Masters of their Conditions III: Clinical applications of theater anthropology in cultural psychiatry

Abstract

Body learning gives actors basic structures and references that enable them to codify their actions in a script or score. With this score, acquired through training, performing and transmitting, actors who work with theater anthropology methodology offer strategies and tools that healers can use with their patients. This actor’s score has inspired a mode of working with patients both to understand the case history and guide the course of therapy. In this approach, patients are like authors who want to act out their dramaturgy, but who need a director-healer to organize the story and help them build their healing process. Together, patient and therapist work on stage to advance the treatment, at the same time enhancing their strategies and methods for collaboration.

Introduction

This is the third paper in a series describing the Masters of their Conditions project which aims to build bridges between medicine and the performing arts, specifically between cultural psychiatry and theater anthropology. The paper builds on certain concepts central to my work presented in these earlier reports. “Masters of their Conditions” (Arpin, 2003) examined cultural and clinical identity as a matter of performance, in which the performing body is the result of a series of apprenticeships that involve cultural transmission that leads to mastery. Performance, like culture and medicine, has its systems of learning in the professions of the performing arts. “Masters of their Conditions II” (Arpin, 2008) asked what lessons we can learn from traditions that do not separate theater and performance studies from medicine. Narration cannot be limited to verbal case-history making and verbal therapeutic approaches. Bringing patients and healers together on a stage in the clinical setting and using all forms of text and performance allows for another way of (re)constructing case histories. This article examines the methodology of theater anthropology and other aspects of performance studies in relation to clinical work. In particular, it considers the collaboration of nonhealth professionals from Asian theatre traditions and how they can contribute to novel therapeutic interventions.

My work takes place in the context of a general psychiatric and psychotherapeutic practice, specializing in cultural psychiatry, in Geneva (Switzerland), a very diverse city with many different cultural and professional milieus. As a medical doctor, I work with somatic treatments. I am a consultant for organizations dealing with abuse, rape, and torture. I have patients who are artists or who are interested in the performing and fine arts. At my office, I have arranged a physical setting that includes a 3 x 3 meter stage and a 6 x 3 meter additional space, with basic lighting and sound equipment to create a “mise en scène.” I have designed and developed a mode of therapeutic practice that incorporates insights and methods from theater and other art forms into work with patients many of whom have “body issues” related to trauma or physical conditions.

Body language tells stories of which patients may not be aware and reading patients’ bodies is part of the repertoire of clinical investigation, from the first session on through assessment and intervention. With experience, healers become actors of particular therapeutic practices: learning, training, performing, and transmitting their knowledge. Much of this work happens within the patient/healer relationship, which is, in some respects, analogous to the partnership of actor and director. Thus, I have found inspiration in the work of actors who can explore a character’s body and transmit emotions, information, insights, and even solutions to the very problems we learn about in first sessions with patients.

The actor’s score and subscore

At my first seminars and workshops at Odin Teatret and International School of Theater Anthropology (ISTA) in 1992, I was impressed by the seriousness with which the actors described how they had developed their techniques. They explained how they connected with the logic of director Eugenio Barba’s demanding exercises in their daily practice. These actors had also been exposed to other traditions and spent time in India, Japan, or Cuba. All had toured, collecting other learning techniques. This multifacetted experience provides a repertoire of techniques, which they demonstrated to participants. This is what we may call the actor’s score. In their accounts of their apprenticeships, experiments, work with decors, costumes, puppets, props, the actors disclosed their difficulties, joys, and disappointments with the company. These stories have similarities to clinical case histories. The difference with patients is that actors are aware that they have built a score (e.g., from a script) whereas most patients are not. The techniques the actors use to organize their stories can be used to investigate and treat patients.

My understanding of the actor’s score borrows from theater anthropology as taught by and trained at the Odin Teatret of Eugenio Barba. The expression “dramaturgy of the actor” refers to one of the levels of organization of the performance (Barba as cited in Barba & Savarese, 2005, p. 112). ¹ The score is what the spectators see. Behind the score is the “subscore,” which is the underlying structure upon which the story of a score develops. Barba does not mean that the subscore is a hidden scaffolding, but a personal process, “often impossible to grasp or verbalize, whose origin may be a resonance, a motion, an impulse, an image or a constellation of words” (p. 112).

In a sense, the score is the actor’s case history. Underlying elements of structure that support the score—the subscore(s)—feed the whole montage of the actor’s work. A director may ask his actors to imagine and develop improvisations that he will eventually string together on one or more narrative threads. The actor has his montage, the director has another and together they will present themselves to the spectators who have their own montage (Arpin, 2003, pp. 313–314). All the above structuring occurs before we even try to put meaning into the actors’ work. It is basically physical.

In my clinical work, I explain this notion of the score to my patients. I describe the underlying structure of the subscore that I use the same way a director does, through improvisations, rehearsals, and montage editing. As Odin Teatret actress Julia Varley explained:

Mixed in this concept are personal techniques, elements of support that keep the score alive, starting points for creating material, the actress’s thoughts before and during the performance, a character’s motives, the inner world, emotions, energy, memories, sensations and everything that cannot be conceptualized. (Varley, 2011, p. 78)

Pre-expressivity

Actors of different traditions express inner feelings, emotions, moods, motivations that are universal according to their particular methods of training. To identify the “universals,” we can look at them in terms of Indian notions of Abhinaya and rasa-esthetics as explained by Schechner (Arpin, 2008, p. 374). Rasas are the essence, the inner “taste” of fundamental elements: heroism, love, laughter, compassion, anger, disgust, fear, surprise, serenity. Similarly, patients express universal experiences of pain, anxiety, and other “clinical rasas.” ²

Theater anthropology has been interested in observing how these elements are dealt with across cultures. Barba developed the idea of pre-expressivity (Barba & Savarese, 1991, p. 5 and Note 6). This refers to the way the body is imprinted with training and memories that one can identify just before it begins performing. For example, based on one’s study and observations of a dance form, it is possible to understand something of the performance about to occur, even before the dancer begins. In effect, a “cultural complicity” or “traditional complicity” develops between pre-expressive actor and preinterpreting spectator, analogous to that between the patient and the healer (Arpin, 2008, p. 363). ³

Odin Teatret actors demonstrate how they organize their basic materials—what they call their body “archives.” The actor begins with an improvisation the first time. The second time, the participants bring comments and corrections to help him reproduce this first segment in exactly the same way. After many repetitions of the segment, the improvisation transforms into a codified segment and becomes part of the actor’s tradition stored in his “archives.” In ancient traditions, like Japanese Noh theater, there is a codified body work that has been preserved over centuries. As Barba explains:

Codification is the visible consequence of specific physiological processes in the performer in the attempt to dilate them and produce an equivalent of the dynamics which are active in life.… Codification aims at a dilated body by means of a double path: by a dilation in space which amplifies the dynamics of the movements, or by a set of oppositions which the performer generates within his/her body, thus activating its muscular tonus. (Barba & Savarese, 2005, p. 221)

We can codify a posture, a gesture, or an action and reenact them as an ensemble of techniques involved in the restoration of behavior. ⁴ Exercises give the actor’s body an “independent” life with its own memory and its ability to reproduce learned behaviors. This is useful for the actor’s solo work as well as in the company’s group work. Exercises also contribute to preserving cultures that apply to patients performing their condition and their therapy. Patients create a tradition of their condition, illness, uprooting, or other.

One effect of codification is the occupation of space and the ability to create natural effects by means of, for example, concentration (reduction) and opposition. The technique of reduction is described by Japanese actor Oida (Arpin, 2003, pp. 310–311) as the incorporation of an ancient tradition and by Russian director Vakhtangov’s work with actors (Arpin, 2008, p. 368). Both show how the codified body can reduce amplitude while maintaining an emotional tension that increases the intensity of the actor’s presence. A clinician can evaluate this kind of presence in a patient performing her or his condition by tracing back the “apprenticeship” of this condition from the angle of the body memory and training (assuming that one can “train” an illness). Continuing the evaluation, we zoom back to figure out the multicultural society our patients come from and see that among the numerous cultural communities involved, not all are capable of preserving traditions and restoring behaviors.

The search for a codification that could give the performer a pre-expressive body has been carried out everywhere.… In Asian theater, because of the continuity of a living tradition represented by the master, codification has been transmitted without interruption, based on the process of imitation that is typical of all forms of direct theatrical pedagogy.… In the West, discontinuity in the tradition, the search for realism or, better, naturalism and psychological rather than physical bases for action have gradually destroyed a heritage of rules fixing performer behavior. (Barba & Savarese, 2005, p. 222)

When confronted with a group of performers of different origins, traditions and techniques, it proves useful to try and find a common denominator, as in a situation where actors of different professional and cultural origins are challenged to perform. For example, Japanese Butoh can provide a common platform. The director will then ask the actors to forget about their traditions, step out of familiar ground, and agree to reconsider their respective teaching methods via Butoh (Arpin, 2008, p. 366). This search for common ground is basic work with my multicultural clientele of couples, families, and groups.

The actor’s plasticity allows him to perform a protean transformation, becoming and moving out of the character in ways that may parallel how a patient becomes ill and later moves out of illness. An actor can also revive and interpret a familiar character. However, unless they have had previous experience with an illness, patients tend to approach coping with an illness or condition as if it were a “foreign” character. This is a process of body transformation, the result of the intensive training learning that the actor receives.

Theater anthropology used to complete the definition of pre-expressivity with that of preinterpretation. Although theater scholars seem to have abandoned this approach, it remains useful and relevant especially when applied to the patient–healer interaction. Spectators may be able to guess the identity and condition of characters by their posture, costume, props, the color of the costume, the position of the hands. These clues can be used in the clinical work developing a form of complicity between patient and healer. We may then include healers, clinicians, health professionals in this teaching project. This is distinct from the usual considerations of therapeutic distance because it does not concern emotions, but rather body learning.

The actor’s score: Body transformations as a result of organized learning

When patients experience illness, injuries, or other trauma, they undergo a more or less visible body transition. Their bodies will be modified either by the condition itself or by its impact, personally or socially. An illness and its treatment create a series of transitions. In the process of building a score the actor moves across similar transitions. There are passages across cultures and across time periods. The actor’s score is a variant of a case history, an organized way to figure out his itinerary or narrative that compares with a person’s case history. It offers many techniques to apply with patients as illustrated in the case study of the work of Roberta Carreri.

Case study: The three faces of Roberta

As part of the annual Odin Week Festival (teaching, workshops, performances) held in Holstebro, Denmark, actress Roberta Carreri and actor Torgeir Wethal of the Odin Teatret staged a scene from Ibsen’s A Doll’s House (1879/2005), in which Nora leaves her home and family, confronting her husband Torvald. ⁵ In 2010 Roberta presented the demonstration alone. Torgeir had died of cancer 2 months before. He was her husband, her colleague in the company, and played Torvald to her Nora. The demonstration consisted of explaining how actors use their score to build the characters. Nora is torn between the excitement of her emancipation and the pain of leaving her children. Following the text of that scene, Roberta created directions, for example: Nora enters, she feels excitement (looks up, shoulders and chest open) and she feels pain (looks back, down, chest closed). She explains how Torvald reacts to Nora’s departure, step by step.

Toward the end of this performance, a sparrow flew on stage and hopped up to Roberta. She stopped and began talking to the bird, suddenly letting go and allowing the emotion she had previously held back to appear. “My husband died 2 months ago. We used to present this work together. If I didn’t have my actor’s score (puts an open hand on her chest), I wouldn’t have survived these weeks,” she said to her audience. Roberta was in grief. She was mourning her husband, her colleague, and her character’s husband’s impersonator. She shared her use of her actor’s score to cope with this situation. Her score is an auto-therapeutic process, a self-learned strategy that she now had the opportunity to show. The sequence of Nora entering, leaving her wedding ring and her keys, grabbing her suitcase and exiting the room was originally a demonstration of actor’s method. Her disclosure made it clear that it was also a grief-coping method that could be adapted for clinical work. ⁶

The actress gives stage directions, the didascalies (Greek didascalia: teaching, instruction), that may appear as an author’s directions in a play’s text or as instructions that actors have in their copy. Here the didascalies designed by the actress are directly transferable to work with patients. Indeed, as a patient enters a consultation for the first time, she or he may produce a number of didascalies that are not stage directions but elements of body language to be deciphered. Later, when working with the patient on stage, these yet undefined elements are transformed into an actor-patient’s own didascalies. In her solo demonstration called “Traces in the Snow” (Carreri & Wethal, 1994) and in her book Tracce (Carreri, 2008), Carreri explains her art, step by step. We hear about her childhood in Italy, shared experience at the Odin, and her stay in Japan with butoh master Natsu Nakajima, a disciple of Tatsumi Hijikata. In this presentation and in the company’s collective demonstration, she explores how she created parts such as Molly Bloom or the clownish parade character Geronimo. In her life as an actress and in the specific story of her grieving, we observe that there are different layers. ⁷

We can expand the grief experience and see grieving as “dealing with losses.” This opens onto a way to apply the concept of the actor’s score in clinical situations. In my own work, I use a codified body sequence to pinpoint the discrepancies between a patient’s verbal and nonverbal narration. I have worked on a Nihon buyō (traditional Japanese dance) for the kabuki theater, called Kuroda bushi (the samurai from the [province of] Kuroda). I chose the first part of the dance, which is 3 minutes long. I did it a first time with music only. I did it a second time without music but with the didascalies that I delivered as I was dancing:

I am the samurai of Kuroda, Kyushu (entering with spear). The governor of the Province decided to honor my courage during the battles I have fought. He offered me the best spear in the country. I am coming into the governor’s palace to thank him for his present and to demonstrate my skills (kneeling, putting spear on floor in front of me). I am now greeting the governor and the notables (saluting; taking fan and opening it). A servant pours sake in a cup (represented by opened fan); I drink it and get tipsy (getting up, staggering); I get a hold of myself and proceed to show some basic postures with the spear (pointing spear front-left, turn around, pointing again, etc). The dance continues with the old warrior courting his lady and finally taking care of his horse.

I did it a third time, with identical postures and gestures—the same didascalies—but another text:

I am a 28-year-old woman. My name is Patricia (entering with spear, etc). When I was a child, we used to spend summer holiday at our grandparents. I had a room of my own. At night, my grandfather used to come join me and lie in my bed and introduce his fingers into my vagina. I told my mum, but she said I was a liar: her father wouldn’t do such a thing. A few years later—I was 12—a friend of my father’s seduced me. He forced me to have sex with him. Repeatedly. When I tried to refuse, he would beat me and rape me anyway. I told my father, but he said I was behaving like a prostitute. His friend was an honorable man; he wouldn’t do such a thing. But an aunt of mine believed me and took me to the police. Then I saw doctors and social workers. I also had sessions in psychotherapy. And there was this doctor—a general practitioner—who abused me. I filed a complaint to a deontology board of health professionals. It didn’t help—someone even said that I was making this up: a medical doctor wouldn’t do such a thing.

I used the samurai from the old Japanese tradition to tell the true story of a modern Western woman. Having trained in this dance form, and developed my own “Japanese score,” I am capable of performing these two distinct stories, one with the body, one with words. This enactment helped me in her treatment. From trauma to consultation, from a first session of casual talk to a session where the patient tells all, there are zones where the patient’s body is poised between trauma and healing. It is easier to grasp this with the performer who is neither actor nor character. As a healer I want to know if (a) a patient is aware that a transition is taking place: from actor to character and back, (b) the patient has control over the transition, for instance through techniques and training, and (c) I can have patients collaborate with trained actors. These bodily “zones” are those of the fictive body. The fictive body can be considered pre-expressivity in action—an axis in theater anthropology—and it offers an explanatory model that can be presented to patients to establish a referential framework.

The fictive body

Traditions that have lasted across generations belong to the intracultural system of transmission, within a single nation, people, or culture (Pavis, 1992, p. 20). Once one has identified and explained such learning, one may proceed to compare traditions in a transcultural exercise. ⁸ Intracultural traditions produce performers who become “extracts” of their own learning systems. Postwar Japan honors such individuals with the title “living treasure.” Theater anthropology explores how performers of such traditions create characters and use their bodies through codified systems of expressive behaviors. For example, theater anthropology has described techniques borrowed from classical Indian dance, natyadharmi (dance behavior), as opposed to lokadharmi (everyday behavior; Barba & Savarese, 2005, pp. 7–8), which we can translate as scenic and daily behaviors (Christoffersen, 1993, pp. 78–80). On becoming the character, the actor’s body migrates through a transitional state where it is neither the actor's nor the character's; the same occurs when the performance is over and the character withdraws to let the actor reemerge. This involves what has been called “the fictive body,” a transitional body state. ⁹

Patients’ grieving may make other losses obvious such as mobility, independence, self-confidence, speaking, enjoying (e.g., Patricia lost innocence, trust, and her faith in justice). Their acting space will be modified and their body will have to adapt to it. Asian stages use little decor or special effects; everything is displayed through the body, costume, and props. The fan in Japanese dance forms is a polyvalent prop that can represent flute and drum, helmet and chariot, sword and flower, door, horse, sea, and so forth. The kimono does not reveal the body’s shape: it elongates the body, from arm to sleeve, and sleeve to fan. The amplitude and oppositions of the kimono enhance an action, offering insight into what patients do not say and we must guess. To allow this process, we must remain silent lest the patient delve too soon into a painful narration. Building a safe acting space for the patient takes time and preparation.

Look the space in the eyes. Use as much time as necessary to perceive but don’t meditate. It takes a fraction of a second and one must use that time. Control the space with the eyes. The space surrounds you completely. You survey it all. Cheat the space with the eyes. The space believes that you are going to look at a particular part of it but, at the last moment, you surprise it and look somewhere else. A place that didn’t think it was going to be looked at. (Torgeir Wethal as cited in Christoffersen, 1993, p. 109)

The actor interacts with space the same way he does with a partner, by looking, being looked at, establishing a relation, introducing new parameters.

When talking to patients, we constantly have to adapt to their geographical and psychological spaces to construct together a dramaturgy that expands way beyond the verbal or written text. ¹⁰ This is crucial with patients because, in this interval, there are many elements, clues and explanations, secrets, taboos, and traumas. Understanding the patient’s way of codifying enables practitioners to better perceive symptoms in order to complete the case history.

In cultural psychiatry, we face new challenges as multicultural societies become confusing and people lose their roots. Such situations call for a reconsideration of the traditions that defined the once distinct cultures. Constructing a score is for the actor an in-depth exploration that defines and exploits discipline as taught in traditions that the Odin, collaborators, and network have emulated and developed. The following is an exposé/exercise I regularly refer to with my patients.

Body discipline for the actor and the patient

The following demonstration and explanation, drawn from this teaching, ¹¹ is indispensable in my consultation. It serves as a model for patients to better grasp the logic of “becoming a master” of oneself, where bodily discipline is integrated into basic therapeutic vocabulary. Discipline in learning, training, performing, and transmitting is a building block when proceeding to the restoration of culture because we want to reenact rituals and other performances.

In Asian body learning traditions discipline and codified structures are the frame of learning, practice and performance, and essential to the transmission of these traditions. Ethnic and spiritual incentives drive the underlying search for, and the maintenance of, cultural identity. Trained bodies become signifying bodies that extend far beyond the limits of the body-envelope. The body is a vehicle of the soul, and this is reason enough to treat it with respect, discipline, and concern for tradition. There is no political double entendre here, since we are concerned with freedom of choice, autonomy in managing one’s body, and honesty, refraining from superficial motivations such as vanity. There is little room for denial in such learning; on the contrary, it facilitates the acceptance of natural changes and strengthens the body memory and skills needed to cope with change.

Of the Asian traditions that have inspired this work, the Japanese traditional forms in particular explain how the body of a performer may become a writing instrument, a canvas, or stage. From martial arts to dance forms, such trained bodies become pre-expressivity in action. Clinicians who are familiar with Asian methodologies can use such “narrative software” in their work.

Consider the Japanese tradition of onnagata, the male actor specialized in female parts in nihon buyō, the traditional Japanese dance, where we can spot some of the origins of Roland Barthes’s commentary (1987) on deciphering the written body. Since the written face and body become quotations, they tell about both tradition and acting: we are revisiting a cultural grammar.

The Oriental transvestite does not copy Woman but signifies her: not bogged down in the model, but detached from its signified; Femininity is presented to read, not to see: translation, not transgression; the sign shifts from the great female role to the fifty-year-old paterfamilias: he is the same man, but where does the metaphor begin? (Barthes, 1987, p. 53) ¹²

To signify woman, the apprenticeship is wrapped into a whole different consideration of sensory perception so well described in Tanizaki Junichirô’s In Praise of Shadows (1933/2001). Every posture, every gesture are deep perceptions involving sensory stimuli and memories. Differences in sensory perceptions across cultures also belong to basic case-history-making observations. They contribute to forming and organizing the acting space the patient has grown into. Sensory experiences carry many of the narrative elements ingrained in the patient’s body memory. The expression of the actor is not patched on the exterior of the body; it is an inner construction of sensory perceptions that are gradually transformed through acting. ¹³

The theatrical face is not painted (made up), it is written. There occurs this unforeseen movement: though painting and writing share the same original instrument, the brush, it is still not painting that lures writing into its decorative style, into its flaunted, caressing touch into its representative space (as would no doubt have been the case with us—in the West the civilized future of a function is always its aesthetic ennoblement); on the contrary, it is the act of writing which subjugates the pictural gesture, so that to paint is never anything but to inscribe. This theatrical face (masked in Noh, drawn in Kabuki, artificial in Bunraku) consists of two substances: the white of the paper, the black of the inscription (reserved for the eyes). (Barthes, 1987, p. 88)

In such a culture, a body that expresses an ideogram can combine several components into one. The human face is one such body part and thus a quotation. Like the ideogram, quoting the different parts can produce a new body. Here is an example: 男. The ideogram reads otoko, in Japanese (dan in Sino-Japanese, as in 男性 [dansei], the masculine gender). It is one whole character on its own. However, we can isolate the two elements of the ideogram: 田 (ta) rice field and 力 (chikara) strength. Thus, “man” is the strength (that works) in the rice field.

The distinct parts of the written body may either be in harmony or they may produce oxymorons. At an ISTA session in Londrina, Brazil, 1994, the mime and founder of the Mime Journal Thomas Leabhardt demonstrated how Western traditions also create body oxymorons:

It’s Mrs Grady who sees a car parked in her driveway (walks to the front of the stage, his hands upon his hips, elbows out): “Get out of my driveway!” She now walks back into her house (walks backwards elbows in against his waist and hands apart and open): “Now, where do I put these flowers?” Then, he does it a second time, with a change: Elbows in for the driveway, elbows out for the flowers, creating a contradiction between the body language and the verbal text.

Here again, didascalies form as the actor progresses in choreographing this sketch. Take away the didascalies, the text is not enough for the reader to see the point of this demonstration (see also Leabhart, 1996).

Bodies may then “behave” like ideograms and may express reinforcements and contradictions ¹⁴ when words, postures, and gestures fail to coincide. During case-history making and sessions in general, a patient’s body language may not correspond to what a clinician may expect after reading the diagnosis. Changes in modes of communication also alter the patient’s narration and its interpretation, as seen for example, with the use of cell phones, and texting.

Signifying the body (as in the rasas of Indian theater) conveys the expressive essence of emotions, moods, and motivations. Such deliberate signifying involves discipline, and hence can be useful in dealing with traumatized patients who may have a confused perception of their body organization.

The patient’s score: “Nosological” characters

Working with me on stage, patients present their own performance strategies and skills that they develop from case-history making to therapy, in a way that needs arranging and editing. In effect, I approach patients as authors who need a director to organize their dramaturgy. Performance then becomes therapy. This way of working stems from my conviction that a clinician can use a director’s methodology to promote healing.

An actor builds characters. What corresponds to “character” in our consultations?

When listening to physicians’ conversations in hospital cafeterias, we often hear them refer to patients in terms of diagnostic labels, as “a Crohn’s syndrome,” “a complication of a new treatment,” or “a car accident casualty.” These are nosological characters. Indeed, actors can learn how to play these illness roles; for example, in medical education, actors may simulate patients’ symptoms in role-playing for students. Involved in deliberate dramatization of their illness, patients may learn how the nosological characters develop to better master their condition and to more easily set aside the role when and if they heal.

Such building of characters belongs to the social actor and the making of stereotypes. Stereotypes abound in the schoolyard: there is the boss, the victim, the sidekick, the kid with the glasses, the fat boy, the effeminate one, the nerd, the rich kid, the buffoon. Asking my patients about their role(s) in the schoolyard is a highly informative moment. How were they cast? How did they cope with the character or the role in which they were cast? How did they transform the stage directions for a given character? The schoolyard is a natural theater laboratory where children can explore these characterizations. ¹⁵ We see these children later as adults in consultation, still stigmatized by these stereotypes and how they used to play them in the schoolyard. Reflecting on these characters can be helpful for patients who must do similar work with their medical conditions.

I regularly ask my patients about their traditions and inspirations, models, and templates. I will ask a patient like Patricia to come up with female characters, abused or not, who have responded to trauma by developing some sort of bodily transformation, the equivalent of a score. ¹⁶ Thus, patients’ bodies may borrow from memories and from fictive characterizations. They may also have to deal with elements that are external to them and that they have not chosen to incorporate. This transition shifts from “body competence” that depends only on the actor’s work, to a composite of personal and medical narrative elements.

Case study: Davison, the assembled man

The son of a Portuguese man who had lived in Angola and had to leave because of the revolution in 1975, Davison was born in Switzerland, where his parents had emigrated. Though a promising student, he had a motorbike accident when he was 19 years old. Hospitalized in critical condition, he remained in a coma for 2 months, first spontaneous and then medically induced. His body was a mass of fractures many of which needed drastic surgical reconstruction: one leg, one shoulder, and especially his skull and face. He had multiple facial trauma involving his eye cavities, nasal, maxillary and mandible bones including his teeth. Several groups of surgeons worked on him, performing orthopaedic, maxillofacial, dental, dermatological, and plastic and reconstructive surgeries. After the critical stage, Davison was operated on many times during a span of 7 years. The surgical schedule followed a medical logic obliging him to live through a bizarre adaptive process of rehabilitation. This made his recovering a physical identity difficult. It took him years to readjust to having a face, never quite the one he had before, now forever stigmatized by the memory of the damage he could see in the mirror. During the whole process, he felt he was like a mutant or a cyborg, his body now a mix of flesh and various metallic and plastic elements. Hoping to improve this destabilized identity, his father took him to Portugal on a cultural quest to reestablish their links with origins, family, and other networks. Instead of being the actor building a character, Davison was the character trying to build the actor.

When a patient becomes a medical curiosity, his identity is hijacked by the diagnoses, and therapeutic performances take center stage. In therapy, Davison soon understood that his identity as a person must resume independently from his “nosological” character and the score attached to it. I then had to de-condition part of his recently acquired score, to reestablish the actor beyond the character. De-conditioning in this context meant that I worked at separating his clinical body from all of its new foreign elements/artificial implants and nonorganic textures. Going back to before the accident, we reenacted the steps that reconstructive surgeries had taken to produce this composite body. This served as an explanatory debriefing.

Injury and life-threatening events create transformations in the body, its memory and perceptions, which may turn into a delusional experience where the patient cannot determine what is real and what is virtual, dreamed or reconstructed afterward by imagination.

Case study: Ilka the puppeteer and the canoe incident

First session: Ilka, an actor, clown, and puppeteer had had a near-death experience 3 years before in a canoeing accident. On a cold and rainy day, two canoeing instructors led a small group of beginners into a tunnel. Bad conditions caused the beginners’ canoes to capsize and the instructors left the students behind. Incapable of reaching the edge of the tunnel by paddling, Ilka tried to swim to safety, but was pulled under water by the currents. She lost consciousness and was miraculously pulled out of the water by one of two other participants. Firemen rescued all three beginners and took Ilka to hospital.

Newspapers reported that some inexperienced boaters nearly died on that river but that everyone was now fine. Ilka said they downplayed the event and that the school denied responsibility for what happened. She reported a near-death experience, describing how she “left her body” as she lost consciousness. We agreed on a diagnosis of posttraumatic stress disorder.

To help her create distance from the experience, I suggested that we work on the stage at my consultation, with puppets. Between sessions, Ilka began creating characters. She presented them as protagonists of the accident. However, she started the reenactment with another story, a tale that she had written a year before, apparently unrelated to the event. It was about two ugly persons (a pig and a head with a hand), living far away from each other. A duck-narrator arranged for them to meet and live together. Later, these characters became herself (the “swimming-pig”), two other participants, another beginner (the duck) and an advanced student (the “helping-head” with the hand, because he had pulled her out of the water). There was a fourth character (one canoeing instructor “pear-double-faced-death”), with a pear-shaped head, whose open mouth represented the entrance of the tunnel. The dramatization progressed along with the characters sculpted in papier mâché, painted, and dressed. Ilka also wrote the musical score. She planned on expanding this experience into a play with real actors, which she produced 1 year later.

During her traumatic experience, Ilka journeyed out of her body. To redesign her acting space, she proceeded the same way: she projected her story out of herself into the puppets.

In the above case studies, my work was not a substitute for patients’ ideas of a therapeutic performance; it provided the venue, space, and other accommodations for patients to be able to perform. My intervention was through editing the patient’s case history. Recounting traumas takes time, and we cannot merely fill it with other issues, waiting for the revelation. When a young man came and immediately spoke about his parents abusing him as a child, I had the information. He went through a busy period commuting between Geneva and the country where his father had died, taking care of the business and inheritance problems. During this period, he warmed to the idea of working on stage. Under my guidance, he chose to develop a score of his own: he decided to learn sign language which allowed him to return to and express the issue he had hitherto avoided. This detour was his unconscious strategy, which I accompanied and directed for him in order to connect his score with his story.

Conclusion

I am a physician and therefore my first contact with a patient is medical while introducing my know-how as a psychiatrist. My medical training allows me to first rule out organic illness and other conditions. As a cultural psychiatrist, I then proceed to develop a nuanced understanding of the patient’s predicament through cultural case-history making. As a healer, I explore the notion of the actor’s score with patients with the intention of having them develop their own score. The actor composes his subscore under the influence of his various masters, directors, and collaborators. Similarly, I provide guidance and support to patients in their own production of a score that affords them opportunities for distance, reflection, and transformation of their illness experience.

The concepts of pre-expressivity and pre-interpretation, drawn from theater anthropology, provide useful ways to look at the patient–healer relationship, in which the healer is called upon to read the patient’s hidden language. As a healer trained in codified body methods, I am able to use these methods to decode this hidden language and help patients develop a new score.

The inspiration for this approach comes from theater anthropology and it borrows actors’ methods from around the world. In many of these approaches, the performer does not merely follow a director’s instructions but actively contributes in composing his or her own score.

In this article, I have followed a thread of Japanese traditions: butoh with Roberta, kabuki in my demonstration, noh to define the fictive body, nihon buyōh to explain the body discipline. I borrow from many other traditions in my work: Indian, Balinese, African-Brazilian and other fields of performing arts, dance, visual arts, and documentary film. These techniques and tools help my patients overcome their blocks to personal expressivity and exploration. Essential in theater anthropology, the concepts of fictive body and body discipline are about transitions that occur between health and illness. These close-to-the-roots approaches are precious for patients living in multicultural societies.

Working within the theater metaphor, while I am a clinician, I am also a director with the patient as actor and a facilitator for patients who require a venue to be able to (re)construct their performance. Like a director with actors, I guide the patient through acquiring a score that will enable him to build a therapeutic process and stay on a healing path in the eventuality of further traumatic experience. As with actor and director, the patient does not merely follow a healer’s instructions but actively contributes in composing his or her own part. Patients must build “nosological characters” to cope with their conditions and acquire new competence and skills. As the case vignettes show, no two patients are the same, no two paths can be identical; each score is customized. The healer must arrange opportunities for mastery to enable patients to better handle their conditions. The aim throughout is to stimulate and enhance the therapeutic process, leaving patients with greater capacity for decision-making and autonomy.