Headspace Theater is designed for small group learning of psychiatric conditions via modified role-play situations that simulate the experience of the condition. The modification is in having the learners role-play characters who have differing perceptions of reality—the interaction between characters helps create cognitive and emotional experiential learning for the students.
It is much easier to help learners acquire knowledge and skills in psychiatry than it is to help them develop professional attitudes towards and empathic capacity for dealing with people suffering from mental health disorders (
1—
3).
Attitudinal factors have an impact on professionalism, communication, scholarship, and collaboration capacities in a learner. Providing students the opportunity to experience, through role-play, the emotions and cognitive trajectory of specific psychiatric conditions can help them develop their empathic capacity as well as shape their attitudes towards mentally ill patients. The role-play experience accompanied by reflective exercises can ultimately have a positive impact on patient care. This concept fits well with adult learning theories, such as Kolb’s experiential learning cycle (
4), as well as other constructivist and phenomenological theories which articulate that through experience we construct our reality and sense of efficacy in the world (
5,
6). According to these theories, our understanding of reality is built upon our experiences that, in turn, shape our ideas about what is valued as knowledge. With Headspace Theater, each individual student is encouraged to acquire a depth of understanding about a medical condition, with special focus on the condition’s personal impact on the patient.
Although techniques have been developed in the past (
7,
8) in an attempt to simulate psychiatric symptoms for learners, most have been limited in that the learners are cognizant that it is a simulation or the method does not capture the true experience of living with the conditions.
Headspace Theater is an innovative initiative, central to which is the unique nature of the role-play experience. In one scenario, all of the learners are assigned a role that appears to be one thing but, in fact, is based on a set of perceptions different from the assigned role. Other learners may take roles to help create or reinforce the reality of another. For example, in the simulation of psychosis, the protagonist thinks he or she is a doctor interviewing a patient with a medical student. In fact, the protagonist is the person with psychosis, and the other actors help create a paranoid atmosphere. Afterward, a discussion takes place about how the protagonist felt. This experience is then linked after a debriefing to activities such as the teacher delivering a lecture on a differential diagnosis of psychosis or the student being assigned the task of interviewing a patient with psychosis about his or her experience with the illness.
To help put Headspace Theater in context, the techniques are based on and adapted from improvisational theater, role-playing games, and live-action role-playing games.
Improvisational theater (also known as improv) is a form of theater in which the actors perform spontaneously, without a script. In all forms of improvisation, the actors invent/discover the dialogue and action as they perform. Many companies and artists use dramatic improv as a means of generating text and content for later performance (
9).
In order for an improvised scene to be successful, the actors involved must work together responsively to define the parameters and action of the scene. With each spoken word or action in the scene, an actor makes an offer, meaning that he or she defines some element of the reality of the scene. Accepting an offer is usually accompanied by adding a new offer, often building on the earlier one; this is a process improvisers refer to as "Yes, and…" and is considered the cornerstone of improvisational technique (
10).
Improvisational theater has been used in the education and business world for training (
11—
16).
With Headspace Theater, there is a difference: the imaginary environment/reality for each character is slightly different, and so some players will be respecting one "reality" while others have another, which is often the basis of mental health problems via misattributions/improper salience. The interactions that occur because of the differences in perception are the source of the emulating/simulating the psychiatric symptoms and creates the material to be processed after the "play."
The original role-playing games were often with dice, figures, or a board, with players sitting around a table. Another mode of play is live action role-playing, in which the players physically act out their characters’ actions. This type of game play is usually more focused on characterization and improvisational theatrics and less focused on combat and the fantastic, if only because of the physical limitations of the players themselves (
20).
Some live action role-playing games avoid combat whenever possible, leaving only minimal or nonexistent combat systems. Many murder-mystery live action role-playing games lack any combat system, the focus being entirely on social interaction and investigation. Some games that discourage and penalize combat might use very simple rules, for instance, pointing a toy gun at someone and shouting, "Bang!" means that the target character is dead. In Headspace Theater, the scenarios are designed so that there is no physical "combat" or interaction, as this might result in a student feeling distraught. Again, in building and running any scenario, every player is asked about his or her personal comfort before assuming a role and is aware anyone can stop the play at any time if there are any concerns.
We conducted a review of role-playing techniques, interactive teaching, and experiential education, and performed consultations with experts in improvisational theater, live-action role-playing and cognitive psychology (constructivism).
Headspace Theater uses a selection of interactive teaching techniques and role-playing methods. It lends itself to adaptability and includes active feedback from learners and teachers (e.g., "play testers") on the content to help shape the methods and scenarios for further play-through of scenarios.
A series of improvisational scenarios allows students to take on various roles or be spectators. The basics of role-playing and improvisation and the basic outlines and framework for the teaching are taught to students. Students rotate being the main "protagonist" of scenarios. Afterwards, the experience is processed using reflection techniques and tied into specific content teaching points.
A key element is creating a learning environment where the learners trust in the process. If the teacher does not spend time creating the frame, explaining how some learners are intentionally going to perhaps feel "tricked" as part of the simulation (e.g., feeling "tricked" is part of feeling paranoid), there is the danger the learners might feel manipulated and taken advantage of. Instead, the learners are hopefully brought to a point where they understand the techniques involve surprises and intentional information distortions in order to evoke the emotional and cognitive processes of the condition being simulated.
Many of the scenarios are works in progress and are offered as frameworks for educators to modify for their individual learning groups. The scenarios have been run multiple times for many groups of learners consisting of medical students (three groups); psychiatry residents (three groups); staff psychiatrists (one group); interprofessional (combinations of the previous and psychologists, registered nurses, social workers, child and youth workers) (five groups); gambling therapists (one group); and public participants (one group).
The Headspace Theater techniques were used in various teaching activities by Dr. Ballon at the University of Toronto, Canada. The simulations were rated highly when run as stand-alone techniques or as part of larger workshops on mental health education. The exercise has received excellent evaluations from workshop participants; learners have enthusiastically endorsed the simulations as a useful and enjoyable learning tool because of its experiential strength and its ability to help learners engage with the content. There were 14 runs of Headspace Theater where two to three scenarios were run in a session. The number of participants ranged from six to 20 participants per session (N=94).
The following themes were obtained by the facilitators from verbal (recorded by the facilitators) and written feedback from a satisfaction questionnaire (in the section for general comments, most respondents wrote narrative statements. These comments were analyzed for pertinent themes related to the simulation exercise [Appendix 1
]).
The feedback contained no negative comments or criticisms.
At an additional test site, the Headspace Improvisations were performed both as improvisation plays in which participants did not know the entire scenarios or outcomes and as improvisation plays with the difference that the participants knew the full premise of the scripts and the desired outcomes in advance. Student participants reported that they gained equal amounts of learning about empathy by either method. Dr. Fidler, who tested both formats, also teaches acting in the drama department at West Virginia University. He remarked that the goal of well-rehearsed plays is to allow actors the safety of knowing the outcomes so much that actors can immerse themselves in enormous depths of emotion as the characters experience events. This unguarded suspension of disbelief is the reason actors enjoy and learn from repeated performances; they learn something fresh and of more depth with each reenactment. For both methods, it was considered essential to follow up with reflection and discussion about the experiences.
Currently, we have a work-in-progress manual for Headspace Theater. This contains in detail how to set, run, process, and develop scenarios (as well as many example scenarios ready to use—talk to students on an individual basis in-between sessions if a student wishes to have a private discussion over an issue. The importance of debriefing should never be overlooked [
21]). The following information is drawn from that manuscript to allow one to understand the framework and encourage running Headspace Theater in one’s own settings. There is more information on how to obtain this manuscript at the end of the article.
It should be stated up front that the goal is to simulate psychiatric symptoms by having people role-play characters with different perceptions of a situation. This leads to interactions that create the cognitive distortions and hopefully evoke the feelings that someone with a particular psychiatric condition experiences. Hence, students are told they are going to be surprised and that certain characters do not have all of the information on what is really going on intentionally so that the learner can experience the symptom. This is rooted in the basis that numerous psychiatric disorders have misattribution and/or abnormal salience placement issues (e.g., anxiety placing unrealistic concerns on a low-risk situation; psychosis creating the perception that people are staring at them for malevolent reasons; a gambler mistakenly thinking s/he understands the odds of a game).
This is an environment for exploration. There are surprises and unexpected twists when doing the role-plays. However, anyone who feels uncomfortable can stop the play at any time with a proper pre-agreed action or word. As mentioned above, every student is asked about his or her personal comfort before assuming a role and is aware anyone can stop the play at any time if there are any concerns.
Also, it should be emphasized that debriefing/processing time is always built into the sessions (around a ratio of 1 part role-play to 4 parts processing in terms of time) so that the learners’ experiences can be dealt with in detail. The educator/facilitator is also available to talk to students on an individual basis in-between sessions if a student wishes to have a private discussion over an issue. The importance of debriefing should never be overlooked (
22), and Headspace Theater should not be run unless there is the proper amount of time to allow participants a chance to reflect and discuss their personal experiences.
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Resistance to Role-Play and Assigning Character Roles
All students are able to be part of the role-play but as most educators know, learners often dislike role-playing as they are afraid they will be "judged." This is often due to the role-play scenario structures in medical school where the student has to play "a medical student" or a resident has to play "a resident." Invariably, most students try to pick the patient role or other less "in the spotlight" character at first. Keeping this in mind, Headspace Theater scenarios try to keep away from setting the scene in a medical setting or playing high-stress roles—although when these are present, the situation is set up so that the roles do not require the students to have extensive psychiatric knowledge or skills. The students just have to go along with the experience of playing out the character’s reactions.
In starting the scenarios, the educator/facilitator chooses a student who seems to be the least shy and is keen to role-play. The "Paranoia Will Destroy Ya" scenario is used to demonstrate how Headspace Theater works. The student plays the center role where he or she experiences social anxiety symptoms via the use of the role-play. The volunteer is told ahead of time exactly what to expect from the situation; for example, "People will be looking at you, staring, and whispering about you—if you feel you want to stop the process, say "Cut!" or put down the glass of water" (this is a built-in part of the scenario to signal to other players to stop).
The other learners are invited to take on the other roles of the scenario as the characters who will do the staring and whispering. If anyone is uncomfortable, they do not participate at this time and just observe.
After the scenario runs, it is debriefed to demonstrate all of the above principles of Headspace Theater and to highlight the experience of the volunteer, the students "inducing" the anxiety, as well as any observers.
With enough sessions, each learner can take a turn playing the "protagonist" of a piece, sideline characters, or just observe the play per the interactive technique of the "fishbowl" (i.e., watching the play as audience members in a circle or semicircle). By playing characters often outside the typical medical role-play scenarios, supporting them when they are not sure what is going on, and having the students build up their role-play skills, this helps decrease resistance to role-playing and builds up students’ confidence in stepping into roles.
In the first session, it is important to discuss the frame and establish the environment of exploration. This takes about 10 minutes. Then the "Paranoia Will Destroy Ya" scenario is enacted, taking about 2 to 3 minutes to select learners and up to 5 minutes to run. The next 20 minutes are devoted to debriefing the action. At the end, the teacher can give the students a reading on social anxiety disorder or paranoid symptoms. The rest of the time can be used for reflection on the entire session.
For the following sessions, we suggest having 10 minutes of discussion about any issues from the last session; 10 to 15 minutes of enacting a scenario; 25 to 30 minutes of discussion; and 5 to 10 minutes of winding up the session, giving any relevant readings on the topic at hand to students and allowing any self-reflection (via optional journaling). The order of the scenarios is up to the educator.
The scenarios usually run for about 10 minutes. The facilitator calls participants into play by saying "Action!" (he or she may have a few narrative comments to set the scene for the audience before calling this word out). At the end of 10 minutes, the facilitator/educator calls "Cut" and stops the action to begin the discussion process.
Anyone, including the players, audience, or facilitator can call "Cut," which ends the play immediately and begins a discussion process. Only the facilitator can call "Action" and only when he or she is sure that if a student stopped the play, that everyone is comfortable to continue. If not, the facilitator continues the discussion process.
No student should ever feel compelled to participate in any role (of course, most will have self-selected to come to this—but that does not mean they are comfortable to play any role).
No one needs to physically touch anyone during the play action. Players may come close into a person’s "space" as part of creating/evoking an emotion—but that is all.
Those not participating should remember not to make any comments or interact or disturb the players while the action is taking place.
Everyone in the play receives a character. This lets the player know the setting, personality sketch and motivations. The information each student receives also contains information on other characters to help work together to create the situation that will emulate/simulate the psychiatric symptoms.
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Scenario Design and Connection to Content
The teacher/facilitator should consider articles and references relevant to the topic at hand. Often, the action will result in a discussion bringing up issues that the teacher did not anticipate. This often leads to the educator and students agreeing to look up topics and information to bring back to the next session to share with the group (thus encouraging motivation and literature searching skills).
The discussion can be processed in the following order:
1) The protagonist’s experience
2) The other players’ experiences
3) The audience members’ experiences
After processing the experiences, the facilitator focuses on bringing in content information, helping elaborate the cognitive and emotional factors in a psychiatric symptom, and helping the students reflect further on the experience. The discussion needs to be built around the experiences of the students as the scaffolding to give the content a base.
The concept of Headspace Theater has been developed for simulation of mental health and addiction issues in an innovative way but its potential for experiential learning involving any situation that involves multiple view-points is clear. Thus, Headspace Theater can be beneficial for students in the health care field, including medical students, social work students, nursing students, and pharmacy students at all levels of training. The essence of Headspace Theater is taking role-playing techniques to truly capture experiences that can help open windows in the learners’ minds on what it would really be like to have a particular mental illness. In designing Headspace Theater, the principles of proper set-up, safety, and debriefing were refined and made central to the successful running of scenarios. These principles can be applied to all forms of experiential learning using classical role-plays, or even other forms of narrative experiential learning (e.g., showing a film clip with highly charged emotional content).
Preliminary reactions to Headspace Theater have been universally positive according to qualitative feedback. It is interesting that at least at this point, no negative feedback has been given when role-playing has been often looked upon as a method that may make participants anxious. Perhaps some participants felt they could not give negative feedback, although this was actively solicited for in terms of asking about dangers, pitfalls, reality, and improvement of scenarios. It should be noted in setting up any of the scenarios, the facilitators took great care to set up the learning climate, build trust, create an atmosphere of sharing, and experience with less intense scenarios building up to more intense scenarios if the participants seemed to be engaging with the methods and content. This may also have been part of the reason no negative comments were created. By not following basic education concepts of creating a positive learning climate, possessing the appropriate facilitation skills, and being attuned to the learners’ needs, this method, like most interactive methods, could then indeed garner negative comments—but we assert that is due to the context and the teachers not taking time to learn the ins and outs of a teaching methodology and how to employ it properly and with thoughtfulness and reflection.
In the future, once the materials are further elaborated and developed, evaluation will include both qualitative and quantitative measures. Eventually, comparing teaching of similar subject material with and without these can be compared on multiple levels from content retention to impact on attitudes, empathic connections, and professionalism. Finding and/or developing an appropriate "Attitudinal Scale" (attitudes toward the mentally ill) will be key in measuring both before and after the intervention to determine whether mind-set had shifted and how that may relate to professionalism. Recent research in studying countertransference (
23) has also opened up other ways to investigate the impact of Headspace Theater (e.g., examining such dynamics before and after Headspace Theater experiences—especially scenarios involving portrayals of such conditions like borderline personality disorder).
However, at this stage, this manual is being distributed to innovative educators who will pilot the materials with their learner groups and share the outcome with the author(s). It is hoped this will result in the creation of further scenarios, elaboration of methods and process pearls, and the eventual creation of a book for publication created through international collaboration! For those interested in participating, please e-mail the authors.