comic tension on stage builds until your partner delivers a funny line that stretches the tension to breaking point. The actors seem to be oblivious to the incongruity, the tension cannot be sustained and must release somewhere, and so the audience explodes into laughter. Laughter is the audience’s contribution to the play, its emotional response. On stage, you are to speak the next line. The audience is laughing. When do you speak again? Figure 17.2 symbolically represents the arc of the audience’s laugh-

224 

17  Managing Emotions

Emotional arousal

4

3 2

5

1 Duration

Fig. 17.2  Model indicating potential intervention points after expression of emotion

ter. Which number in the diagram represents your best moment to intervene? The correct answer, of course, is at point 4. If you speak before then, your words will not be heard through the laughter. The audience is “speaking,” and their attention is focused momentarily on the delicious enjoyment of incongruity. If you speak too early, you will in fact interrupt the audience. As they hear you speak, they will quickly learn to stifle their laughter so as not to miss the next line. This is the last thing actors want. The conversation between stage and auditorium immediately becomes awkward and remains so for some time. Why not wait till point 5? In comedy, as in all stage work, suspense and attention depend upon maintaining tension. Laughter dissipates some of the tension, but you want to keep as much tension as possible as your starting point for the next comic escalation leading to the next release of laughter. If you let the audience laugh until the last feeble titter, the tension will dissipate, and you will have to start building from ground level all over again. Actors refer to inappropriate delay with such terms as a hole you could drive a truck through. By point 4, the audience has safely had their say. They know they have contributed and been heard and that their response was welcome. By waiting till then, you show respect to the audience. You speak at the exact point where tension is still high, but you can once again be heard.

  Learning to Address Emotion 

  225

The principle applies to any explosion of emotion. Like laughter, expressions of tears, anger, or guilt are equivalent to words. The underlying emotion communicates a clear message. Distress: I am temporarily overwhelmed and I don’t know how I will cope. Anger: I am frustrated, or afraid, and no one takes any notice of me until I raise my voice, and look fierce.

Guilt: I am probably responsible for what has happened. Whatever am I going to do? The precise words are not as important as the underlying emotional message. If clinicians feel alarmed for the patient or for themselves, they will tend to react and to react too quickly. However, as patients just as an audience, we cannot fully take in outside messages while we are still expressing our own. Early intervention at points 1, 2, or 3 is a form of interruption. As patients, we recognize that the doctor is speaking, and that it may be important, so we stifle tears or bury guilt, and the doctor’s words do not really touch us. There is one significant difference in the matter of timing between the world of the stage and that of the therapeutic encounter. Drama needs to keep conflict going for as long as the story demands. Point 4 is the ideal point of intervention for dramatic purposes. It ensures good communication, yet maintains tension. Clinicians, on the other hand, are in the opposite business of reducing and eliminating conflict. While it is quite possible to respond at Point 4, tension is still high. By Point 5, emotional tension has dropped still more, and the patient is returning to ground level. Though 5 would be an ineffective place for an actor to respond, it makes much more sense therapeutically for health professionals. As in all things to do with performance, timing is perfected through practice.

Learning to Address Emotion How would an acting teacher go about teaching trainees how to manage disabling emotion? What you would not do is first hand out crib sheets on how to handle particular emotions, complete with research references

226 

17  Managing Emotions

and evidence base, even if every detail were accurate. By so doing, you tacitly inform the student that communication problems can be solved by memorization and a well-credentialed handout. The students must grapple with everything else they learn in medicine because it is demanding in its nature. From the provision of a handout, it is easy to infer that communication, on the other hand, must be a simple issue. This inference finds ready support in a widespread prejudice of medical culture that regards the exacting mastery of human interaction as a soft option. As in all performance, learning begins with appreciation. Until you have an experience, and identify and name it, you have nothing real to analyse. You have only theory and not the phenomenon itself. This is the same principle as if you were to enrol in a course on Shakespeare and leap straight into a critique of one of his plays from any one of a fashionable set of theoretical frameworks, without first allowing yourself to experience and appreciate just how powerful the play is. You may end up with an analysis, but you have no idea of the life of the play, because you sat in judgement on Shakespeare without ever allowing yourself to fall under his spell. Your teacher may give you an A, but you will be unlikely to know how to perform the play or to appreciate it. Consider then the phenomenon of our emotional life. Emotions surface within us as a response to our changing circumstances. They are variable like the weather. There can be long periods of wonderful calm, endless cycles of devastating drought, or thunderstorms can rush in without warning. They have their own life, but strong emotions are indications of much deeper forces. It is as if tectonic plates in the psyche collide and create explosions on the surface. Expressions of strong emotion point to equilibrium disturbed and thrown out of balance. They are not phenomena purely in themselves nor are they ideas to be understood. They are complete human experiences and need to be appreciated as such. Emotions are intelligible because they are shared currency. When beset by serious disease or trauma, we all travel along fairly familiar emotional trajectories. We begin with apprehension and anxiety and screech to a halt in shock as our path is blocked and seemingly comes to an end. The world as we know it crashes down around us. We discover that the road behind us has been washed away, and that there is no possibility of return. A mist of disbelief settles upon us making it hard to see where we are, and

  Role-play Workshops 

  227

we wander numbly through the mist looking for a way out, or for some way forward. We may try to pretend for a while that none of it is happening, or we may dissolve in tears and not know what to do. We may lash out in anger, and try to reestablish control. We may revert to routine in an anxious attempt to restore things to the way they were. Whatever we do, we are trying to deal with what is going on. Over time we adapt, but it takes time. The emotions gradually subside, and we move into a new kind of normality. These coping patterns generated out of shock are a universal experience.

Role-play Workshops Any role-play workshop may profitably explore emotional distress when the situation warrants. Alternatively, workshops can be designed with this specific focus in mind. In the Sydney Medical School of the University of Sydney, we have run a programme for two decades for first-year medical students to explore the place of emotions in the consultation. We call the programme Dealing with Bad News. The students divide into groups of four with a facilitator to guide the learning. Rooms are set up as hospital wards with professional actors in bed as patients. Each patient is waiting to hear back from their surgeon post surgical removal of a neck lump. The patients have been told that the lump was a lymphoma and that the surgeon would return to discuss the operation and ongoing treatment. The groups spend half an hour with a patient and then move on to another patient for half an hour, and so on for two hours. In this time, they explore as groups how to relate to four patients, one of whom is experiencing anxiety, another distress, a third anger, and the fourth disbelief. Each student has the opportunity to interact with one of the patients while the other students watch and assist. The students are instructed to take a history from the patient but to be ready to drop their own agenda should the patient have an agenda of their own, which, of course, they do. Each interaction is discussed, strategies are considered, and different approaches are tried. The programme is always highly rated by the students.

228 

17  Managing Emotions

The students are encouraged to focus on the challenges intrinsic to each emotional presentation and to look for the causes of distress rather than focus only on the emotional expression itself. The facilitators encourage group over individual work and emphasize the safety of the exercise. Most students are able to manage their own emotional responses to the scenarios. However, groups quickly discover that they tap into the emotional life of the scenarios and find themselves moved emotionally. Sometimes players need to pull back from an interaction to work through the experience. While emotionality could be argued to be unprofessional in an actual clinical consultation, in a rehearsal situation, this opportunity to work through one’s own emotional responses is entirely appropriate and healthy, as we discussed in Chapter 4 “Role-Play as Rehearsal.” It is difficult, if not impossible, to develop a healthy balance between personal engagement and clinical detachment if you do not allow yourself at some stage in training to engage with your own emotional life. A well-­ run workshop allows this experience in a safe environment. If students are of an empathic nature, they may express anxiety about not being able to control their tears in real interactions on the wards. Occasional tears are not a problem. Patients report back that they interpret appropriate tears in a clinician as a sign that the clinician cares, and that they are not put off but, on the contrary, are touched by the demonstration of fellow feeling. The students usually are not so much afraid of the tears as that they will become a basket case, and the patient will feel moved to console them. The usual course is that, over time and with practice, the emotions pull back under control. However, if a student becomes distressed when interacting with a distressed patient, then pay attention to their posture. It is quite possible that they are leaning forward, and that their body mirrors that of the patient. We mirror each other regularly. Carry out a simple experiment if you are in any doubt. If you are a male, when standing talking with a group of men, cross your arms, and see how long it takes for other arms to cross. In the students’ case, their open posture unconsciously expresses their fellow feeling. Their torso functions something like an emotional antenna. By mirroring the patient’s posture (and the action is mostly unconscious), the students tap into the strong feelings

  Summations of Emotional Interaction 

  229

of the patient. Their body picks up the emotion as an empathic response. Try it yourself. Lean slowly forward when in that situation, and you will find words coming to you and things to talk about that are quite different than when you sit fully erect. The students may be sensitive, as empathic people often are, and the empathic posture may be overloading their system. In other words, whereas someone else may need that degree of mirroring to pick up emotional signals, in their case the emotional signal is too strong. Give them control over future interactions by a simple acting technique. If they feel overwhelmed, have them slowly pull back to an upright position. They will still maintain contact with the patient’s distress but will gain a measure of detachment which will give them emotional self-control. Some students need the opposite advice as they sit ramrod stiff and clinically upright and wonder why they cannot get in touch with the emotional reality of the scene. Encourage them to soften their posture, and lean forward, and to wait for the impulse to speak. Invariably, a different kind of conversation will take place. Those who cannot, or will not, allow themselves to tap into the emotional core of an interaction in role-play may find it hard to interact with authenticity in that kind of situation in general. In the world of drama, this blockage is sometimes called hitting the wall. The way forward from this impasse to authentic performance comes not through self-protective detachment (this may amount to little more than mouthing lines), but by allowing oneself to experience the emotion of the situation in a safe environment. That is part of what rehearsal is for.

Summations of Emotional Interaction After the role-play is a good time for crib-sheet summaries. The students may construct them individually, in small groups, or in a large plenary. What is important is that the summaries reflect what the students have learned and contain performable information for future interactions with patients. The summaries may include the following kind of information.

230 

17  Managing Emotions

Anxiety Presentation. The patient is fidgety, unfocused, fragmented, hypervigilant, overexcited, tense. The patient fiddles with a ring or tissue, wrings her hands, or bites her lip. She doesn’t know what to do, or where to look, has a broken quality in her movement, nervous hands, and fingers. Her sentences are broken and unconnected, she has a large number of questions with no answers, seems to be preoccupied mentally, and has broken eye contact. Patient’s need. The patient needs to know that the situation is not necessarily out of control, and the converse, that the situation is manageable. The patient needs some sort of structure. To meet this need. Return control to the patient by providing structure of some kind. Acknowledge the anxiety, and bring it to the foreground of the conversation. Normalize and routinize the situation, and help the patient to order her disordered thinking. Perhaps clarify timelines, discuss what will happen next, or help the patient to make a list of questions to ask the doctor. Your role. The patient needs to manage the situation. Play compassionate, and confident manager, and return the reins to her hands.

Distress Presentation. The patient is withdrawn with closed posture, low introvert energy, and weary, flat affect. Her eyes are teary, there is a quiver in the voice, a sense of defeat, and a lot of fear. She feels very isolated. Patient’s need. The patient needs to feel safe. She lacks and needs family, a mother, the familiar, intimacy, a friend. She needs to feel that you have all the time in the world. She needs comfort both in the modern and traditional sense (to provide strength and courage). To meet this need. Return control to the patient by providing safety. Drop your agenda, and give your time. Sit with the patient in the patient’s space. Become consciously calm, quiet, and comforting. Listen. Allow the patient to voice fears and yet remain safe. Do not try to fix the situation, and do not look for magic words that will wipe away the tears.

  Summations of Emotional Interaction 

  231

Offer tissues as a comfort measure, making sure that your motivation is not to stop her crying. Be alert to the value of talking about the patient’s family. Maintain an atmosphere of empathy, calm, and lack of tension. If appropriate, touch the patient’s hand/arm or the bed, move your chair closer, or touch with your eyes and your voice. Once the storm has passed, help the patient to journey back to reality. If appropriate, introduce the notion that things may not be as bad as envisaged (if patient has taken a dire reading of the situation). Offer something to drink—water, or a cup of tea, or coffee. Your role. The patient needs a companion who is unafraid and empathic. Be a good listener, an unexpected friend.

Anger Presentation. The patient gives off high extrovert energy, is volatile, aggressive, and voluble. That is, if the anger is red-hot anger. If white-hot anger, the anger seethes dangerously under the surface and threatens at any moment to break through. The action of stress hormones makes itself known in the edgy, sharp quality of speech and movement and sense of unpredictability. There is an overriding sense of clenched fist. The patient is threatened, frustrated, and focused on self-protection against uncontrollable outside forces. Underlying the anger, there is probably fear and anxiety that is protected by a hard crust of aggression. Patient’s need. The patient needs to restore order and control through action. He or she probably feels unable to do this, so is in need of support, of someone to hear what the issue is, and to become an ally. They need to see results and changes in their circumstances. To meet this need. Return control to the patient by providing practical support. Recognize and acknowledge the anger as soon as possible. Actively remain calm, and reduce your own anxiety by breathing slowly and deeply. Consciously remind yourself that you are not the target, and that the patient is probably actually afraid. Actively listen to identify the source of the problem.

232 

17  Managing Emotions

Validate the patient’s concerns, and let the patient know once you have heard. Ask what you can do to help. Do it. Once the patient’s anger begins to defuse, and if the situation is appropriate, shift topic to the underlying anxiety, “this must be upsetting.” Your role. The patient needs action, and therefore someone who acts rather than just talks. Play the professional and competent ally.

Disbelief Presentation. These patients may be quite calm but have a problem with focus, which may be selective or disjointed. This problem with focus is because they have a split understanding. Something has happened that has pulled the rug from under their feet. They cannot stay where they are but are reluctant to abandon their status quo and embark upon a frightening new reality. They live in a twilight world of unreality that is neither past nor present, and they are reluctant to face the future. Patient’s need. The patients need to face inevitability and unpleasant, sometimes catastrophic, change. The change is monumental enough that they cannot do it immediately. They need time out to think things through in their own way and their own time. They must slowly recognize that return to how it was before is not possible, and they must watch their bridges burn. They must identify the necessity to go on and find safe footholds in a situation of high uncertainty. To meet this need. Return control to the patient by helping them to think their way forward. Allow time, be sympathetic to what the patient is going through, and ensure that they retain control of the process. Facilitate their thinking, confirm correct readings, and check their understanding of things that seem uncertain. Ask the logical questions that the patients would ask if they were fully in command of the situation: “Tell me again, what happened? What did the doctor say exactly?” Let the pennies drop one by one in the patient’s own time. Let the patient play catch up, and do not impose your own understanding. Your role. The patient needs time to think aloud. Play the role of sounding board and anchor to reality.

 References 

  233

As mentioned earlier, these summaries are best not handed out when students first begin to consider how to deal with emotion in their patients, and in themselves. To do so only preempts the necessary learning process. They need first to tease this subject apart in order to reassemble it with appreciation and understanding. The summations that they come up with late in the process are then reflections of their own hard-won insights, insights which they are able to put into practice and to perfect over time. Compiled at the end of the study process, the summary is a reminder of things learned and, therefore, is a living document.

References Anderson, L.A., and M.A. Zimmerman. 1993. Patient and Physician Perceptions of Their Relationship and Patient Satisfaction: A Study of Chronic Disease Management. Patient Education and Counselling 20: 27–36. Brown, R.F., P. Butow, S.M. Dunn, and M.H.N. Tattersall. 2001. Promoting Patient Participation and Shortening Cancer Consultations: A Randomised Trial. British Journal of Cancer 85 (9): 1273–1279. Butow, Phyllis, R.F. Brown, S. Cogar, M.H. Tattersall, and S.M. Dunn. 2002. Oncologists’ Reactions to Cancer Patients’ Verbal Cues. Psychooncology 11 (1): 47–58. Levinson, Wendy, and Debra Roter. 1995. Physicians’ Psychosocial Beliefs Correlate with Their Patient Communication Skills. Journal of General Internal Medicine 10: 375–379. Roter, Debra L., J.A.  Hall, and N.R.  Katz. 1987. Relationship Between Physicians’ Behaviours and Analogue Patient Satisfaction. Medical Care 25: 437–451. Roter, Debra L., J.A. Hall, D.E. Kern, L.R. Barker, K.A. Cole, and R.P. Roca. 1995. Improving Physicians’ Interviewing Skills and Reducing Patients’ Emotional Distress: A Randomised Clinical Trial. Archives of Internal Medicine 155 (17): 1877–1884. Shem, Samuel. 1979. The House of God. New York: Dell Publishing Co. Stewart, Moira A. 1984. What is a Successful Doctor-Patient Interview? A Study of Interactions and Outcomes. Social Science and Medicine 19: 167–175.

18 Facilitation Techniques How to Choose Among the Many Different Intervention Techniques Available to You as a Facilitator

This chapter provides a variety of interventions that address many of the common issues in role-play. Some provide ways to buy into the virtual world of the role-play, some temporarily halt the action to allow time for reflection and adjustment, and others finesse the action by enhancing the ability to observe, interact, or expand personal repertoire. These techniques grew out of work on medical scenarios but are equally applicable to other fields. Many, if not most of them, you will recognize from elsewhere in the book. They are reprised here for your convenience, so that you can access them in one place.

Good facilitation holds two seemingly contradictory forces in tension. At a basic level, this intrinsic tension is analogous to the familiar dumb clown–clever clown partnership. One clown is an ingenuous naïf, the other a clever knave. Whatever is happening, the first has never seen it before and has no idea what is going on. The other is right on top of it, or being a clown, thinks he is. This ancient comic device dramatizes the universal dichotomy of openness and shrewdness within the human mind, in that it personifies each part and pits both sides against each other.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_18

235

236 

18  Facilitation Techniques

Facilitators must play both parts simultaneously, although of course in serious mode. In order to communicate in an effective way, we need first of all to be present in the moment, to actually be there taking it all in. We need to bring an open mind to the task. One part of our mind needs to remain aware that we cannot know in advance exactly what is taking place until we consciously put distraction aside and pay attention. It is only then that something looms forward out of the shifting interaction— a word, a phrase, a decision, or an action—and we see it, and are struck by it. In educational terms, we notice it (Boud 1991, 23). This is the point at which reflective problem-solving can begin. At the same time, through experience, we have accumulated a library of resources and a bag of tricks that have proven themselves in similar situations in the past. Our experience of past failures and successes makes us canny and provides us with the discipline and technique that make us effective. This combination of openness and shrewdness makes it more likely that we will identify and address important issues. We have considered the importance of openness throughout this book. In this section, we focus exclusively on shrewd facilitation techniques. Of course, all facilitators discover their own style and their own effective approaches, and you will undoubtedly have discovered techniques that work for you. You may also find some of these interventions helpful in your facilitation. It is highly unlikely that any one technique is guaranteed. I like to think in terms of an 80% Rule: that is, the best techniques generally work 80% of the time. For this reason, it is wise to have one or two back-ups for the other 20%. The first group of techniques address issues around getting a role-play started. Later techniques are used once a role-play workshop is underway. Each technique is introduced with its title followed by the context for selecting it.

Crossing Over into the World of the Role-play Experiential learning can only occur once members of the group have allowed themselves to be transported, that is, swept up into the interaction as if it were real, so as to discover their questions within it. The group

  Crossing Over into the World of the Role-play 

  237

needs to cross from the everyday into the virtual world of role-play. Ideally, you will have moved into that hypothetical world yourself before you engage with the group. Your first facilitation task is then to assist everyone in the group to join you in the virtual world of role-play. Not all participants have equal facility in this task. Some players find it hard to buy into the notion of an imaginative world. Some have had unsatisfying experiences with role-play in the past. We need techniques both for buy­in in general and for those who baulk at the prospect.

Use Basic Techniques to Reduce Performance Anxiety To lower anxiety, eliminate distractions, and sharpen the focus of a group

It is virtually impossible to focus on a new potentially threatening experience such as role-play if we are already preoccupied, distracted, or anxious. Without reducing anxiety, a group is likely to remain overly distanced and unable to engage personally. The same measures that you take to reduce performance anxiety will mostly be sufficient to lead a group across into the virtual world (see Chapter 10 “Managing Performance Anxiety”). These measures include the following: • Preparing yourself well so that you model a way forward • Setting up the room to be conducive by eliminating distraction and increasing focus • Arranging the role-player’s chair to face towards the actor and away from the group • Diminishing tensions around the presence of the unknown actor • Emphasizing group learning over individual performance • Emphasizing notions of safety, exploration, and potential new insights • Easing the group in and perhaps not even referring to ‘role-play’ at all • Casting your first role-player well and keeping the first experience positive • Keeping boundaries and rules clear so that they cease to be issues needing attention.

238 

18  Facilitation Techniques

Open Chair An effective, general cross-over exercise for clinical scenarios

After welcome and introductions, briefly introduce the clinical case for the workshop, and then invite the actor-patient to come in. Have the patient sit in a chair facing the group arranged in a semicircle. The group takes a history of the patient. The conceit of the exercise is that each one and all of them are the patient’s doctor, or nurse. Each one in turn asks a question, and bit by bit the group builds up a composite picture of the patient. The facilitator makes sure that everyone has at least one turn and keeps the exercise going until the group has amassed enough information to proceed. The patient is then asked to leave the room. The group discusses clinical and potential psychosocial issues, agrees on prognosis and treatment options, and one of them volunteers to begin the first role-play interaction. The exercise has many advantages: • The group does not waste time but leaps straight into the business of the workshop. • The group meets the case not as an abstract medical problem but as a person of flesh and blood. They all gain a good sense, not only of the relevant clinical issues but also of the patient’s character and understanding of what is happening. • The facilitator has a chance to watch everyone in action and to select likely candidates for the first role-players. • Every participant has, perhaps unknowingly, already begun to role-­ play. Each one has spoken to the patient, asked questions, listened, and weighed up the answers. Each has done the same thing vicariously through the questions of their peers. This means that they all now have a visceral experience of the patient, have interacted, and begun to relate, have heard the history in the patient’s own words, and will find it much easier to role-play one on one.

  Crossing Over into the World of the Role-play 

  239

Involve the Player in Setting Their Own Scene To enhance the reality of the virtual world, reduce aesthetic distance, and sharpen focus

When it is time to begin the role-play proper, ask the first volunteer to move the furniture to match what they are used to or how they would like it to be. Ask them, “Where would you normally sit in relation to the patient or client?” or “Is this how you would set up your room? Change it around till you’re happy with it.” As the role-player shifts the chair or table to suit, he or she begins to engage actively in the hypothetical reality of the scene. Overintellectualization is inimical to performance. At a certain point, you have to get up and have a go. As long as there is another possibility still to consider, the anxious mind prevaricates in a safe, theoretical zone. However, once you turn to consider a concrete problem, no matter how simple, to make decisions, and follow them through, the mind moves into active mode. You commit yourself to choices of action, and that commitment to act is a potent springboard for performance. Anxiety now has a focus for action. The world of the role-play begins to come to life.

Talk Their Way In A player has difficulty imagining what they would say or do

This is a very common situation. The player does not necessarily have an intrinsic difficulty with imagination per se but simply may not know how to buy into this particular situation. Their problem is that they have not yet warmed into it, and the situation has not yet come alive for them. Therefore, they don’t know what to do, and they are anxious at the prospect of failure. Ease them in by having them hypothesize aloud a course of action. The principle behind this exercise is that we are usually able to do what we can imagine ourselves doing. Ask them, “What would you do here? What

240 

18  Facilitation Techniques

would you say, do you think?” Give them enough time to warm to the theme. They may say, “I might start by …, and then I might …” As they talk, listen, and ask yourself, “Is this a potentially viable approach? If they were to do this, is it likely to head into good terrain?” As soon as you sense that they have enough to get going with, simply say, “That sounds like a good idea! Why not give that a go? Let’s just begin with that, and we’ll see where we go.” Invariably this exercise is sufficient to motivate the player to walk into the role-play and begin. You have seen, and they can sense, that they have viable things to do. The word “role-play” has perhaps not even been voiced.

Acknowledge the Fact of Simulation Player has difficulty with the notion of simulation

Sometimes a player tries unsuccessfully to pretend that the role-play is real, that is, not the hypothetical situation he knows it to be but actual as real life. Naturally, such players are doomed to failure, because they simultaneously know this fact to be false. The players are in fact attempting to resolve the intrinsic irresolution of a world that is simultaneously both real and not real. They are often personally locked into a world of fact and find it difficult to manoeuvre outside that world. Confirm that, of course, this is not a real situation but a simulation. Role-play, like all art and performance, is the next closest thing to real life. It is close enough to access all manner of insight but, nevertheless, it remains a simulation. You accept it to the degree that you can. Do not pretend that the actor is a real client, or patient, because you know that this is not true. Simply walk into the room, act as you would if this person were actually real, and run with what happens. In most cases, players will settle more or less into the interaction once they begin to move and speak. Their focus is drawn more and more onto the character before them who acts in every way as if the situation were real. Everything they see, everything they hear, and everything they themselves feel is virtually indistinguishable from everyday life. Their senses

  Crossing Over into the World of the Role-play 

  241

are saturated with stimuli that tell them that this is really happening. There is a consistency and a coherence that admits of no cracks or fault lines to indicate that it is not real. The interaction feels truthful, all their senses tell them that this is so, and they have only peripheral thoughts reminding them that it is an illusion. Usually the messages to the senses are strong enough to suspend disbelief and to bring the player into that intermediate zone of aesthetic distance where they are involved enough to become transported.

Don’t Be Afraid of Laughter If players break into nervous laughter

Occasionally, a member of a group will break into nervous laughter, crack a joke, or drop suddenly out of the interaction to make some sort of editorializing comment. These actions usually indicate that the tensions inherent in the exercise are high, so the player or players disengage for a moment in order to release the excess. They are reminding themselves that this situation that feels so real on some level is, in fact, only a fiction. Their insecurity demands that they increase their distance to increase safety. Unless it is ongoing and threatens to destroy the workshop, do not be concerned with the laughter. Usually, it is momentary. The player recovers and finds his way past his nervousness back into the scene. At other times, the group will crack up at something either the actor or the role-player says or does. The cause may be incongruity or the delight of recognition. These moments can sometimes be very funny. I suggest that we treat them as a real bonus. They temporarily lighten what is often a serious issue, making the experience more bearable, and they provide good entertainment value to the workshop. The group is more likely to leave at the end feeling that they have had a good time and more likely to repeat the experience by signing up for another workshop.

242 

18  Facilitation Techniques

 alting the Action to Provide Time to Discuss H and Regroup The two most common forms of intervention temporarily call a halt to interaction so that the player and the group can discuss, regroup, and plan the next moves. It is during these times of discussion that we become conscious, perhaps for the first time, of our actions, strengths, weaknesses, and ways we can expand our repertoire of behaviour.

Timeout The universal intervention of role-play providing opportunity to become more aware of our actions

Either the facilitator or role-player can call timeout at any time. We may decide that we now have enough to discuss, may have reached a decision point, or may be uncertain how to proceed. In some cases, the player may have become anxious and wishes to stop for a moment. All are valid calls. Generally, allow no more than four or five minutes of interaction; otherwise there will be too much to process. On the other hand, do not micromanage, or there will be nothing to discuss. We call Timeout to halt the interaction for a short time, so that the player and the group have opportunity to reflect and discuss. We are unable to do this in actual life, and this opportunity to become aware of our actions is perhaps the greatest contribution of role-play. Periods of timeout provide opportunity to step back and gain perspective on what has taken place before reengaging. Though timeout discussion tends to be more detached than the role-play action, discussion ideally stays in touch with the experience on stage and avoids retreat into intellectualization. “What did we see, hear, and feel? What does that mean? How did we go? Where do we go from here? What are we learning?” All these questions are those we ask as engaged players from within an interaction not as disinterested researchers looking in objectively from the outside. You might think of Timeout as the Stop button on a DVD player. When you call or press Timeout, the interaction stops, and the player

  Halting the Action to Provide Time to Discuss and Regroup 

  243

leans or steps back out of the reality of the interaction. It is as if the picture disappears from view. You find that you talk in the past tense about what is now a past event. The conversation inevitably cools  a little, becomes more cerebral, more abstract, and feels quite objective. We draw conclusions and general principles and think about how to proceed. Though the patient is clearly in view, the virtual world temporarily fades. Aesthetically, the group becomes inevitably more distanced. Discussion is crucial for new understanding, but do not remain too long in timeout mode, as the virtual role-play world will fade when not actively alive. If discussion is prolonged, provide the player a strong objective for reentry to reenergize the role-play. For further information on Timeout, see both Chapters 12 and 13 for choosing the focus of discussion. If you consider that the group is becoming too detached, try calling Pause instead of Timeout.

Pause (Variant of Timeout) To put players who are becoming too detached in touch with their experience

The Pause is a variant of the usual Timeout call. If you wish to use this device, it sometimes helps to introduce it up front as a potential intervention, so that later the group knows what to do when you call it. In practice, however, I have often called Pause without introduction, usually in groups that are working well together, and found that they instinctively knew how to respond. You can use this device when you sense that players are too distanced and not sufficiently in touch with what they are experiencing and need to get in touch with their feelings, sensations, or perceptions. Pause is like the DVD Pause button. Press or call Pause, and both actor and player stay in the action where they are. Their body posture, focus, and distance from each other remain in place. As with a Pause button, the picture stays visible and unmoving in front of you. It is important that the players do not stiffen and freeze. If this happens, vital physiological and emotional information will be lost. Say something like, “Just pause where you are. Relax a bit, but stay just as you are. Keep in touch with

244 

18  Facilitation Techniques

what is going on.” For the group, the tableau is a visual reminder of the interaction. Time seems to be standing still, and the interaction seems to be still taking place. The two players, meanwhile, continue to feel much of the sensation of the interaction because their postures and gaze still contain the feelings and the attitudes they have been experiencing. The sense now is of a present event still taking place, and conversation tends to be in the present tense. Ask the player questions about what they experience right now in the interaction. You might coach him or her along the lines, “Stay where you are, looking at the patient, talk to me from where you are, you don’t need to look at me.” Then ask along the following lines, “What are you feeling now? What do you see? What are you hearing? What are you thinking? What do you want to do? What is going on, do you think?” In contrast to the more usual call of Timeout, the player speaks back to the group from within the interaction. He or she can now identify relevant sensations and perceptions that give a reading of the situation far richer than is possible from a more detached point of view. Aesthetic distance is kept low, and the group remains close to the experience of the action.

Specific Issues Within the Interaction Other issues surface once the group has bought into the premise, crossed over into the world of the role-play, and begun to experience the situation as players within it. The issue is no longer how to find one’s way into this world but how to find better ways to navigate within it.

Streaming or Layering The situation is complex, and the player needs to focus on a specific aspect of a rich interaction

This technique was introduced in Chapter 4 “Role-Play as Rehearsal.” If the interaction is rich, as most are, or if a particular part of an i­ nteraction

  Specific Issues Within the Interaction 

  245

suggests the primacy of one particular element, you might choose to have the player and the group pay conscious attention to that element. Clarify that this is an exercise, and that they would not act this way in real life. Invite them for the next few minutes to pay particular attention to the chosen element, and see where that leads. For example, you might suggest that they pay attention to: • the way they naturally use language, knowing that they will discover jargon, sentence structure, volume and speed of information, excessive factuality, or unintended frightening language; • the way that a patient or client presents their story, the exact wording used, the impact of paralinguistic factors such as tone of voice, hesitations, things said, or implied; • the messages conveyed by body language; • the impact of their own voice, how a factual tone appropriate for transfer of scientific fact changes when faced with vulnerability or distress; • presenting a complex piece of information as simply and clearly as possible; • how well their partner in role-play is taking in their explanation; • their partner’s changing anxiety levels and whether their actions heighten or allay that anxiety; • their own levels of anxiety or personal emotions aroused within an interaction.

Practise Split Focus Player is either too detached, or too involved

This is a special case of streaming. Proficient communicators have learned split focus, that is, the ability to operate both as an engaged human being and a detached professional. This balance common to all superior performance is difficult to master, as one must figuratively both lean forward and pull back at the same time. It cannot be assumed in young trainees.

246 

18  Facilitation Techniques

Separate the two strands. Draw the player’s attention to this faculty. If players have warm interactive skills but need to tighten up their objectivity, have them focus on their inner, cool clinician, and thus treat the other as object, a clinical problem to be solved. If they are low in relational skills, have them develop their capacity for engagement by treating their partner as another subject, that is, a fellow human being. Because the focus is so specific in each case, the practice interaction will inevitably lack the balance of accomplished performance. The point of the exercise, however, is not to achieve balance but to work towards it by strengthening a weaker side.

Imagine You Are an Acquaintance A player is stiff and does not interact in a natural manner, the cause possibly being uncertainty over role

A player seems to treat an interaction simply as a task to be carried out or a problem to be solved and does not relate to the client, or patient, on a human level. You sense that the player does not normally have difficulties in interaction but that he is seeking refuge in his professional role and hides behind it as a protective mask. His spine may be stiff, he may hold himself in a serious posture that he imagines to be professional, he may stumble to know what to do or say. The interaction, however, may require little more than relating on a person-to-person basis. Say, “Imagine that you know this person. Not well, not a close friend (because that would demand that the player act a part instead of being himself ). This is someone you simply  recognize, so find out what has brought her in today.” Give the actor and player a minute or so to work out the personal connection before they resume role-play. This exercise does not always work, but when it does, you can see the player’s spine relax from the demands of the self-imposed, clinical persona as he begins to relate simply and as a person. It is common in subsequent discussion for the group and the player to differ considerably at first in how they interpret what happened. Let us assume what we hope, that the interaction went more smoothly and authentically. The player

  Specific Issues Within the Interaction 

  247

may acknowledge that he felt more comfortable but be uncertain as to whether his behaviour was still professional. The group will invariably take a much more positive view and voice aloud that his interaction was an improvement, and entirely appropriate.

Analyse Your Way In A similar problem, the player remains detached and has difficulties establishing empathic engagement, this time an issue possibly of undeveloped emotional intelligence

In dealing with a distressed client, or patient, the player may remain emotionally detached, the voice retains a purely factual tone, the interaction is stilted, and the player is uncertain how to proceed. You sense in this case that the issue is not the previous one of uncertainty of role, but that the player has more highly developed intellectual than emotional intelligence. Use that intellectual strength to engage with the situation. Change the player’s focus by reframing the problem. Draw attention to two or three important factors that the learner may have overlooked. Maintain a light touch, and let the player do most of the thinking. For instance, does the player notice how their voice has retained a very factual tone. Encourage conjecture as to whether sometimes a quieter, calmer voice might be more appropriate. Has the player remained too physically distanced? How might a change of distance affect personal interaction? Has the player relied too heavily on reason and a stream of words to solve the problem, and do they recognize this? Which might be the better approach, many words, or fewer? If sitting, does the chair face the patient in a potentially confrontational manner, or is it placed at an angle so as to imply that they are both together in the same space? Such players are often natural experimenters, so suggest an experiment. “Why not sit a little closer, slow down, let your voice become quieter and calmer, err on the side of speaking less, and don’t worry about silence, and start again.” More often than not, the interaction will begin to take on a more personal tone, and the group will see improvement. The player may sense some improvement but may need time to come to terms with what has

248 

18  Facilitation Techniques

happened. They are used to remaining detached from their own experiments and to observing the results from a safe distance. In this case, they have found themselves in the middle of their own experiment and unexpectedly to be acting differently. This experience could be surprising, as it is not their usual or natural viewpoint. The student benefits from encouraging, positive feedback from peers.

Watch the Hand! The player is uncertain how to interact with a distressed patient or client

The player may be either reluctant to engage, or overly inclined to “fix” the situation rather than simply relate on a human level. Have a similar discussion as in the previous intervention. Make sure that the player is sitting close to the patient and has considered the need to slow down, speak less, and quietly. Sit directly opposite the player so that you are in his line of vision, and add the instruction: “When you resume, you will see me raise my index finger and put it over my mouth. Watch the hand. Only begin to speak when I lower it.” The player will experience an urge to find magic words that will fix the situation but be constrained by the instruction. There will be nothing left to do but to engage and listen. At a certain point, you will sense the player relinquish the need to be in control and to begin to engage. Allow sufficient time of silence, and then lower your hand. Very often a much more empathic conversation will ensue.

The Body Is an Antenna The converse is the issue, the student becomes overwhelmed by emotion

This exercise is summarized here from its fuller discussion in Chapter 17 “Managing Emotions.” If you notice that a player becomes emotionally overwhelmed and is on the verge of tears, the problem is potentially that of a sensitive and empathic nature. Pay attention to their posture. Have they softened their spine, leant forward, and unconsciously m ­ irrored the

  Specific Issues Within the Interaction 

  249

posture of the distressed patient? Volunteer the notion that the torso can function like an emotional antenna. Through empathic mirroring, they are receiving emotional signals from the patient. In their case, because of natural sensitivity, the signals are too loud. Have them experiment by slowly bringing their posture to an upright position. In many cases, this simple movement will dilute the emotional intensity of the engagement. The player will remain in empathic contact but discover a new measure of detachment. Add further distance by clarifying the nature of the player’s objective. What do they want to achieve? Having something very specific to do provides extra protection from the strong emotion in the room.

Change the Viewpoint To give an emotionally overloaded player the benefit of distance

A player may be too caught up in an interaction and needs to move back a little to regain perspective. Take, for example, players who find themselves confronted by an angry client. The whole situation is utterly convincing; they are caught up in a confrontation and are struggling to know what to do as the barrage continues. You call timeout. You do not sense that the player is overly sensitive, or out of their depth, or in real trouble. However, their behaviour or feedback tells you that they are definitely overloaded with sensory information, and could do with a little distance to make sense of it all, and to think their way through. The player may still be standing where they had stood in the interaction. Tell them to “leave a copy of themselves” or have someone else stand where they are standing and come and join you at a little distance from the scene. Ask them to describe what they now see and review what happened. Their changed physical viewpoint will inevitably alter their interpretation. They now see the central issue confronting them, its impact on them, the objective they need to pursue, and the outcome they want to achieve. Once they come up with a valid interpretation and a viable course of action, direct them back into the world of the role-play to pick up from where they left off. Previously, the player was overwhelmed with emotional information and had lost needed distance. They now go back

250 

18  Facilitation Techniques

into the interaction having regained access to the cool, clinical streak which guides them into resolving the situation.

Role Reversal The player does not seem to empathize with someone else’s situation

A player seems to have little idea what a situation feels like from someone else’s point of view. He or she may have all the right words, but you sense that there is little empathy and rapport. For example, a female trainee oncologist talks to a patient normally seen by the consultant. The patient presents with recurrence of cancer in the spine which causes considerable back pain. The trainee is overly aware of her junior status and assumes the patient would prefer to see her boss, who is unfortunately away at a conference. The conversation is awkward. In discussion, the trainee mentions the absent consultant. The facilitator senses that the trainee does not read the importance of the pain and suggests a role reversal. She asks the trainee and actor to switch places for a few moments. They do so, and the trainee now sits in the patient’s chair. The facilitator allows a few moments for the trainee to adjust to her new position. “Tell me about the patient,” she says. The trainee begins to talk about the patient, but this time from the patient’s point of view. “Tell me about the recurrence in the spine,” prompts the facilitator. “The pain is severe,” the trainee recognizes. “What are you thinking about?” “I am not thinking about the consultant. I want someone to do something about the pain. I don’t give a damn if the consultant is here or not.” The change of atmosphere in the room is palpable. Some of the group have almost forgotten to breathe. “Why don’t we switch back, and go on from here?” The trainee and patient resume their positions, and a very different conversation takes place.

“Patient-cam/Doctor-cam” You consider that the group is being too factual and needs to pay more attention to the experiences of the fictional character and the role-player

  Specific Issues Within the Interaction 

  251

Apply the cinematographic convention of camera placement to the seating of the group. Change their angle of vision. Have one or two members of the group sit at an acute angle facing the actor so that they can clearly see the character’s face and another one or two at a similar angle facing the role-player. This placement will heighten their awareness of the subjective experience of character and role-player. Compare and contrast their feedback during discussion. This technique was described more fully in Chapter 14 “Observation and Appreciation.”

Go On! A player exerts too much control over an interaction, and the client’s voice is lost

The player dominates an interaction and does not allow the client, or patient, to tell their own story. For instance, he or she gathers information by collecting answers to a stream of specific questions. By so doing, the patient does not get to tell the story in their own way, which means that much of the context to explain the facts is lost. This exercise aims to give the patient back their own voice. Challenge the player, as an exercise, how much of the story might they be able to elicit while asking only one or two opening questions? From then on, restrict them to the simplest prompts such as “go on,” or “what happened next?” or “uh-huh” or “tell me more.” Call timeout once you assess that they have amassed considerable detail and a sense of coherent story. Discuss how much information was collected with great economy and how the patient’s story made sense of that information.

Voice Bubble The player or group seems oblivious to, or misreads, the client’s or patient’s experience of an encounter

Sometimes a group misreads what the client, or patient, is saying and through group-think assumes that he or she is thinking like themselves. Propose to the members of the group that it might be interesting to listen

252 

18  Facilitation Techniques

in to the client’s thought processes in a way that is not possible in their working lives. Use the metaphor of a thought bubble, as in a cartoon, or a soliloquy, as in a Shakespearean stage play. Address the client and ask, “Could you tell us a bit about what you are thinking/feeling/understanding right now?” The actor comes to life and delivers a brief monologue expressing how they are actually experiencing the interaction. The unexpected, new information redirects subsequent conversation.

What Is your Objective? When a player does not seem to know what they are trying to achieve

If an interaction lacks focus, energy, and direction, and the player appears uncertain about what they are doing, ask, “What is your objective? What do you want to achieve? What is the outcome you desire?” Discuss until players can express their objective in simple, bold, and active terms. For example: “I need to find out exactly what is going on. I need to get to a conclusion.” “This time I need to make sure that she understands what I am saying. Feedback suggests that she didn’t.” “I need to capture his full attention as I have something unwelcome and unexpected to say which they won’t want to hear.” “I need to get across three important facts. He needs to understand how significant they are for him.”

Go for Broke When a player appears excessively constrained

Players sometimes act in a very constrained manner, and you sense that they have boxed themselves into very circumscribed behaviour. You may already have attempted to loosen up their approach, but the gains were minimal. Tell them, “This time, how about we go for broke. This is not

  Specific Issues Within the Interaction 

  253

how you would do it for real, I know that, but just this once, see how far you can push it. Go beyond what you think is comfortable. We’ll work out later what we’ve come up with. Have some fun. Go for broke!” The idea is to exaggerate their behaviour. They are probably thinking in incremental terms, rate themselves at seven or eight out of ten (whatever the issue might be) and thus consider themselves dangerously close to the boundary of unacceptable behaviour. You, on the other hand, estimate that they have managed to move from two to three out of ten. They need to break out and bust beyond their boundary into what is for them no-go behaviour. They may need to think in the unthinkable terms of 15 out of 10. Give them licence somehow to act in a manner that to them is excessive. They may find to their surprise that, even though they push hard, they have not yet reached that dangerous border but are still in safe territory. Feedback from the group will hopefully confirm that this is a massive improvement. If they do happen to cross over that boundary and go too far, they will have travelled a tremendous distance. If they now pull back a fraction, they have far more scope than before.

Worst Case, Best Case When the player acts in a way that is excessively blunt, or excessively reassuring

The most appropriate course of action is often in the middle ground between two extremes. Unless the group has some experience of the spectrum of possibilities open to them, it may be hard to find their way to that subtle intermediate terrain. For example, a patient may present with worrying symptoms, the young doctor suggests a couple of tests, and the patient asks, “What do you think it is?” The symptoms do suggest a likely diagnosis of cancer, though there are other possibilities. Does the doctor bluntly inform the patient that it is probably cancer, or hedge their bets with a range of possibilities and not mention cancer at all, or find artful middle ground? If the group seems naive to the nature of this dilemma, have the group play Worst Case, Best Case. Play the scene first for the worst case. Play it

254 

18  Facilitation Techniques

factually, accurately, clinically honestly, hide nothing from the patient. This interaction externalizes the scenario of scientific probability playing out in the doctor’s mind. This is an example of the cool clinical streak of split focus in action. Then play it for best case. Play it reassuringly, allay the patient’s anxieties, minimize the danger, do not even bring up the possibility of cancer. This is the warm streak of split focus with emphasis on patient comfort and minus factual reality. The group will likely recognize that the most appropriate course of action is in artful navigation of the choppy waters between the Scylla of brutal reality and the Charybdis of evasive platitude. Having identified the extremes, the group can then search for a satisfactory way through the passage.

Triage Expectations When a player is unsure how to introduce potentially bad news

Most people experience considerable anxiety when called upon to deliver bad news. Their approaches tend to fall into one of three categories: cut straight to the chase (your husband is dead); fire a warning shot (I have some bad news, I think we need to sit down); or prevaricate in the hope that the other will guess. These approaches are called in the literature Blunt, Forecast, and Stall (Shaw et al. 2012, 2013). A blunt approach is more likely to be appropriate when there is a prior relationship and/or the news is more or less what is expected. A forecasting approach is usually called for when the news is unexpected and serious. Stalling hardly ever works. If a player has difficulty in knowing how to approach this kind of situation, suggest that they triage the patient’s expectations. Do they think the message is (1) better than the patient expects; (2) more or less what is expected; or (3) worse than expected. Suggest that sometimes it helps to be proactive and to specify the category up front, for example: “You will be happy to hear that the news is better than we’d feared.” “The results are basically what we’d discussed.” “I’m afraid the news is not as good as we’d hoped.”

  Specific Issues Within the Interaction 

  255

Ask Three Questions The player has not grasped potential subtext and begins to explain to a patient or client prematurely

This is a common situation with medical students, for instance. In their minds, there is a little box to be ticked off which is marked Elicit patient understanding. We see a student ask the obligatory question “What do you know about chemotherapy?” hear the answer “Not much,” sense a tick go into the box, and watch the student launch into a presentation of their current knowledge of chemotherapy. The students do not seem to realize (1) that they still have no grasp of what the patient understands, and (2) that “not much” signals something. The resulting interaction is invariably awkward because the student has no sense of where the patient stands on the issue and so is working blindly forward hoping for illumination to strike. The problem here is that the students respond prematurely; they obediently follow instruction without internalizing what the instruction means. One solution is to sell the idea of asking three questions, even if only for this exercise. Tell them, “ask three questions, one after the other, any three questions. Simply ask a question, listen to the answer; another question will come to mind, ask it, listen; ask the next question, and listen. Wait for the penny to drop, you will sense something like, ‘Oh, I see,’ then respond.” The following kind of conversation might ensue. Q1 “What do you know about chemotherapy?” “Not much …” Q2 “When you say, ‘not much,’ what do you mean?” “Well, it’s obviously pretty toxic. It can make you really sick.” Q3 “Right. Do you know someone who had chemo?” “My aunt had chemo for breast cancer. Her hair fell out, she was really sick, and in the end, it didn’t work, the cancer came back and she died. It was awful.” “I see, right,” and the student begins to answer, but this time in an entirely different way, because they now have a clearer sense of where the patient is coming from. They have in fact established some degree of rapport and understanding.

256 

18  Facilitation Techniques

In subsequent discussion, encourage conversation that recognizes the shift that occurred within the student once they had gathered enough information to proceed. There was a significant mental movement, a kind of settling of things into place, a sense of knowing what they were dealing with, at least sufficiently to begin to interact with some confidence. The quality of the interaction, once we sense what we are dealing with, is radically different than if we launch out into the deep and hope for the best. If the exercise is successful, encourage them to practise being a Three-­ Question Man or Woman for a while and see how this changes their interactions. There is no magic in three, of course, they can ask as many questions as they like, though three questions are usually enough to ground them for the interaction. The important outcome of this exercise is to experience the inner shift that indicates readiness to respond and to learn to wait for that impulse.

Does It Make Sense to the Patient? A player relies entirely on provision of details to communicate information to a client or patient

A player may have communicated well, spoken slowly and clearly, packaged the information, and avoided jargon, and yet the patient may have heard something entirely different. The problem may be that the patient has no helpful model by which to interpret all the in-­coming details. The players may be oblivious to this fact. They have a unifying model in their mind which makes sense of all the details, but they may not realize that they have to communicate the model along with the details if it is to make sense to the patient. The group may need to reach for a helpful model, or metaphor, or draw a diagram.

Patient Has the Wrong End of the Stick The player does not address an unhelpful paradigm

  Specific Issues Within the Interaction 

  257

This is an extreme variant of the preceding situation. You notice, or know, that the patient’s grasp of her situation is based on an erroneous paradigm. The player may remain oblivious of this fact and attempt to bring clarity simply by providing correct information. However, the patient unsuccessfully attempts to glue all the new details onto the old paradigm to make them fit. The new information does not displace the faulty model, and the patient is left in confusion with the basic problem unaddressed. For instance, the student asks, “What do you know about radiotherapy?” The patient answers, “Not much. I just saw the door and the sign, but nothing really.” The student then proceeds to unload his understanding of radiotherapy, but the interaction remains awkward. Why? The patient saw the thickness of the door and the radiation sign, and assumed that the treatment was highly dangerous, and she might become radioactive. The student did not disabuse her of this belief when he told her what he knew about radiotherapy. None of this new information contradicted the model in the patient’s mind. Whatever the student said, the treatment remained dangerous. Have the player discover the mismatch by checking the patient’s understanding. Once the mismatch is discovered, address the fallacious idea up front so that new information can be written on a clean slate. Let the patient hear that the door is actually thick for the benefit of the staff who are exposed over the long term. The treatment is in fact very targeted and aimed as much as possible solely at the cancer. The ensuing interaction is likely to be much more satisfying.

Put On Your Translator’s Hat When a player relies on one-size-fits-all answers

Introduce the notion that a good communicator needs to become an able translator. Some trainee clinicians are reluctant to discard the clinical

258 

18  Facilitation Techniques

accuracy of medical language for the inevitably less accurate vernacular counterpart. How able are they to communicate the same diagnosis: 1 . to a colleague in a meeting; 2. to an educated lay person outside a medical context (perhaps at a social gathering) who is not a patient; 3. to that educated lay person who is this time your patient; 4. to an uneducated patient; 5. to someone from a different cultural background? One player might attempt these tasks, or you might share them among the group.

Slow the Delivery and Check for Understanding A player seems unaware of the disparity of understanding between patient and clinician

Most patients even if highly educated cannot process new medical or scientific information anywhere near as quickly as a clinician. It is easy for trainee clinicians to forget that they have been initiated into a world where information is characterized by its vast volume and hair-splitting detail. Whoever the patient and whatever their background, the implication is the same. Slow down! Slow your breathing, slow your mind, slow your words! Take your time! Make sure the patient has time to take it in.

Stimulus, Move, Speak When a group seems oblivious to body language

The exercise is based on the common understanding in drama that movement naturally precedes speech (see Chapter 21 “Observation Exercises”). Have the group pay attention to shifts of thought and learn to recognize movements that precede them. The movement may be as slight as a sudden intake of breath, shift of position on the chair, crossing

  Specific Issues Within the Interaction 

  259

of legs, or something obvious like reaching for a bag, or moving to the front of the chair. Beware of prescriptive interpretations. Have them watch for integrated clusters of actions and words. On the other hand, what do you do when words and actions do not match? Notice how movement is more reliable than words alone.

Play the Detective When a group sees only the surface of an interaction

Use this exercise if the workshop allows a little time to diverge from the main business, or as a stand-alone exercise for training in observation. To heighten focus, prompt the group to watch a rich interaction carefully for “clues.” Behind the surface noise of words there is a complex world. Glimpses into this world may throw an entirely new light on what is taking place. Emphasize that the clues may be tiny and momentary, so the group will need to pay close attention. The major question is, how much can we discover in a short time? Then discuss what they noticed and what it might mean. Cross-check their findings with feedback from the actor. The exercise produces a very focused conversation and alerts those taking part to the thousand and one signals that come our way every day to which we potentially pay no attention.

Find the Arc of the Scene When someone cannot see the wood for the trees

Sometimes a player can become lost in detail, and the scene becomes very murky and loses its through-line. If this happens, give the player and actor a few minutes to work out between them how to play the arc of the scene. The arc of a scene is the simplest and boldest depiction of the journey through the interaction shorn of all extraneous detail. It consists of a beginning, a middle (which is sometimes a turning point), and an end. It should take no longer than a minute to play. They are not to attempt any

260 

18  Facilitation Techniques

kind of realism but to find the germ of the interaction that identifies the real issues of the scene. While they are preparing the arc, the rest of the group can discuss the same thing. The player and actor return, play the arc of the scene, and then discuss with the group. The exercise removes all extraneous details, and identifies the most important issue, and a way to address it that is satisfying to both parties. The group then discusses how to apply this concept in professional interactions.

Workshop the Scene To emphasize the collaborative nature of a consultation

This is a similar exercise as above for when a role-play becomes bogged down, and one or two interventions have not found a clear way forward. Have the player and the actor pull aside for a few minutes to work out together a satisfying course of action for the scene. The resulting interaction is to be two to three minutes long, the style realistic, and the interaction plausible. The actor and player come back and play the scene, and the group discusses the interaction. This exercise reinforces the potentially collaborative nature of good communication.

Referral Letters To facilitate better written communication between specialists

This is a specific application of Workshop the Scene. If you have more than one group of specialists in a workshop, you may find that they are not entirely happy with the written communication that usually passes between them but have never actively sought to do anything about it. Sit two specialists down (e.g., a surgeon and oncologist, or a general practitioner and a physician), and have them work out the kind of information they want from each other in referral letters. They need to consider content, volume, and style. This is something most doctors have never done. Then, have them return, and dictate letters aloud to each other on the basis of the case in question.

  Specific Issues Within the Interaction 

  261

From Where You Are To increase the repertoire of group members, and/or to provide more people opportunity for active role-play

One of the great benefits of a role-play workshop is that it provides novel opportunity for people to watch their peers in action. There is a lot to be learned from swapping stories and from watching someone else do what you do every day. To your surprise, you see a completely different approach that solves a situation that you find intransigent, or you discover to your satisfaction that you and your colleagues are all on the same page. One downside of drama is that only one thing can happen at any time, and there are no shortcuts, so things can take some time. Time constraints in a workshop often do not allow each person to interact fully with the actor. So at a certain point well into the workshop, suggest that group members interact with the actor from where they are sitting. Simply say, “Just from where you are sitting, what would you say to this patient?” The actor turns and focuses attention on their new partner. We have found that people have no trouble addressing the patient and do so as if they were sitting with them on stage. The fact that this is not a realistic convention is usually not a problem. This exercise potentially increases the repertoire of each member of the group. For example: • Have the patient ask the same question to each participant in turn. As each person provides their answer, the patient and the group consider and discuss. • Group members may have different ways of approaching a situation. Ask each participant to try their approach, and seek feedback from the patient. • Over time, all clinicians develop set lines and speeches to explain complex or difficult matters to patients (see Chapter 16). They rarely discuss this fact with each other. The speeches are invariably creative responses that they have crafted over a long period. At a relevant point in the consultation, ask each member of the group to give their usual explanation or speech.

262 

18  Facilitation Techniques

This exercise is also useful for workshops incorporating multidisciplinary groups, where different explanations, speeches, and versions of prognosis sometimes produce unintended confusion in the mind of patients.

References Boud, D. 1991. Learning Experience. In Experience and Learning: Reflection at Work, ed. D. Boud and D. Walker. Geelong, VIC: Deakin University Press. Shaw, J., R. Brown, P. Heinrich, and S. Dunn. 2013. Doctors’ Experience of Stress During Simulated Bad News Consultations. Patient Education and Counseling 93 (2): 203–208. Shaw, J.J., S.  Dunn, and P.  Heinrich. 2012. Managing the Delivery of Bad News: An In-depth Analysis of Doctors’ Delivery Style. Patient Education and Counseling 87 (2): 186–192.

19 Workshop Formats The Format of a Workshop Is Determined by Whether You Wish Primarily to Explore Scenarios, Prepare for Performance, or Develop Skills

All role-play is a form of rehearsal, that is, practice for the real thing. However, rehearsal is a broad term. It consists of at least three different modes of practice, each of which generates a different kind of workshop format. The three main formats, introduced in Chapter 4 Role-Play as Rehearsal, are workshops for exploration of scenarios and expanded repertoire; rehearsal to craft or polish performance; and training for skill acquisition.

Communication skills workshops are not limited to one particular format. A school or training department will often gravitate to a particular format through accidents of history, the predilections of the teachers at the time, constraints of time-tabling and finance, or any number of other factors. The discussion in this book is mostly around workshop mode because that has been most appropriate for our purposes, that of providing opportunity to develop communication skills. However, no one format covers all the bases when it comes to providing practice in communication. In this chapter, we consider how the three practice modes produce different kinds of workshops.

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_19

263

264 

19  Workshop Formats

Workshop Mode Role-plays in workshop mode tend to be scenario based. That is, they explore the nature of consultations between professionals and members of the public, or interactions among colleagues. The interactions need to be sufficiently rich and complex to provide plenty of terrain to explore. They also need to be familiar. If they are too idiosyncratic, there will be insufficient application for whatever is discovered. However, even though these situations may be familiar, that familiarity soon fades in role-play. This sense of aliveness is due to the distancing effects of role-play. As observers, we experience the novelty of watching ourselves in action from an outside point of view. As role-players, we behave as we usually do in the workplace but with heightened awareness and insight. The subject matter for scenario improvisation is potentially vast. For instance, our workshops in communication in healthcare include the following scenarios: • Discussion of test results (which usually equates in role-play to breaking bad news) • Mopping up after bad news (usually for nurses and allied health) • Prognosis • Treatment options, risks, benefits, and side effects • Obtaining consent • Handling relapse of cancer • Discussing complications • Discussing surgery or any other potentially threatening procedure • Clinical trials • Genetic counselling • Sexuality • Pain management • Adverse events and open disclosure • End of active treatment and switch to palliative care • End-of-life issues. Workshops based on any one of these scenarios provide more than enough material for a three-hour exploration. However, workshops can

  Workshop Mode 

  265

be more adventurous and be extended in time and subject matter to comprise two, three, or more separate scenarios. Such a workshop might explore the following: • Interactions among different members of a medical team, including the composition of referral letters between health professionals • A multidisciplinary team meeting • Conversations between a patient and the same medical specialist down the pathway of a disease; the group explore initial diagnosis or referral, recurrence of disease, end of active treatment, and end-of-life scenarios • Conversations between a patient and different health professionals involved in their care, such as a surgeon, nurse, oncologist, and general practitioner • Conversations between doctor and relatives after an adverse event as part of a larger programme involving simulation of surgical procedures. Scenario-based workshops tend to be in realistic mode, that is, they reproduce everyday life. This kind of work is akin to scene work undertaken by actors. In scene work, actors engage in active scene analysis. They pull scenes apart, try out different options, identify the subtext underlying the surface conversation, look for through-lines, turning points, crises, and resolutions and explore different ways of playing the interaction to find the most effective and appropriate way forward. The focus is on the scenario itself and the intrinsic challenges that it poses rather than on the ability of any one player to carry it off. A common facilitation pattern for such a workshop would be creative introduction of a case, brief initial discussion leading to role-play, timeout for discussion and feedback, more role-play, discussion and feedback, narration by facilitator of results of physical examination or to progress the passage of time, role-play, feedback, and so on. Beware of presenting too much theory and research at the beginning of a workshop. This traditional approach assumes that theory leads smoothly to practice. Much recent educational research questions the validity of this approach (Korthagen and Kessels 1999; Dowie 2000; Schwandt 2005), and mere common-sense suggests that 20 or 30 beautifully presented PowerPoint slides do not translate automatically into

266 

19  Workshop Formats

changed behaviour. The group will struggle to remember the content of even two or three slides, let alone figure out how to apply them. Introductory presentations are satisfying to the teacher who gets a creative buzz from compiling the presentation. They may be less so for the learners, who gamely attempt to follow the argument and remember the details so that they can put them into practice. A more practical approach is to introduce relevant research at moments of discussion where it is most needed, and where its application is most obvious. Exploration demands time, whether the players are novices or competent practitioners. In novice workshops, students may begin with the most rudimentary grasp of a scenario. In this case, the workshop aims to open up a whole new approach which students can take away and begin to apply in the workplace. The real gains in learning take place outside the workshop itself. For competent practitioners, a workshop provides an opportunity to review the familiar and to move into much greater depths of understanding. The group comes away having discovered new insights to invigorate their usual practice.

Rehearsal Mode Rehearsal proper has an entirely different focus and generates activity of a different kind. When Stanislavsky developed his ideas on actor training, he had the luxury of long periods of preparation for performance, sometimes three months or longer, which meant opportunity to workshop and explore options. Today, directors and actors can only look back with envy on that kind of luxury. Contemporary theatre practice suffers from significant financial constraints, which means that there is little opportunity for workshopping, and the cast tends to concentrate on rehearsal proper. The basic process of rehearsal in theatre consists in reading the script, blocking the action, revising and stabilizing the scenes, and polishing till ready for performance. The aim and purpose of rehearsal is to produce professional performance. The script is never far from one’s thoughts, and the fast approaching performance dictates the use of time. Rehearsals are practical and focused journeys with an unswerving through-line from script to performance.

  Rehearsal Mode 

  267

Role-play sessions based on rehearsal mode will differ depending on whether they address early or later parts of the rehearsal process. In early rehearsals, the major activity is what is called in theatre blocking the action. Later rehearsals are devoted to refinement and polish. Let us take a simple example to illustrate these distinctions. A medical school may decide upon a standardized approach for its students when they introduce themselves to a patient on the wards. In other words, the students are to learn how to perform a basic script for action. The script will comprise a fixed number of elements, the sequence will be recommended if not fixed, and some of the wording may be almost verbatim. The first task is to block the action. The student is coached to approach the patient perhaps with a smile, to address the patient by name with a clear voice, perhaps to shake hands, to give their name, their status as a medical student, their purpose for talking with the patient, the fact that further interaction is voluntary on the patient’s side and that they are perfectly free to say no or to change their mind at any point, the confidentiality of the exchange, and a request for permission to sit down and have this conversation. This is a lot of information to convey in a very short time, and to remember. This first step of blocking the action leads the student through all the elements and the recommended sequence that holds them all together. Note that blocking is not primarily an intellectual exercise but comprises words to be spoken, actions to be carried out, and a manner in which that is to be done. Once the script for action has been blocked, the students need to practise the steps and polish their act. They need to get each element in sequence, identify which ones they have forgotten the first time through, consciously include them in the next practice run, practise the phrasing so that it becomes familiar and requires less effort to remember and to say, and develop a comfort with the performance (because it is a little performance) so that they approach the patient in a natural and empathic manner. The mechanicalness eventually disappears, so that all that is left is a professional, but friendly, human exchange. Let us take a more complex example. We have for several years run workshops for junior medical officers on how to break bad news. The scenario specifically deals with a common situation faced by over half of

268 

19  Workshop Formats

these young doctors in their first year, namely, to inform someone that a loved one has died. Junior doctors are extremely time-poor, so there has been opportunity for only one training session of two hours. From a dramatic and an educational point of view, this is a very tough call. Even seasoned actors would struggle to wrap their heads around this kind of interaction and carry it off to their satisfaction after only one such session. Novice doctors vary tremendously in their readiness and capacity to carry out this task. They have little or no direct experience of this kind of interaction, and those who have already been called upon to do so have given it their best shot but often have no real idea how well they went. As a group, they have only the most rudimentary idea of what is involved and are extremely apprehensive. Hospitals and area health services invariably have protocols for breaking bad news, but protocols and guidelines are not entirely helpful, as they are not scripts for action. Protocols are a little like the rules of tennis. They set out the size of the court, the line markings, the rules of play, the system of scoring, and the personnel that facilitate the match, and arbitrate in cases of doubt. They do not teach the players such important skills as how to swing the racket, keep their eye on the ball, serve, read their opponents and analyse their games, monitor their own performance, and maintain equanimity and composure under stress. The young doctors most of all need a script for action. They need rehearsal so they can, in terms of the tennis analogy, actually play the game. A scenario-based session in workshop mode would take longer than busy schedules allow, and be way too open-ended. If the young doctors already knew what to do, that would be a different matter. A session in workshop mode would then provide opportunity to deepen and refine their current practice. However, they often do not even know how to think about the situation or know what they are to do. They need clear, unambiguous take-home messages. When such a situation subsequently does occur on the ward, it will most likely be without much warning, and they will need immediately to be able to recall exactly what they have to do. They need an early rehearsal structured around blocking the action. Blocking takes the group forward one step at a time. You start where they start. You give them a putative case, and say,

  Rehearsal Mode 

  269

“You have been part of the arrest team, resuscitation was unsuccessful, and you have been charged with informing the relatives. How do you feel when told you are the one to break the news?” We identify the anxiety and dread. “How do you become calm and focused?” We learn to become calm and focused. “What do you do just before you walk in?” We learn how to marshal our resources, settle our nerves, wait for the impulse to walk in, and then do so with composure. “Why do you say, I have some bad news?” What is your objective, that is, what do you want to happen? We learn how to cue the relative, not just say the words. “What is the story you have to tell?” “What is the punch line?” “Why might your account make sense to you, but not to the relative?” “Why do you pull your voice back into your throat when it is time to say the word ‘dead?’” “What do you do now?” “How do we recognize and manage shock, disbelief, grief, anger?”

Step by step we work our way through the scenario: how to know what to do at any moment, how to understand what is going on within ourselves and within the relative, what to do next and why, what the relative is likely to do or say, the temptation to verbal diarrhoea caused by our own distress at the distress of the relative, how to provide comfort and empathy, till we walk with the relative to the bed where their loved one lies dead. As much as possible, the rehearsal remains practical, and new understanding is tested on an actor playing the relative. Time is spent on activating awareness and learning to compose oneself, paying attention to words and body language, speaking in understandable English, and identifying the overall shape of the encounter and the main stepping stones through it. There is no possibility of polish in early rehearsal. Blocking is about identifying the structure of an encounter, the main elements, the beginnings of meaning, and learning what you need to work on. If you are lucky, you may have access to later workshops where you can polish and refine understanding and practice. In the reality of Australian hospitals, polish unfortunately only comes through subsequent practice of the real thing on the wards.

270 

19  Workshop Formats

Training Mode Training usually occurs before workshop or rehearsal. The dominant interest is that of acquiring and combining new skills. The training mode of role-play is akin to drama exercises, games, and mastery of props in the world of theatre. The interaction between Hamlet and Laertes during their onstage duel presupposes that both actors know not only how to handle a sword but also how to do so as a privileged upper-class Dane with years of experience and expertise. They will have fast-tracked a history of many such sword fights and learned the choreography of this particular duel. This training in stage combat needs to precede later rehearsals. By focusing on one specific aspect of performance, players become aware of that aspect, and gain competence in it. The training exercises steadily place new insights and skills into the conscious hands of the students. They usually comprise elements of demonstration, modelling, practice, feedback, correction, and more practice. Student health professionals receive training in clinical skills from very early in their education as they master basic tasks, such as washing hands, taking blood pressure, palpation, suturing, catheterization, plastering, auscultation, various physical examinations, histories, and so on. Later in their careers they receive training in advanced skills, such as life support, trauma and crisis management, teamwork, or deteriorating patients. Training is often carried out in simulated operating theatres, anatomy labs, and clinical skills centres using resources such as laparoscopic models, patient-simulator mannequins, and video replay. Once purely clinical skills are mastered, they are often then integrated into the communication required among colleagues and with patients and their relatives. At this point training often switches over to workshop mode. Training in communication skills is currently often not as advanced as is the case for clinical skills. Technical equipment is not as much an issue as it is for clinical skills. A video camera or DVD player for feedback is usually the most that is required. In most cases, however, the most effective instrument is an accomplished facilitator. The following are some examples and suggestions for training sessions in communication. Some

  Training Mode 

  271

training goals, such as learning a new clinical approach, might fill an entire workshop. In other cases, training can take the form of stand-alone exercises, or training slots within a scenario-based workshop.

Learning a Specific Approach Training in communication skills based on algorithms, acronyms, or approved philosophies

Communication skills workshops that seek to inculcate a particular approach inevitably are a form of training. Such training sessions recommend specific approaches, sequences of actions, and even specific language. They are less open-ended than workshops proper. Usually they involve modelling of some kind, followed by practice, feedback, and correction. For example, practice in collaborative frameworks, shared decision-­making, patient-centred communication, the use of decision aids, discussion of clinical trials, DNR (do not resuscitate) orders, or recommended acronyms such as PLISSIT (discussions around sexuality), or SPIKES (breaking bad news) are all examples of workshops heavily based on training mode.

Reflective Observation Using a Video Trigger The observational powers of students and trainees are often blunt, and they miss important distinctions. This exercise sharpens powers of observation and discrimination.

Students watch a videoed interaction as a focus for observation. The footage may be that of an actual consultation, approved with the consent of all parties concerned, or a scripted, dramatized interaction. Through stop-and-start and directed questioning, students are encouraged to develop their powers of observation. They learn to pay attention and to shift it from one area to another; to recognize the meaning of body language; to listen to exact wording; to grasp the meaning of pauses and silences; to sense the subtext below the flow of language; to understand

272 

19  Workshop Formats

the choices and appreciate the communication of a proficient practitioner. This kind of exercise needs to be done slowly. The group needs time to notice, to make fine distinctions, and to reach for the most appropriate words to describe what they see. As they do so, they begin to get in touch with the complexity of what happens when a professional and a client interact. By heightening powers of observation, the exercise produces a richer vocabulary by which to understand professional interactions and increases potential repertoire of behaviour.

Reflective Observation of Each Other Professional conversations are a special subset of the way that we communicate with each other every day. However, students are often unaware of the natural elements of everyday communication (see Chapter 21 “Observation Exercises”).

Students take turns to tell the group a short story from their own life for no more than three minutes. The story might be comic, or serious, it is simply enough that it is meaningful to the teller. In discussion after each telling, lead the group to identify important elements in the storytelling. When does the teller get back in touch with the experience of the story? Notice how we shift from narrative to dramatic mode. Notice how the teller unconsciously but immediately cues us as to how the story will end. How do we sense whether this is the first time that this story has been told, or whether it is a well-rehearsed routine? Notice the use of the hands particularly at key moments in the story. The quality of the observation and discussion rises with the telling of each new story as the group very quickly become more  aware as  observers. Allow time to consider how to apply these insights to future conversations in the workplace.

Change Your Objectives Our actions become far more effective if we are conscious of what we are trying to achieve when we speak or listen.

  Training Mode 

  273

This exercise introduces the power of one’s objective to alter the course of an interaction. In subsequent discussion, the students recognize how their behaviour changes with their changed objectives. Divide into groups of three. Each group decides upon a simple but interesting case, whereby the doctor must inform a patient of a diagnosis and treatment. One of each group takes on the medical role, one the patient, one an observer. Allow two to three minutes for each encounter, then call timeout, and have each group discuss what they have found. Perhaps ask one group to present a summary to the full group. Then have them rotate roles and play the same conversation with a different objective. The different focus each time produces a different interaction. Some examples of possible objectives: • Make sure that you give every factual detail (become aware of the difference between talking to a colleague and a patient). • Make sure that you do not unnecessarily upset the patient (monitor, and allay, the patient’s anxiety levels). • Make sure that the patient understands the implications of what you are saying (recognize that patient reception is more important than the words that leave your mouth). • Try to avoid anything that will cause possible distress (discover the negative impact of evasion). • Make sure that the patient grasps the three most important facts (learning to become proactive in information transfer).

The Importance of Space Have students discover for themselves the significance of spatial considerations in conversation with patients

Divide into groups of two or three. Instruct them to stand in different configurations from each other and to discover what they can about differences in distance, height, and angle. The exercise lasts ten minutes, and each group presents its findings.

274 

19  Workshop Formats

Finesse their findings during discussion, for example, by having them stand too close, and then too far, from each other. Where is the most comfortable distance? How do they know? Their insights will tend to be of two kinds. They will quickly theorize reasons for the differences and identify age, status, gender, and familiarity as factors determining comfort and discomfort for distance. However, this theoretical knowledge is not what leads them in the moment to decide on the appropriate distance. Pull them back to the moment. How do they know in this case that this distance feels most appropriate? Get them in touch with their own kinaesthetic awareness that gives them this information. Usually this exercise translates automatically to more heightened awareness on the wards both of their own behaviour and as they watch doctors interact with patients.

Other Exercises Use some of the interventions listed in Chapter 18 “Facilitation Techniques” as exercises in training mode. For example, you might consider any of the following exercises: • • • • • • • • •

Three questions Split focus Stimulus, move, speak Best case, worst case Go for broke Wrong end of the stick Arc of the scene Workshop a scene Play the detective

References Dowie, A. 2000. Phronesis or ‘Practical Wisdom’ in Medical Education. Medical Teacher 22 (3): 240–241.

 References 

  275

Korthagen, F.A.J., and J.P.A.M.  Kessels. 1999. Linking Theory and Practice: Changing the Pedagogy of Teacher Education. Educational Researcher 28 (4): 4–17. Schwandt, T. 2005. On Modelling our Understanding of the Practice Fields. Pedagogy, Culture and Society 13 (3): 313–332.

20 Composure Exercises That Produce Greater Composure, Focus, and Confidence, That Lower Performance Anxiety, and Improve Your Voice and Diction

Many facilitators have not had the benefit of training in dramatic performance. This chapter offers simple techniques to reduce background anxiety and to promote a calm and focused state of mind in challenging situations. This material offers practical, hands-on instruction. Therefore, it is somewhat like a computer manual—hardly enjoyable as bedtime reading, but useful when you have a problem to solve. Real benefit comes only from doing the exercises. The best approach is to read and practise.

The following exercises develop the basic composure skills that are presupposed whenever we step up and turn to address our colleagues and superiors. This is not the kind of work you do immediately  before a workshop. This is the work you do in private on yourself so that you will have well-honed techniques to draw upon whenever you need them.

Diagnosis: Take Your Own Pulse Impending performance can have an unnerving effect upon the would-be performer. You know that you need to be calm and collected in order to © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_20

277

278   

20 Composure

handle the upcoming task. Meanwhile, your body recognizes potential danger and has kicked into vigilant mode, leaving you anything but calm. If you take this inner turmoil with you into action, most of your personal resources will be diverted into keeping the lid on the anxiety and into driving it back down into the subconscious so that it won’t show. With few inner resources left, you will not be able to act as an autonomous agent, but will instead react to incoming stimuli. Your faculties will be fragmented. In a workshop, you will miss many messages that come your way. Instead of calmly reading a situation de novo, your need for a sure-­ fire solution may have you hastily take a previous script off the shelf, dust it off, and prepare to roll it out as before. You end up with one of the cardinal sins of performance, namely, imitation rather than the real thing. At the end, no one will be satisfied, including you. There is no life in it, only suppressed anxiety, and a feeling of relief at the end. There is nothing in it to make you want to repeat the exercise. Firstly, recognize that your experience is universal and normal. Performance anxiety is not a sign of inability or of something gone wrong. It signals the presence of forces within you that need to be brought out into the open and mastered so that you can perform with confidence. Anxious arousal is a normal and natural part of the process, the breeding grounds of the proverbial butterflies in the stomach. You need noradrenalin-­adrenalin-­fuelled arousal for vigilance, increased concentration, and strong, purposeful action. The anxiety component reflects your attitude to that arousal. Direct your attention to the presence of alarm within you, and to the ways that it affects you and your body. You might think that becoming aware of your anxiety would only make the situation worse. However, by identifying muscle tension, shallow breathing, stiff posture, and overexcitability, and by linking them to the anxiety and to the challenge that has created that anxiety, you are given potential mastery over each factor and over their combined effect. You may discover that your breathing is shallow. Why is this? Check your rib cage and your intercostal muscles. You may find that they are locked tight like a suit of armour. Normally, the ribs and muscles move in and out as you breathe like a set of bellows. However, when the intercostal muscles tighten, the rib cage becomes locked, and your breath is forced up

  How to Do These Exercises: Paying Attention 

  279

high in the chest. The intercostals are no longer as directly involved in the process of breathing, and you may try to control the outflow of breath by constricting the air flow with muscles in your throat. The moment your body recognizes that your breathing has become restricted, it goes on the alert and scans your environment for good reasons not to be anxious. The physical tension affects your breathing, emotional state, mental focus, and voice and diminishes perception and situational awareness. You find it hard to access necessary spontaneity and creativity. You might make an attempt to relax and to not be anxious. You have probably already discovered that that route may lead to even greater tension and anxiety. Drama is about doing things that produce desired consequences. To relax, you do not try to relax but instead do something that will lead to relaxation. The simplest way to reduce your global experience of anxiety is to go for the most fundamental element under your control, which is your breathing. To perform without anxiety, you need to be able to breathe freely, and to breathe freely, you need flexible muscles that allow you to do so.

How to Do These Exercises: Paying Attention The most important aspect of this training is the new awareness that the exercises produce in you. Hidden tension and overlooked muscles appear on your radar screen as the first step towards ownership and mastery. Pay full attention to what you are experiencing, and become aware of insights moving from the subconscious into consciousness. Breathe in and out slowly, and coordinate the exercises with the breathing. Take your time.

Shoulders Direct your attention to your shoulders. Under prolonged social pressure, we tend to lift our shoulders and to keep them slightly raised, as if to ward off physical blows to the back. Muscles are assigned to keep the shoulders raised throughout the day as we go about our work. The result is physical tension and soreness around the shoulders and between the shoulder blades. To relieve the tension, raise both shoulders as far as comfortable. Consciously release the neck muscles so that only the shoulder

280   

20 Composure

muscles are working. Hold that position for about ten seconds. Then, release the shoulders, and let the shoulders and arms drop. Swing the shoulders from side to side in a shimmy movement so that the arms swing freely about the torso. Do the exercise at least three times. Pay attention to the physical changes. The sensations will change slightly every time you do the exercise. Your arms should eventually hang like dead weights from the shoulder joints.

Stretches In order to breathe freely, the intercostal muscles need to be flexible and responsive to the movements of the lungs. Any stretching exercises will help to loosen the intercostals. Reach your hands gently up to the ceiling, and nudge them as high as they naturally go. Send your fingers a little higher by extending the rib cage. Become aware of the warmth in the intercostal muscles as you do so. Relax and slowly lower the arms. Do at least three times. Be aware of the muscles warming and loosening. Then raise your arms, and stretch first to the right and then to the left. Do it gently, and become aware of the intercostal muscles stretching as you do so. Explore with stretching in different directions. Use exercises from any tradition or school known to you. Do whatever feels good. You gain greater benefit if you enjoy the process. Move slowly, and pay attention to the shifting sensations in the muscles and limbs. Do not strain, but simply allow your limbs and muscles to move towards their natural extensions, and then return. Set out on a voyage of discovery, and invent your own exercises. In our work life, we usually restrict our limbs to a very narrow repertoire of movement. Use these exercises to challenge that limitation, and rediscover your full repertoire. As for all else in performance, the rule of thumb is use it or lose it.

The Spine and the Neck Under stress, our spine tends to sag. Try this experiment yourself. Stand upright, and let your attention travel to your spine. Allow your spine to sag by a centimetre or two. Pay attention to your state of mind as you do

  How to Do These Exercises: Paying Attention 

  281

so. You will potentially sense a drop in confidence even with such a tiny deflation. Inflate the spine back to an erect position, and confidence returns. Extend the movement. As you let your spine sag, let your neck bend and your head and jaw move forward. This is the common posture of someone burdened with stress. This means that the posterior neck muscles must support the weight of the head which no longer rests upright on top of the spinal column. Become aware of the neck muscles working to hold your head upright. Imagine the impact on neck muscles forced to hold your head up all day as you go about your work. They will certainly be sore, and you may suffer from headaches. To relieve stored tension in the neck, take hold of the muscles in the back of the neck with the left hand. As you hold the muscles tightly, make small head movements up and down, and side to side. Yes, yes, no, no. Yes, yes, no, no. Yes, yes, no, no. Repeat with the right hand.

Locked Knees Stand with feet slightly apart so that you feel stable. Ask yourself, are your knees locked? If they are locked, unlock them. You will become aware of the muscles in your legs which are now fully supporting your body. Usually, the bones in our legs carry much of the weight, so this may be a novel sensation. You will probably also feel out of balance. Loosen the muscles in your pelvis, and move your upper body slowly back and ­forward over your feet. Let your legs carry the weight, and you will be standing in something close to natural posture. You may feel a little strange and conclude that you are doing something wrong. The sense of strangeness is simply that the new realignment and the absence of tension feels new. Be empirical, and identify the effect of locked knees for yourself by a small experiment. Stand with your knees unlocked, and then lock them rapidly. Your head and torso move automatically forward (first impulse), and then self-correct, and pull back into an upright position (second impulse). Now, scan your body for tight muscles. There will be tension all through the upper body in such muscle groups as the neck, the shoulders,

282   

20 Composure

the lower back, the diaphragm area, and the buttocks. Your body is working hard simply to stand upright. At the end of a working day, much of your fatigue may have a lot to do with these locked muscles. Unlock the knees, allow your body to adjust, and find its new centre of balance. You will notice that muscle tension is significantly reduced throughout your entire upper body.

Divide the Body in Two Now, allow your attention to move to the bottom half of your body, that is, your legs and pelvis. With unlocked knees, become aware how strong your legs are, and how capable they are of holding you upright, and keeping you in balance. Imaginatively separate the top half of your body from the lower half. The impression is of sitting on your bottom as you stand. Let your attention favour your legs. You don’t need your upper muscles to do anything in particular, so you can “sit” quite calmly on your legs. Notice how relaxed the breathing becomes once you get used to this idea. You should find that your state of mind has improved considerably as well.

Walk With Your Legs Go back to standing with locked knees. Become aware again of the muscle tension throughout almost every muscle group in your body. Do not generalize in your observations but become aware of every group. Then walk. People commonly experience a physical jolt and muscle tightening as they begin to move, and many hold their breath for a moment. The freedom in movement usually disappears. Now unlock your knees again. It might sound ludicrous, but tell yourself to walk with your legs, and then do so. Let your leg muscles do all the work, and let your torso sit calmly on the pelvis with minimal muscle tension. Note that your breathing is free, and that your mind is clear. Notice that, when you give yourself the instruction to walk with your legs, you tend not to hold your breath as you start off.

  How to Do These Exercises: Paying Attention 

  283

Double Objectives: Be Calm and Act If you discover that you tend to tense up at work, and to become preoccupied and anxious, you may find the device of double objectives useful. Start with a simple task. Sit on the floor, or in a chair. Sit for a minute until your breath steadies, and you feel calm and collected. Tell yourself, I have two objectives: the first and more important objective is to retain whatever calm and clarity I have achieved. The second objective is quite simple: I am going to stand up. The double objectives can be summarized in one sentence as be calm and stand. So now, remembering that the first objective of retaining a sense of calm is the more important one, stand up. Then, contrast to the experience of standing without the first objective. Simply stand up. You will probably notice that with double objectives there is little jerkiness or muscular tension in the movement. You do not hold your breath as you get up. Your visual and mental focus does not fracture during the movement but maintains an unbroken flow of attention from floor to standing. Extend the exercise into movement. Be calm and walk, then compare to when you walk without being ready. You will notice similar or identical results to the exercise walking with your legs. You do not lurch into action, hold your breath, or tighten your muscles, but instead move smoothly from stillness into movement. Use whichever technique works best for you personally. Practise first during work hours when you don’t need it. Develop the skills for a time when you will face a really challenging situation, and you want to be on top of things. The technique can be used at any time when you need to be calm and in control of yourself— be calm and write, be calm and listen, be calm and introduce yourself, or be calm and sit down.

Reprise You may be asking yourself, why are we spending time sagging and unsagging spines, and locking and unlocking knees? Physical tension affects us at the most basic levels, even in low-stress situations. Some of us are all too often anxious bundles of tight muscles and shallow lungs. We breathe shallowly, tense easily, and do not respond in the moment as well as we might.

284   

20 Composure

Now add in the stress of a challenging task set before you such as facilitating a new role-play workshop. Ask yourself whether you are best served walking into the situation unconscious and a bundle of nerves, or walking in self-aware, in the moment, muscle tension at low levels, and your mind clear and calm. The ultimate goal is for your attention to be harnessed and under your control and for you to be calm, focused, and alert.

The Importance of Breathing Four Deep Breaths What do you do in a challenging situation when things slip out of control, and you suddenly  realize that you have become unduly anxious? What technique do you use to pull yourself together and get back in control? If you do not already have a strategy, remind yourself, “I am only twenty seconds away from self-control,” and take four slow, deep breaths. Breathing is the simplest and most effective way I know to break into the cycle of anxiety. Regular physical stretching is a fundamental prerequisite, in that free and natural breathing is impossible in a tense torso. The effect of taking four or five slow, deep breaths is heightened even more if you pay attention to the impact of each breath on your state of mind. Notice that each in-breath has an effect different in quality to the one before it. It may help to imagine a dial on your forehead with a needle that moves steadily across from red in the direction of green with each breath. Notice that your mind becomes calm and clear in a remarkably short time. Four deep breaths is a handy technique to take into a workshop situation. Use it whenever you realize that you are no longer calm. Focus on the breath has a long history in theatre. The young actor feels daunted by his first important role and asks the director for some advice on what he should do when he goes on stage. “Keep breathing,” says the director, “and don’t knock over the furniture.” The actor looks surprised and a little disappointed at the apparently prosaic advice. However, he soon discovers that, in fact, his breathing is the one thing he can always control. As he controls his breath, that sense of control permeates his being and steadies his nerves. The technique is useful to anyone who is called upon to perform on a public stage.

  The Importance of Breathing 

  285

Natural Breathing To breathe more calmly under stress, I suggest that you enhance your understanding of breathing and spend a little time on some breathing exercises. Find a quiet place where you can lie down on a carpet, and simply breathe slowly and deeply for five minutes or so until the nerves steady. You can gain similar benefit sitting in a chair or a car seat. However, by lying on the floor, you are largely freed from the effect of gravity, and you are able to breathe more calmly. Become aware of the floor or the chair supporting you. Sink back into it. Breathe slowly in and out, and let your attention dwell on your breathing and the movement of your torso. Within a few minutes, your breathing will slow down and settle back into your natural breathing pattern. Become aware of the pattern of your breathing and the fact that your breathing may not have the same pattern as those who work around you. The way you are now breathing is the way that your body wants to breathe. Let your attention expand to include the effect on your mind. You should experience a growing sense of calmness and focus. Do not rush the exercise. Many actors faced with a demanding stage performance find that this exercise, simple as it is, is the most effective way to steady the nerves and centre their energies. Quiet breathing cleanses the system from agitation, induces a sense of calm and control, washes away all other tangential considerations, and focuses the mind on the task at hand. If you feel that you do not have time to do this, tell yourself that it is actually work, which it is. If you feel that you do not have time to do this, then you probably need to.

Holding the Breath Pay attention to the moment when you have breathed in and are about to breathe out. From the experience of workshops, anywhere from a third to a half of us hold our breath momentarily before breathing out in a recurring act of self-censorship. This is not surprising when you consider the stressful nature of the modern workplace. The fractional hold of the breath may seem insignificant. No one else sees it, and most people

286   

20 Composure

remain unaware of it in themselves until it is pointed out. However, years of experience as an acting and voice teacher has drilled in the importance of such an apparently insignificant catch in the breath and its self-­ reinforcing, negative impact on confidence and self-esteem. The solution is simple and effective for most people. Simply allow yourself not to do it. Tell yourself any of the following: “I don’t need to do this anymore.” “Let my breath flow in and out.” “There is no such thing as the end of a cycle.” “The breath naturally ebbs and flows like the tide.”

For many people, the change is almost immediate; for others it takes a little longer. It is important not to force yourself to stop. Simply give yourself permission not to hold your breath.

Waiting to Breathe Now let your attention move to the point where you breathe out and are about to breathe in. Do you breathe in before you really need to? Wait to breathe in. Wait as long as you like. Let your body itself decide when it wants to breathe in. Continue to breathe in, allow yourself not to hold the breath, breathe out, and wait to breathe in, and so on.

Deepen the Breathing Pay attention to your torso as it rises and falls. Imagine that there is a balloon within your torso that fills with air as you breathe in, and deflates as you breathe out. Where in your torso is this balloon? Place a hand directly on top of the balloon so that it rises and falls with the breath. If your hand is above your navel, let the balloon and your hand drop a couple of centimetres down towards the navel. You may perhaps feel resistance of some kind as if there were a kind of band underneath stopping the balloon from moving down. If so, imagine that the in-breath melts away the resis-

  The Voice 

  287

tance. Some people feel some emotion with this exercise, and that is quite normal. Physical and emotional tensions are linked. Your deepening breath may encounter factors that drove it to be shallow in the first place. Continue to deepen your breathing in an unforced manner. Then return to natural breathing.

The Voice Australian and British actors undertake many hours of voice work as part of their training. This is impractical for most people, even though we use our voices all day and every day. However, vocal warm-up in the morning shower takes no extra time and makes the voice more resilient and less tired at the end of a busy day of talking. Simply sing in the shower, or hum forward onto the lips as you lie on the floor doing your breathing exercises. Do not sing or hum too loudly, until the voice is warmed up. You can tell when this has happened. The voice loses its “sticky” quality, and becomes smooth. Try it, and you’ll see what I mean. The length of time varies from person to person, but during shower time should be ample. The ready supply of water vapour helps to lubricate the voice, and bathroom tiles are wonderfully flattering to the ego. To check that your voice is warmed up, perform this simple diagnostic test. As you hum, imagine that the sound travels away from your lips in a straight line like a thread. If the voice is warmed up, the thread will be smooth and even. If not, you will notice little kinks in the thread. Now hum, or sing up and down, through your vocal range and listen carefully for any jumps or breaks. The voice should slide smoothly up and down its range without jumps, like the slide of a trombone. If you discover a break in the voice, iron over it by humming up and down over the break. Then test to see that the voice has become smooth. You may be unaware that physical tension in the torso affects your voice in a negative way. As the intercostal muscles tighten, and the breath becomes shallow, the voice loses what voice teachers call its support. Think metaphorically of the voice floating atop a column of air rising upward from the lungs. In a natural state, sound is generated on the out-breath as

288   

20 Composure

the diaphragm and the intercostal muscles release air up through the larynx. However, with physical tension and shallow breathing there is less breath for the supporting column. The problem may be compounded if you try to counteract the lack of voice by using muscles in the throat to generate the sound. Without your being aware of it, your voice retreats into the back of the throat in what is called pull back. You open your mouth and address the group and are completely unaware that anything has happened to your voice. To you, it sounds the same as usual, if a little nervous. Your voice, however, has lost its resonance. Through tension, it no longer has access to the large resonating chamber of the torso. The result to your audience is an impression of high pitch. The voice takes on a tense and disembodied quality. There is an impression that you are sending out a copy of your message and waiting to see what kind of reception it meets. The sense is that, if you meet a good reception, perhaps you will send out the original. However, the whole process is unconscious until you are made aware of it, and so the original remains unsent (Rodenburg 1992, 169). Though you think that things are continuing as normal, your listeners do not perceive you in the same way. Your audience may be a group of peers, delegates at a conference, examiners, or your boss. You may be unaware of what is happening, but this does not stop your listeners from feeling disquiet. Some of them may begin to feel physically tense themselves as your anxiety transfers to your audience, who feel your agitation as if it were their own. Unbeknownst to you, you cease to sound authoritative and confident, and your audience struggles to give you credence. The cause of this disquiet is not your inability to communicate but the simple retreat of your voice due to the unrecognized physical tension in the torso and throat. The solution to pull back is simple enough. Take a moment to stop. This is the most important. Stop! Perhaps cover the moment with a drink of water, or by rearranging your notes. Take a moment to breathe out, and release the pent-up tension in your torso, and then slowly breathe in to a relaxed torso, fully and deeply, and with enjoyment. Take your time. The whole process may seem to you to drag, but it is likely only to take two or three seconds. Practise this skill in a situation where you have the freedom to wait until ready. You will quickly learn to recognize the moment when you are ready to speak again. Resume talking when you are ready.

  The Voice 

  289

There is a calm, pleasant, and full feeling when your breath has stabilized, and you are ready to speak. Your voice now projects forward and out into public space. This impression of full voice is often called projection in common parlance, though voice teachers prefer terms like placement. Your voice sounds warmer, fuller, louder, deeper, and more assured. Your listeners have the sense that your voice fills the space and reaches over and touches them. You sound convincing, as if you know what you are talking about, and your listeners become less tense. If you want to gain greater control over your voice and to minimize the chance of pull back in inconvenient moments, practise pulling your voice back in your throat, and then placing it forward. “I pull my voice back,” then, “I place my voice forward.” Once you can do both at will, you are ready to remedy the situation immediately should you suddenly find yourself tense and sounding somewhat less than convincing. Others resort to another unconscious vocal stratagem to manage stress. The phenomenon is more common in men, but it also in occurs in women who have to play the game tough to make it in a man’s world. It is called clamp down. We have all seen and heard the clamped voice. The speaker steadies the torso and nudges his or her chest forward while simultaneously drawing the head backward in an impression of a powder pigeon. The voice comes out deep and apparently authoritative, which is the intention. However, the voice does not have the warmth of a well-placed voice and conveys an impression of aggression. “Any questions?” the lecturer declaims, and there are surprisingly few. The stance is actually born out of insecurity and is an example of mimicry and imitation at work. The speaker creates an imitation, or an impression, of authoritativeness rather than trusting it to occur as a natural by-product of confidence and self-­ assurance (Rodenburg 1992, 164). Now consider the clarity of your speech. Do you mumble or swallow your words? Do you speed up and gabble under stress? Imagine that you walk forward and introduce yourself to a group. My name is William and I’m your facilitator today in this communication skills workshop on breaking bad news.

290   

20 Composure

If the members of your audience have English as a first language, the name “William” is instantly recognizable. The sound of your name is not something new to be processed for the first time. However, if you had said, “My name is Nilru, Fadzeela, or Akanksha,” the same easy recognition might not apply. Multicultural Australia is blessed with a profusion of names from the mundane to the exotic. Unless your audience possesses the same ethnic heritage, your name may not register on their list of known names. Their history will not have prepared them, and they will find it hard to assimilate the strange name as it slips by in your introduction. Two simple drama techniques are useful here. Both techniques remind us to be proactive and to give our name or any other information that we wish to communicate rather than just open our mouth and hope that others will pick up the important details.

Consonants Carry The most important component in the sound of your name is the consonants. Consonants carry is an old stage adage. If you want to communicate a word, a phrase, or a complex argument, clarity comes with clear consonants. Without clear consonants, vowels can sound murky. Your name may not have the easy recognizability of William. The vowels of your name may be i-u, or a-ee-a, or a-a-a. If you make no effort to communicate your name, that may be all your audience hears. Pay attention to the consonants in your name. Practise saying your name aloud while you emphasize the consonants one by one. Exaggerate a little. Linger on them long enough to produce their correct sound. The robust sound produced by paying attention to consonants, by savouring them, and giving them their due weight, is referred to as muscularity. The aforementioned vowels now become NiLRu, FaDZeeLa, and aKaNKSHa. Once you have done this a few times, you will be able to communicate your name more clearly (Berry 1973, 43). The same issue applies to any specific phrase you wish to communicate to someone who is unacquainted with it. Try the consonants in some medical terms: VeNTRiCuLar FiBRiLLaSHon, SeNTiNeL NoDe,

  The Voice 

  291

CoLoNoSCoPy, RaNDoMiZaSHoN, STRePToKiNaZe. Imagine that each word is a gymnastic routine on the high bars. The passage through some consonants is relatively simple, while for others it is quite complex. Each consonant cluster has its own natural rhythm and duration. Hurry through it, and you muddy the sound. Take your time. Pay respect to the sounds, give them their due, and they spring to life resonant and clear. Memorize this sentence, practise it aloud, and use it as an exercise to clarify your speech: Muscularity of lip and tongue fills the room more fully than volume.

Work forward word by word. Treat the sentence as a gymnastic routine. Each word has its own weight, rhythm, and duration. Let the words determine your pace of progress. As you repeat the exercise on subsequent occasions, you will notice that your diction becomes clearer. The sentiments of the sentence reinforce the value of the exercise. This exercise is of benefit for performers of all ethnic backgrounds, including native English speakers. Native speakers often absorb lazy speaking habits that omit, substitute, slur, and combine consonants. As a result, we often mumble or swallow our words. The English language includes complex clusters of consonants (e.g., STR, STS, SKS, SPL, NTR, LZ) which can be daunting for speakers of some other languages and need to be mastered. Time spent muscularizing your consonant sounds is time well spent if you wish your communication to be clear. Once you develop clear diction, you can be heard at the back of an auditorium even if you whisper on stage. It is the muscularity of the sounds, and your commitment to them, that is far more important than volume.

Pointing The second allied technique is called pointing. This means that you actively separate out words or phrases from your message that you particularly wish to convey to the listener. For instance, if you stand somewhat nervously and introduce yourself without any particular objective in mind, the audience may hear a stream of sound, something like,

292   

20 Composure

GoodafternoonmynameisprashadhineeI’myourfacilitatortodaywe’llbelooking athowtodiscussprognosiswithananxiouspatienttheworkshopwilllastforthree hours.

You have given your audience no assistance in distinguishing which words are more significant than others. Your name flies by before they are aware of it. By the time they realize that you have told them your name, the moment has passed, and they are focusing on what is coming next. They weren’t cued to pay attention to it, and they can’t go back to catch it a second time. The onus was entirely on the group to process the message. In this situation, there were possibly four things you wished to communicate: 1 . Your name, which you would like them to remember 2. The fact that you will be responsible for the task of facilitation 3. The central focus of learning for the day 4. How long the workshop will last. These four points are the most significant elements of your opening message. To point them, you simply place a pause before and after each significant word or phrase, or slow the delivery of that section, or emphasize it in some other way. In typographic terms, it is as if you underline, or highlight those particular sections. Instead of leaving your listeners to work out the most important information, you need to do the work for them. You can probably do this simply by consciously choosing which components you want to give to your audience, which components you want them to hear. The unbroken stream of sound transforms into: Good afternoon. My name is Prashadhinee. I’m your facilitator. Today we’ll be looking at how to discuss prognosis with an anxious patient. The workshop will last for three hours.

Use pointing wherever there are new technical terms, or bits of information you want people to remember. The technique shifts the onus for identifying important information from the group to you.

  The Voice 

  293

Getting Onto Stage You have now identified and released excess physical tension. Your breathing is deep and calm. Your voice is warmed up, and you know how to speak freely and without constriction. You have practised simple vocal exercises, and your diction is becoming clearer. You sound articulate. Your anxiety has been significantly reduced. The butterflies in the stomach simply remind you that useful stress hormones are at your disposal. Now, when you walk onto the stage of your demanding performance, how will you appear? Will you seem at home, or ill at ease? Often, our attention is focused on getting onto the stage in one piece and on remembering the first words to tide us over the initial awkward moments. You will probably enter somewhere between two default modes. You may walk in, appear confident, and project a sense of stage presence. That sense of presence reflects the fact that you are in fact present, that is, wholly in the moment. Your breathing is natural and calm. You do not retreat from the room but seem to embrace it and to fill the space. Or you might walk in ill at ease. Your hands seem to belong to someone else and don’t know what to do. You have an ambivalent sense about you, a sense of not really being completely there. You appear overly formal or nervous. You talk the talk, but your audience does not feel comfortable and feels they must respond in a formal way. The mood in the room is awkward, and no one is able to relax. Which is closer to your default position? If your default mode is the former, you already know exactly what to do. If your default setting varies, or is predominantly the latter mode, you may want some choice in the matter. If you feel unconfident about your ability to speak in public, you are in plentiful company. You may assume that confidence is something that some people have and others, namely you, do not. You may not realize that confidence is available to all, at will. I overstate for effect, but not by much. There are a couple of exercises which nudge you towards the more confident option. I suggest that you try them out well before they are needed, so that the effects have time to become second nature and make

294   

20 Composure

few demands on your attention. The first works from the inside out by activating and changing your will in order to change external behaviour and mood. The second works in the opposite way: a change of external movement realigns your behaviour and mood from the outside in. Both produce the same result. Some people benefit from both, some from one, or the other. The choice of exercise is not important. Both exercises are more beneficial if done with colleagues, as you have access to both inner subjective data, that is, how it feels to you, and outer more objective data, what it looks like to an observer.

Confidence Stand in a room with space enough to walk without tripping over furniture. Decide that in a moment you will clap your hands and that you will become unconfident by choice. You are not to pretend to be unconfident. You know full well how you feel when you are unconfident. Clap your hands, kick back into that memory, and walk about unconfidently. Raise a finger when you feel unconfident. Consider what you have experienced. You will probably have raised your finger within ten seconds, sometimes even within a second or so. Your energy drops, your attention flags, you lose all sense of confidence, and all desire to engage with anyone or anything outside yourself. An observer will see your shoulders and spine sag, your eyes and head drop, and your energy dissipate and shrink back within you. Your gait slows, hand movements are nervous, and you seem isolated and non-interactive. Now, give yourself the opposite instruction. Decide that in a moment you will again clap your hands, and this time you will become confident on the basis of nothing at all. Do not pretend and strut around with bravado. You know how you feel when you are confident. Just kick back into that experience. As before, raise a finger when you feel confident. Simply on the basis of your decision, your back straightens, your shoulders pull back, your head looks up, and your eyes feel free to look straight ahead, or at others around you. Your gait increases in pace and length, your energy builds, a smile may appear, and you want to engage,

  The Voice 

  295

and to interact. You will probably have raised your finger very soon after your decision to be confident. Notice that confidence looks and feels more natural. It clears the mind and fills you with energy. It makes you happier and more able to interact with other people and with your environment. Confidence can be activated at will by the simple decision to be confident. Delay from decision to sensation usually takes no more than ten seconds. It can be immediate. Your confidence is based on nothing at all because that way nobody can take it away from you. If you try to be confident on the basis of experience or knowledge, a simple wrong step or a curly question can bring you unstuck. Confidence is simply the better strategy. You function better, feel better, look better, and can better handle any eventuality that comes your way.

Spheres Spheres is an exercise that works from the outside in but gives the same result (Chekhov 1993). Stand with space around you sufficient to stretch out your arms to either side. Now, imagine that you are standing inside a very tight cocoon or sphere that surrounds you from head to foot, and leaves a gap of about 15 cm (6 inches) between your arms and the sphere. Decide that the sphere is there, and it will imaginatively be so. Gently nudge your elbows out until they touch it and can move out no further. The sphere will have no impact on your freedom in walking. Walk around the room. You will discover that the result is similar to non-confidence, though even more constricted. Now, if you raise your hands to just below shoulder level and push gently out against both sides of the sphere, it will give way, and recede in every direction. Now extend your fingers, and push out so that you have at least 15 cm (6 inches) free each side beyond your fingertips. The sphere remains pushed back in every direction and just beyond your reach. Drop your arms, and immediately walk. You will find yourself striding boldly around the room as you did in the earlier confidence exercise. It is astonishing to realize that the simple act of consciously stopping, pushing your arms out on each side, and dropping them back to your

296   

20 Composure

sides automatically realigns all the elements within you and produces a unified effect of confident action.

Standing in the Wings You are now standing in the wings waiting to walk forward to play your part. This time, you do so having undergone some basic training in performance skills. You have learned to loosen up and to remove excess muscular tension, which you do on a regular basis so that tension does not establish itself in your torso. Now you steady your breathing one last time by taking a few slow, deep breaths and feel the agitation settle down to manageable proportions. The time has come. You remember back to your experience in walking and acting calmly. You remind yourself to move when you are ready. You decide to assume control of yourself and to be confident. You know that your ability to read the situation will depend upon your ability to pay attention, so you focus your attention. You wait for one or two seconds, and then the impulse is clearly palpable. It is as if an inner voice said, “Now, go!” No one else knows what is happening. No one pays attention to the second or so delay. You walk out ready for action.

References Berry, Cicely. 1973. Voice and the Actor. London: Harrap. Chekhov, Michael. 1993. On the Technique of Acting. New York: Harper Collins Publishers. Rodenburg, Patsy. 1992. The Right to Speak: Working on the Voice. London: Methuen.

21 Observation Exercises Exercises to Strengthen Skills in Observation

The following exercises strengthen powers of observation. The exercises have value both to develop your own skills as an observer and as potential exercises to run in training workshops.

Observe a Friend Tell a Story The ability to read, and interpret, a story is important for any communicator. We all store our experiences in story form. It is no accident that story and history began life as the same word-idea. A doctor takes a history from a patient and is trained to extract the important elements that pinpoint disease, its treatment, and the resources of the patient to deal with it. The story is recorded as a list of disconnected facts, the itemized approach necessary for analysis by science. However, an overly itemized approach sometimes removes the context required to assess how the illness impacts the patient, and the patient’s capacity to comply with treatment. It removes the patient’s voice. The following exercise produces a wealth of fruitful insights into human behaviour around storytelling. The next time you meet with friends for a relaxing get together, drop into observer mode, and pay close attention to the stories that appear as © The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8_21

297

298 

21  Observation Exercises

the evening warms up. A bottle of wine is always a wonderful lubricant for story. Watch how the story begins. The natural storyteller will jump in without hesitation; the more reticent teller will begin hesitantly. It does not significantly matter whether the teller is male or female. There will be stylistic differences, but the principles remain the same. Initial hesitation invariably expresses itself in awkwardness with the hands. Your friends sit on their hands or hold them awkwardly on their lap. As they warm up, the hands take on a life of their own. They begin to gesticulate and to illustrate the events that they are telling. You will quickly recognize how integral hands are to storytelling style. Some of us rely heavily on language and use our hands very little. Others are more pictorial and tell the story through gesture as much as through language. Notice how the hands sketch pictures in the air and how those pictures change as the teller changes mode. There are basically two natural modes of storytelling; narrative and drama. In narrative mode, we take on the role of storyteller. In dramatic mode, we jump into the midst of the action and replay ourselves or other key players in the story. We usually start in narrative mode as we find our way back into the experience. Narrative has the wonderful capacity to move quickly and flexibly through time and space. Using narrative, you can potentially jump within one sentence through a thousand years and across continents in a way that is impossible with drama. Drama is far less flexible and takes more time. In dramatic mode, we travel forward at a pace similar to when the event occurred. You can tell when we switch into dramatic mode. Suddenly your friend strikes a pose, changes her voice, puts her hand on her hips and says, “And just where have you been, young lady?” In that moment, your friend momentarily disappears, and there stands her father, stern and disapproving. It is not a faithful reproduction of her father but her interpretation of how he appeared to her. We can sense how she felt about him in that moment in the way she characterizes him, in this case close to caricature. Notice how we use cinematographic techniques in our storytelling. One moment your friend’s hand is a tiny car whipping down a winding road. She is showing you a camera long shot to establish the scene. Suddenly, she has her hands on a steering wheel and is wildly turning from left to right. She has taken you into the car with her, and you see a

21  Observe a Friend Tell a Story 

  299

close up of her as driver. Recognize that this is all unconscious and that she is probably unaware of how she is telling the story. This is how we naturally communicate. Notice how gestures become especially clear at the climax of the story. What does this tell you? A vast amount of information is coming at you very quickly, very succinctly, and very tightly packaged. You sense how many times the story has been told before. You can at least distinguish if this is the first time, or whether this is a well-honed story. How can you tell? You will discover that stories simplify over time, as the through-line becomes clearer to the teller, and extraneous details drop away. Notice how you can tell to what degree they are caught up in the story, and how they have imaginatively returned into the midst of the original events, and relive the experience from within the scene. You can see from their eyes when this is so. This is what remembering is. Through imaginative recall, they have gone back in time. They describe what they see, how they felt, and what they see happen next. The tense may suddenly switch from past to present tense as they relive the events as if they were occurring now. You can tell from the very start whether this story turns out well or not. How? Look for the cueing devices. Usually we have stereotypical cues. If I were to say to you, “You’ll never guess what happened to me today,” you would know that I was about to tell you something interesting, or unusual, and that it will end happily, or at least without tragedy. “Once upon a time” introduces a fairy tale. If I ask you, “Have you heard about the Englishman, the Scotsman, and the Irishman?” you know that I am not actually asking you if you know anything about the three men, nor am I about to tell you that they were the victims of a hit-and-run accident reported on the evening news. The cue is stereotypical, signals loudly to you that a joke follows, and awakens an expectation of laughter. The joke will probably be fairly concise, comprise a plot line of three different responses to the same situation, and have a punch line which you hope is funny. You also know that it is the Irishman who will produce the unexpected outcome. Films such as The Sting, The Sixth Sense, or The Others are intentional exceptions in that the screenwriter deliberately obscures the cues in order to mislead the audience for entertainment value. We generally do not like unexpected surprises, with the possible exception of pleasant ones, and

300 

21  Observation Exercises

many people do not even like them. We want to know what’s coming, especially if the news is negative. We want to know so that we can be ready and protect ourselves.

Become More Aware of Body Language This is a huge subject which deserves an entire book. Suffice to say that educational programmes often relegate body language to the periphery, and regard it as an add-on. Communication guidelines sometimes seem to regard body language, or non verbals, as something that you trot out when needed in order to add authenticity to your communication. In fact, the reverse is true. Your body responds automatically to the way you perceive a situation and decide to address it. There is an old English acting technique which goes by several names but which we will call here stimulus movement speech. The technique is based on the observation that movement naturally precedes speech in life. Imagine that your hand has landed on the hot plate of a stove. Ask yourself, what happens first, the quick removal of your hand, or the anguished cry? The sequence of course is sensation of heat (stimulus), removal of hand (movement), and anguished howl (speech). Actors look in their script for sudden changes of thought expressed in the text, and scan immediately beforehand to find the stimulus, and to imagine the movement that preceded the words. They perhaps make a mark on the page to indicate the stimulus. In performance, they recreate the stimulus in their imagination, move in reaction to it, and then let the words pour out as they will. Their words appear completely natural because they are the end result of an action, namely, an impulse or stimulus to which their character has responded. The impulse may be something they have suddenly seen, something they remember, or a phrase spoken to them. Pay attention in consultations or conversation to shifts of thought. Learn to recognize movements that precede them. The movement may be as slight as a sudden intake of breath, shift of position on the chair, crossing of legs, or something obvious like reaching for a bag, or moving to the front of the chair. In time, you will be able to recognize the impulse that precedes the movement, such as an impulse in the eyes, or the suggestion

  Become More Aware of Body Language 

  301

of a thought passing through the mind. Do not make the mistake of ascribing specific meanings to a movement. A patient may cross her legs because she has heard enough and cannot take in any more information, or she may simply have become uncomfortable. Another patient may cross his arms to protect himself, support himself, or because he is cold. Body language communicates meaning in context. The body speaks normally in integrated clusters of actions and words. What do we do when the words and the actions do not match? We are hard-wired to believe the body over the voice, as the body is usually the more truthful. The hand rebounds from the hot plate and, aware of listening ears, we may say “Bother!” As a species, we are creative with the truth when it comes to speech, but most people cannot dissemble physically, except for actors, and conmen (who mostly do it well), and politicians (who have an uneven track record). When there is a mismatch, be alert for hidden information. “I need to see Raymond,” says the newly bereaved wife who has just been told of her husband’s death. Yet, no part of her body has moved. Her feet and hands are stationary. She has not shifted in her chair, nor made a move to pick up her handbag. The discerning doctor recognizes the disjunction between her words and lack of movement and gently tests to see where she is at. “Certainly, any time you’re ready. There’s no hurry. Is there anyone you’d like me to call?” A discerning communicator does not respond to words alone but to the combined message of words and body language. For example, a patient has given a history, undergone a physical examination, and now asks, “What do you think it is?” The patient perhaps sits at an angle. Her words may be direct, but her body places her in an oblique and indirect physical relationship with the clinician. She seems ambivalent and unsure whether she wants to hear the news or not. The signals suggest that the clinician be clear but gentle. Alternatively, the patient asks the same question, but sits straight on, and looks directly at the clinician. There is no suggestion of hesitation, and all the indications say not to beat around the bush, but to tell it straight. Or the patient may have folded her arms and sends confusing signals. We know from workshops that many clinicians interpret the folded arms as a blocking gesture, and an indication that the patient does

302 

21  Observation Exercises

not want to hear, and is preparing to resist the news. She could just as easily be supporting herself in readiness for news that she anticipates will require courage. The clinician’s interpretation of the situation will inevitably alter the answer that is given.

Observe Speakers on TV When you watch television, whether it be news, documentaries, or dramas, use the opportunity for active viewing. Pay closer attention to language and behaviour. When people make statements, are they rehearsed, or spontaneous? Do people actually answer questions, or do they find clever ways to mask their non-answers? What is not being said? In fact, how much is often said without words? Are the body and the mouth in agreement, or in conflict? Learn to assess the nature of those you observe. What kind of people are they? What kind of data leads you to these inferences? What kinds of patterns do you discover?

Observe Recordings of Clinical Consultations Watch video recordings of actual, or dramatized consultations. Learn to pay attention even to small details and to read and interpret what is taking place. Pay attention to body language; listen to exact wording; consider the meaning of pauses and silences; sense the subtext below the flow of language. Look for the best words to describe what you see. Avoid generalized description, and search for the most precise reading you can come up with. This is a good reflective exercise to run with students. After two or three runs through a short clip of a consultation, the skills of the students should become far more nuanced and acute.

Index

A

active listening, 192–3 actor, 31, 124, 143, 149, 159 actual performance, 169, 171, 173 aesthetic distance, 9–12, 22–4, 29, 30, 40, 46, 76, 79, 86, 95, 98, 114, 146, 147 and action on stage, 150–2 in discussion, 154–6 engagement, 7, 10, 12 and facilitation, 149–50 and observation, 152–4 under-distance, 10 aesthetic performances, 4, 23 aha moments, 30, 158, 159 analytical and emotionally cool, 86 anger, 231–2 angle of vision, 181–3 antenna, 248–9 antenna exercise, 152 antithesis, 205–6

© The Author(s) 2018 P. Heinrich, When role-play comes alive, https://doi.org/10.1007/978-981-10-5969-8

anxiety, 230 appreciation, 175, 183, 226 arc of the scene, 259, 260, 274 ask three questions, 197, 198, 255, 256 asking three questions, 199 attention, 7, 11, 16, 20, 42, 177, 215, 224, 279 authentic, 40, 55, 59, 60 authenticity, 4 awareness, 7, 30, 159 B

back story, 103, 108, 194 bad news, 107, 193, 222, 254, 267 balance of attention, 141 Barrows, Howard, 99 best case, 253, 254, 274 block the action, 45, 267 blocking, 269

303

304  Index

blocking the action, 267, 268 Blunt, Forecast, and Stall, 254 body language, 201–17, 300–2 Brecht, Berthold, 11 Bullough, Edward, 9–10 butterflies, 122, 293 C

call, 113 Centipede’s Dilemma, 51–5 Chekhov, Anton, 18 Chekhov, Michael, 83, 90, 295 cinematographic techniques, 210, 298 circle of concentration, 82 clamp down, 289 Coleridge, Samuel, 6 compose, 76 composition, 27, 28, 79 confidence, 294–5 consonants carry, 290–1 cool, 56, 58, 145 down, 17, 21, 72, 116 editing modes, 87 mind, 106 mode, 86 zone, 22, 93, 151, 180 counter expectations, 29, 94 creative, 27, 40, 72, 79, 82, 86 creativity, 26, 27, 77, 87 creep principle, 52, 59–62 Csikszentmihalyi, Mihaly, 128, 144 cue/cueing, 58, 70, 90, 111, 220, 299 D

dealing with bad news, 227 debriefing, 116

defamiliarization, 11, 12 dénouement, 23, 24 de-roling, 115 detective, 164, 165, 259, 274 diagram, 201, 214–16 difficulty with engagement, 150–1 disbelief, 232–3 discrepant awareness, 153, 159 distress, 230–1 DNR, 271 double objectives, 136, 283 dramatic fiction, 114, 115, 149, 150, 155 dramatic mode, 298 dramatized metaphor, 211–13 dumb clown–clever clown, 235 E

edit mode, 85–7 eighty percent rule, 236 emotional antenna, 228 emotions, 45–7 empathic wash, 21, 146 engagement, 11, 22, 97 enter the zone, 123 expectations, 16, 17, 19, 20, 24, 26, 94, 97, 119 extroverted energy, 27, 123 F

facilitation, 70, 71, 178–83 facilitator, 33, 34, 121, 143, 159, 176 feedback, 114, 154, 198 feedback from the actor, 195 fiction, 6, 7, 10, 12, 22, 23, 72, 76, 97, 100, 129, 142, 144 fight-flight-freeze response, 117

 Index    

figures of speech, 205 flow, 144 focus, 16, 17, 19, 20, 72, 93, 94, 159, 214 four deep breaths, 284 fourth wall, 155 foyer, 17, 24, 70, 94. See also intermediate space; zone frame, 7–9, 15, 80 framing, 24, 29, 93, 94, 159 front of house, 70

305

into the zone, 81, 82, 87, 135, 138 introverted energy, 27 K

knowledge, 173 knowledge base, 168, 170, 171 L

layers or streams, 41 lost necessary distance, 151

G

gesture, 208, 209 go for broke, 252–3 golden mean, 91 green room, 113 group learning, 125 H

Hamlet, 56, 270 hot spot, 21 hottest zone, 146 hypothesis, 44, 127, 153, 165, 177, 219, 239 hypothetical approach, 148 hypothetical questions, 150

M

management, 173 management plan, 168, 171 managing aesthetic distance, 141–59 managing performance anxiety, 121–2 medical term, 202 medicalization, 100, 103, 187, 189, 216 metaphor, 186, 201, 206–8 modes of rehearsal, 47 morphine speech, 212 muscularity, 290 N

I

imagination, 26, 27, 32, 41, 82–5, 87, 111, 135 imitation, 60, 289 improvisation, 28, 33, 44, 57, 99, 101, 119 in the zone, 139 intermediate space, 17 intermediate zone, 17

narrative mode, 298 neutral zone, 145 notice, 42, 183, 236 O

objectives, 52, 62, 151, 180, 181, 192–4, 199, 252, 272, 273 observation, 175–84, 203, 297–302 observer, 71–2

306  Index

Open Chair, 126, 138, 238, 239 optimal moments of respond, 223 organization, 28, 68, 69 overdistance, 19, 22, 155, 159, 180 P

Patient-cam and Doctor-cam, 182, 250, 251 Patientspeak, 190 pause, 155, 156, 159, 243, 244 performance, 27, 28 performance anxiety, 32, 93, 117–30, 147, 237, 278 placement, 289 play within a play, 221–3 PLISSIT, 271 pointing, 291–2 pre-scene, 105 presence, 55, 145 present, 55 projection, 289 pull back, 288, 289 R

realization, 30, 41, 42, 159 rehearsal, 43–5, 47, 108, 109 role-play as, 34 rehearsal mode, 266–9 rehearsal space, 38–41 role-player, 32–3 role reversal, 250

script, 44, 83, 101–8, 268 serious fun, 129, 144 set behaviour, 20 Shakespeare, 29, 221, 226, 252 shared awareness, 153 shared to discrepant awareness, 181 simile, 186, 201, 206, 213 simulation triad, 31–4, 99, 101 situational awareness, 168, 170, 173 Socrates, 77 space, 273–4 spatial buffer, 80 spatial frame, 16, 17, 87 specialist co-facilitator, 71, 79 speech, 209–11, 213, 214 spheres, 295–6 SPIKES, 43, 271 split focus, 30, 52, 56–9, 245, 246, 254, 274 stage, 19–22, 24, 93 stage fright, 117 Stanislavsky, Konstantin, 6, 60, 195, 266 stimulus movement speech, 300 stimulus, move, speak, 258, 259, 274 streaming and layering, 41–3 streaming or layering, 42, 244, 245 subjective, 56, 86, 102 subjectivity, 20 subtext, 194, 195, 199, 302 support, 287 suspended disbelief or suspension of disbelief, 6 suspense, 7, 23, 143, 153, 224

S

safe, 39, 125, 126 safety, 40, 47 scenario, 143, 159

T

temporal frame, 80, 87 temporal frames, 18

 Index    

thought-emotion-actions, 195 three questions, 274 time frame, 23 time-manage, 95 timeout, 111, 156–8, 195, 242, 243 timing, 223–5 training, 43–5, 47 training mode, 270–1 transitional space, 70 translation, 194, 199 translator, 189, 190, 257, 258 transport, 100 transportation, 144, 145, 154, 159, 236 triage expectations, 254 U

underdistance, 11, 22, 159

virtual world, 3–13, 25, 30, 80, 119, 135, 142, 143, 145–9, 237 vocal warm-up, 287 voice, 77, 102, 134, 287–90, 297 W

Wallas, George, 76 warm, 56, 58, 86, 87 areas, 180 mind, 106 mode, 86 zone, 180 workshop, 43 workshop mode, 264–6, 268 workshopping, 44, 45, 47 worst case, 253, 254, 274 wrong end of the stick, 256–7 Z

V

Verfremdungseffekt, 11

307

zone, 72