‘Better than Medicine’: Theatre and health in the contemporary Norwegian Context

Abstract

This article documents the practice of act2 and Teater Vildenvei, two collaborative theatre in health companies in Norway. Based on an analysis of the company’s aims and objectives, their ethos, their particular working methods and the plays they have produced, I will examine the values that underpin the work of the two companies. The aim here is to assess what strategies the company use in their work to promote health and wellbeing for marginalised and socially excluded groups in society. Working with people affected by addiction and mental health service users respectively, act2 and Teater Vildenvei are using the medium of the theatre to empower these groups and to make their voices part of public discourses. If health is the manifestation of empowerment, what might the empowerment of these voices mean for both individuals and for the groups at large? This article will not address the health effects of theatre in terms of medical effects, but it will assess why some participants of act2 and Theatre Vildenvei describe the interventions as ‘better than medicine’ and ‘good medicine’. A tentative explanation is that both act2 and Theatre Vildenvei provides radically different solutions to people’s problems than those offered by the biomedical model. Instead of treatment and diagnosis, act2 and Teater Vildenvei focuses on personhood, enablement, social support, social capital and empowerment in their attempt to promote health and well-being.

Keywords

Theatre and health, empowerment, recovery, act2, Teater Vildenvei, addiction, mental health    

Introduction

Theatre is ‘better than medicine’, theatre is a ‘good medicine’, theatre is ‘healing’, theatre ‘does good’, theatre is ‘better than pills’, theatre is ‘therapeutic’, theatre ‘gives me hope’, and theatre ‘gives me health’. These observations come voluntarily from participants in act2 and Teater Vildenvei – two contemporary theatre and health practices in Norway. Significantly, these comments give us strong testimonies about the therapeutic effects of theatre, but opportunities to benefit are limited because the performing arts are not commonly used in health and care in Norway today. According to the founders of act2 and Teater Vildenvei, it has not been easy to gain broad acceptance for their theatre in health projects although the interest in theatre as a “tool” both in health and care settings and community settings has increased in recent years. Both stress that many struggle to understand what theatre in health is and what it can do. In Norway a distinction is rarely made between “theatre in health” and “drama/theatre therapy” and there have been limited efforts to capture nuances in theatre/health work. When the work of act2 and Theatre Vildenvei is commented on in the media, it is therefore systematically referred to as a form of theatre therapy.

Both Eliann Stålem Berg, the founder of act2 and Eduard Myska, the founder of Teater Vildenvei, are uneasy about this classification and its association with clinical practice and medical power. This scepticism also reflects other concerns about the legitimacy of the arts in the meeting with powerful health care agencies and the fear that the arts will be reduced to a tool in the service of health. It also reflects the unease that has been expressed about using art to meet certain predefined goals and that the powerful discourses of medicine will define the aims of arts in health projects (Berg 2014; Seur 2013). Helen Nicholson raises ethical concerns about applied theatre practices that want to change or transform people. In her view, theatre practitioners must be aware of the potential power they have over people. ‘If the motive is individual or personal transformation, is this something which is done to the participants, with them, or by them? Whose values and interests does the transformation serve?’ (2005: 12, author’s emphasis). When working in the context of medicine and health it is important to be sensitive to the ways in which power is executed. It thus becomes essential to assess whose values and interests particular theatre in health initiatives serve and what they are trying to achieve. In the contemporary Norwegian context, little is known about this.   

            There is a general consensus among practitioners, scholars and politicians that more emphasis must be placed on evaluation and research to capture what theatre in health projects do and what the potential benefits of these initiatives might be.  The status of this work to date is under developed. So far, there has been little emphasis on the evaluation and documentation of individual practices. Academic research in the field of theatre in health has also been limited and projects/initiatives in this area are largely undocumented. The result is that little is known about the ways in which theatre in health projects/initiatives are designed, delivered and evaluated. However, in the last years there has been a growing interest in the field. This interest can be exemplified by the fact that the Nordic dramapedagogic journal Drama launched a special issue about drama and health in 2013. Academics such as Rikke Gürgens Gjærum and Gro Ramsdal have published articles about theatre and health that documents and analyses the ways in which theatre is used with people with dementia and school dropouts (2013, 2014, 2015). A theatre in health research network has also been established, so more research is underway. This article will hopefully contribute to the positive theatre in health research development in Scandinavia.

In this article I shall examine the work of act2 Forum Theatre and Teater Vildenvei and consider the strategies they employ to promote health and wellbeing. I have carried out four months fieldwork with the companies (March-June 2015), which has allowed me to follow their rehearsals and production processes closely. The material was gathered primarily through participant observation, dialogues, semi-structured interviews and narrative interviews. The focus of this article will be on the documentation of two largely undocumented practices, providing a space where the voices of these companies can be heard. Based on an analysis of the company’s aims and objectives, their particular working methods and the plays they have produced, I will examine the values that underpin the work of the two companies. I will investigate whose values and interests the initiatives serve, how the companies negotiate power, whether the companies support or subvert the work of official health and care agencies, and what it might be that makes the theatre practices of act2 and Teater Vildenvei such good medicine. In order to answer these questions, I will first provide a brief overview of definitions and theoretical perspectives.

Theatre in Health: A Developing International Field of Practice and Research

Both act2 and Teater Vildenvei work within the emerging tradition of international theatre in health. According to Emma Brodzinski, a leading theatre in health expert in the UK, it is important to establish theatre in health as a distinct practice with its own traditions and histories, acknowledging the differences between theatre in health and drama/theatre therapy 2010:15). The British Association of Dramatherapists (BADTh) offers the following explanation of the difference: 

Artists working in health care or educational settings may engage people in creative projects that will enhance well-being and increase self-esteem. Their input may be deemed as therapeutic rather than providing the in-depth therapy offered by Arts Therapists (Quoted in Brodzinski 2010: 15).

Macnaughton et al. argue that the specific arts in health movement dedicated to the improvement of health ‘differs from arts therapists in that the artists involved are not trained therapists. Rather artists, as arts in health practitioners, wish to engage ‘unhealthy’ individuals or communities in their work and to feed that engagement into their own creative input’ (Macnaughton et al. 2005: 333). It is an awareness among arts in health practitioners that the arts in health movement is developing and that it might be premature to offer a ready-made definition of the field. However, the broad definition provided by Macnaghton et al. for the Centre for Medical Humanities at the University of Durham has general accept. According to this definition arts in health are:

activities that aim to use arts based approaches to improve individual and community health, health promotion and healthcare, or that seeks to enhance the healthcare environment through provision of artworks or performances (2005: 333). 

Theatre in health also differs from therapy in that the emphasis on artistic quality tends to be greater in the former. It is indeed an established fact among arts and health practitioners ‘that the quality of the art produced is most important, otherwise it will not do anyone any good’ (Angus: 2002 14). As the field is developing and defining itself in Norwegian contexts, it is important that the value of art should be understood and emphasised. Sue Roberts warns that “an arts project needs to be absolutely crystal clear about its artistic purpose and integrity… [or] it will become a health project which just happens to use the arts, rather than arts development in a health setting” (Quoted in Brodzinski 2010: 15).

The Medical Gaze: Discourses and Counter-discourses

To understand contemporary theatre in health practices it is important to understand what model of health the companies employ in their work. Since theatre in health projects are working within the context of health and medicine, many assume that these projects have the same aim as medicine, although these projects often try to do something quite different than conventional medicine. In Scandinavia, arts in health projects indeed often have a quite radical or activist stance where the dominant biomedical model of health is criticised both directly and indirectly (Priebe and Sager 2014: 56-7; Stige and Aarø 2012). What, then, is the biomedical model of health? And how do act2 and Teater Vildenvei position themselves in relation to this model?

In Norway, the biomedical model of health has dominated health care for the past century (Gjernes 2004). Wade and Halligan stress that the biomedical model is based on three underlying assumptions: “all illness has a single underlying cause, disease (pathology) is always the single cause, and removal or attenuation of the disease will result in a return to health”(Wade and Halligan 2004: 1398). This model then, embraces reductionism and separates the somatic from the mental and the existential in the attempt to cure people. Moreover, the biomedical model of medicine is paternalistic in its treatment of people. According to Chamberlain, ‘[t]he emergence of biomedicine shifted the diagnostic and treatment emphasis away from a patient’s personal experience of illness and disease and towards the objectively obtained facts pertaining to a clinical presentation’ (Chamberlain 33). The power of the professional clinician is thus great. It is the expert who identifies the patient’s problem, makes the diagnosis, prescribes the medicine and provide expert advice about the effects of the treatment.

This reductive, top-down approach to health have been widely criticised. The biomedical belief that health is synonymous with absence of disease was challenged by WHO’s 1948 definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. This definition opened up a more positive definition of health that involved: well-being, quality of life and personal resources to cope with the stresses of everyday life. It also embraced that wider determinants such as culture, education, access to good housing and networks are important factors for health. Social medicine has always been concerned with how social determinants influence health. This emphasis became stronger during the 1970s with the emergence of what has been called the social model of health.

Radical approaches to health emerged during the 1970s. Ivan Illich, for instance, criticised the biomedical model of health and the power it had over people’s bodies and minds. In Illich’s view, medicine was harmful because it pathologised people and medicalized life (Brodzinski 2010: 4). According to Illich, medicine undermined health because the medicalization of people destroyed people’s natural ability to cope with human weakness and suffering. Michael Foucault also problematized the medicalization of people’s bodies. He identifies the “medical gaze” as an important instrument of power because it could define disease, health, normality and abnormality and thereby manage relationships and lives (2003: xx). According to Armstrong, the term ‘medical gaze […] encompassed all the techniques, languages and assumptions of modern medicine’ (Quoted in Chamberlain 2013: 35). The medical gaze thus denote the dehumanizing medical process of separating the patient’s body from the patient’s person or identity. The medical gaze reduced the patient to an object that was deprived of a voice. In short, ‘[i]t was the emergence of the medical gaze which led to the patients’ narrative of their personal experience of illness and disease becoming wholly secondary to the doctor’s esoteric clinical-anatomical experimental expertise’ (Chamberlain 2013: 35). The result of this pacification was according to Foucault the production of ‘docile bodies’, or people who conform to the knowledge of the experts without questioning the effects of this power on their bodies and lives (Foucault 1991:138). People thus internalize the dominant discourses of medicine as ways for being and acting in the world. According to Onken et al, ‘[s]uch embedded dominant discourses become objectifying, subjugating, stigmatizing, and oppressive for people whose experiences have led to being defined as “deviant other” – not normal, not healthy, not sane’ (2007:13). Questioning negative dominant discourses is thus important for the development and maintenance of people’s health. 

The reductive, diagnostic system of the Western medical model has also been severely criticised. According to Lars Svendsen, the use of mental health diagnosis might make the life and the prospects of coping more difficult for people (2015: 61-77). Stigma is perhaps the most harmful and most difficult aspects of the diagnostic system because it makes it difficult for individuals to deal with their problems and get the help they need (Svendsen 2015: 63-66). A more holistic approach to health where patients are treated as ‘people’ rather than ‘patients’ has thus been called for. Recovery research has indeed shown that there is a need for a more humanistic approach to mental health where the person should be more important than the diagnosis (Krogstad et al. 2011: 480). A person- centred approach where the person is listened to is according to Krogtad et al. essential for recovery. When personal narratives are listened to, it is found that “recovery is a fundamentally personal process that involves finding a new sense of self and feeling of hope (Krogstad et al. 2011: 479). Other very important factors for recovery include: hope that change is possible, good relationships, being involved in meaningful activities, exercising citizenship, the countering of stigmatising media portrayal, respectful approaches to people and the right to feel responsible (Krogstad et al. 2011). Peer networking is also important. “Connection among peers allows a nonpathologizing community discourse that is less susceptible to judgement and fosters expressions of power and collective social action. These efforts serve to counteract the stigma imposed by society and internalised by individuals while instilling meaning in life pursuits” (Onken et.al., 2007: 16).

According to the sociologist Ray Pahl, self-esteem, being valued, close personal relations and wider social networks have a great bearing on people’s health (White 2009: 57). By contrast, the lack of empowerment, a sense of powerlessness and lack of control over what is happening to ourselves and to our lives, increases the risk for illness substantially (Tveiten 2007: 29). Indeed, research has shown that there is a direct link between empowerment and health (Tveiten 2007: 29). According to Wallerstein and Bernstein, ‘powerlessness is linked to disease, and conversely, empowerment is linked to health’ (1988: 382). On a personal level, empowerment is linked to feelings of self-esteem, self-worth, self-confidence and self-efficacy, but there has been increasing focus on the fact that individual empowerment must be understood in a social context. New developments in public health have emphasised this aspect of empowerment. According to WHO, ‘‘Empowerment’ refers to the process by which people gain control over the factors and decisions that shape their lives. It is the process by which they increase their assets and attributes and build capacities to gain access, partners, networks and/or a voice, in order to gain control’. Empowerment must therefore be understood as a process where individuals can achieve greater control over factors that influence their feelings of self-worth and self-esteem at the same time as it builds capacities to form close personal relations and good social networks.

In Norway, the biomedical model of health has changed and adapted over the years as a result of the criticism levelled against it (Gjernes 2004: 149). Over the two last decades, the doctor-patient relationship has changed and patients have gained more legal rights and more power. Physicians are also encouraged to incorporate some social health values in their assessment of patients, but the biomedical drive to find a single underlying cause for illness is still dominant. Although biomedicine is celebrated for all its advances and achievements and successes, the biomedical model is still criticised for being reductive, top-down and inhuman. The GP and professor of social medicine at the University of Oslo, Per Fugelli, even argue that the specialised biomedical model can have a tendency to weaken people’s health because it only addresses health as absence of disease and disregards other aspects of health such as a holistic view, dignity, freedom and equilibrium (Fugelli 2011: 7-9).      

act2 Forum Theatre

act2 Forum Theatre is a professional Theatre of the Oppressed company based in Oslo. The company was established by theatre practitioner Eliann Stålem Berg in 2008 as a theatre activity under SAFIR, a voluntary centre for people affected by addiction. SAFIR is a collaboration between the Church City Mission and Oslo Red Cross and characterises itself as a ‘doing, being, learning space’, where people can come to take part in meaningful and purposeful activities. SAFIR offers low threshold services to help people develop confidence and skills that can enhance prospects of social inclusion, social reintegration, long-term recovery, education and employment. Within this framework, act2 uses theatre to support change processes necessary for health, well-being and recovery. 

act2 is the only group in Norway that systematically uses theatre to address the particular problems and challenges experienced by people affected by addiction. All the participants in act2 have experienced addiction at some level and many have a long history of substance abuse behind them. A great many of those who come to act2 don’t have any social network outside the local drug culture and many feel utterly powerless in their meeting with “normal” society. For many, act2 is their first experience with theatre. Every week act2 arranges theatre workshops where participants get theatre training and the opportunity to explore various theatre techniques. Much work also goes into building social capital, resilience and self-esteem. Participants who want to commit to the group also get the chance to devise plays together and work as actors in the company. The activity of the company is extensive and today the plays act2 devise are performed in mainstream theatres, treatment institutions, rehabilitation centres, day centres, network centres, and different parts of the social services in Norway. Initially, act2 predominantly devised plays about and for those who suffered from addiction. This exclusive focus has changed over the years and today the company is also commissioned to produce plays for other groups in society including schoolchildren, businesspersons, bureaucrats, mental health service users and other marginalised groups. When act2 performs for other groups or devise plays together with other groups the aim is to create dialogue between different groups in society, emphasising the common elements of human existence to create understanding and to counteract stigma. Whoever the target audience, the overall objective of the company is to combat the oppression, marginalisation and social exclusion experienced by (former) substance abusers. The company has six programmatic aims designed to meet this goal. These are:

  • To make high quality devised theatre.
  • To facilitate change through processes that enhance personal and social empowerment and by challenging oppressive institutions.
  • To create dialogue in order to promote relationships and combat stigma. 
  • To create spaces where marginalized ‘outside voices’ can be heard as legitimate voices in the cultural field and in debates about social services, health and care.
  • To provide spaces where the participants can explore identities which are not their own and where the participants can experience new social roles.
  • To market art as a special kind of knowledge in social work, health and care in Norway (Berg 22 June 2015 interview).

All in all the aims of the group are thus activist, aesthetic, therapeutic, social, performative, pedagogical and ethical. According to Eliann Stålem Berg, the company focuses on ‘each person’s chance to change his or her life situation. Our work is about courage, to impact, empowerment, passion, pleasure, fun and self- esteem’ (Berg, 2014). In short, the company is committed to change the lives of the individual participants and their audience by creating strong networks, by valuing their unique experiences and by sharing and discussing their problems, hopes and dreams through the medium of theatre. The idea that change is possible is at the core of act2’s work and is expressed in the company’s name. act2 = it is never too late to act because there is always a second act in a person’s life. This act can be influenced by the ways in which theatre can empower people to gain access, networks and a voice.

Augusto Boal’s theories, techniques and methods constitute a major influence on the work of act2, and the company uses the theatrical methods developed by Boal as a starting point to fight the oppression experienced by people affected by addiction. In Boal’s understanding, oppression has a very straightforward definition. For him ‘oppression exists when a dialogue becomes a monologue’ (Boal 1996, 47). Denying people a voice and visibility is, according to Boal, an act of oppression that makes both individuals and societies unhealthy. For individuals and societies to be healthy, dialogue is thus essential and must be encouraged. According to Boal, ‘the aesthetic space’ (the stage) provides a unique arena to cultivate dialogue using the multifaceted language of the theatre. In short, the aesthetic space is a mirror where humans can observe themselves and in ‘[o]bserving itself, the human being perceives what it is, discovers what it is not and imagines what it could become. It perceives where it is and where it is not, and imagines where it could go’ (Boal 1995: 13). Observing is, therefore, the first step towards understanding the problems we have. Passively observing is not, however, enough. Finding solutions require active spectatorship, and embodied action.  In Boal’s theatre, observers are, therefore, encouraged to become active ‘spect-actors’. This means that the audience is encouraged to enter ‘the aesthetic space’ to use the language of theatre to suggest alternative ways of being and acting in the world. In Boal’s view, this process of interactive theatre is empowering because it provides individuals with tools to redefine themselves and their world (Boal 1996: 49). This is particularly true of the Forum Theatre model, which Boal describes as ‘the most democratic form of the Theatre of the Oppressed’. This model is based on the idea that theatre should give the spect-actors the possibility to change the reality reflected on stage. According to Boal:

the æsthetic space allows democratic interchange, allows us to say, ‘OK that’s the way things are but not the way things could be, and now I am going to create an image of how I want the world to be’. As we penetrate that space we can create a new image. This is empowering (Boal 1996, 49).

A Forum Theatre play always ends badly, defining problems that make the protagonist disempowered. This play is then performed again for a second time. This time the ‘spect-actors’ are invited to come on stage to suggest possible alternatives that might alter the course of the play and the protagonist’s life. According to Boal, ‘This theatre should be a rehearsal for action in real life, rather than an end in itself’ (Boal 2006: 6). The end of the event is, therefore, the beginning, the aim being to empower both actors and spect-actors.

The plays devised by act2 are based on the participants’ stories and their own experience of oppression. The process starts with everyone telling personal stories about a given subject. At this stage, everyone get the chance to develop their voices. Here, as in the whole process of devising and making theatre, the individuals are treated as indispensable resources and the knowledge and wisdom they have are recognised and valued as an essential part of the creative process.  According to Jan Cohen-Cruz, the social and personal potential of autobiographical storytelling is great. This potential rests on ‘storytelling’s capacity to position even the least powerful individual in a proactive, subject position’ (Cohen-Cruz, 2006: 103). This is the first step towards empowerment because it enables the participants to develop their voices and identify the larger power structures of the dominant discourses that control their lives. It takes courage to envision change and according to the founder of the internationally renowned Theatre of the Oppressed [TO] company Jana Sanskriti, ‘[t]he courage to embark upon this search is, to me, empowerment’ (Ganguly 2010: 256). Identifying problems can also be therapeutic according to Adrian Jackson: ‘Looking at the problem is in itself therapeutic: it is a step toward doing something about it’ (Boal 1995: xx). These individual stories are then the starting point of an intensive creative process where the company collectively make a play that they tour with in a variety of venues around the country. In this way, the histories of the marginalised voices of (former) substance abusers are also deemed important in the public sphere. 

Over the years, the company has devised a number of plays that discuss important personal and political questions for the participants and their spect-actors. One recurring theme in the company’s history is the struggle experienced by the participants to become socially integrated and create new networks after drug rehabilitation. In Bagasje/Baggage (2009), the company thematises the tragic early mortality rates of substance abusers. The play narrates the sorry about Nicolay – a man that has been in and out of drug rehabilitation programs for years. At the opening of the play, Nicolay is about to leave the institution for the fourth time. He wants to tackle the challenges of a drug free life, but he realises that this is difficult because his whole identity revolves around the local drug culture. When he approaches the health professionals for help, they are patronising and arrogant. So intent on following prescribed procedures, the carers are refusing to see the individual’s needs. Leaving the institution he is supposed to be ‘empowered’ to tackle the challenges of life outside the institution, but he has gained no strategies to become empowered in the true sense of the word. Despite his personal desire to change his life, the play shows that he in reality has no real chance to succeed. Without social support, social networks or the necessary help from health and care services, Nicolay’s health deteriorates and finally he is so disempowered that he commits suicide.

Gjøkungen/The Young Cuckoo (2012) similarly thematise the importance of human-connectedness and social networks. Here the protagonist wonders if it is “worth becoming clean?” Contemplating what this would mean, she fears that becoming clean is synonymous with utter loneliness: 

Is it worth becoming clean?

Do I have to abandon all my friends then?

Thoroughly lonely (My translation). 

The extreme loneliness experienced by former substance abusers are also a central theme in En ensom historie/A lonely history (2010), Bare Line/Only Line (2011) and Utestemmer/Outside Voices (2014).  Many of these plays focus on the ways in which the medical gaze disempowers people and make their isolation even greater. In Bare Line, Line’s doctor, Bodil Eik, treats her as medical diagnosis rather than a human being. As she is about to leave the treatment institution where she has been for three months, Line is confronted with WHO she is according to biomedical power:

                                 LINE:

(She reads the medical journal […]): Relationship problems,

anxiety, depression. Social challenges. What does all this mean?

EIK

You can read your journal in full later.

LINE:

But I don’t understand this – what does it mean?

EIK

But Line, we have worked on this for three months now. (She looks at her watch).

LINE:

But I don’t understand, I thought, I don’t know. I don’t know

what the diagnosis mean. I thought I was well now.

EIK

Line. You can read about all this on the internet. […]. You cannot expect me to have the time to sit her and explain every single concept to you. […]. What is written there is YOU Line. The life you have created for yourself (My translation). 

In this play, the medical gaze reduces Line to a set of diagnostic labels that she cannot escape and that defines everything she does. The irony is that no one asks or attempts to find out why she has these diagnoses.  In the final scene, we learn that she has been sexually abused when she was young, but the diagnoses do not help her to deal with her traumas. In fact, it makes her life more difficult. Even though Line tries to explain that the labels will make it difficult for her to integrate, find a job and live a ‘normal’ life, the doctor is unwilling to help or listen. Line’s fear proves right and as she is met with a lack of understanding, ignorance, preconceived opinions and stigmatising comments, she finally loses all hope that change is possible.

All in all, the plays in the history of act2 demonstrate how disempowerment lead to ill health, disease and even death. act2, then, performs a stark critique of the biomedical health/care system and the social services, which fail to provide sufficient health care and support for this group of people. In the view of act2, the medical model is ill equipped to give the participants what they need in terms of empowerment, mastery, social networks and human connectedness. This critique is important, but it is only the starting point for finding solutions that can challenge the oppressive situations and institutions that the participants encounter in their daily life. Through the Forum event the participants and their spect-actors get the chance to counter the stigma, the unjust treatment and the medical objectification they experience. In this setting they get the chance rehearse strategies for empowerment that can strengthen their confidence and voices to the point where they can challenge oppressive patterns of behaviour and oppressive authorities the next time around.

act2 is also working to improve the material and social conditions of the participants. Small Forum Theatre plays are regularly used in workshops to help the participants to get access to legal advice, housing and other social services.  Moreover, the company collaborates with the health, care, and social services in order to improve the situation of the group. In 2012 the company worked together with employees from NAV, (the Norwegian Labour and Welfare Administration), the social services and the care services in the borough of Buskerud to create Forum Theatre plays about ‘human encounters’ in work related contexts. The plays were performed to 190 conference participants from the health, care and social services and the aim was to create dialogue and understanding between service users and employees. After the event many of the involved expressed that the encounter had been valuable. The actors in act2 have many experiences that the employees could benefit from and vice versa. One participant working in NAV claimed that this way of working erased the difference between user and employees. It made it easier to understand the users’ main concerns (Mandal 2012). The plays also created a lot of dialogue about what social integration meant, how it should be achieved and on whose conditions.  

This politically engaged work has become a trademark of act2. In June 2015, act2 performed Den blå timen/The Blue Hour at a National Conference for community innovation in Arendal. Den blå timen discussed how local government best could support people with a background from mental health and/or substance abuse to gain work and prosper in employment. More specifically, the play addressed the need to increase employment opportunities within mental health services and drug rehabilitation services for people who have themselves experienced mental health problems and/or substance abuse. The play, which was performed for approximately 150 community politicians and service users, created a lively debate about the benefits and challenges of employing people with lived experiences of mental health problems and substance abuse in the rigid, expert driven health care system in Norway. 

Although not explicitly stated, act2 adopts a holistic model of health in their work to promote empowerment and personal and social change. The project is designed and delivered in ways that promote self-esteem, social networks (both within the group and between different groups), and help to access social welfare services. In all their work, act2 is treating personal and social change as two sides of the same coin. The belief that the problems and limitations experienced by individuals often is echoing something in their world underpins the work of act2. This holistic approach to the human being and to health means that the social, cultural and political dimensions of the participant’s world always are important in the work of the company.

Many of the permanent members of the company express how life-changing participation in act2 has been for them. It is at the personal level that the effect is greatest. Many highlight that participating in act2 has given their lives a sense of purpose. Many of the participants do not have any other social networks than act2, and the regular support they get here from good relationships quite literally give them life-support (Bringsli 2012: 61-66). Some of the younger members of the company have moved on to re-stablish themselves in a variety of areas, including the creative industries. For most of the participants, however, the changes are associated with personal growth, better self-esteem, more courage, better health and well-being. According to Berg, they have learned to re-define themselves, to recognise their own experiences as valuable and ‘their own voices and stories as useful for other people’ (Berg 2014). One actor of the company who was interviewed by the national Newspaper Verdens Gang in connection with their performance of Velkommen to NAV/Welcome to NAV (2010) stressed that one of the reasons why he had become so involved in the company was that their performances mattered for their audience. In his view, it is “healthy for [the spect-actors] to enter the stage to make new choices” (VG 24 June 2010: 46). In the words of one actor:  “I feel that I do something good both for myself and others” (VG 24 June 2010: 46). This ability to re-author oneself, to turn negative experiences to competence that can help others and the ability to envision that change is possible are all important aspects of recovery.

Teater Vildenvei

Teater Vildenvei is Norway’s leading mental health theatre group. Formed in 1995 by Eduard Myska, Teater Vildenvei has been part of the rehabilitation programme for mental health service users in Oslo for twenty years. Myska is a Check born, Norwegian director who gained his professional training in Poland, where he also worked as a director in mainstream theatres for eight years. From 1975 to 1995 Eduard worked both full-time and part-time as a mental health assistant in Oslo, so when he returned to Norway permanently in 1994, he had all the passion, knowledge and qualifications needed to initiate a successful theatre in health company. Today Myska is employed by Oslo University Hospital, and the theatre practice is recognised as an important service for mental health users in the region. Over the year, the company has gained much recognition from both the health and the culture sectors, winning a number of health and culture awards and prizes.

            Theatre Vildenvei identifies four aims that underpin their practice. These aims are summarised in the following:

  • To make high-quality theatre that appeal to large sections of society.
  • To improve the health and well-being of the participants through the medium of theatre.
  • To enhance values of equity and social justice in the field of art by making marginalised voices heard.
  • To create dialogue between mental health service users and the larger community in order to reduce stigma and counter negative stereotypes about people with mental health problems (Myska 16 June 2015 interview).

When the reports of the company are studied, more detailed aims are expressed. These aims can be divided into three categories, including personal development, social skills, and practical skills. In these reports, it is stressed that the participants will get training in collective creation, concentration, interpersonal skills, ability to listen, ability to understand, ability to memorise, imagination, discipline, group belonging, social networking, self-esteem, self-confidence, self-efficacy and active participation. All in all, the aims of the group are thus aesthetic, therapeutic, social, pedagogical and ethical.

Despite the fact that Teater Vildenvei is organised under Oslo University Hospital, the company’s identity as an arts group is more important than their identity as a mental health group. Of all their aims, the primary aim of the group is to make high quality theatre and to produce plays that work effectively outside the parameters of the psychiatric hospital. Myska is adamant that if the starting point is good art, the other aims will follow. This is the logic according to Myska who maintains that ‘the better the performance, the stronger the group identity becomes, the more socially integrated the actors become, and the better everyone’s health is’ (Myska 24 February 2015 interview ). In Myska’s view, the artistic quality of the practice is, therefore, intimately linked to the health benefits of the practice. This is a view that also is expressed by Eliann Stålem Berg, who stress that the production of high-quality art is the starting point of the social processes that will lead to personal and political change (Berg 23 February 2015 interview).

            In Norway, Theatre Vildenvei is unique in its kind. The theatre is a low-threshold service. From the beginning, the theatre became a very popular activity that recruited its members broadly. Over the years, the company has had between 15 and 30 members and all together, over 100 people have been performing in a Teater Vildenvei play. Today there are about 20 actors in the company, their age spanning from 24 to 82. Both mental health users, mental health professionals and professional actors have been part of the group. Together these people have worked to produce plays in a wide range of venues including psychiatric wards, day centres, mainstream theatre, conferences, schools and churches in and around Oslo. For many years, the company performed Easter and Christmas plays in the community. The group has also toured with their plays, visiting theatres in Poland (Łódź), the Czech Republic (Prague) and Ireland (Galway).

The company has thirty productions to its credit. Taken together, the plays presented by Teater Vildenvei have addressed a range of issues and include plays for both children and adults. The plays performed include pieces written by established national and international playwrights, musicals written especially for the company and group-devised performances. The first play performed in 1996 was Our Town by Thornton Wilder. The play tells the story of the everyday lives of the people living in a fictional American town called Grover's Corners. The setting of the play is in the actual theatre and the lives, sorrows, anxieties, hopes and dreams of the individuals are thus reflected on through the illusion of the theatre. This metatheatrical aspect of the performance has become one of the key elements in the work of Teater Vildenvei. In their work, metathetrical devices are used to comment on human existence in general, emphasising the common existential elements of all human beings. The company’s focus on common human experiences is a conscious strategy, the aim being to normalise mental health problems and reduce the distance between mental health service users and ‘normal’ people. For this reason, the company rarely perform plays about defined mental health issues or include autobiographical material in their plays. When these elements are part of the performances, they are generally found within the metatheatrical framework of the plays. In Drømmen om hammeren/The Dream about the Hammar (1999) and Kafé det tapte ord/Café the Lost Word (2003) the metatheatrical framework is used to criticise the mental health services that focus too rigidly on expert opinion, individualised treatment and medication. This approach does not work alone and the plays suggest that participating in creative activities including music, dance and drama adds the social, emotional and aesthetic dimensions to human life – all elements that are important for healing. In this way, metatheatrical devises are used to illustrate how important art/theatre is for health/well-being.

In Drømmen om Hammeren (1999), the indifferent and arrogant doctor is part of a general critique of the system, but the sharpest critique of the mental health services is found in Min Prosess/My Trial (2007). This play takes Kafka’s novel The Trial as the starting point for the dramatisation of people’s experiences with bureaucratic systems that make life difficult, distressing and ultimately meaningless. Just like Josef K, who one day is arrested without any clear charges, the characters in this play are imprisoned by a bureaucratic system that is both absurd and meaningless. The play show how social determinants influence people’s lives and how impotent and powerless everyone becomes when confronted with a hierarchical and authoritarian bureaucracy. Everyone is seen to suffer under such systems, but the system is arguably particularly perilous for the vulnerable and the ill. Scene five of this play thematises the participant’s experiences with psychiatric ‘services’. The absurdity of the stories is chilling. All the stories demonstrates the failure of common sense in the face of difficult laws and contradictory rules and procedures. One character relates a story of a particularly difficult time in her life when she experienced so heavy depressions and anxiety that she found it unsafe to live at home. The GP was helpful, but there were no treatment alternatives for her. She was too ‘well’ to become an in-patient, collective aftercare housing in the community was only for those who had been patients in the first place, so the only option was to find a private psychologist; a solution that did not address the problem in the first place. One character was hospitalised because she felt unsafe at home. She told the senior consultant that she felt safe in the hospital environment because it removed her from a situation at home that made her ill. 

The senior consultant said: ‘Safe?! You are not supposed to feel safe here. Patients who feel safe and think that the hospital is a good place to be, don’t become well, don’t move on’. Does he mean that one becomes well by living in constant fear? That is not my experience. Some senior consultants are really arrogant (My translation).  

Another character was thrown out of the outpatient clinic when she was experiencing a severe mental breakdown, only to end up traumatised in the emergency ward. One character’s social benefits depended on the therapy she received, and when the therapy ended, her money also ended. It proved very difficult to find a new doctor that could help her. One character lived in the wrong place in order to receive help and another was too rich because she at the age of 70 owned the house she lived in. What should she do? Sell her house and live on the street? All in all these stories provide a stark critique of a healthcare system that is more concerned about following absurd bureaucratic rules than about the well-being of the patients.

Teater Vildenvei has to navigate their own practice in this bureaucratic jungle. The funders, the media and other social commentators constantly try to pigeonhole their practice and place it within a treatment setting. To get money, the treatment/therapy aspect of the practice must be emphasised and the ‘effects’ must be ‘proven’ in terms of clinical output. High quality theatre is not recognised as a clinical output. Funders thus seem to emphasise the process over the product, but many of the health effects are indeed dependent on the product. This is a classical catch 22 conflict in the arts/health field. It is not therapy in the traditional interpretation of the term, but it is therapeutic because of all the factors that go into the creation and production of high quality social art in the community. In this way it is therapy.

Many commentators have tried to link the practice to a form of art therapy, but Myska wants to deemphasise this side of the practise for a number of reasons. First of all, this can be read as Myska’s personal critique of the dominant biomedical model within psychiatry that focuses on diagnosis and medicine rather than the person. Therapy is often associated with problems, pathology and diagnosis, all aspects that he finds unhelpful in his practice. In his view, diagnostic labels are not necessary in this kind of work. Indeed Myska believes that this might work to stigmatise and exclude people. Much evidence suggests that this is true. There are even theories that suggest that the use of a mental health diagnosis might make both life as well as prognosis worse for people (Maddux 2008; Krogstad et al. 2011). Rather than emphasising illness and pathology, Myska is thus focusing on bringing out the best in individual people and the group as a whole. Myska’s approach is holistic, and in his work, the whole person with all his or her ‘baggage’ is the starting point. The complex health issues, anxieties and personal problems that the individual participants experience, inform the group’s work, but these problems are transformed into positive qualities. The mental health problems that constitute a little part of the total ‘baggage’ of the individuals are perceived to be valuable because this offers a unique dimension to the artistic work that the group produce; it adds another dimension to our understanding of the human condition (Myska 2012: 1).

According to Myska, the production of good theatre is dependent on a well-functioning ensemble. Over the years, there has thus been much emphasis on creating good social networks and a strong group identity. Much of this work has been done through collective theatre making, but there has also been much emphasis on strengthening social networks through other activities. Every week after the rehearsal, the group dine together. Occasionally they socialise outside the theatre, attending mainstream performances and they have been on a number of journeys together both literally and metaphorically. This have made the group very close and many referred to the group as an extended family or a family of brothers and sisters. One actor said that they call themselves ‘special’ because they have common experiences with mental illness (Larsen 2013: 63). It is possible to say that the group has developed what Helen Nicholson has defined as a ‘community of identity’. This is ‘a deeper sense of belonging to a community’ that is ‘constructed when people recognise their own experience in others, and share an understanding of each other’s values or stories’ (Nicholson 2005: 94). That the group experienced a deep sense of belonging to a community was expressed through acts of love and concern for those who were absent. The physical closeness was also apparent as everyone was met with hugs, smiles, and laughter as they come into the rehearsal. The positive atmosphere of inclusion was indeed very special. I have never before received so many hugs from people I did not know. I feel totally integrated already after only brief encounters. This must be group empowerment.

The examples of how the individual participants have become empowered through the theatre practice are many. One very powerful story is about a participant who characterised herself as voiceless before she joined Teater Vildenvei. The other participants affirm the woman’s story – remembering that her voice was barley audible when she joined the group. The group becomes very animated when they think about how the woman slowly gained a voice through the theatre and how she finally was so empowered that she could scream: ‘SHUT UP’ as Mrs. Meadow in Nell Dunn’s Steaming. The woman had never dared to raise her voice in her life, and doing it in front of an audience in a public space was something she perceived to be an impossibility. When she finally dared to do it after much coaching, it became one of her life’s great victories. Today she refers to the moment as a life changing experience. Another important aspect of the story is that the woman came from Northern Norway, but because Northern Norwegians was perceived to be inferior and since this dialect was stigmatised in the 1950s when she moved to Oslo, she had suppressed both her dialect and her regional identity, adapting a normalised southern dialect. The woman describes this assimilation as a traumatic process. On stage, she was encouraged to speak her native dialect, something she describes as therapeutic. As she describes it, the theatre had helped her to regain both her voice and her identity. In her study Drama in Health and Care, Emma Brodzinski explains that theatrical exercises and mechanisms can help people develop their voice ‘to a point where the person is enfranchised. People may, therefore, literally be given a voice through theatre, or given the confidence to speak through the experience of hearing themselves speak in front of others’ (Brodzinski, 2009: 95). The actor in our example was quite literally given a voice through the theatre. Meeting her today, it is hard to envision that her voice ever has been inaudible. Today she has a very distinct voice, and she is using this voice both to empower others and to build a strong community of identity. This is a great testimony of the transformative power of theatre.

Theatre and Health in Norway = Better than Medicine?  

In various ways, both act2 and Teater Vildenvei subvert the work of official health and care agencies. Both act2 and Theatre Vildenvei work within a holistic/social model of health, recognising that social determinants are central to people’s health and well-being. The activist quality of these two companies work is thus paramount. An important focus of the companies’ work is their explicit and implicit critique of the medical model of health, which focuses on individualised treatment, diagnosis and medication. This critique is explicitly articulated in the plays that the companies are performing and is an important part of their critique of the dominant discourses within psychiatry and drug rehabilitation. The public act of performing can thus be seen as acts of resistance that make voices and bodies that generally have been invisible and silent, visible and heard. This is significant for a two reasons. First of all, it supports the political aim of including new voices in the cultural field. Secondly it enables new perspectives on dominant discourses and established truths. Participants thus get the chance to counteract the biomedical gaze with its diagnostic emphasis and show themselves as individuals with complex and rich lives. This critique of current practice is also indirectly articulated in the particular working methods of the companies that provide more humanistic alternative to the biomedical model. Instead of treatment and diagnosis, act2 and Teater Vildenvei focuses on personhood, enablement, social support, social capital and empowerment in their attempt to promote health and well-being. Both companies work within an ecological framework that understands treatment and recovery as issues that must be framed both in terms of personal and social problems and barriers that must be overcome for people to experience health, community inclusion and social integration. Both companies are thus addressing aspects of health and wellbeing which conventional medicine does not address and which generally are not emphasised by health and care services. In 2002, the editor of the British Medical Journal, Richard Smith, argued that ‘if health is about adaptation, understanding and acceptance, then the arts may be more potent than anything medicine has to offer’ (Quoted in White 2009: 4). Based on the two case studies discussed in this article, it can be added that if health is about voice, visibility, self-efficacy, social support and participating in social networks, then theatre may be better than anything conventional medicine has to provide.

If theatre is so successful in addressing various aspects of health, surely theatre must become an accepted alternative or supplement to other health and care services in Norway in the future. More well designed, cross-disciplinary and longitudinal studies are needed to examine the health benefits of these projects. This research is under way. There are, however, no doubt about the success of these two theatre in health companies. If we accept Macnaughton et al.’s assertion that the success of a theatre in health project ‘is predicated on the quality of relationships built up between all involved in the project’, then the two pioneering theatre in health companies discussed in this article are indeed very successful projects (Macnaughton et al. 2005: 336). As this article has shown, this success is closely connected with the ways in which these projects are designed and delivered. It is thus important that the companies retain the freedom to develop the strategies necessary to support health according to the theatre in health practitioners’ own values and visions. This is not always easy as funders, stakeholders, mother organizations and medical authorities want to influence the ways in which the companies work. Eliann Stålem-Berg addresses one of the big challenges faced by the companies in the following question: ‘how can we be visible and valued as a tool inside healthcare in Norway, standing on our own feet defining our own goals and values?’ (Berg 2014). Perhaps a stronger sense of identity coming from the fact that these companies belong to a vibrant international theatre in health movement can make the challenges that these companies face easier. Both act2 and Teater Vildenvei are currently in the process of redefining their practices as independent theatre in health companies in the community. Both companies have been given an office and a rehearsal space at Sentralen – a new social innovation and cultural production centre in Oslo. Hopefully this move will be the beginning of a stronger theatre in health movement in Norway.


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Interviews

Berg 23 Februar 2015 interview

Berg 22 June 2015 interview

Myska 24 February 2015 interview