Introduction

Buried in the verbiage of the document regulating graduate medical education in the country, the Medical Council of India (MCI) (1) does attempt to include study of the humanities in the MBBS curriculum. Interestingly, it is clubbed with community medicine. Seemingly unconnected to this, elsewhere at the bottom of the list of “institutional goals”, personal characteristics and attitudes required for professional lives of graduating students find mention, suggesting that clarity of thinking on the issue is still some way off. Small wonder, then, that any attempt to engage the teaching fraternity in a discussion of the subject only manages to raise the occasional curious eyebrow, amid a sea of frowning disapproval. However, a Google search using the phrase “medical humanities” demonstrates that world-wide there is a gathering storm of interest in this discipline. Journals (2, 3) are devoted to medical humanities, universities offer courses (4) and funding agencies (5) are keen to support research in the area. Clearly, priorities and perceptions differ across the globe.

At the University College of Medical Sciences, Delhi, we have attempted to introduce our students to the humanities. To achieve this, the Medical Humanities Group of the Medical Education Unit (6) has organised a series of events over the past few years relating to literature, philosophy, ethics, the visual and performing arts, street theatre, and the social sciences (7, 8, 9, 10, 11, 12). This paper examines our experience with “Theatre of the Oppressed” (TO), a unique form of theatre devised in Brazil by the legendary Augusto Boal (13, 14). Designed to help communities to understand their social reality and find solutions to their own problems, TO has been used as a tool to bring about change in diverse environments; however, its use in a medical community has not been documented.

The personal characteristics and attitudes required for professional life specifically identified by the MCI for MBBS students are “personal integrity, sense of responsibility and dependability and ability to relate to or show concern for other individuals” (1). Considering that these lie squarely in the domain of philosophy and ethics, it is interesting to speculate on how these ends can be achieved.

We must explore how the student can be exposed to situations where such learning is facilitated, so that she may learn on her own. Importantly, to be effective, such learning, all learning really, must be perceived to be fun. It must not only attract the curiosity of the student, but must also have a lasting impact. The 2-day workshop in Theatre of the Oppressed that we organised was an attempt to achieve some of these goals.

The workshop

The 26 participants in the workshop included students from the University College of Medical Sciences (UCMS), the Army College of Medical Sciences and Amar Jyoti Institute of Physiotherapy, Delhi, and two members of the faculty from the UCMS. The sessions were conducted by the facilitator, or in TO parlance, the “Joker” – one who guides the group.

The workshop included: (i) Introduction to Theatre of the Oppressed, and rules and responsibilities of the group; (ii) warm up games/community building exercises; (iii) image theatre and other structured exercises; and (iv) Forum theatre

The introduction to Theatre of the Oppressed was followed by an important process-setting the container for the workshop with some “agreements” such as “listen for understanding”, “agree to disagree”, “step up/step back”, “right to pass”, etc.

Of the many exercises and games described by Boal (14, 15), the following were used in the workshop:

• Warm up/community building: Name playback, Cover the space, Fainting by numbers, 1-2-3, Zip-zap-zop, Sound and movement transformation
• Structured games and exercises: Columbian hypnosis, blind games including Glass cobra
• Image theatre: an introspective exercise for breaking the mind–body dichotomy, and discovering ‘secret thoughts’. Participants explored themes such as selection into MBBS, your first encounter with a cadaver, classroom, religion, lack of passion, and good medical practice.
• Forum theatre: a problem-solving technique to demonstrate the power of a community and its collective wisdom, democratic processes, and critical thinking. The group created five short plays, after identifying recent, real and unresolved moments of conflict in their own lives. Two of these scenes (Relationship and Abandoned) were selected by the audience and these were then forumed – that is, replayed to elicit their intervention and solutions.

At the end, the participants submitted written feedback of their impressions of the workshop.

Feedback

In this section we reproduce and interpret some of the responses, both to specific exercises as well as to the workshop as a whole. The responses indicate that TO provides a multitude of experiences and addresses a wide range of learning domains.

The games and exercises in TO act at two different but interrelated levels. Working with their bodies, participants often get new insights into themselves. The games, often played without words, and sometimes in silence, stir longdormant feelings. The cumulative effect is the possibility of a shift occurring in the participant, and in his/her interactions with others. In the context of mental health (MH), where communication with patients is the key focus, these effects work in indirect and cumulative ways to improve caring, empathy and communication.

Community building

Community-building exercises, played in the beginning, as well as in between the sessions, had a tremendous role in eliminating the apprehension of being a group of diverse participants from different colleges, branches and semesters. It introduced the feeling that interacting with strangers should never be difficult – an important life skill for people in the medical profession, helped in building instant rapport, a sense of togetherness and trust. Some comments by the participants were:

I remembered my old days, when I used to take part in plays. Also, today I was not afraid of anything.

I was a very shy girl before today who was not actually able to talk comfortably. The games that we played gave me confidence to deal with a new group of people.

Participants were able to connect the games to their lives, both personal as well as professional. Sometimes these insights went quite deep. For example, as one participant put it, “There are things that we know, emotions that we fail to acknowledge, realise… like when we played ‘fainting by numbers’. We all want someone to be always there; to catch us when we fall.”

Structured games and exercises

Columbian hypnosis, a game that uses the metaphor of power, provoked this response from a participant: “…in an abstract way, how a patient gives all control over himself to a doctor and how a doctor should channelize it so as not to oppress the patient.”

Glass cobra, among the most enjoyed of exercises, established that being guided by someone can be liberating. It also inculcated a sense of responsibility and awareness of the situation where participants realize that people are dependent on each other. The feeling of fear and vulnerability when alone vanishes, a real-life situation for doctors when made to play God. Here are some participant responses to this game:

When I finally got hold of the shoulders of the partner I was desperately in search of, everything was just fine and relaxing.

By finding my partner with my eyes closed, I actually started overcoming my fear.

Image theatre

Image theatre is often a journey of self discovery. Some of the responses to image theatre were

During a difficult situation, my mother consulted an astrologer about me who said that I would become a teacher regardless of the profession I chose. That was the beginning of my self-conflict – whether to become a teacher or a doctor. Then, when in image theatre you gave the topic “classroom”, I did not know how to fit into the group; so I automatically became the teacher. Whether my instinct was clouded by predictions or not remains to be thought out!

I found out some truths about myself through the ‘secret thought’ exercise. I could feel my deepest emotions and fears… it filled me with energy and the fire to do this all over again.

Doing image theatre, when I touched my teacher’s feet, it felt great; as if it was something I had always wanted to do.

This exercise was a perfect example of diversity in unity. Liberating imaginations, exhibiting group work and fostering interpersonal understanding, it was a life-like scenario resembling an operation theatre, where different specialists work in a team.

Forum theatre

Forum theatre was a problem-solving exercise, which not only attempted to provide solutions to community problems but was also a self-realisation and introspective exercise.

A practice forum scene during the workshop which depicted an eve-teasing scene on a bus evoked the following feedback:

Eve teasing is one of the most important problems I have faced, and I learned many things I can do to take care. Now I don’t feel scared. If it ever happens again, I will rub it in his face.[sic]

At the end of the workshop we organised a public forum theatre performance for the college faculty and students. Here, participants not only learned from their own experience as actors but were also forced to adapt quickly to the changes incorporated by the spect-actors, inculcating the skills of quick judgment and decision-making required of medical professionals when they may be in difficulty.

Our forum theatre on ‘Abandonment’ challenged the spectators with a problem, shown in an unsolved form. The protagonist with debilitating Parkinson’s disease was shown abandoned by family, doctor, and faith. The forum theatre methodology also provides a dialogic structure for deconstructing deep-seated, bitterly divisive issues with sensitivity and respect.

I will always remember playing a patient with Parkinson’s disease. It raised my confidence to new heights. I am feeling more complete from inside; to the extent of making me aware that we are not just a body, but a body with mind and senses.

The unprecedented outcomes suggested by the spectactors were awesome. I was surprised that actors could even change their roles because of the interventions. It was learning through evaluation by the community.

Outcomes of the Forum theatre process translate back into community science that acknowledges and incorporates vital elements of local knowledge (16). Below is a sample of feedback that attests to the therapeutic and transformative power of TO. It is possible to see connections between these deeply personal responses and their professional application:

The part where we were asked to close our eyes and mimic a conflict in our lives from the past really helped me resolve certain unresolved issues just by thinking about them with so much attention.

Hidden behind many of the group exercises were personal experiences; mine, as well as those of others. Very often a voyage of discovery.

The games helped me understand that my structured way of thinking prevented me from being spontaneous.

I was relieved of some of the grief and guilt that had built up in me for a long time.

This workshop, with all of the philosophies, actually created, or recreated the same passion inside me to be what I was, and what I always wanted to be.

It reminded me of my mistakes, small or large, which I shouldn’t have made; my actions which should have been avoided.

During this MBBS course of ‘becoming God’, we lose our humility. This workshop actually helped me’re-humanise’ myself.

Discussion

The literature has widely reported arts, literature, performing arts and visual arts-based interventions as tools to explore medical humanities (17). However there is a dearth of interventions whereby medical students participate actively. Practising under realistic conditions enables students for their future role as healthcare professionals. Nordstrom reported death notification training among Swedish medical students using forum theatre and found it a useful form of simulated learning (18). A workshop using forum theatre techniques was effective in training the faculty to facilitate small group discussions about multicultural issues (19). Their approach can be utilised to foster critical consciousness in medical education.

Participating in TO is not without challenges. The literature reports potential for misperceptions, manipulation and other negative process outcomes (20). Challenges of the implementation phase include some changes in the script dialogue, inconsistent icebreaker activities and lack of consistency from performance to performance (21). We were fortunate in having an exquisitely trained facilitator with remarkable commitment to her cause. Such people cannot be mass-produced. Introduction of TO into the medical curriculum on a large scale may be problematic as it requires skilled facilitators. Mandates, forcing MH onto reluctant medical educators and restrictive policies are likely to be counterproductive. Eventually, organisers at each institution should be granted the freedom to adopt what works best for them, and be encouraged to explore their own avenues.

For the participants, without exception, the overall experience was positive. The authors, all of whom participated, agree that the workshop promoted a new bonding, trust and kinship among the group. This being a mixed group of students from different institutions and semesters and two members of the faculty, it was remarkable how quickly the facilitator could inculcate a feeling of camaraderie and provide a non-threatening atmosphere.

In the Indian context, with its rigid hierarchies and social constructs, this breaking of barriers was an important lesson to learn. Teachers and students are increasingly expected to cope with diversity in the classroom ranging from class distinctions to social, caste, and linguistic disparities. In our experience, even a single exposure to the workings of TO goes a long way towards the better understanding and resolution of these issues.

Our experience at the UCMS, though limited, suggests that TO, the road less travelled, enables the participants to be observers as well as actors of their emotions, and thus fosters real communication. In summary, this article presents the UCMS experience with TO in our pursuit of introducing medical humanities to MBBS students. TO challenges the senses and offers a promising and enjoyable option to learning MH and advancing the goals set out by our policy-makers.