IPTN JOURNAL APRIL 2023

From the Editors

Editorial
By Radhika Jain and Steve Nash

Articles

When the Streets are the Mirror of Playback
By Farah Wardani

Anti-oppressive Playback Theatre
By Mireya P. Ruiz Esparza

Playback Psi (Ψ) Greece – Documenting Stories of Expatriation through Playback Theatre
By Vera Lardi

“Breaking Silence Together”: Outcomes of Playback Theatre Therapy and Participation in the Play “He who made me a woman”
on the Lives of Single Mothers who Participated in the Process
By Inbar Serfaty Netz

Understanding the Impact of an Online Playback Theatre Intervention on Staff Wellbeing
By Samantha Swift, Paras Patel, Angela Kennedy & Steve Nash

Abstract

In early 2021 the National Health Service in England funded the development of ‘Staff Wellbeing Hubs’ to help health and care staff to access wellbeing resources during the Covid-19 pandemic. In the Hub that was set up in the north of England, the therapeutic value of the arts, and of narrative and reflective approaches in helping people cope with adversity and recover from trauma, was recognised from the outset.

This article looks at the impact on a group of ‘front line’ health practitioners who chose to attend an online Playback Theatre event as a way of dealing with their experiences of providing health care during the pandemic. A significant majority (82%) reported that it was a worthwhile experience that they would recommend to their colleagues. Qualitative feedback from participants suggests that Playback Theatre can provide an innovative and valued intervention for collective reflection and sharing, and that it encourages connection, emotional processing, personal healing, and hope.

Authors

Samantha Swift, Assistant Psychologist, North East and North Cumbria ICS Staff Wellbeing Hub

Paras Patel, Senior Researcher, North East and North Cumbria ICS Staff Wellbeing Hub

Angela Kennedy, Clinical Director, North East and Cumbria ICS Staff Wellbeing

Steve Nash, Playback Theatre York, Independent Mental Health Consultant

Introduction

The Staff Wellbeing Hub

The Covid-19 pandemic created a unique set of pressures for health and care staff who were trying to continue to provide high quality care, whilst simultaneously managing major changes in service delivery and responding to the needs of service users and colleagues who were experiencing reduced social contact as a consequence of shielding and isolation.

North East and North Cumbria (NENC) Staff Wellbeing Hub was developed in the north of England in January 2021 with funding from the National Health Service, to ensure that support was available to help front line staff to address their individual and collective needs. The Hub provides confidential access to a range of wellbeing resources and to experienced therapists, based on the following five trauma-informed principles:

  • Relationships are the basis of recovery: staff want and deserve real contact with experienced mental health experts from the outset
  • Whole-system thinking: working productively across agencies to create easy and timely access for staff and to plug any gaps
  • Normalisation and strengths-based approach: non-pathologising language and preventative offers for individuals and teams
  • Empowerment: a range of good quality offers to choose from, including specialist therapy and confidential self-referral
  • Addressing complexity: dealing with the unique and multi-layered nature of staff mental health

Those responsible for developing the Hub felt it was important for staff to have access to a diverse range of activities so that their individual needs and style of coping/processing, could be supported. From the outset the value of the arts and of reflective and narrative approaches in promoting collective healing following adversity and trauma was recognised. Playback Theatre was selected as one of the offers that would be made available and reviewed via a focused evaluation.

How pandemics impact health and care staff

A metanalysis of 38 studies exploring how pandemics impact on staff mental wellbeing found that staff who are working with affected patients, where there is a risk of transmission of virus, had greater levels of both acute and post traumatic and stress (Kisely et al, 2020).Similarly, frontline workers in the UK during the Covid-19 pandemic had higher prevalence rates of depression, anxiety and PTSD compared to the rest of the population (Murphy et al, 2020). In the US, Panchal et al (2020) compared all essential workers in any role or setting compared to non-essential workers, and found that essential workers were more likely to report depression and anxiety (42% vs. 30%, respectively), the onset or increase of substance use (25% vs. 11%), or to have seriously considered suicide in the past 30 days (22% vs. 8%). In a UK poll of 996 healthcare staff 50% reported that their mental health was impacted by the Covid-19 crisis (Thomas & Quilter-Pinner, 2020), with 95% supporting government actions for more support for health and care workers’ mental health.

Evidence of related interventions

i. Communal approaches

Collective approaches to healing following adversity, where groups come together to process events and facilitate support have been shown to be effective (Pinderhughes, Davis, & Williams, 2015, Igreja & Baines, 2019). Theisen-Womersley and Theisen-Womersley (2021) refer to qualitative research on the experiences of people in non western communities who were isolated from their fellows, often under adverse or traumatic circumstances, noting the value of collective recognition and acknowledgement of experience. Reneau and Eanes (2020) considered literature in relation to students with collective experiences of loss and adjustment as an impact of the pandemic lockdown restrictions on work settings. They highlighted the importance of ‘meaning making’ including the reappraisal of beliefs and reflection on events that have occurred. They also recognised that sharing stories with others can be an important way to target the collective pain of the pandemic.

ii. Narrative methods

Narrative approaches are used therapeutically and, in the media, to acknowledge experience and support sense making. They include talking therapies that focus on hearing and understanding a person’s story (White & Epston 1990); systemic therapies that value narratives from multiple perspectives within a family or group (Dallos & Draper, 2010); the use of relational dialogic approaches such as Cognitive Analytic therapy (Ryle & Kerr, 2020), and other methods that emphasise using narratives to facilitate emotional processing or healing. Eyerman, Alexander and Breese (2015) highlight the value of approaches that transform lived experiences into television and written media, requiring a retelling and reconstruction of stories of war and other large scale traumatic events.

iii. Reflective Practice

Reflective practice is recognised as a valued way of providing team support in health and care settings (British Psychological Society, 2007). To support the psychological needs of healthcare staff during the Covid-19 pandemic, space for taking stock was recommended, using trained psychologists to facilitate reflection and processing of experiences (British Psychological Society, 2020). Established reflective practice formats in healthcare include individual supervision, and group based processes. “Schwartz rounds” focus on key topics for staff delivering a service, and the feelings elicited (Robert et. al, 2017, Flanagan et. al, 2020); “Balint Groups” focus on clinical cases, paying attention to the therapeutic relationship (Balint, 1979,1993); and “Taking Care Giving Care rounds” use a structured format to promote compassion for oneself and for others (Flowers et al, 2018, Jones, Waites, Sciar, 2020). All these formats align with Schon’s model (1983), with reflection on action after it has taken place, and each provides space and time to process and take stock of what has happened.

iv. Therapeutic use of drama

Applied theatre and drama therapies have been used to support those with emotional suffering and trauma, often targeting cultural experiences (Leveton, 2010 & Van Der Kolk, 2015). Drama techniques “allow us to speak the unspeakable, experience comfort, compassion and support from others” and ensure that “hope is restored” … (Leveto, 2010). In Taiwan, drama therapy activities were used in counselling groups for college students identified as needing support related to traumatic experiences, life adjustment, and behavioural concerns (Chang Liu & Yang, 2019). Delivered in ten group sessions over six months, these activities had several measurable beneficial impacts, such as increased self-awareness, and self-expression.

v. Performance and healing

A literature review (Heras and Tàbara, 2014) found that drama/performance is a powerful tool for disseminating information, providing a way to reflect as a group and to think critically on a topic. When applied to therapeutic or healing purposes, this was linked to increased freedom of expression and empathy towards others. The study concluded that performance methods appear to serve several potential functions, including integrating knowledge and different perspectives, and communicating complexity, which in turn provides an opportunity for a self-reflective process.

Playback Theatre

Playback Theatre is a performance-based methodology that incorporates many of the beneficial aspects of the therapeutic interventions that are summarised above. Whilst it is not a clinical intervention, Playback Theatre is increasingly recognised as an arts based medium that can help groups and communities explore and address a wide variety of personal, social and cultural issues (Fox and Salas, 2021). Potential wellbeing benefits include promoting healing from collective and individual trauma and personal suffering (Salas, 2020, Munjuluri, et al., 2020). It provides a way of encouraging reflection, witnessing individual experiences, and building group connection and communal understanding (Fox, 2007).

The suitability of Playback Theatre as an offer from the Staff Wellbeing Hub was strengthened by the fact that at the outset of the Covid-19 pandemic, playback practitioners quickly adapted new techniques that allowed the form to be accessed as an online methodology (Rosin, Vogel & Lebron, 2021). This meant that staff could participate in a creative and interactive group activity without breaking the social distancing regulations introduced to reduce the spread of the Covid-19 virus.

Method

The NENC Staff Wellbeing Hub commissioned Playback Theatre York to design and host an intervention for frontline staff working in health and social care settings, with the aim of providing an innovative approach to supporting individual wellbeing as a part of a shared reflective experience. The result was a series of two online performances called “Beyond the mask – your stories seen and heard“.

As this was a new intervention for health and care staff, in addition to being implemented during the Covid-19 pandemic, evaluation was built in to learn more about attendees’ experiences of Playback Theatre and its impact, and to inform its potential future use.

i. Recruitment

An electronic advert was shared via the Hub distribution list, and Hub clinicians also promoted the opportunity with key contacts who acted as “spokes and outreach” leads. Staff attending existing reflection groups (such as Balint groups) were also informed. A promotional video was created to explain what to expect when attending the event. Attendees completed an online form to book a “seat” and a Zoom link giving access to the event was shared via email. Staff could contact Playback Theatre York or the Hub for further information.

ii. Participants

In total, 23 health and care staff attended one of two individual playback performances, the first was held in May 21 and the second in September 2021. Attendees included 11 women and 8 men, with 4 not providing a response for gender, and with a mean age range of 46.5 years. Professional roles were mainly clinical, but included those working in communications, data analysis and public health. 19 attendees were from North East and North Cumbria Health and Care Services, and 4 with employers from other regions.

iii. The online events

The two staff wellbeing interventions each ran for 1.5 hours. After each event (or show), an anonymised online questionnaire containing a mixture of qualitative and quantitative questions was sent to attendees by Playback Theatre York, using email addresses provided when booking a place. All 23 audience members completed this and a further 4 responded to a second evaluation from the NENC Staff Wellbeing Hub. This second survey was only available for the first (May) performance; for the second show the two questionnaires were merged, to simplify the ask made of participants. Questions asked related to the expectations, experiences, and impact of participating in the event.

Results

Quantitative Feedback on the Experience and Impact of Playback Theatre

Twenty-three attendees provided responses on their level of agreement to a set of statements about their experience of participating, selecting one of five response options:

Statements related to the experience of Playback Theatre  Strongly AgreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
I found listening to other people’s stories valuable  80%16%4%0%0%
Listening to other people’s stories made me feel less isolated75%12%13%0%0%
Playback Theatre helped me connect more with my own feelings80%12%8%0%0%
Playback Theatre helped me connect with other people’s feelings67%24%4%0%4%
I thought this was a worthwhile experience  83%12%0%5%0%
I would recommend Playback Theatre to my colleagues80%16%0%4%0%
I would like to attend another Playback Theatre show in the future71%25%4%0%0%
Table 1. The percentages of staff (n=23) for responses on the level of agreement on a number of statements related to their experience of Playback Theatre
Table 2. Percentage of staff who reported that the show made them feel this way, on a range of feelings and experiences

Qualitative Feedback on the Experience of Playback Theatre

After the first show, 4 attendees responded to a Hub survey regarding expectations and the impact of Playback Theatre, and whether needs were met. All reported their expectations had been met, with three stating their needs were also met (one person described not having any needs to be met). No one reported having outstanding needs or distress that the Hub could help with, although one person suggested the need to further develop preventative interventions. All four reported that attending Playback Theatre had no negative impact on them or their capacity to function.

An inductive thematic analysis of this qualitative data was guided by Braune and Clarke’s (2006) six step method. Two researchers from the Hub reviewed the data to identify themes independently for reliability, and then agreed on ten concluding themes.

ThemesQuotes
Connection – includes connection to others in the audience, to the wider community and the story of covid, as well as to themselves and their own experience.A true sense of feeling connected! Validation of Playback as a powerful form to connect.   Connectedness to the wider story of Covid   Connecting to the emotions of my experience and shared experiences of others. There was nothing in this that did not connect in some way. Thank you.
Reflective process  – the extent to which the experience gave an opportunity for reflection That playback theatre, is a very powerful reflective tool. The beautiful art mediums of music, dance and theatre, which playback champions, there is a space for reflection and connection. Hearing and seeing my story skilfully played back
Processing emotions – that participation facilitated processing in some way, including thoughts and emotional reactions, and the impact of external eventsI think it was a good experience and method to process some difficult experiences. The experiences that people were sharing seemed to come from their experiences and their internalised thoughts about the whole situation. I talked through my wellbeing with a psychologist which was helpful too. This was more dramatic and powerful a form of processing. It helped me access some cathartic method as I don’t have clinical caseness of problems currently which require intervention.
Collective Sharing of Experiences – those with some form of common shared experience, were able to come together to share stories, and this process and hearing others’ experiences was appreciated.I liked how the experiences that people were sharing were not well rehearsed scripted stories. That we have a shared experience amongst one another. Appreciative of the vulnerability that able to be shown, shared and felt among the group. It has encouraged me to share more…
Validation – of one’s own and others’ experiences, recognising common humanity, with a need to be heard, understood and validated. The sense that a safe space was created, an environment to contain emotional experiences.Validation of experiences of NHS staff    It helped me to feel acknowledged and created a sense of sharing. It made me feel understood better. You showed how seasoned you are at containing people emotionally.  
Increasing awareness of others – Attendees’ comments indicated a theme of increasing awareness of others, both in terms of their experiences and how this has impacted them, and sense of empathy for others.How important it is to support our health and care staff who have experienced trauma due to working in the pandemic. Empathy towards others. That we have a shared experience amongst one another.
Acknowledging the Playback Theatre Approach – the unique approach of Playback Theatre as an intervention, recognising relational skills. such as sensitivity, kindness, honesty, genuineness, authenticity and respect.   Also recognition of the skilfulness of the performers in delivering an organised and professional show, understanding the stories shared, and performing in a containing and meaningful way. This mostly covered positive appraisals to acknowledge the Playback Theatre approach, though one person provided a contrasting view.Thank you for the authenticity and respect from the performers. Acknowledgement to the conductor for his honesty and genuine care for people throughout. I was quite blown away by how well organised, orchestrated and delivered by the Playback team – really impressive! At times I found myself thinking it was all a bit weird, the ‘playing out’ of people’s emotions and their experiences that I worried for them in my feeling this discomfort (“are they OK with these people putting their feelings out there?”) but actually you showed how seasoned you are at containing people emotionally … I felt the performance lacked gaiety and energy and felt I had been at a funeral by the end of it. The music was monotonous. I think you can interact with people in an energized way even on painful topics but i didn’t feel you got the rhythm right – at least not for me. It was so professionally hosted. Excellent. I thought the mix of actors/methods improvising stories was really good. Thanks so much to all of the actors who were sensitive and kind.
Positive Experience – comments related to attendance being a positive experience, which is reflected in descriptionsEnjoyed the experience. Was a lovely way to reflect. Was a very nice way to spend my time one evening after work. An incredible experience!
Personal Healing – the impact of the intervention in terms of facilitating personal healing, and the potential for this to have a powerful impactThrough the zoom online PT performance, and it was both enlightening about a complex topic like the impact of covid on health care, as well as personally healing. Very powerful experience which I gained a lot from. You might think what on earth is this at first, but then you will discover how powerful it is.
Hope – themes of hope that was developed and drawn on throughout working in the pandemic, and hope for the future after covid, with awareness that hope may not yet be processed or felt.I will take away from my experience of the playback performance … so many things haven’t been processed fully, or at all…, as well as positive things like progress and hope. My participation has fostered my hope and resilience and strengthened my sense of humanity that I am not alone when going through this journey. There is hope for the future after COVID.
Table 3. Qualitative Themes Relating to Attendees Experiences of Playback Theatre

Discussion

These findings suggest that Playback Theatre offered as a single session event for health and care staff provided an opportunity that enabled staff from different organisations to connect to their own and each other’s emotional experiences. Given the impact of the pandemic on staff mental health – including higher rates of mental health problems (Murphy et al, 2020, Thomas & Quilter-Pinner, 2020), increased problematic methods of coping or serious considerations of suicide (Panchal et al., (2020) and the prolonged pressures and lack of social connection that staff have faced, Playback Theatre may provide a timely and effective way of addressing staff wellbeing needs.

This evaluation did not attempt to assess changes in mental health symptoms or presenting problems, but the findings suggest that the beneficial impacts and experiences closely align with the aims of mental health or stress management interventions. For example, the theme of “hope and feeling hopeful” is recognised as a source of strength during times of stress (Folkman, 2013), a theme that is relevant to the needs of staff who have been exposed to multiple and prolonged stressors as the result of a pandemic.

Shattell, Starr & Thomas (2007) found that people with mental health problems need to feel “heard, seen and validated” to support their recovery, which Playback Theatre clearly achieves, as evidenced in attendees’ feedback around the theme of validation. This outcome may be linked to Playback Theatre York’s ability to provide a safe space to hear and contain emotional experiences sensitively, as was noted in the data, and to use personal stories to help people feel heard and able to make sense of their experiences, both being objectives in many narrative approaches (White & Epston 1990). Attendees’ experiences suggest that Playback Theatre produced important effects like those found in other mental health interventions. This includes personal healing, hope, and increased awareness of others.

Furthermore, to target mental health needs effectively, one of the requirements of compassion focused therapies (Gilbert, 2014) includes recognising the common humanity we all share. Evaluation themes of connection and increased awareness of others, and attendees’ reports that the event helped them to connect to others, suggest that Playback Theatre enables people to recognise this common humanity in each other. Moreover, this also aligns with aims of mentalization based therapy, which is to understand the perspective of others, as doing so provides a mechanism for emotion regulation and being able to relate to others (Bateman, Fonagy, & Allen, 2009).

The data suggests that this intervention enabled participants to heal, instill hope, increase their awareness of others and of themselves, and to develop a sense of the wider story of the pandemic, transforming individual stories into a shared narrative, with attendees participating in a structured communal experience. This seems comparable to Reneau and Eanes (2020) who recognised the value of college students sharing stories together to help to address the collective pain of the pandemic.

The data also provides evidence that arts based methods can assist with processing of emotional experiences, with one quote highlighting that the event “was [a] more dramatic and powerful form of processing… it helped me access some cathartic method”, in addition 92% of attendees reported that Playback Theatre helped them connect with their own feelings. This perhaps links to Heras and Tàbara’s (2014) proposed function of performance methods as offering a powerful way to share information and discuss complex ideas, in this case, the stories and emotions of staff during the Covid 19 pandemic. It may also be related to offering a meaningful way to reflect back emotional experiences and speak the unspeakable (Leveton, 2010); and to increase self-expression and self-awareness (Chang, Liu & Yang, 2019). Although the exact mechanisms are unknown, the data demonstrates that the use of improvisational theatre had a beneficial impact for staff who shared stories on their experiences of the covid-19 pandemic. It also highlights Play back Theatre’s ability to sensitively validate emotions and contain challenging experiences. It can provide an attractive offer for staff who wish to try something different, and participate in something which may have a beneficial impact after a single 1.5 hours session.

Implications for further work

This evaluation included both quantitative and qualitative feedback, providing an overall understanding of staff experiences of the impact of Playback Theatre. Limitations included the sample size for the evaluation which related to challenges in recruiting staff to a novel and therefore unfamiliar intervention, and the nature of a survey based evaluation as compared to using more in depth focus groups or interviews.

This evaluation has highlighted that Playback Theatre provides an overall positive experience with beneficial impact, but it was not able explore in any depth the mechanisms that gave rise to this. Further qualitative surveys may provide greater insights as to which aspects of Playback Theatre contribute to its impact. Larger scale evaluations, with comparison reflective group formats and a control group may also broaden this understanding. Further work could explore the use of Playback Theatre with single teams, or with different professional roles.

Conclusion

Overall, the data reflects that Playback Theatre can be a positive intervention for health and care staff in a pandemic. The methodology does not allow for causal conclusions on these outcomes, but this innovative reflective process appears to have been restorative for the health and care staff who participated, and it created an opportunity to pause and take stock on the impact of the pandemic.

To support the psychological needs of healthcare staff the British Psychological Society (2020) recommended using trained practitioner psychologists to facilitate reflection on the pandemic and processing of these experiences. The findings described in this evaluation demonstrate that Playback Theatre offers an innovative format that can support staff to engage in a reflective group and process their emotions, and to empathise with the feelings of others. The sensitivity and skill of the Playback Theatre Company was acknowledged in several feedback quotes from attendees. This is suggestive of the practitioners’ ability to listen to staff stories of the pandemic and attune to the emotional content of the narrative, which is necessary in order to re-enact what can be intense and sometimes traumatic individual and group experiences, whilst at the same time providing a safe emotional container.

These skills align with core interpersonal competencies in a therapeutic relationship (Liddell, Allan and Goss, 2017, and Roth and Pilling, 2007). This suggests that Playback Theatre is a reflective practice format that can be an effective way of supporting health and care staff to process the personal and professional impacts of the pandemic. Whilst this evaluation does not provide research controlled comparisons to other formats that are available, it strongly suggests that Playback Theatre could be an additional offer to supplement clinician led reflective processes, or formats such as Schwartz rounds, Balint Groups, and Taking Care Giving Care rounds. Further use of Playback Theatre and ongoing evaluation to better understand its beneficial impacts is recommended. Offering Playback Theatre events may be a worthwhile way to address the wellbeing needs of health and care staff as they continue to adjust to the pandemic and its aftermath.

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Link to promotional video used to attract participants: //youtu.be/Q5M8xKmjE1c

About the authors

Paras Patel

Paras Patel, PhD, a Research Lead for the North East North Cumbria Staff Wellbeing Hub. He completed his PhD in Psychophysiology, understanding the link between the heart and brain and how this can impact wellbeing. He developed an integrative framework for the holistic assessment of wellbeing which included both objective (Heart Rate Variability) and subjective (Questionnaires) measures. More recently, he has been working on staff wellbeing projects including understanding the impact of various interventions on wellbeing and a project focused on Learning from health care staff experiences of attempting to take their own life: how we co-create lives worth living.

Samantha Swift

Samantha Swift, Assistant Psychologist for the North East North Cumbria Staff Wellbeing Hub developed an interest in supporting innovate ways to support Staff Wellbeing across her career. She worked on the front line during Covid19 in adult mental health inpatient services, supporting those in crisis, later joining the hub to support research and the set-up of the service. More recently she continues to support staff wellbeing in Northumbria Healthcare Trust when implementing workforce solutions and modelling a relational approach in her role as a Systems Lead. The impact of this research inspired her to attend a Playback Theatre event and she found this to be worthwhile and impactful.

Dr. Angela Kennedy

Dr. Angela Kennedy is a Consultant Clinical Psychologist with 33 years’ experience of working in mental health. Her work has focused on the relationship of trauma to severe mental health problems, as well as issues of compassionate leadership and system transformation. The Trauma Informed Community of Action emerged from her efforts to bring people together towards change and inform best practice. More recently she set up the regional support services for staff during covid and her current research is focusing around staff experience of suicide, leadership, and trauma related projects. She is passionate about using the arts and collective healing
to support and connect communities.

Steve Nash

Steve Nash has worked in mental health services in the North of England since 1980, in a variety of settings and roles. He has been active in Playback Theatre since 1991 when he became a founder member of Playback Theatre York. This project, prompted by the need to find creative ways to deliver staff support during the Covid19 Pandemic, provided an opportunity to bring his interests together. He became co-editor of the Journal of the International Playback Theatre Network in 2021.

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By Stephen Meagher & Johanna De Ruyter

The Mythological Path of the Playbacker
By Roman Kandibur & Marat Mairovich

Exploring Light for Playback Theatre
By R.B. Mickie Marie

Practitioner Updates and Resources

New Agreement Between the Centre for Playback Theatre and Affiliated Schools
By Deb Scott

Conferences, Performances and Events

New Scots Creative Arts Residency: Beautiful People with Beautiful Stories taking Beautiful Risks
By Karen McClain Kiefer

International Event Playback Theatre Camp 10th Anniversary Event
By Raz Balian, Joke Rood & Steve Nash

Book Reviews

An Introduction to Psychotherapeutic Playback Theater: Hall of Mirrors on Stage. By Ronen Kowalsky, Nir Raz, Shoshi Keisari
Reviewed by Diane Adderley

Playback Theatre Around The Globe – Pocket Stories to Learn from. By Anastasia (Nastya) Vorobyeva
Reviewed by Cornelia (Conny) Hartmann

Signpost: recent books and articles about Playback Theatre

Books (and chapters in books) about Playback Theatre

Other Sources of Writing (and talking) about Playback Theatre