Category Archives: Drama

“They ought to tell us if we’re allowed to laugh”

This is a copy of a blog that I wrote for the Manchester Ethnography Network – check us out:

It’s August 2013. I’m part of a group of researchers, artists, educators and health care professionals, and we have just completed the two week premiering of a play about dementia care. The play is based on an ethnographic study of low status health care assistants in dementia wards. I was one of three ethnographers on the original project. In June 2010 we had found ourselves with the project all but wrapped up and £10k left in the dissemination budget, and through a serendipitous confluence of events, had ended up giving it – along with around a ½ million words of fieldnotes – to a playwrite. 12 months later we were reading through the first draft of a script, which told a story of an ethnographer entering a locked mental health ward, taking on the duties of a health care assistant and documenting the experience. Another 12 months and we workshopped the script on a shoe string budget with a small group of actors in order to try and attract some funding to stage a full production. Another 12 months and the full production was premiered for two weeks to capacity audiences for a two week run. Approximately 3000 people saw the performance over that fortnight, and thanks to the involvement of local healthcare trusts (among them the same ones with whom we had conducted the original research), almost half of those people were the members of staff whose everyday work we were re-presenting back to them.

The title of this blog is a comment that was made by a member of the public who had come to see the first show. The first show was in the evening, and was not one of those that were to be attended by the health staff (these were to be day-time performances followed by workshops for staff). Almost the whole way through the first half of the performance you could have heard a pin drop. There was not a noise from the audience. It was tense and uncomfortable. We thought the play was funny – all be it darkly so – at times laugh-out-loud funny, at time sad, at times surreal, disorienting, frightening, but at all times we had expected to get a response – any response. Several of us who had been sitting out in the audience were filing out of the auditorium for the interval when we overheard a conversation in which two audience members were discussing what they’d seen:

‘what did you think?’

‘not sure what to make of it…’

‘I thought it was kind of…funny…in places…but, do you think it’s supposed to be funny..?’

‘they ought to tell us if we’re allowed to laugh’

At the beginning of the second half of the performance the playwrite took to the stage and addressed this matter – providing a little context to the play, and quite literally giving people permission to laugh. At the start of each subsequent performance she did the same. It had a marked effect, but we couldn’t help thinking after that first performance that maybe we’d missed the mark. Was dementia too much for a general theatre audience to stomach? Had lengthy exposure desensitised us so thoroughly to our subject matter that our sense of what was ‘ok’ had drifted far from public norms? In our desire to render in words, sounds and images the emotional, visceral worlds that we had encountered, to open the locked doors of the ward and raise awareness of the invisible work within, had we in fact betrayed the good faith of the people whose worlds we invaded? Had we exposed them, held them up like some caricature for this silent public humiliation?

The daytime performances with the staff stood in direct contrast. Without prompt or direction they laughed, groaned, screeched, sucked teeth, hummed, clucked and squawked. They were noisy. Only pantomime audiences make more noise than this. In the auditorium we basked in the warm  sensation of a shared understanding. In the post-show discussions their talk was full of words like ‘captured’, ‘voiced’, ‘spoke to’, ‘represented’.

Words to make the neurotic post-critical ethnographer shiver. We don’t capture, we problematise, and under no circumstances do we represent.

I’ve since thought about many different ways in which these contrasting events might be read. I’ve thought about the immediacy of visual representation, not always a comfortable reflection when we think about the potential fear and violence of the image. But in the clear sense of recognition that the health care staff communicated to us, can we also read the image as potentially powerful and trustworthy?

The silence, by definition, is a more enigmatic object of interpretation. I’m struck by the novelty, as an academic, of being so close to my audience and experiencing their response to my work so directly, and yet at the same time I’m still filled with such doubt as to the  meaning of that response. If they had been entertained, then perhaps there would have been a clearer sense in which we had used, or even commodified, our participants. But I wonder if in that silence is to be found many uncomfortable individual encounters with otherness, and our novel re-presentation could therefore be said to have prompted some kind of critical consciousness raising. This is certainly not to lay claim to some kind of new and authentic language, but rather to draw attention to a brief moment in which something ordinarily hidden might have been made visible, and to which there was no practised response.

Small Change/Big Change

This post presents a response to my last post, which talked about routines, and I think probably gave them a little bit of a hard time. Yes, they can be a little dehumanising, and we can be far too dependent on them, and external agencies can use our patterned behaviour against us…but, they are also very powerful little strategies which can be put to good use. If we use them reflectively, perhaps we can avoid many of the pitfalls I talked about previously.

One of the things I have come to learn about critique in general is that it feels a bit disingenuous to simply stand at the sidelines pointing out all the implications and consequences of everyone else’s action. At some point you have to get your own hands dirty, whether that be making recommendations to practitioners, contributing to policy debates, or even just having an honest conversation with someone you’ve done some research with.

I don’t know if i’ll ever find it easy – nailing my colours to the mast, while simultaneously being able to see the potential problems with each new solution. Nevertheless, it is necessary if you wish to make a contribution to a debate, if you wish to engage with practitioners and policy makers in their languages, and if you wish to have some kind of impact. Bringing about change in practice is one of the biggest challenges we face in our work. So often, the change you really want to be able to make is transformational, not this piecemeal, do things slightly differently, change one or two procedures, but the big, system changing, relation changing, heavy change. I don’t know whether lots of small changes add up to a big change in institutional terms. I think in some cases they can do. After all one of the greatest sources of power is alliance, so collecting enough small things together might prompt change in much bigger things.

I used to have a job with the National Institute of Health and Clinical Excellence (NICE). They produce guidelines which are non-statutory but make up the official benchmarking for clinical practice in the NHS. I was employed by one of the NICE guideline development groups as a service user representative. This was never a role I managed to find any great comfort with. Some of the reasons for this was to do with my own hang ups about what or who I was supposed to be representing, and what exactly it was that made me representative of a particular group. But all sorts of other things were just to do with the a priori constraints that existed and limited the possibilities that could be achieved through such a guideline. For example, when making assessments about which treatments to recommend for particular conditions, we were constrained by the existing health technology assessments, which used a health economics measure of efficacy called a QUALY. Basically, this is a numeric tool combining the cost of a treatment with its reported improvements of quality of life. We had the calculation and its method explained to us – it was problematic to say the least. QUALYs are seen as significant to the fourth decimal point, and yet the calculation that goes into them is hopelessly vague and subjective. But regardless of how many of the group offered their own anecdotal best practice, if it did not fit the QUALY hierarchy then it could not be recommended.

And yet, there were things about the NICE process where there was a certain amount of compromise available between the group of individuals producing the guideline, and the institutional codes which constrained us. We managed to persuade the college that was funding the guideline to commission some primary research the analysis of which was included in the guideline. This is the first time that this has ever been the case with a guideline, which ordinarily is more like a systematic review of existing research. I think it strengthened the guideline greatly, made it appear more human, and will have given cause to stop and reflect for any practitioner reading it. I suppose that this was a fairly small, but nevertheless significant change that we prompted, and I suppose if it became the norm within a guideline process then that could be considered a bigger change. Yet, there were many accepted methods and languages that we found no give in at all.

I’m approaching the stage in my current project where we will be required to write a report back to the funders, including our recommendations. Research recommendations are often the least interesting bit of a report. They can be so dry, stripped of life, taken out of context, superficial, preachy and obvious sounding. You can imagine people reading them and going ‘duh! I already know that!’, and yet they are difficult to flesh out, give context too, make thicker, because they are intended to be snappy, direct, practice focussed, headlines.

Another project I am involved in found a creative solution to this issue. We wrote the report in as ‘lively’ style as we felt able, nevertheless we had a huge amount of really rich research material that would and could never make it into this rather dry 40,000 word document. So, the PI decided to use the remaining dissemination budget to commission a writer to write a script based on our fieldnotes. This had never been a stated intention of the project, when we were researching it we never had any sense that our work was going to be dramatised – and thus we never ‘went looking for’ dramatic moments. It has been a fascinating process to be involved in though.

Roughly two years later the script has been written, workshopped, well received by stakeholders, and we are now working towards a full production of the play in June 2013. One of the most exciting things to have happened is that the healthcare trust with whom we conducted the original research have remained engaged in this unexpected follow-up – to the extent that they and two other trusts in the area have already reserved 1000 seats across 12 performances of the play for their staff to attend. This feels like double impact – both a novel and creative means to disseminate research findings, and a largely new theatre audience, drawn from some of the most poorly paid frontline staff in the NHS. That three healthcare trusts – with all the recent policy flux and budget slashing – are prepared to release something like 150 staff at a time to come and see a piece of theatre…that certainly defies expectation, perhaps represents a certain amount of transformation in itself, and if we are able to present something to challenge as well as entertain then the ripples could spread much further.

I’ll certainly be blogging more on this process, so watch this space.