3–6 Ross W. Prior
7–18 Drama as a means of preventing
post-traumatic stress following
trauma within a community
Robert J. Landy
19–34 Choral singing and
psychological wellbeing:
Quantitative and qualitative
findings from English choirs in
a cross-national survey
Stephen Clift, Grenville Hancox,
Ian Morrison, Bärbel Hess,
Gunter Kreutz and Don Stewart
35–51 Performative encounters:
Performance intervention in
marketing health products
in Nigeria
Victor I. Ukaegbu
53–61 Best foot forward: An
orthopaedic odyssey through
the world of dance
Bill Ribbans
63–80 Inspiring transformations through
participation in drama for
individuals with neuropalliative
Anne Fenech
81–92 Emotional responses to music
listening: A review of some
previous research and an
original, five-phase study
Michael J. Lowis
93–110 You don’t have to like them: Art,
Tate Modern and learning
Hannele Weir
111–126 Creating a space for the
individual: Different theatre and
performance-based approaches
to sexual health communication
in South Africa
Katharine Low
127–129 Transforming Tales – How
Stories Can Change People,
Rob Parkinson (2009)
JAAH_1.1_FM_001–002.indd Sec1:1 8/21/09 2:21:31 PM
Dr Judith Ackroyd, Regent’s College, UK
Dr Susan Corr, The University of Northampton, UK
Dr Alida Gersie, Freelance Consultant, UK
Prof. Robert Landy, New York University, USA
Dr Michael Lowis, The University of Northampton, UK
Prof. Shaun McNiff, Lesley University, USA
Dr Laury Rappaport, Notre Dame de Namur University, USA
Dr Frances Reynolds, Brunel University, UK
Prof. Bill Ribbans, Hon. Orthopaedic Surgeon English National Ballet, UK
Jill Riley, Cardiff University, UK
Prof. Emeritus Juliana Saxton, University of Victoria, Canada
Thérèse Schmid, Charles Sturt University, Australia
Dr Anne Shordike, Eastern Kentucky University, USA
Dr Philip Taylor, New York University, USA
Dr Victor Ukaegbu, The University of Northampton, UK
JAAH_1.1_FM_001–002.indd Sec1:2 8/26/09 8:48:06 AM
JAAH 1 (1) pp. 3–6 Intellect Limited 2010
Journal of Applied Arts and Health
Volume 1 Number 1
© 2010 Intellect Ltd Editorial. English language. doi: 10.1386/jaah.1.1.3/2
Principal Editor, JAAH
I wanted to take the principle that it was not just a matter of
interpreting the world but of changing it, and apply that to the
(Brecht 1935)
A warm welcome to the first issue of the Journal of Applied Arts and
Health (JAAH). This has been an ambitious undertaking. However,
with tremendous support from Intellect Publishing, and those around
me, we have given birth to a sustainable vehicle for on-going scholar-
ship within this important and ancient, yet developing, field.
Last year on a trip to Greece I was reminded of the long-standing
acknowledgement of the therapeutic value of the arts. The sanctuary
of Asclepius at Epidaurus is a spiritual place visited by the ancient
Greeks in order to pay tribute to Asclepius (the god of medicine and
healing in ancient Greek mythology) and to ask the gods for remedies
for their physical ailments. Epidaurus was built around the third cen-
tury BC and it is adorned with a multitude of buildings, most famous
of which is the ancient acoustic marvel the ‘Theatre of Epidaurus’.
Epidaurus was a healing centre as well as a cultural centre – the two
purposes closely entwined in ancient times. Whilst standing in this
ancient healing place I realised that these arts-based healing tradi-
tions still continue today.
This is the first international journal of its type specifically address-
ing the interdisciplinary concerns of applied arts and health. The arts
and health movement has gathered considerable momentum in the
JAAH_1.1_edt_Prior_003-006.indd Sec1:3 8/21/09 12:12:40 PM
Ross W. Prior
1. Arts and Healthcare
event ‘Open to All’:
Mental Health, Social
Inclusion and Museums
and galleries, The
Wallace Collection,
Tuesday 16 September
2008. This speech is
available at http://
2. A copy of the review
can be downloaded
from http://www.
last thirty or so years. It is a movement which has built upon long-
standing practices yet has seemed to largely ignore two vital areas:
what precisely is meant by the use of the term ‘arts’ and how we
understand ‘evidence’ – verification of the subsequent benefits of arts
within health contexts.
Firstly, let’s take the notion of ‘arts and health’ as a beginning point.
I support the value of art for art’s sake. I abhor the notion that art must
have a particular purpose other than that which art already does best
and that is use and play with aesthetic qualities. Aesthetics act upon
our senses to make us feel more, hear more and see more than we oth-
erwise might. Yes, art is highly manipulative and it should make no
apology for that. However, alongside the arts is recognition of the pow-
erful affect they can have for health; after all feelings are intertwined
with mental, physical, spiritual and social health. Arts which are applied
to a purpose outside of their usual context can be termed ‘applied arts’
which defines them more clearly than the use of the term ‘arts’ alone.
The term ‘applied’ within the arts has a more explicit recent history.
In the visual arts the term ‘applied art’ has been used for some time in
a limited way to suggest that some particular art created has a func-
tional use, particularly within design. The performing arts have activ-
ity used the term ‘applied theatre’ since the early 1990s. The applied
theatre movement is significantly influenced both in theory and prac-
tice by the work of Bertolt Brecht in the 1930s. Brecht was an actor,
director, theorist, playwright and poet. Brecht hoped to ‘re-function’
the theatre to a new social use in developing the combined theory and
practice of his ‘epic theatre’. He synthesised and extended the experi-
ments of Piscator and Meyerhold to explore the theatre as a forum for
political ideas and the creation of ‘critical aesthetics’. Brecht’s modern-
ist concern with drama-as-a-medium led to his refinement of the ‘epic
form’ of the drama. However, there have been many others who have
moved this agenda forward. For example Paulo Freire (1972), whose
work was a significant exploration of dialogue and the possibilities for
liberatory practices, and Augusto Boal (1979), who developed a thea-
tre for the oppressed and created the now often used ‘forum theatre’
form as participatory theatre.
More recently Alan Johnson (Secretary of State for Health in the
United Kingdom) publically declared that ‘access and participation in
the arts are an essential part of our everyday wellbeing and quality of
This explicit and high-level acceptance and support for the role
that arts have to play within the delivery of healthcare, and the sup-
port in developing individuals’ own sense of wellbeing, demonstrates
a positive shift towards a growing orthodoxy.
A significant attempt to move the agenda forward in the United
Kingdom was the publication of A prospectus for arts and health (2007).

This prospectus, produced jointly by the Department of Health and
Arts Council England, celebrates and promotes the benefits of the arts
in improving wellbeing, health and healthcare, and supports those who
work in and with the National Health Service (NHS) in England. The
JAAH_1.1_edt_Prior_003-006.indd Sec1:4 8/21/09 12:12:40 PM
prospectus aims to demonstrate that the arts can, and do, make a major
contribution to key health and wider community issues. The publica-
tion stems from the recommendations of the Review of Arts and Health
Working Group, commissioned by the Department of Health.
The will to make change is political and this notion has given birth
to the rise in the use of the arts for change and empowerment. This
journal, therefore, is specifically concerned with the ‘applied’ nature
of the arts; it is a combined attempt, along with launching an inter-
national conference entitled ‘Inspiring Transformations: Applied Arts
and Health’, co-convened by Cath Poyser and myself in 2009 at The
University of Northampton, UK. The aims (of the first international
Applied Arts and Health conference) were to share and critique various
practices; create innovative connections between the arts and health;
probe how knowledge can be advanced by their conjoined applica-
tion; explore what is meant by ‘evidence’; and interrogate debates and
future agendas.
Evidencing applied arts practices has been variously dealt with but
has largely been ignored in the scholarly canon. To these ends there
appears to be a significant, but not insurmountable, tension between
the arts and health sciences. Historically these fields have drawn from
two distinct methodologies: arts have been largely qualitative and
health sciences largely quantitative. Having said this there has been
a tremendous shift in the last fifteen years or so where the division
between these methodologies has been weakened in favour of
understanding the merits of both methodologies. It is therefore in this
fascinating interplay that we see great progress and potential for the
future of health and healthcare.
The nature of how we evidence the effectiveness of applied arts
practices is very much at the core of this journal. In fact the very idea
of what actually constitutes ‘evidence’ is a particularly interesting one,
and we hope that we will see lively scholarly debate within future edi-
tions of JAAH.
In this inaugural edition of JAAH we have an opening article by
Professor Robert J. Landy, who presents a paper on the way drama
can be used therapeutically following trauma. The paper draws upon
the work that he undertook with children in New York City follow-
ing the 9/11 atrocity. This paper discusses an applied use of drama
in preventing the onslaught of symptoms following 9/11. The author
discusses one drama therapy approach called ‘Standing Tall’, which
transformed the roles and stories created by 9-year-old children who
witnessed the attacks into a theatrical performance.
Professor Stephen Clift et al. investigate the use of choral sing-
ing and psychological wellbeing. In a fascinating study, this team of
researchers present their quantitative and qualitative findings from
English choirs in a cross-national survey to identify how singing may
impact on wellbeing and health.
Dr Victor I. Ukaegbu takes us to Nigeria where he explores curious
performative encounters in the marketing of health products. With
JAAH_1.1_edt_Prior_003-006.indd Sec1:5 8/21/09 12:12:40 PM
Ross W. Prior
the inclusion of transcribed dialogue we learn about the performa-
tive methods of ‘sales-performers’ or dealers and their techniques of
touting modern medicine to villagers through the use of performance.
Ukaegbu makes a link with past shamanistic practices and these per-
formative acts.
In a shift of emphasis, Professor Bill Ribbans offers a healthcare
perspective on health within the arts industry. His role as Honorary
Orthopaedic Surgeon to The National English Ballet brings him into
contact with numerous injuries associated with the rigours of profes-
sional dance. He outlines the specific problems of a major ballet company
and the requirements for a multi-disciplinary team of healthcare pro-
fessionals to support such an organisation.
The next paper reveals a study into the use of drama participation
for individuals with neuropalliative conditions. Anne Fenech claims
that participation in drama appears to offer individuals with neu-
ropalliative conditions an engaging leisure experience. She explores
how the occupations need to be adjusted or adapted in determining
individuals’ optimal level of engagement.
Dr Michael J. Lowis investigates fascinating emotional responses
to music listening. In this paper Lowis reviews some previous research
and an original five-phase study. He finds that whilst the combined
outcomes of the research add to the knowledge and understanding of
the role of music, many opportunities for further work remain.
In a departure in style from the other papers, Hannele Weir reveals
her experience of a workshop that takes place at Britain’s Tate Modern
in London, with a focus on exploring violence. The material is drawn
from two small-scale research projects. The overall purpose of the
article is to consider how consciousness of complex and difficult issues
that surround violence can be explored by experiencing ‘live’ contact
with works of art; how viewing art may reveal depths that spoken
words in a lecture may not do; and how such an experience might
impact directly or indirectly on approaches to practice.
The final paper looks at different theatre and performance-based
approaches to sexual health communication in South Africa. This paper,
by Katharine Low, offers a critical account of the plight of Africans and
the government’s attempts to curtail the spread of HIV infection. In an
endeavour to offer supplementary applied arts practices the article
considers three examples of theatre and performance-based practices,
namely the Themba HIV/AIDS Organisation, the Etafeni Centre and ‘our
place, our stage’ (OPOS) project.
Finally, I wish to thank my Associate Editor Dr Mitchell Kossak,
Reviews Editor Hayley Singlehurst, and the Editorial Review Board for
their support and enthusiasm for seeing this dream come true. The
future of this journal is now in the hands of those who are willing to
share their scholarship, interrogate it and learn from it.
Happy reading and good health.
JAAH_1.1_edt_Prior_003-006.indd Sec1:6 8/21/09 12:12:40 PM
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.7/1
JAAH 1 (1) pp. 7–18 Intellect Limited 2010
drama therapy
post-traumatic stress
1. A version of this
paper was originally
presented as a key
note address by the
author at Inspiring
Transformations: Arts
and Health Conference
at The University
of Northampton in
September 2007.
New York University
Drama as a means of
preventing post-traumatic
stress following trauma
within a community
Drama persists as a natural form of healing and has existed as a ritual heal-
ing process for thousands of years. Developmentally, children naturally use
dramatic play to master difficult moments in their lives. Historically and
cross-culturally, individuals and communities have sought out the perfor-
mative qualities of shamans to contact the spirit world and apply its healing
medicines to various forms of personal and communal ills. When confronted
by unexpected trauma, people can also turn to an applied form of drama
to contain their fears and forestall debilitating symptoms of post-traumatic
stress. This paper discusses an applied use of drama, that of drama therapy,
in preventing the onslaught of symptoms following the terrorist attack on the
World Trade Towers in New York City on September 11, 2001. The author
discusses one drama therapy approach called ‘Standing Tall’, which trans-
formed the roles and stories created by 9-year-old children who witnessed
the attacks into a theatrical performance. Through the dramatic process and
the subsequent performance, the children were able to begin to make sense
JAAH_1.1_art_Landy_007-018.indd Sec1:7 8/21/09 12:14:39 PM
Robert J. Landy
of the events they observed and share their roles and stories with their com-
munity, leading to a mutual sense of support and hope.
An examination of any random twenty years in world history
would likely yield reference to numerous natural and human-made
disasters – great disturbances in the earth and sky and seas, war,
crime and abuse. Living in the United States over the last twenty
years, I became painfully aware of a number of acts of terror, includ-
ing: the bombing of the Murrah Federal Building in Oklahoma City;
two attacks on the World Trade Center in New York City (the sec-
ond on 9/1l ); several massacres of students in schools and colleges
in Colorado and Virginia; and a devastating hurricane that brought
the great city of New Orleans to near ruins. As a witness to global
disasters, I have been very aware of the devastation of the tsunami
in Indonesia and the wars in the Balkans, in Afghanistan and Iraq, in
Rwanda, Somalia and Sudan, in Lebanon, the Palestinian Territories
and Israel, among many other places. The drama of disasters is
played out on a broad stage, large enough to overwhelm its unsus-
pecting audiences. It is especially devastating when it is spontaneous,
appearing out of the blue. Of the hundreds of stories I heard about
9/11, so many of them begin with a description of the ordinariness
of that beautiful, clear, unseasonably mild morning. As I remember,
in New York City on September 11, 2001, there was not a cloud in
the sky.
If disaster is an unexpected and terrifying drama, it might be amel-
iorated by another form of drama that is more within human control,
that is equally exciting, but without the real life traumatic conse-
quences. Because the human mind has never been able to prevent
certain disasters, it has mercifully discovered means of preventing
or assuaging the human suffering associated with catastrophe. We
can easily think of various forms of spiritual and psychological heal-
ing as well as systems of communication, medicine and disaster relief,
as means of preventing further injury and damage in the wake of a
catastrophic event. However, the subject of this paper concerns a non-
technological, non-medical and, in some ways, non-verbal method of
preventing debilitating symptoms of post-traumatic stress following a
disaster; this method, that of drama, has been around for many thou-
sands of years. Dramatic forms go by many names: ritual, shamanism,
play, psychodrama, drama therapy, applied theatre, theatre perform-
ance. All these forms have one thing in common – they exist at a
safe distance in time and space and feeling from real-life events. That
distance is marked by a representation of the actual events. That is, in
dramatic action, an actual event is re-played in the mind and/or body,
so that the player and/or observer of the play can discern a safe way to
see it more clearly and to cope with its consequences, thereby discov-
ering a certain degree of mastery and balance.
When a child is abused by a parent, the child will often re-visit the
incident in play. As an example, Jane is a 10-year-old girl, living alone
JAAH_1.1_art_Landy_007-018.indd Sec1:8 8/21/09 12:14:39 PM
Drama as a means of preventing post-traumatic stress following trauma within a community
with an unstable and highly stressed mother who is incapable of pro-
viding a secure attachment for her daughter. Jane has refused time and
again to obey her mother’s demands. On one day, feeling particularly
out of control, her mother slaps her in the face and tells her that she
is bad. Trying to be brave and stand up to the abuse, Jane doesn’t cry,
but reacts stoically and walks away. When alone, Jane grabs her most
favourite doll and scolds it for being defiant. Getting no response, Jane
hits it hard and throws it to the floor, calling it bad names. In playing
the role of the abusive mother, Jane feels empowered. But then, she
experiences a great sadness, aware of the pain she has inflicted on the
doll. She then holds the doll to her and asks for forgiveness, explaining
that she has had a hard life and feels powerless. By empathizing with
the pain of the daughter, as well as with the pain of the mother, Jane
works through play to reach a small degree of mastery of her domestic
dilemma, all on an unconscious level. Certainly, not all children who
are abused by a parent reach this level of mastery all by themselves
through their play. But the natural play of children provides a model
for the kind of healing that occurs through drama following a harsh
rend in the natural fabric of everyday life.
Beyond the personal therapeutic benefits of dramatic play, dramatic
forms of healing also benefit societies and cultures. These forms are
based in ancient shamanic healing practices still extant in various abo-
riginal cultures throughout North and South America, Africa, Asia
and Australia. In shamanic healing, the agency that modulates disas-
ter is located within the spiritual world. In order to affect events in the
natural world and keep people safe from harm, the shaman symboli-
cally journeys to the spirit world to retrieve the necessary medicines.
According to Mircea Eliade, the shaman serves many functions: ‘he is
believed to cure, like all doctors, and to perform miracles of the fakir
type, like all magicians [...] But beyond this, he is a psychopomp,
and he may also be a priest, mystic, and poet’ (2004: 4). For our
purposes, the shaman, as mediator between the natural and super-
natural worlds, is a dramatic figure trained in the arts of song and
dance, storytelling, slight of hand and trance. Through these perfor-
mative channels, the shaman receives medicines and messages from
the spirit world to bring to imbalanced human beings – assuring the
latter their ills will be favourably resolved. Many in the contemporary
field of creative arts therapy compare their healing arts to that of sha-
manic practices (see, for example, Glaser 2004; Lewis 1993; McNiff
1988), as arts therapists traverse the dual realities of everyday life and
the life of the imagination, and use embodied, expressive and meta-
phorical forms to heal the wounds of individuals and communities.
There is sufficient evidence to suggest that the art form of theatre
derived from early shamanic and ritual practices, such as the perform-
ance of ancient Greek Eleusinian mysteries and of the dithyramb, a
song cycle in praise of the god, Dionysus (see Brockett 1991). The
ancient priests engaged in their early dramatic rituals on the part of a
community that recognized its limited ability to control the mysteries of
JAAH_1.1_art_Landy_007-018.indd Sec1:9 8/21/09 12:14:39 PM
Robert J. Landy
the universe – the outcomes of war and uncontrolled nature, the inevi-
tability of sickness and death, the vagaries of extreme behaviour and
mental anguish. By performing their rituals, they attempted to mas-
ter or at least forestall that which is beyond human mastery. Although
no longer shaman and priest, the theatrical actor retains some of their
spiritual and healing qualities. Like shamans, actors often experience an
altered state of consciousness as they inhabit and bring forth the life of
archetypal roles for the benefit of their audiences, and like priests, they,
too, create a sacred space for others to engage in a shared moment of
joy, contemplation and, at times, transformation.
And yet actors are not trained as dramatic healers. Within the
domain of applied forms of drama and theatre, those who do practice
a therapeutic form are drama therapists. The practice and theory of
drama therapy, like that of theatre, evolved from ancient ritual and
shamanic practices (see Emunah 1994; Landy 2008). However, the con-
temporary practice of drama therapy claims its roots in western forms
of psychoanalysis (see Landy 2008), psychodrama (Moreno [1946]
1994), and educational drama (see Jones 2007; Landy 1994). Drama
therapy incorporates elements of ritual and theatre, shamanism and
dramatic play in the service of healing the wounds of psyche and soci-
ety. Its preventive power lies in treating people who have experienced
trauma, helping them to discover the internal and relational strength
necessary to prevent the onset of symptoms of post-traumatic stress.
Such symptoms include: persistent flashbacks, dissociated thoughts,
avoidance and phobic reactions, emotional numbing, hyper-vigilance
and hyper-arousal, among many others (see van der Kolk 1994).
Drama therapists consciously apply play and drama to help individu-
als and communities discover some form of mastery and balance. Like
the shaman, the drama therapist makes use of expressive actions, work-
ing through story and role as the basic means of restoration. Although
the metaphor of the spiritual journey is not apt for many drama thera-
pists, the metaphor of the hero’s journey is. Like the shaman, the drama
therapist is a guide on this journey toward awareness and transforma-
tion: a kind of Virgil guiding Dante into the wonders and dangers of the
inferno, or Athena guiding Odysseus across the magnificently terrifying
waters of the wine dark sea toward home. In Eliade’s (2004) terms, the
guide is a psychopomp, a mythical figure like Hermes, who shepherds
the souls of the dead into the underworld.
Although based primarily in an art form, drama therapy is also
informed by recent advances in neuroscience that suggest that the
brain itself is a dramatic entity (see Demasio 1994, 1999) as it trans-
lates external reality into representational internal images, and by
classical literary metaphors such as Shakespeare’s notion of drama as
a mirror held up to nature.
The dramatic nature of the brain is buttressed by the recent discov-
ery of mirror neurons. Mirror neurons are structures that link percep-
tion and action, as they fire in a common fashion when one acts and
when one observes another performing a similar action. Researchers,
JAAH_1.1_art_Landy_007-018.indd Sec1:10 8/21/09 12:14:39 PM
Drama as a means of preventing post-traumatic stress following trauma within a community
such as Gallese (2003, 2005), hypothesize a neurological relation-
ship between acting and the more distanced witnessing of an action:
between the emotional experience of self and that of the other. The
discovery of mirror neurons helps to explain how catharsis, a moment
of weeping when identifying with the tragedy of a protagonist, con-
nects one person’s feelings to those of another. And it provides the
beginning of an explanation of how playing the role of another, as in
the earlier example of the abused child at play, can help to transform
a painful experience.
There is further neuroscientific evidence in the research of van der Kolk
(1994, 2002) and others that trauma causes a disruption of the natu-
ral homeostasis of the brain. In trauma, the left brain, responsible for
verbalizing feelings, is de-activated, and the right brain, responsible for
decoding danger and assuring survival, is hyper-activated, causing the
individual to behave in an irrational manner. Further, when trauma-
tized at an early age, the development of the right hemisphere of the
brain is disrupted, limiting one’s ability to engage in nurturing and non-
abusive relationships. Van der Kolk (1994, 2002) notes that the hyper-
arousal and disassociated behaviour common to trauma is stored in the
body and that the most optimal forms of therapy require a non-verbal
channel that activates the body. Van der Kolk, championing drama as
an effective therapy, has embarked on several research projects with
children and adolescents through drama and theatre where traumatic
episodes in their lives are replayed, revised and transformed. This work
serves as a model for others who use drama therapy as a means to pre-
vent the development of persistent symptoms of post-traumatic stress.
It is significant in that it is developed by a psychiatrist whose research
has revealed critical aspects of the etiology of post-traumatic stress and
who has come to the conclusion that an embodied dramatic approach is
crucial in treating post-traumatic stress. As we shall see, I used a some-
what similar model for treating a group of children at risk of developing
symptoms of post-traumatic stress. Although this model is not based in
empirical research, it is theoretically grounded and provides anecdotal
evidence in support of the findings of van der Kolk.
The drama therapy model that I used was called ‘Standing Tall’ and
is featured in a film of the same name (see Stern 2004). The model is
based upon role theory and its practical extension, the role method
of drama therapy (Landy 1993, 1994, 2008), which I developed over
a period of twenty years. Briefly, role theory conceives of intraper-
sonal and interpersonal relationships in terms of prototypical role
types, similar to Jung’s ([1921] 1971) notion of archetypes as collective
images of universal human experience. These role types exist as polar-
ities, such as victim and villain, which attempt to seek balance even
as they clash with one another. The figure of the balancer is known
as the guide. Optimal states of being are ones where individuals and
groups are able to discover ways to live among their personal and
cultural contradictions, accepting the paradoxes created by the polari-
ties of being. In drama therapy, the therapist serves as guide; he/she
JAAH_1.1_art_Landy_007-018.indd Sec1:11 8/21/09 12:14:39 PM
Robert J. Landy
helps people move toward integration and facilitates the development
of an inner guide figure. Through this approach to drama therapy, the
stories one tells and performs extend from the roles one takes on. The
process is viewed metaphorically as a hero’s journey into and through
obstacles, toward a destination that is often unknown.
‘Standing Tall’ was a four-month process intended to help chil-
dren who witnessed a potentially traumatizing event, the attack on
the World Trade Towers by terrorists on September 11. This drama
therapy approach was viewed as a preventive measure, rather than
as a direct treatment. Our assumption was that some of the children,
given their backgrounds and mental status, might be affected, but that
all, at the very least, lived through a catastrophe and had a need to
make some sense of that moment in a safe, contained way.
‘Standing Tall’ was funded by the New York Times Foundation
School Arts Rescue Initiative and implemented through City Lights, a
youth theatre organization located in New York City. I developed the
project in collaboration with City Lights and worked with a teaching
artist, who also doubled as the director, and an assistant who at the
time was a graduate student in drama therapy. The purpose of the
School Arts Rescue Initiative was to help children in New York City
public schools most affected by the events of 9/11 feel a greater sense
of wellbeing through exposure to an experience in the arts. As con-
ceived, our project concerned the creation of fifteen classroom theatre
workshops intended to create a fictional community called ‘Standing
Tall’, not unlike New York City on September 11, 2001. We aimed to
facilitate the creation and exploration of fictional roles and stories by
the children, to devise an original play based on the children’s stories
and roles, and to present the play to an audience of peers, teachers, par-
ents and community members. The children involved, all nine and ten
year olds, witnessed the attacks on the World Trade Center through
their classroom window.
The film, directed by Peggy Stern (2004), documented the full process,
which is told from the point of view of the classroom teacher. The film
captures the essential goal of the process – to explore and question the
ways that drama can help children learn how to transform a frightening,
chaotic experience into one of hope and clarity. At the heart of this proc-
ess is the notion that drama has the potential for helping children, as well
as the teacher, to express the inexpressible in a safe way, through meta-
phor, and in so doing, to feel more balanced and in control.
In that the work was informed by role theory, all involved were
challenged to explore the contradictions within a single role, such as
villain, and those between discrepant roles, such as hero and villain.
In that role theory is also about working in metaphor and distanc-
ing clients from their everyday roles and realities, I intended to safely
distance the children from their direct experience of the events of 9/11
and move them into a fictional community named ‘Standing Tall’:
one where they could imagine figures similar to the real ones, coping
with a disaster. The fictional community had figures that represented
JAAH_1.1_art_Landy_007-018.indd Sec1:12 8/21/09 12:14:39 PM
Drama as a means of preventing post-traumatic stress following trauma within a community
archetypal heroes, villains and victims. The facilitators took the chil-
dren through an intensive but also playful process where they could
make fun of the villains. The film portrays one example as the children
imagine the pregnant parents of Osama bin Laden discussing their
hopes and plans for their new baby boy.
This experience allowed the children to look at other sides of the
roles of hero, victim and villain and humanize the figures. For example,
after exploring certain obvious heroes like firefighters and police, the
children chose Mom as hero, because she tells her son to express his
feelings and not hide them. The villain, Osama, is made fun of and
then humanized – he had a mother and father who had hopes and
dreams for their son. ‘He wasn’t born bad,’ says one girl. And, adds
another, ironically, ‘Perhaps he fell on his head when he was small.’
Once the children’s roles and stories were explored and many
polarities and complexities discovered, I wrote a play based upon their
creations. The play was performed by the children to the faculty and
students in the school, as well as to the parents and friends of the
children living in the community. Moving into performance gave the
children a chance to dramatically tell their stories to an audience that
needed what they did: a sense of clarity and a ritual through which to
share a common disturbing historical moment. After the play was per-
formed, at the end of the school year, all involved – children, peers,
teachers, parents, community members – engaged in a reflective and
emotional discussion. For some adults, that was their first opportunity
to openly express their own thoughts and feelings regarding 9/11. For
many parents, this was their first opportunity to acknowledge their
children’s depth of feeling and courage to speak out and to create a
beautiful memorial through their drama. As so many voices of children
and adults were expressed and witnessed following the performance,
the community bonded and asserted its common need for connection,
support and hope. In the interaction of parents and children, adults
and young people, ‘Standing Tall’ offered a model of how drama, story-
making and performance can enable an intergenerational community
to transform a tragic event into one of hope and connection.
I’d like to now address ways that educators, therapists, administra-
tors, social workers, arts professionals, and parents can think about
this model of preventive drama therapy and even in small ways apply
it to their interactions with children. The following are some of the
specific objectives I had in mind for ‘Standing Tall’:
To understand the human need to tell stories as a means of mak- •
ing sense of difficult, potentially traumatising experience.
To understand the therapeutic value of role-playing, storytelling •
and story dramatisation.
To understand the concept of aesthetic distance in transforming •
potential trauma in real life into safely contained forms of enactment.
To learn how to transform stories and roles into script form ready •
for performance.
JAAH_1.1_art_Landy_007-018.indd Sec1:13 8/21/09 12:14:39 PM
Robert J. Landy
To explore the value of metaphor in role-playing, storytelling, •
scriptwriting and performance.
To extract a sense of meaning from the events of September 11, •
2001, or any disaster, for children and adults.
For those who are familiar with and skilled in implementing such
creative and therapeutic objectives, the ‘Standing Tall’ model can be
replicated with modifications based upon particular circumstances.
This experience does not need to be a response to a catastrophe on
the scale of 9/11, but rather can be a way to process any significant
and/or troubling moment – an earthquake or senseless crime, a tragic
accident or family disturbance, a clash of races or cultures or ideolo-
gies within a community.
For those less trained in implementing such a model, there is a fun-
damental philosophy at work that can guide similar work with chil-
dren. The main idea is that children process reality through a variety
of creative and playful means, some of which are more powerful than
traditional cognitive and verbal approaches to learning. This creative
learning recapitulates the child’s natural inclination to make sense of
the world through play. If expressive, playful approaches, such as role-
playing, story-making and performance, can be incorporated in educa-
tion, healthcare, therapy and even parenting, the adult has a powerful
way into the mind and emotional life of the child. Many adults who
work with children will be able to make use of the kind of approaches
exemplified in ‘Standing Tall’. They do not have to be playwrights or
directors. Rather, they have to have an ability to listen carefully to chil-
dren’s stories and the imaginative ways they tell them in role. And
they need to embrace the idea of play as a means of making meaning
and the significance of a community ritual to share collective stories.
Finally, in keeping with a main principle of role theory, they need to
guide children into a place of integration, where villains and victims
and heroes can co-exist not only as characters in stories, but as aspects
of all human beings, where each stereotype can be humanized.
At the conclusion of the play, ‘Standing Tall’, one child took on
the role of Mayor Guiliani, who held a memorial service at the his-
toric St. Paul’s Church that stood in the shadow of the twin towers.
Mayor Guiliani’s dialogue was taken verbatim from his actual memo-
rial speech. Included in the text is a song written by Anna and several
classmates. The children performed the song. The following is the text
that concludes the play:
NILES (AS MAYOR GUILIANI): We are a city that has withstood the
worst attack of any city in the history of America and people are stand-
ing up as tall, as strong and as straight as this church. We are in a very
holy place, hallowed in very special ways, by the presence of George
Washington and all of our brave heroes that gave their lives. We should
think about how we can find the most creative minds possible who love
and honor America and can express that in artistic ways. And we should
JAAH_1.1_art_Landy_007-018.indd Sec1:14 8/21/09 12:14:40 PM
Drama as a means of preventing post-traumatic stress following trauma within a community
think about a memorial that just draws millions of people here. We have
to be able to create something here that allows people to build on it and
grow from it – a soaring beautiful memorial.
VICTORIA: We are the artists. We are the builders. We are the children,
the hope, the reason this city must be rebuilt.
LEE: And so we went to work.
JESSE: We made art and installed it on our classroom windows.
CATIE: It was the first thing we saw when we looked out at the empty
space in the skyline where the tall, shining towers used to stand.
DYLAN: We put art in the windows so we’d see things that would
make us feel better. We wrote songs about the New York that we
knew and loved.
ALEX: This is Anna’s song.
Look out! There’s Harlem blues,
Watch out, those 42nd Street tunes,
Change lights at the bust of the horn,
You’ve gotta be grateful that New York’s
Where you’re born.
Yankees, get a hat and a tee,
Bronx for the zoo and Natural History.
You’ve gotta get to Chinatown
And Little Italy.
City lights,
Ba dooba dooba dadoo.
City lights,
Ba dooba, dooba dadoo.
City lights,
Ba dooba dooba dadoo.
City lights.
Central Park, the best in the spring,
Statue of Liberty, take a ride to Fort Greene.
Want toys? The biggest of course
Are found at FAO Schwarz.
Macy’s, Thanksgiving parade,
Taxi cabs, buses and trains,
Shopping, as easy as one step out the door,
A dizzying mix of department stores.
The Empire, big buildings that shine,
Cafes, nice places to dine,
JAAH_1.1_art_Landy_007-018.indd Sec1:15 8/21/09 12:14:40 PM
Robert J. Landy
2. The full text of the play
is published as part
of the Study Guide
accompanying the film.
The Study Guide can
be downloaded from
the website, http://
films/393_st.php. Also
in the study guide is
a series of questions
that can serve to
generate dialogue
among teachers and
students, educators and
their peers, parents
and children anyone
interested in continuing
to explore some of the
issues raised in the
Street lamps, evenings so bright,
Isn’t it nice those city lights.
CHRISTA: And so the children began to rebuild, one story at a time,
not with bricks and mortar, but with words and images, until the city
of darkness was once again a city of light and hope.
GARRETH: We are the artists.
ROBERT: Our city is a place called New York, New York where build-
ings stand tall.
ANNA R.: Our city is a place where we stand tall. This play is our
As lights fade to black, two light sculptures are created with flashlights
(torches), representing the two phantom towers. As all the children turn
on their flashlights, they begin to hum softly. The humming increases as a
bridge is created between the two towers of light. The humming dims as the
flashlights fade to black.
I end with several questions that arose for those of us involved in
the Standing Tall project. It is my hope that readers of this paper will
engage with the film and with these and related questions that remain
in their minds:
In working creatively with such a trauma as 9/11 in a classroom, •
should the leaders inform the children that their work will be about
the trauma? When is the best time to do so?
Does drawing a picture of, or dramatically re-enacting, a trau- •
matic event re-stimulate the trauma or help a child release some
feelings associated with the trauma? Or does it have some other
When the media portrays a political figure, such as Osama bin •
Laden, as a treacherous villain, are children able to see other sides
of him? How?
How does media coverage and public discussion post-9/11 shape •
the children’s feelings and opinions?
In dealing with the effects upon their children of a potential •
trauma such as 9/11, what is the role of the parents? What is
the role of the classroom teacher? What is the role of the school
When learning through drama, should children be encouraged or •
permitted to enact stereotypical, even frivolous role-plays, e.g. por-
traying Osama bin Laden as a boy playing with a machine-gun?
Or viewing Osama’s parents as buffoons?
Do you agree with Rachel that the children’s making fun of Osama •
bin Laden and, by implication, Muslims, was ‘uncomfortable’?
How is this kind of stereotypical behaviour useful or harmful to the
JAAH_1.1_art_Landy_007-018.indd Sec1:16 8/21/09 12:14:40 PM
Drama as a means of preventing post-traumatic stress following trauma within a community
process for the children and adults involved in the workshops and
in the audience?
When a student says that he understands the ‘true value of com- •
edy’, what does he mean? What is the true value of comedy when
working with children who have witnessed a tragedy?
Will the drama therapy experience have a lasting effect on the chil- •
dren and the teacher months or years later?
When a student says that without the drama class she would have •
been ‘dead in my mind’, what does she mean?
Were you surprised by the depth of the children’s understanding •
or expression of feeling about the events of 9/11? How did watch-
ing them express their thoughts and feelings affect your views of
9/11 or similar catastrophes?
Brockett, O. (1991), History of the theatre, Boston: Allyn and Bacon.
Demasio, A. (1994), Descartes’ error: Emotion, reason and the human brain,
New York: Putnam.
Demasio, A. (1999), The feeling of what happens: Body and emotion in the making
of consciousness, New York: Harcourt Brace & Co.
Eliade, M. (2004), Shamanism: Archaic techniques of ecstasy, Princeton: Princeton
University Press.
Emunah, R. (1994), Acting for real – Drama therapy process, technique, and per-
formance, New York: Brunner/Mazel.
Gallese, V. (2003), ‘The roots of empathy: The shared manifold hypothesis and
the neural basis of intersubjectivity’, Psychopathology, 36:4, pp. 171–180.
Gallese, V. (2005), ‘“Being like me”: Self-other identity, mirror neurons and
empathy’, in S. Hurley and N. Chater (eds), Perspectives on imitation: From
cognitive neuroscience to social science, Boston: MIT Press.
Glaser, B. (2004), ‘Ancient traditions within a new drama therapy method:
Shamanism and developmental transformations’, The Arts in Psychotherapy,
31, pp. 77–88.
Jones, P. (2007), Drama as therapy. Theory, practice and research, London:
Jung, C. ([1921] 1971), Psychological types: Collected works, 6, Princeton:
Princeton University Press.
Landy, R. (1993), Persona and performance – The meaning of role in drama, therapy
and everyday life, New York: Guilford.
Landy, R. (1994), Drama therapy – Concepts, theories and practices, Springfield,
IL: Charles C. Thomas.
Landy, R. (2008), The couch and the stage: Integrating words and action in
psychotherapy, Lanham, MD: Jason Aronson.
Lewis, P. (1993), Creative transformation: The healing power of the arts, Wilmette,
IL: Chiron Publications.
McNiff, S. (1988), ‘The shaman within’, The Arts in Psychotherapy, 15,
pp. 285–291.
Moreno, J. L. ([1946] 1994), Psychodrama, 1, Beacon, New York: Beacon
Stern, P. (2004) (producer/director), Standing Tall, 24 minute video, Boston:
Fanlight Productions.
JAAH_1.1_art_Landy_007-018.indd Sec1:17 8/21/09 12:14:40 PM
Robert J. Landy
Van der Kolk, B. (1994), ‘The body keeps the score: Memory and the emerging
psychobiology of post traumatic stress’, Harvard Review of Psychiatry, 1,
pp. 253–265.
Van der Kolk, B. (2002), ‘Post-traumatic therapy in the age of neuroscience’,
Psychoanalytic Dialogues, 12:3, pp. 381–392.
Landy, R. J. (2010), ‘Drama as a means of preventing post-traumatic stress
following trauma within a community’, Journal of Applied Arts and Health
1: 1, pp. 7–18, doi: 10.1386/jaah.1.1.7/1
Robert J. Landy, Ph.D., RDT/BCT, LCAT is Professor of Educational Theatre
and Applied Psychology and Director of the Drama Therapy Program at New
York University. A prolific researcher and writer, Landy has published numer-
ous books, articles and plays in the fields of Drama, Musical Theatre, Drama
Therapy and related topics.
Contact: New York University, Drama Therapy Program, 35 West 4 Street,
room 777, New York, New York 1012, USA.
E-mail: rjl1@nyu.edu
JAAH_1.1_art_Landy_007-018.indd Sec1:18 8/21/09 12:14:40 PM
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.19/1
JAAH 1 (1) pp. 19–34 Intellect Limited 2010
choral singing
cross-national survey
Canterbury Christ Church University
Canterbury Christ Church University
Canterbury Christ Church University
Canterbury Christ Church University
Carl von Ossietzky University
Griffith University
Choral singing and
psychological wellbeing:
Quantitative and qualitative findings
from English choirs in a cross-national
Over 600 choral singers drawn from English choirs completed the WHOQOL-
BREF questionnaire to measure physical, psychological, social and environ-
mental wellbeing, and a twelve-item ‘wellbeing and choral singing scale’.
They also provided accounts of the effects of choral singing on quality of life,
JAAH_1.1_art_clift_019-034.indd 19 8/26/09 8:52:57 AM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
wellbeing and physical health in response to open questions. High average
scores were found on all WHOQOL-BREF scales, and a high degree of consen-
sus emerged on the positive benefits of choral singing. A significant sex dif-
ference was found on the choral singing scale, with women endorsing the
wellbeing effects of singing more strongly than men. This finding replicates
the earlier result reported by Clift & Hancox (2001) in a pilot study with a
single choral society. Low correlations were found between the WHOQOL-
BREF psychological wellbeing scale and perceptions of wellbeing associated
with singing. However, examination of written accounts to open questions
from participants with relatively low psychological wellbeing and strong
perceptions of positive benefits associated with choral singing served to
identify four categories of significant personal and health challenges. They
also revealed six ‘generative mechanisms’ by which singing may impact on
wellbeing and health.
A recent systematic review (Clift, Hancox, Staricoff & Whitmore 2008)
identified 35 research reports addressing connections between singing,
wellbeing and health in non-clinical samples and contexts, published
since the early 1960s. The literature is highly diverse theoretically and
methodologically, and low levels of cross-citation indicate an aca-
demic field in an early stage of development. Nevertheless, a number
of important findings have emerged from the more substantial studies
undertaken to date.
A range of small scale qualitative studies using ethnographic,
interview and focus group techniques with diverse samples have
shown that singers commonly report a wide range of social, psy-
chological, spiritual and health benefits associated with singing
(e.g. Bailey & Davidson 2005; Silber 2005). These findings are sup-
ported by questionnaire surveys in which choral singers are asked
to respond to a range of statements about the effects and benefits
of singing. Beck, Cesario, Yousefi & Enamoto (2000), for example,
report that 67% of semi-professional choral singers in their survey
agreed or strongly agreed that ‘Singing has contributed to my per-
sonal wellbeing’; Clift & Hancox (2001) report that 71% of singers in
a university choral society agreed or strongly agreed that singing was
beneficial for their ‘mental wellbeing’, and Hillman (2002) reports a
significant perceived improvement in ‘emotional wellbeing’ among
participants singing in a large community choir. A number of stud-
ies have also shown significant improvements in affective state after
singing, using previously validated mood questionnaires (e.g. Kreutz,
Bongard, Rohrmann, Grebe, Bastian & Hodapp 2004; Unwin, Kenny
& Davis 2002).
On a more objective level, a range of studies has assessed the
impact of singing on physiological variables assumed to have well-
being and health implications. Several studies, for example, have
JAAH_1.1_art_clift_019-034.indd 20 8/21/09 4:06:36 PM
Choral singing and psychological wellbeing
assayed levels of immunoglobulin A in saliva taken from participants
before and after singing, and reported significant increases, pointing
to enhanced immune system activity (e.g. Beck et al. 2000; Kuhn 2002;
Kreutz et al. 2004; Beck, Gottfried, Hall, Cisler & Bozeman 2006).
Few studies have employed standardised measures of wellbeing and
health, or objective indicators of health status, in assessing the impact of
active participation in singing. However, two quasi-experimental stud-
ies have reported positive health impacts from group singing for eld-
erly people. Houston, McKee, Carroll & Marsh (1998) report significant
reductions in assessed levels of anxiety and depression in nursing home
residents using common standardised measures, following a four-week
programme of singing, and Cohen, Perlstein, Chapline, Kelly, Firth &
Simmens (2006) found significant improvements in both mental and
physical health in a group of independent elderly people participating
over one year in an especially established community choir.
Despite the interest of these studies empirically, many of them are
small-scale and essentially exploratory and only one study has specifi-
cally built upon and independently replicated a previous study (Kreutz
et al. 2004). Further major shortcomings in the literature are the lack of
a common conceptual understanding of wellbeing and health, and the
absence of a comprehensive theoretical framework that elucidates the
key contextual factors and causally generative mechanisms through
which singing can be beneficial for wellbeing and health (Harré 1972;
Pawson & Tilley 1997).
The present study aims to address these shortcomings by build-
ing on the previous work of Clift & Hancox (2001) through a large-
scale, cross-national survey assessing choral singers’ perceptions of
the effects of singing in England, Germany and Australia.
In the earlier study, a structured questionnaire was used to assess
experiences and perceived benefits associated with choral singing.
This was developed on the basis of an initial qualitative survey,
which gathered written accounts in response to open-ended ques-
tions. Factor analysis of the structured questionnaire data produced
a six-factor solution, with a substantial initial factor concerned with
‘wellbeing and relaxation.’ A scale based on this first factor had high
internal consistency, and a statistically significant sex difference was
found – with women indicating a stronger sense of wellbeing asso-
ciated with singing than men. Surprisingly, no other study iden-
tified in the systematic review, that included both sexes, reported
comparisons between responses of men and women. Two specific
objectives of the current study were to devise a new scale based on
the first factor identified by the Clift & Hancox study, and to deter-
mine whether the sex difference found in this study was confirmed
in larger cross-national investigation.
In terms of grounding the study in an established framework for
conceptualising and measuring health and wellbeing, it was considered
appropriate to work on the basis of the World Health Organization’s
definition of health (WHO 1946), and the WHO Quality of Life project
JAAH_1.1_art_clift_019-034.indd 21 8/21/09 12:24:14 PM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
(Power, Harper & Bullinger 1999). For the WHO, health is defined as
follows: ‘Health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity’ (WHO 1946).
Quality of life is defined as: ‘A person’s perception of his/her position
in life within the context of the culture and value systems in which they
live, and in relation to their goals, expectations, standards, and con-
cerns’ (WHOQOL Group 1994).
The WHOQOL project has produced a range of validated quality
of life instruments for use in cross-national research. The WHOQOL-
BREF was developed for use in large-scale surveys to avoid too much
demand on participants completing a lengthy questionnaire. A con-
siderable body of research, in many different national contexts, has
demonstrated high levels of factorial stability, internal consistency,
reliability and discriminative validity. The WHOQOL-BREF was con-
sidered particularly appropriate for the current study as versions of
the scale are available for use in the UK, Germany and Australia, and
published data are available from previous studies with UK, German
and Australian samples (see e.g. Skevington, Lofty & O’Connell 2004;
Hawthorne, Herrman & Murphy 2006).
The present paper reports on findings from English choirs and
choral societies participating in the study. A fuller account of the sur-
vey and findings from the three national groups can be found in Clift,
Hancox, Morrison, Hess, Stewart & Kreutz (2008).
To assess the relationships between perceived experiences and effects
associated with choral singing and broader dimensions of health-
related quality of life (as assessed by the WHOQOL-BREF) among
singers in English choirs and choral societies.
1. To develop a new scale to assess experienced wellbeing effects
associated with choral singing.
2. To examine differences between men and women in their experi-
ences of singing using this scale.
3. To further explore the value of choral singing for wellbeing, draw-
ing on qualitative accounts gathered through written answers to
open questions.
Questionnaires were distributed to members of participating choirs at
the start of rehearsals during May 2007 for completion at home and
return in a sealed envelope at a subsequent rehearsal.
JAAH_1.1_art_clift_019-034.indd 22 8/26/09 8:56:34 AM
Choral singing and psychological wellbeing
The questionnaire contained three main sections.
Section 1 asked for personal data (e.g. sex, age, partnership status,
employment) and experience of singing and music-making (e.g. time
in the choir, ever auditioned, singing lessons).
Section 2 included three open questions on the effects of singing
on quality of life, wellbeing and health, followed by a structured 24
item ‘Effects of Choral Singing’ questionnaire with a five-point ‘agree-
disagree’ response format. The 24 statements on the effects of singing
were based on instruments used in two previously published studies
with choral societies. Clift & Hancox (2001) developed a question-
naire based on an initial detailed qualitative analysis of choral singers’
views on the benefits of singing and impact on wellbeing and health.
Analysis identified a substantial component concerned with ‘well-
being and relaxation’. The highest loading items on this component
were selected for this survey instrument. Additional items were taken
from the ‘Singers’ Emotional Experiences Scale’ developed by Beck et
al. (2000). All items used in the earlier studies were positively worded.
To counteract possible response bias, half of the items included in the
current survey instrument were positively worded, e.g.: ‘I find singing
helps me to relax and deal with the stresses of the day’ and half were
negatively worded e.g.: ‘I wouldn’t say that singing is an activity that
has made me physically healthier’.
Section 3 contained the WHOQOL-BREF – the World Health
Organization Quality of Life Questionnaire (short version). The
WHOQOL-BREF consists of 24 questions answered on five-point
scales, which serve to measure four dimensions of life quality: phys-
ical (e.g. How much do you need medical treatment to function in
your daily life?), psychological (e.g. How much do you enjoy life?),
social (e.g. How satisfied are you with the support you get from your
friends?) and environmental (e.g. How satisfied are you with the con-
ditions of your living place?).
The sample consisted of 591 choral singers drawn from eight choral
societies and choirs in the South East and North East of England.
Response rates by choir ranged from 50–70%. The sample was sup-
plemented by a further 42 choral singers from across the South East of
England acting as volunteers in the Silver Song Club Network (www.
singforyourlife.org.uk), giving a sample of 633 choristers. See Figure 1
for an image of one of the participating choirs.
Numerical data were analysed using SPSS PC+ Version 16. Given
the finding of a significant sex difference in responses to choral sing-
ing found by Clift and Hancox, analyses were conducted separately
JAAH_1.1_art_clift_019-034.indd 23 8/21/09 12:24:14 PM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
for men and women and for the total sample. Principal Components
Analysis was used to analyse the structure of the choral singing items,
resulting in a single perceived effects of choral singing scale. Pearson
correlations were used to analyse the relationships between the sing-
ing scale and WHO measures. A preliminary qualitative analysis was
undertaken with a small sub-sample of singers reporting high impact
of singing on wellbeing, but low scores on the WHOQOL-BREF psy-
chological wellbeing scale. Written answers to open questions on the
questionnaire were analysed thematically to identify sources of chal-
lenge to wellbeing and potential mechanisms linking participation in
singing with improved wellbeing and health.
The average age of choristers was relatively high (mean = 61 years),
and women outnumbered men 3:1 (77% versus 23%).
The 24 effects of choral singing items were subject to Principal
Components Analysis separately for males and females and for
the total sample. A strong first component emerged with substan-
tial loadings from twelve items for each sex group (see Table 1). The
main themes defining this factor were: improved mood, enhanced qual-
ity of life, greater happiness, stress reduction, and emotional wellbeing.
Substantially the same pattern was found for males and females analysed
separately. These twelve items (eight positive and four negative) were
Figure 1: The Silver Singers, The Sage Gateshead: one of the choirs participating in the English arm
of the survey. (Reproduced with the permission of The Sage Gateshead, Silver Singers.)
JAAH_1.1_art_clift_019-034.indd 24 8/26/09 9:26:12 AM
Choral singing and psychological wellbeing
used to construct a single measure of the perceived effects of singing
on wellbeing (Cronbach alpha 0.9 for both sexes). A large majority
of choristers agreed or strongly agreed with the positive items, and
disagreed or strongly disagreed with the negative items, so that while
the scale has a potential range of 12 to 60, the actual range is from
27 to 60 with a mean of 49.7 and standard deviation of 6.8. The high
scores on this scale confirm that a large majority of people singing in
choral societies agree that the effects of singing are generally positive
in terms of perceived enhancement of wellbeing. A significant sex dif-
ference was found, with women showing higher scores: men mean
= 48.0, s.d. = 6.9; women mean = 50.2, s.d. = 6.7; t = –3.39, p< 0.001
(2-tailed). This finding replicates the earlier finding by Clift & Hancox
(2001) in their initial study of a singing choral society.
The WHOQOL-BREF was scored in accordance with established
procedures to give measures of physical, psychological, social and envi-
ronmental quality of life. In line with previous research documenting
satisfactory reliability and validity, Cronbach alpha values were very
high for all scales, and mean scores on each scale were significantly
lower for participants reporting ‘long-term health problems’ compared
with those who did not (data not reported here – see Clift et al. 2008).
Helps make me a happier person .76 .716 .78
Gives a positive attitude to life .75 .74 .74
Helps improve wellbeing .75 .68 .77
Releases negative feelings .75 .74 .75
A lot happier afterwards .74 .74 .73
Positively affects quality of life .73 .66 .75
Mood more positive .71 .68 .71
Doesn’t give me a ‘high’ –.71 –.71 –.71
Doesn’t release negative feelings –.70 –.72 –.68
Relaxing and helps with stress .68 .61 .70
Doesn’t help emotional wellbeing –.68 –.69 –.68
No deep significance
–.65 –.65 –.65
Variance accounted for 51.4% 48.4% 51.9%
Pair-wise deletion: Total Sample = 604–616; Men, N = 136–139; Women, N = 468–477.
Table 1: Effects of choral singing items first principal component.
JAAH_1.1_art_clift_019-034.indd 25 8/21/09 12:24:16 PM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
The focus of interest in this paper is on the psychological scale,
which is made up of six items scored from 1–6. The scale has a range
of 6–30, with a midpoint of 18. A majority of people in the total sam-
ple scored well above 18 indicating good to excellent psychological
wellbeing, but approximately 10 per cent of respondents had low
scores which could indicate borderline/mild mental health difficulties.
Interestingly, women scored slightly lower on this scale when com-
pared with men: men mean = 23.6, s.d. = 2.7; women mean = 23.0,
s.d. = 2.9; t = 2.13, p < 0.05 (2-tailed).
Given the sex differences apparent for the effects of choral singing
scale and the WHO psychological scale, correlations between the two
measures were calculated for sexes separately. A significant correla-
tion emerged for women (r = 0.27, p < 0.01), but not for men. These
results suggest that women with higher levels of general psychologi-
cal wellbeing are more likely to express benefits from singing, but
that this is not the case for men. However, the correlation for women
is very low, with a shared variance of just under 7 per cent and the
effective lack of a relationship suggests that some people with rela-
tively low general psychological wellbeing nevertheless experience
high levels of perceived benefit from singing. The converse may also
be the case.
In order to explore this further, scores on the psychological well-
being and effects of singing scales were recoded into three groups
at the 33
and 67
percentiles and then cross-tabulated. This gave
nine fairly evenly sized sub-groups (Table 2). Respondents in the
lowest third on the psychological wellbeing scale, and the highest
third on the effects of singing scale were considered of particu-
lar interest for understanding the impact of singing on wellbeing
(N = 58, 48 women, 9 men, 1 sex not given). These participants
essentially report a relatively low level of general psychological
wellbeing as assessed by the WHOQOL-BREF, and yet report a
strong wellbeing effect associated with their participation in choral
singing. Their written accounts were examined for evidence of the
factors which might explain their low level of wellbeing, and for
Effects of singing
Low third Mid third High third Total
Low third 90 57 58 205
Mid third 78 51 70 199
High third 34 56 83 173
Total 202 164 211 577
Table 2: Cross tabulation of psychological wellbeing and effects of choral
singing (English sample).
JAAH_1.1_art_clift_019-034.indd 26 8/21/09 12:24:16 PM
Choral singing and psychological wellbeing
insights into the ways in which singing may influence wellbeing in
a positive way for this group.
Health and personal issues within this group
The responses of this group to the open questions were examined to gain
insights into their personal circumstances and the ways in which they
accounted for the impact of singing on their wellbeing. From the infor-
mation offered by this group, approximately one quarter stand out as
having particular challenges in their lives. It should be born in mind that
the questionnaire did not specifically ask participants to provide infor-
mation on personal challenges in their lives, which could have a detri-
mental impact on their subjective wellbeing. The examples given below
should therefore be understood as indicative of such challenges within
this group rather than a definitive picture for the sub-sample. Such
accounts are invaluable, however, for providing insights into the mean-
ing of the quantitative data gathered, and for giving a concrete sense of a
range of issues accounting for low psychological wellbeing scores.
Three people disclosed a history of mental health problems, and
explained how singing helped in the process of recovery and sus-
taining a sense of mental wellbeing. The issues of self-esteem and
self-belief are especially emphasised in the first example, and the
second stresses the impact of singing on mood.
I have had to stop working due to an on-going medical condition
(bi-polar disorder). I have had several episodes of this. Requiring
varying lengths of time spent in hospital, followed by months of
time needing support for depression and lack of self-confidence.
Being a member of this particular choir has lifted my self-esteem
again and restored self-belief.
Female, 54
Keeps me happy. Is an excellent hobby. Sociable activity. Need
no special equipment – easy to carry voice around. I have clinical
depression, so it really helps me (original emphasis).
Female, 36
Three people were affected by significant family/relationship prob-
lems, which were clearly a source of significant demand on their
personal resources, and affected their own sense of psychological
wellbeing. In the following examples, the effects of singing on mood,
and the distraction it provides are mentioned.
As a carer of two relatives stricken with schizophrenia, have
suffered from reactive depression. […] Having a pleasant start
to the day knowing I shall meet like-minded people and enjoy
music making, hopefully having a laugh along the way. Hearing
the harmonies helps me forget family worries.
Female, 70
JAAH_1.1_art_clift_019-034.indd 27 8/26/09 10:32:55 AM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
Able to enjoy companionship and makes me feel I am able to do
something. My husband is depressed and this helps me to ‘keep
going’. Lifts mood and helps to forget problems in life.
Female, 65
Seven people reported being affected by significant physical health
issues or disability, which in turn clearly impacted on their psycho-
logical wellbeing. The following accounts provide tangible examples
of the interplay between body and mind – physical and mental
wellbeing – and point to important ways in which the activity of singing
can be beneficial in the processes of recovery and rehabilitation.
It plays a significant part in my emotional health and well-
being. I find music uplifting. When recovering from a major
stroke, singing was one of the ways of lifting my spirits out of
Male, 65
Satisfies a love of music, improves social interaction. Recently
gave me the opportunity to perform in New York’s Carnegie
Hall. Increased social life. Singing with ‘Silver Song Group’ is
very satisfying i.e. helping people older or less fortunate than
I to enjoy a slightly better quality of life if only for a couple
of hours. I suffer from a lung problem and singing is a useful
Male, 72 (chronic obstructive pulmonary disease,
blood pressure, cholesterol and allergy/
sinus problems, all treated by medication)
Three people had been recently bereaved and this is, of course, to
be expected given the high average age of participants in the sam-
ple. The sense of social and emotional support which membership
of a choir, and other musical groups, can provide following the loss
of a significant person is very tangibly expressed in the following
My husband died 3 months ago so all the questions about
negative feelings etc. are distorted by this fact. One of the
greatest supports in my life at this difficult time is the Silver
Singers and the other silver activities – ukulele, guitar, ocarina/
tin whistle. I think choral singing is fantastic for emotional
Female, 64
In today’s world, choral singing offers people one outlet from
stress and worry. It is an experience not to be missed, and has
helped me through the recent loss of my daughter.
Female, 59
JAAH_1.1_art_clift_019-034.indd 28 8/26/09 12:05:44 PM
Choral singing and psychological wellbeing
Generative mechanisms linking singing with wellbeing
The accounts given by this group are also replete with intuitive hypotheses
regarding generative mechanisms linking choral singing with wellbeing
and health. A common thread running through these ‘lay constructions’
is the idea that various component elements of singing, and also being
part of a singing group, exert a counteractive influence on factors poten-
tially detrimental to wellbeing and health. Six commonly recurring pro-
posed mechanisms are identified here with illustrative quotations.
Choral singing engenders happiness and raised spirits, which counter-
act feelings of sadness and depression. In the first example, the linkage
is also made between experiences of happiness and health and well-
being more broadly. The second account suggests that when singing
‘you cannot be sad for long’; this highlights the process of counter-
action at play in mood and emotional states.
I am never happier than when I am singing. This can only have a
positive effect on my health and wellbeing.
Female, 69
When you sing, you cannot be sad for long. It really lifts your
spirits. Being in a choir means you are in a team – you all help
each other which gives tremendous satisfaction.
Female, 52
Singing involves focused concentration, which blocks preoccupation with
sources of worry. Singing is therefore a source of distraction from on-
going concerns, and participants commonly referred to being able to
forget any troubles they had, at least for a short time, while singing.
Singing in a choir puts troubles ‘on hold’, as concentrating on
the music requires all one’s attention.
Female, 65
Imperative to my wellbeing. It lifts me out of ongoing stresses,
and calls for attention to numerous details thereby absorbing me
Female, 54
Singing involves deep controlled breathing, which counteracts anxiety. It is
obvious that singing as an activity is powered by the lungs, and pro-
motes conscious awareness of depth and control of breathing. Breathing
is also highly responsive to emotional states, and anxiety and stress can
lead to rapid and shallow breathing, and relaxation can be induced
by making an effort to breathe more deeply and slowly. The follow-
ing respondents recognise the importance of this connection between
breathing and emotion, and the second account is interesting in high-
lighting the use made of controlled breathing exercises in the control of
anxiety in daily life.
JAAH_1.1_art_clift_019-034.indd 29 8/26/09 9:03:55 AM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
Deep breathing, essential for singing, is one method of helping
with signs of anxiety and stress.
Female, 70
Lung capacity and stamina much greater. Made me use breath-
ing exercises as a technique to reduce anxiety when in distress-
ing situations.
Female, 65 (with chronic back and leg
pain due to a road traffic accident ten years ago)
Choral singing offers a sense of social support and friendship, which amel-
iorate feelings of isolation and loneliness. Just as singing is inherently
dependent upon breathing, so membership of a group is intrinsic to
choral singing, and group membership per se can be helpful in pro-
moting a sense of wellbeing, as the following examples show.
The effect of singing with a group helps to make friends, so this
has widened my horizons quite a bit, and gets me out and about
more. The support you receive from other people helps in gen-
eral wellbeing.
Female, 78
The choir has been a lifesaver for me. I live alone and have no
family. I belong to two choirs and enjoy them both.
Female, 69
Choral singing involves education and learning, which keeps the mind
active and counteracts decline of cognitive functions. This factor is espe-
cially important given the high average age of the participants, and
the following accounts highlight how significant singing can be in
keeping ‘the brain active’.
I think it is good at this age, to learn and remember new words
every week, keeping the brain active, in all, it gives you some-
thing to look forward to, and aim for, when everyone else thinks
you’re passed it! […] You feel that you’re more than somebody’s
old Gran! It has a great effect, and it keeps you young, and to
make the best of your appearance.
Female, 68
Apart from the relaxation benefits, I believe that for me, aged 57,
keeping the brain active and having to concentrate for long peri-
ods will delay if not completely prevent senile dementia!
Female, 57
Choral singing involves a regular commitment to attend rehearsal, which
motivates people to avoid being physically inactive. The motivational
JAAH_1.1_art_clift_019-034.indd 30 8/26/09 9:05:13 AM
Choral singing and psychological wellbeing
aspects of being a member of a group committed to practicing in order
to achieve a good standard in performance are highlighted in the fol-
lowing accounts.
Making the effort to attend choir practice on wet, cold evenings
instead of watching TV must be better for health.
Female, 69
It makes me get up in the morning [rehearsals are during the
day] and puts me in a good mood for the rest of the day and
makes me more alert.
Female, 65
A small number of previous studies have documented potential well-
being and health benefits associated with group singing. These earlier
studies are diverse and often small-scale and exploratory, with little
consensus in theoretical perspectives and appropriate measures, and
include only one example of a planned replication to validate previous
findings (Kreutz et al. 2004).
This study contributes to a process of addressing these shortcomings
by undertaking a large-scale, cross-national survey of singers in choirs
in England, Germany and Australia, based on the WHO definition of
health, and using a rigorously developed cross-national instrument for
assessing health-related quality of life, the WHOQOL-BREF. It builds
upon the earlier surveys of Clift & Hancox (2001) and Beck et al. (2000)
in producing a simple and reliable measure of the perceived effects of
choral singing on wellbeing. Choristers’ perceptions of the effects of cho-
ral singing can therefore be examined in relation to a broader validated
framework for the assessment of wellbeing in four dimensions.
In this paper an analysis of data from over 600 English choristers is
presented. The results confirm previous findings from Clift & Hancox,
(2001) and Beck et al. (2000) that a large majority of choristers per-
ceive the experience of singing to be a positive and beneficial one. In
itself this is not too surprising given that choral singing is a voluntary
activity people undertake through a love of music and the pleasure
they derive from it. Nevertheless, there is considerable variation in
the extent to which singers endorse the idea that singing has ben-
efits for their wellbeing and even health, and an interesting finding
from the survey is that such perceptions are gendered, with women
significantly more likely to report benefits compared with men. This
difference, originally reported by Clift & Hancox (2001), has not been
explored in any of the previous research on singing and wellbeing,
even where samples have included both men and women. The find-
ing may contribute to understanding why choral societies commonly
have more female members than males, and should certainly be a
focus for further research.
JAAH_1.1_art_clift_019-034.indd 31 8/21/09 12:24:16 PM
Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
The findings from the WHOQOL-BREF also demonstrate that a
large majority of singers rate their quality of life as good or better.
However, a minority do give low scores, which indicate that they
are not satisfied with their quality of life. For the WHO psychologi-
cal wellbeing scale, approximately 10 per cent of the sample scored
below the scale’s midpoint; this suggests that they may be coping
with significant challenges to their mental wellbeing. A small gen-
der difference emerges on this scale with women reporting lower
average levels of wellbeing. This is in line with previous large-scale
normative studies using the WHOQOL-BREF, which report signifi-
cantly lower means for women compared with men on this scale
(Skevington et al. 2004).
When choristers’ perceptions of the effects of singing are exam-
ined in relation to the WHO psychological scale, a statistically sig-
nificant correlation emerges for women only, but the value is very
low with 7 per cent shared variance. For both sexes, therefore, the
two scales show a high degree of independence. This is interesting
because it implies, for instance, that some choristers with relatively
low WHO scores are nevertheless strongly endorsing benefits from
choral singing.
This was pursued by identifying those choristers in the bottom
third of the WHO psychological score range, but with choral singing
scale scores in the top third of the range (N = 58), and then examin-
ing the qualitative data gathered for insights into their personal health
circumstances, and the ways in which they explained their experience
of the positive impacts of choral singing.
At this point the results begin to come to life as many par-
ticipants in this group disclosed personal challenges in their lives
that have clearly compromised their general sense of wellbeing.
Nevertheless, it is also clear that participation in singing has been
of considerable benefit to them, in diverse ways, depending upon
their particular circumstances and difficulties. More importantly,
however, the choristers’ accounts provide valuable insights into
various generative mechanisms (Harré 1972) that can serve to pro-
mote a sense of wellbeing, by counteracting processes potentially
detrimental to health.
This paper reports on a small fraction of the qualitative data gath-
ered in this study, and further analysis will reveal whether the quan-
titative patterns and issues emerging from this preliminary analysis
are found among choristers in German and Australian choirs too. A
fuller, systematic analysis of the qualitative data is underway using
the MAXQDA2007 software package for qualitative data analysis (see:
http://www.maxqda.com/). Guided by a realist philosophical perspec-
tive, this analysis is focused towards constructing a grounded theory
account of ‘context-mechanism-outcome configurations’ (Pawson &
Tilley 1997), which can explain the power of singing in maintaining
and promoting wellbeing and health, and provide a foundation for
further research.
JAAH_1.1_art_clift_019-034.indd 32 8/21/09 12:24:16 PM
Choral singing and psychological wellbeing
Bailey, B. A. and Davidson, J. W. (2005), ‘Effects of group singing and per-
formance for marginalized and middle-class singers’, Psychology of Music,
33:3, pp. 269–303.
Beck, R. J., Cesario, T. C., Yousefi, A. and Enamoto, H. (2000), ‘Choral singing,
performance perception, and immune system changes in salivary immu-
noglobulin A and cortisol’, Music Perception, 18:1, pp. 87–106.
Beck, R. J., Gottfried, T. L., Hall, D. J., Cisler, C. A. and Bozeman, K. W. (2006),
‘Supporting the health of college solo singers: the relationship of positive
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Clift, S. M., Hancox, G., Morrison, I., Hess, B., Stewart, D. and Kreutz, G. (2008),
‘Choral Singing, Wellbeing and Health: Findings from a Cross-national
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WHOQOL- Bref: Preliminary population norms and effect sizes’, Social
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to promote psychological wellbeing in residential homes for older people’,
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V. (2004), ‘Effects of choir singing or listening on secretory immunoglo-
bulin A, cortisol and emotional state’, Journal of Behavioral Medicine, 27:6,
pp. 623–635.
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activity on the immune system as measured by salivary immunoglobulin A
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Stephen Clift | Grenville Hancox | Ian Morrison | Bärbel Hess | Gunter Kreutz | Don Stewart
Skevington, S., Lofty, M. and O’Connell, K. A. (2004), ‘The World Health
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‘Choral singing and psychological wellbeing: Quantitative and qualitative
findings from English choirs in a cross-national survey’, Journal of Applied
Arts and Health 1: 1, pp. 19–34, doi: 10.1386/jaah.1.1.19/1
Stephen Clift is Professor of Health Education at Canterbury Christ Church
University, and Research Director of the Sidney De Haan Research Centre for
Arts and Health, Folkestone, United Kingdom.
Grenville Hancox is Professor of Music at Canterbury Christ Church
University, and Director of the Sidney De Haan Research Centre for Arts
and Health, Folkestone, United Kingdom.
Ian Morrison is a Senior Researcher within the Sidney De Haan Research
Centre for Arts and Health, Folkestone, United Kingdom.
Bärbel Hess is an Associate of the Sidney De Haan Research Centre for Arts
and Health, Folkestone, United Kingdom.
Donald Stewart is Professor of Health Promotion, School of Public Health,
Griffith University, Brisbane, Australia.
Gunter Kreutz is Professor of Systematic Musicology, Oldenburg University,
Oldenburg, Germany.
Contact: Sidney De Haan Research Centre for Arts and Health, University
Centre Folkestone, Mill Bay, Folkestone, Kent CT20 1JG, United Kingdom.
E-mail: stephen.clift@canterbury.ac.uk
JAAH_1.1_art_clift_019-034.indd 34 8/21/09 12:24:16 PM
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.35/1
JAAH 1 (1) pp. 35–51 Intellect Limited 2010
The University of Northampton
Performative encounters:
Performance intervention
in marketing health
products in Nigeria
The integration of performance in the sale of medicaments dates back
to ancient shamanic practices. The shift from total reliance on healers
from the 1960s to new products and models of healthcare delivery saw
itinerant salesmen in Nigeria turn the sales of healthcare products into
sophisticated participatory performative acts. Historically shamans
contextualised healing as performed enactments in which trance,
possession, and choreographed actions were important in convincing cli-
ents of their pedigree. The performance quotients deployed by shamans
were significant in how results were viewed: a strategy that Nigeria’s
post-civil war (1967–1970) itinerant medicine salesmen later honed
into theatricalised displays. From the early 1970s to 1990s modern
itinerant medicine salesmen invaded public transports using a com-
bination of spontaneous dramatisation, role-play, costuming, devised
narratives and audience participation to ensure sales. The Nigerian
government banned this activity from public transports in the late
medicine sales
JAAH_1.1_art_Ukaegbu_035-052 35 8/21/09 4:09:06 PM
Victor I. Ukaegbu
1990s, but it persists in other settings. This paper explores the market-
ing of healthcare as a form of ‘direct theatre’ (Schechner 1992) and
how the deployment of performance to functional intentions results in a
unique form of theatricality in which medical products are significant
‘actants’ (Hilton 1987).
Healthcare in pre-colonial Nigeria was delivered by healers and
herbalists, and by spiritualists whose training involved periods of
apprenticeship with expert healers. Whether delivered through
trance, séance or medicaments, healing was an act that depended
on aspects of performance practice. From independence in 1960, but
especially from the mid-1970s, the sale of healthcare products by
itinerant salesmen grew astronomically, becoming a social phenom-
enon between 1980 and 2000; this was due to the wake of growth in
the country’s GDP, migrations of people from rural to urban settings
and the movement of goods across large geographical areas. The
majority of the post-independence salespeople neither produced
the medicines they sold nor underwent the rigorous training and
apprenticeship of their predecessors. Their training, usually brief,
emphasised presentation techniques and prioritised performance
skills over knowledge of medicines.
In the past shamans traversed ancient trade routes consisting of
extensive road networks dotted with numerous market towns and
settlements. They, like modern herbalists, created their own myths;
some built their pedigrees on ancestral fame, on outrageous claims
(see Ogunshe 2007; Adegoju 2008) or carefully devised tales of great
adventures and legendary victories over spirits, and biological
conditions responsible for real and imagined diseases. Shamans’
successes depended on their manipulation of performance skills;
at home or on their journeys their craft depended on a combination
of medicine, divination, and performances designed to reassure
clients of their powers over spirits and of the efficacy of their prod-
ucts. Shamanism did not only survive Nigeria’s independence in
1960; effective healthcare delivery remained beyond a majority of
the populace. The country also witnessed an astonishing growth in
faith-healing and itinerant salespeople, the latter trading all kinds
of wares from cities to very remote villages. Out of the latter came a
new generation of salesmen (yes, they were overwhelmingly, men)
who sold healthcare products but lacked the mystical aura and
authority of shamans; however, what they lacked in knowledge of
modern medicines, they made up for with effective performed pres-
entation strategies.
JAAH_1.1_art_Ukaegbu_035-052 36 8/21/09 12:28:16 PM
Performative encounters
From the moment shamanism, faith-healing and market forces
converged in the delivery of healthcare the entire population became
a contested site. Wherever they found potential clientele-audiences
(school, church or village ground, inside of mass transport, roadside,
or homestead), shaman, faith-healer, and medicine salespeople
converted such spaces into performance venues. Like shamans, faith-
healers rely on their relationship with the spiritual world. Medicine
salespeople tout their unproven knowledge of modern medicines and
like faith-healers, perform their acts. As shamanism declined from
the early 1980s itinerant medicine sales exploded, having successfully
appropriated aspects of Ajasco phenomenon into their acts. Ajasco is
an advertising outfit that entered the public stage in colonial Nigeria as
colourful foreign characters synonymous with dexterous dancing and
cowboy outfits. Their acts involved acrobatics and vaudeville humour,
but by the time they declined in the mid- 1970s they had come to
symbolise anyone, especially performers, with a fondness for dance
and fanciful cowboy costumes. Ajascos imitated American cowboys
in costumes, most wearing toy revolvers and knee-length boots. Some
faked American accents, usually affected a kind of swagger, looping
walk, and other mannerisms associated with Hollywood westerns. At
the peak of their fame in the 1960s Ajascos were cult figures with a
sizable following among young people; they became associated, even
long after their demise, with the lovable rogue in Nigerian literature.
Ajasco was pure entertainment, but its appropriation by sales-
people was significant for two reasons: firstly, it expanded the scope
of theatrical activities thus diversifying the entertainment quotient
for audiences; and secondly, it sustained a through action-line. In its
heyday Ajasco injected humorous banter and spectacle into sales
activities. Its presence facilitated a division of labour that enabled
salespeople to concentrate on sales whilst Ajascos cajoled audiences
into making purchases. The task for modern salespeople to combine
two apparently opposed aesthetics, work and leisure, was hardly chal-
lenging; the two co-exist in many forms of indigenous African theatre.
Globally salespeople work with the shifting loyalties of potential clients
in mind. In the Nigerian context discussed here they used performed
acts to exploit the mental flux between action and inaction, that brief
moment between decision and indecision; the aim being to coax their
audience towards what Schechner (1994, 2002) describes as ‘transporta-
tion’ (temporary change such as one-off purchase) or ‘transformation’
(permanent change or being hooked on the product).
Ajasco, like shamans, did not disappear altogether. It was re-
contextualised with indigenous Nigerian character conventions from
popular fiction and drama; its derivatives display outrageous behav-
iour, satirical wit, comic ignorance, bombastic language, and are often
irreverent of social conventions. Ajasco-derived characters like ‘Papa
Lolo’, ‘Jagua’, ‘Samanja’, and ‘Chief’ Zebrudaya of ‘New Masquerade’
have lent their names to long-running television series with Chief
Zebrudaya and his household of comic buffoons, Ovularia, Gringory
JAAH_1.1_art_Ukaegbu_035-052 37 8/21/09 12:28:16 PM
Victor I. Ukaegbu
and Clarus, creating a peculiar variety of ‘pidginised’ English. Ajasco-
derived characters have become as successful and as diverse as commedia
dell’arte’s stock characters. Ajasco’s successful reinvention is not limited
to theatre and television drama. The character may arguably be credited
with the popularity of enduring pictorial comic cartoon strips, Ikebe and
Ikebe Super Star. In fact these magazines have an antecedent in Atoka, a
Yoruba language ‘publication which began in the late 1960s and contin-
ues today…with glossy cover and added attractions such as horoscope,
advice column, and penpal advertisements’ (Barber, Collins & Ricard
1997: 47). Unlike Atoka which is based on ‘Alarinjo’ plays (Jeyifo 1984),
the English Language Ikebe photo magazines are based on Ajasco; Boy
Alinco, Boy Ajasco, Papa Ajasco, and Mama Ajasco (whose escapades,
outrageous costumes, comic physique, and bumbling forays into social
commentary have continued to evolve new acts). With neither the reputa-
tion of shamans nor the services of Ajasco but inspired by successful rein-
carnations of the latter, the salespeople researched for this article are best
described as ‘sales-performers’. Their routines draw upon elements tradi-
tionally associated with performances such as storytelling, direct theatre
(Schechner 1992), and vaudeville: loose storylines, episodic framework,
spontaneous dramaturgy, mimesis, stage-audience interaction, etc.
The sale of commodities continue in Nigeria wherever there are
crowds but the ‘invasion’ of coaches and trains by medicine salespeo-
ple resulted in a contextual shift in this ancient practice, for reasons
which I now explore in this paper. The desire by government agencies
and pharmaceutical companies to extend healthcare to every corner of
Nigeria transformed the merchandising of medical products into the
collusion of marketing and performance it was at its height. Shamans,
and their modern derivatives, share stylistic sophistication and diverse
product range but the sheer theatricality of the latter’s act set them
apart until the practice was banned in 1995. They employed ‘direct
theatre’ and, without necessarily articulating their praxis in such terms,
they based their acts on well-defined semiotic concepts and utilised
performance-making strategies and models including:
Tadeusz Kowzan’s (1975) communication and sign system; •
Goffman’s (1984) concept of lived reality as a performance; •
Devising and improvisation techniques; •
Indigenous reception strategies and audience participation, a fea- •
ture of African performances that Soyinka describes as ‘returned
compliment’ ‘or the two-way communication between stage and
audience (1988: 225).
The performed sales skits discussed in this paper epitomize Soyinka’s
‘returned compliment’ on account of their highly interactive stage-
audience dynamics, use of signs, characterisation, and role-play.
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Performative encounters
They used spontaneous dramaturgy, participatory interaction and
improvisation techniques to create a make-believe world that val-
orised their actions. Salesmen located themselves in their acts,
becoming performed and performing selves (Goffman 1984); their
sales actions were as real as their stage business was fictional. By
suspending disbelief, by being in the coaches watching passively or
participating actively in the ‘audience of travellers’ and the health
products, they became what Julian Hilton calls ‘actants’ (1987: 29).
Hilton’s description of ‘actant’ as ‘any person or thing, human or
not, who or which participates in the action’ (1987: 14) and the fact
that participation can be active or passive gives some weight to this
description of the coach-bound travellers as an audience. The result
was usually a carefully rehearsed, pre-planned quasi-spontaneous
display that straddled reality and fiction.
By all accounts ‘sales-presentation acts’ exhibit the hallmarks of
performance, ‘a doing and the thing being done’ (Schechner 2002)
and although they lack the sophistication of professional dramatists,
sales performers draw from the same performance conventions as aes-
thetic theatre. Performers of the pre-ban acts, which I refer to as ‘coach
sales performance’ for lack of a better term and because they oper-
ated mainly in the confines of travelling coaches, are the hundreds of
itinerant, poorly-educated, medicine hawkers who utilised a range of
improvised, spontaneous ‘scripts’ that starred themselves as presen-
tation framework for plying their trade before a captive audience of
passengers. The reception strategy in ‘coach sales performances’ is
similar to that of street theatres; what turns product marketing into
performance is advertisers’ deployment of products as ‘actants’ (Hilton
1987) and in the Nigerian context, the salesmen’s transformation of
economic relations into theatricalised encounters and their reliance on
artifice, mimesis, and learned ‘restored behaviours’ (Schechner 1985)
for the creation of a sufficiently dramatic stage presence and dramatis
The performed sales required ‘the creation of presence’ (Schieffelin
1998: 194) without which salesmen would neither convince their audi-
ence nor guarantee sales. Presence occurs in this instance only when
accompanied by expressive performativity that communicates the
right intentions to the audience. Everywhere salespeople mask their
motives as logical service (see Grice 1999); they are twice removed
from truth and many of their claims are, at best, half-truths, fantastical,
or deliberately designed to confuse through amusement. The actions
of sales performers derive from a functional purpose and so, are ‘true’
to some extent but because they are also artificial and contrived, they
are fictional even when they convince ‘audiences’ of the truth of their
claims. By exploiting their knowledge of what the ‘audience’ wants, by
accepting the parameters and temporality of the make-believe world
created right before them, audience collude with the motives of sales-
men and satisfy an important condition for theatre; that of sharing the
same aesthetic world.
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Victor I. Ukaegbu
Salespeople compete with other advertisers for audience’s attention
and, in the case of medicines, there are few more difficult situations
than convincing people unwilling to ‘suspend their disbelief’ about the
unproved efficacy of a medicine. This hurdle, as Adegoju (2008) argues
with respect to the advertising of herbal medicines as alternatives to
modern medicines in twenty-first century Nigeria, is surmounted with
a performed rhetoric in which advertisers use a falsely conceived binary
preposition to persuade potential customers with a ‘speech designed
to create concern about a problem’ with their health, but which
most importantly, ‘asks’ them ‘to agree that [their] specific conditions
should be perceived as a problem requiring solution’ (O’Hairr et al.
1975: 581–582, cited in Adegoju 2008). Success by itinerant medicine
salesmen in Nigeria depended on two factors; firstly, on the fact that
‘performativity’ is ‘part of our active being-in-the-world’ (Schieffelin
1998: 197) and secondly as Goffman (1984) would argue, it depended
on how well communication was articulated through performative
actions. If anything sales-performers relied on their audiences accept-
ing that, despite their improbability, the acts and claims performed for
them were real, sincere and authentic.
As performances go, sales-performers’ created their own protago-
nist, context, action, and storyline. The performance content may be
quasi-dramatic, the action/storyline is a fabrication recounting the
escapades of the protagonist-performer in fabled glowing terms,
however, the efficacy of their medicines was nothing short of stupen-
dous. The boastful and unsubstantiated claims of sales-performers and
shamans have long returned in rather outrageous fashion in herbal
medicine advertising on radio, television and billboards since the
early 1990s (see Komolafe 1998; Tell Magazine 2005; Adegoju 2008).
The context was usually performers’ touching concern for the welfare
of their ‘clientele-audience’. The actions combined rehearsed and
spontaneous routines with low-level mimesis based on a loose frame
of pre-planned sequences that changed as sales-performers adjusted
to the moods of the audience. The storyline, like the anecdotal tales
that constituted a major part of presentations, was imaginary. The
integration of reality and fiction created an atmosphere unlike aes-
thetic performances, as some dramatists have come to use the term,
but the actions are neither less theatrical nor devoid of leaned per-
formance skills. I am referring here to acts in which ‘performativity is
located at the creative, improvisatory edge of practice in the moment
it is carried out – though everything that comes across is not neces-
sarily consciously intended’ (Schieffelin 1998: 199, emphasis added).
In practice, acts developed in different directions: contexts shifted
in the face of probing questions from potential customers. Depending
on how good they were, sales-performers engaged the audience in
comic banter or initiated a ‘cat and mouse’ game with unpredict-
able outcomes; effective presentations generated sales, whereas
failed performances generated no sales or aroused ridicule as in one
of the examples cited later. Convincing audiences to abandon logic
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Performative encounters
and to make purchases was dependent on effective performances, for
which some salesmen appealed to authority – aligning their products
to famous public figures and celebrities, a form of ‘endorsement or
celebrity testimonial’ (Adegoju 2008). Some created theatre from the
information on medicine packages. Both these approaches were a
proven advertising trick that Adegoju (2008) describes as ‘argumentum
ad vercundium’– a ploy designed to astonish and lure audiences to col-
lude with the object of the presentation. It is:
this forgetfulness of the context, partly voluntary on the part of
the audience, but in good part compelled by the quality of the
performance, that constitutes so-called “suspension of disbelief”
and enables the activity of the players to assert itself as an emer-
gent reality, vivid and alive.
(Schieffelin 1998: 201)
A coach of about 40 passengers (traders, businessmen, professionals,
students, etc.), among them is a medicine salesman travelling incog-
nito to others but known to driver and his mate. Salesmen get off at
coach depots, sometimes boarding coaches heading in the opposite
direction, once again appropriating passengers as captive audiences
for their acts.
A discussion of two displays I witnessed in 1993, (1) by a self-pro-
claimed ‘Professor Breezer’ between Lagos and Ore in the west (LOX)
and (2) by a less colourful salesman travelling from Jos to Lafia in the
north (JAL), will highlight the aesthetics of these sales acts. The scripts
used in this paper have been edited and adapted for the benefits of
a wider, non-localised audience, in the process I have left out most
of the ‘pidgin’ English without sacrificing the linguistic flavour and
interactive atmosphere of both performances. ‘SP’ is my acronym for
salesman-performer while ‘PA’ is for individual passengers.
(Salesman gets up, clears his voice to attract attention … whistles a
familiar tune.)
SP: Let us pray (prays)…. Amen! Why don’t we make that Amen
convincing? (diverse response) Sir! Long time no see. How’s life
with you?
PA 1: Brother, life is complicated … but we will survive this regime.
A child that keeps its father from sleeping also loses its sleep.
SP: Na true…o! We dey here before ‘am…we go dey after am too!
(That’s true! We were here before and will be here after him ….!)
(clears voice, then proceeds) … some (gesturing towards audience)
know me, but for the benefit of others, I will introduce myself
again even though the ‘International Assembly of United Nations’
JAAH_1.1_art_Ukaegbu_035-052 41 8/21/09 12:28:17 PM
Victor I. Ukaegbu
has already done it. My name is ‘Professor Willy Breezer’, the
only person Beecham, PZ, Smith & Kline, and Bayer permit to
advertise their medicines. Ten years ago, at the University of St.
Petersburg in Yugoslavia my lecturers see my great intelligent. CIA,
KGB, and Mossad … almost started world war because of me, so
UNO beg me to travel round the world to teach doctors, lawyers,
engineers, pharmacists, and other professors … After 7 years …
PA 2: But I know you from the motor park … are you not that
Agbero (motor tout) I saw last time …
SP: Nooooo!… that go be my twin brother. After 7 years, I decided
to go private, to the real people like you and me. So whatever I
give you, ask no questions, simply pay to help my new research,
(passengers protest) … it’s not for me … Sir, read this yourself
(passenger reads out name on medicine packets given).
PA 3: New PR…, by German pharmaceutical company, Hoechst …
Phensic for joint pains, B- Codeine for headache …
SP: Thank you sir … you’ve heard it from this intelligent man …
vitamin B12 … Magnesium Stearate for strong bones … Providone,
new blood medicine…. Altogether, 1000 mg of pure power …
(pause) … cure for weak manhood, too much urinating, VD,
echetaram! Echetaram!! [Et cetera used to imply listing and
unlisted diseases.]
PA 1: How illiterates go know what that means? We no go school
like you!
SP: I’m sure you go …, (jokingly) to that a run-down school
in Maroko! I went to the international school of medicine in
Washington D. C.
PA 2: Was that before the University of St Petersburg in
Yugoslavia? Incredible.
SP: That was between Petersburg and after a Ph.D. at Chinawawa
University, Toronto.
PA 3: I prefer ordinary paracetamol.
SP: Wonderful … there’s paracetamol inside this pure 1000mg of
‘magnum power’. I recommend it because after taking it … my
wife think say I use mangani … [a potion believed to induce sexual
potency] … Since then I no fear bedroom … I dey get special
breakfast from … this na [is] special for man wey like women
[womaniser] …
PA 1: In that case let me have two packets.
SP: Wise man … you give money to treasurer, treasurer give me
money, from me to bank manager who will pay poor pensioners …
your wife be lucky woman from today … She go thank me very
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Performative encounters
very proper for this … (hands over medicines) … Abeg [please] pay
treasurer quick quick …
PA 2: (protests jokingly) But you say money be for new research …
SP: True! … I dey research why pensioners no get money to buy
medicine, why them depend on their children wey government
no dey pay … why the blood in some people body no dey flow
well well …
(Interaction continues for about ten minutes in several directions, it
involves several passengers and culminates in sales.)
(The passengers are mostly boisterous undergraduates travelling home from
university … opening glee is uncertain, insufficiently theatrical.)
SP: … So I go to University of Wellington in Liverpool … Australia.
PA 1: Wellington is in New Zealand my friend!
PA 2: … (general laughter) he doesn’t know what he’s talking about.
He failed his GSCE Geography!
PA 3: No! He passed. He had an A** but mistook it for the privilege to
transfer towns wherever he likes (prolonged laughter).
SP: So you think I don’t know book. Look, let me tell you people …
PA l: … Shhh…. Silence everyone! Professor … (peers at salesman’s
coat) Schlumberger Drills wants to speak. Lend him your ears …
(Passengers seize opportunity for comic banter, ignoring salesman who
goes quiet.)
PA 2: How much will he pay me for lending him my expensive ears?
PA 3: At least he’ll give you a Chinese balm for your old grandmother.
PA 2: (jokingly) Hey! Don’t insult me. My grandmother is a perfect
eight …
PA 1: (in affected anger)…. What!?
PA 2: Wait … let him finish … he means eight decades, the Course (degree
programme) he’s studying tells you he has problems with figures.
PA 1: I mean ‘figure eight’. Isn’t that why your grey-haired uncle has
been wooing her?
PA 3: You don’t have to display your ignorance, we can tell her age
from your …
SP: (exasperated) Wetin I do you people? [What have I done wrong?]
Na me be Gov’ment wey close university? … Please hear me, even if
you won’t buy anything!
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Victor I. Ukaegbu
(Students continue in satirical vein for several minutes, salesman tries unsuc-
cessfully to get someone to read packages: each gives reasons for declining.)
SP: (exasperated) … You louts! I wan sell medicine to feed my children …
una no dey gree [but you won’t let me]. Which kin people be dis? [what kind
of people are you?] (Packs up, defeated.)
The presentations above reveal four main sections:
1. ‘opening glee’ (Jeyifo 1984);
2. transitional pre-performance stage when commercial intent was
disguised as altruistic concern for public health (see O’Hairr et al.
3. climactic stage, the business section in which arguably, the ‘art’
[of advertising] ‘and drama’ [of entertainment] ‘meet’ (Jennings &
Ase 1993: 187) as salesmen, disrobed of all pretences, relinquished
mimesis and conducted sales;
4. conclusion; in which salesmen ended all activities or waited for
another ‘opening glee’.
Sections one to three depended essentially on the interactive par-
ticipation of potential customers. In ‘opening glee’, sales-performers
announced their presence and pedigree and initiated participatory
interaction with audiences (see Spencer 1990; Okpewho 1990; Osofisan
1991, on ‘opening glee’ in African oral performance). ‘Opening glees’
took many forms; from heraldic voice-clearing and singing, to perform-
ers announcing themselves as the delegated representatives of some
fictional high authorities. ‘Opening glee’ established a relaxed, interac-
tive atmosphere – an important condition for good sales. The second
stage increased interaction between salesmen and passengers – the lat-
ter participating directly or vicariously in the life-drama improvised by
salesmen. The climactic third stage, the business section of performed
sales, dovetailed into the closing fourth stage, when all pretences and
sales ended and normality was re-established. Like ‘opening glee’, the
climactic and closing stages are based on traditional African itinerant
performances during which performers are offered gifts to which they
respond with either praise songs for good gifts or comic insults for poor
patronage. Performance stages flowed into each other. The timing and
content of each stage depended on a salesman’s understanding of his
audience, and on his command and handling of participation.
By resorting to the common advertising strategy of establishing
his credibility with appellations (Adegoju 2008), ‘Professor’ Breezer
gave himself academic and medical credibility in ‘LOX’. This achieved
three purposes: it drew parallels between himself and professional
doctors/pharmacists (Adegoju 2008); it gave theatrical credence to his
boastful claims; and thirdly, it assured the audience that the informa-
tion he communicated was reliable, based on empirical evidence and
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Performative encounters
proven medical facts. All three depend however, on the salesman’s
skilful handling of script and participation. In performance Breezer
integrated camaraderie and gregarious loquacity into a presentation
style that undermined the audience’s natural suspicion. He conflated
three distinct characters: the solo shaman; comic Ajasco; and com-
media dell’arte’s loner, II Capitano (the Captain), who pretends to be
more than he actually is. Like commedia’s II Dottore (the doctor) and
shamans, Breezer understood every ailment and specialised in cur-
ing them all. Through his claims and fictional credibility, an academic
and doctor rolled into one, Breezer, like good advertisers everywhere,
entered the realm of dramatic characterisation whilst simultaneously
urging potential customers to overlook their scepticism: in other
words, suspend their natural inclination to disbelieve. This type of
presentation, according to Goffman, requires observers:
… to take seriously the impression that is fostered before them.
They are asked to believe that the character they see actually
possesses the attributes he appears to possess, that the task he
performs will have the consequences that are implicitly claimed
for it, and that, in general, matters are what they appear to be ….
the individual…puts on a show for the benefit of other people.
(Goffman, in Kendon, 1988: 28)
The actions of the passengers in legitimising the salesmen locate per-
formed sales in Victor Turner’s liminal zone where theatre and social
reality meet. In effect the collusion between medicine salesmen
(Christian evangelists filled this gap after the ban and continue to oper-
ate in coaches in similar fashion without interruption) and passengers
alleviated the tedium of long travel and commercial transactions; it also
left the audience ultimately responsible for their own actions. Goffman
points out that a salesman’s techniques may ‘guide the conviction of his
audience only as a means to other ends’ (1984: 28) as ‘Professor’ Breezer
did. This is a strategy that herbal medicine practitioners now employ to
very good effect in print and electronic advertising. The failure of the
‘JAL’ salesman underlines the importance of integrating dramatic leit-
motif and performance techniques into a salesperson’s act.
The sales acts described in this article, like their highly drama-
tised counterparts on television, are a social phenomenon on account
of their reliance on routine trading activities, and the transformation
of these activities into what Eugenio Barba (1991, 1999) and Watson
(2002) describes as ‘extra-daily behaviours’. They mirror ‘the business
of everyday life’ and are ‘routinely imbued with formal significance’
(Chaney 1993: 24–25) yet they contain ‘the theatrical terminology of
dramatism – role, script, audience, stage, etc. (Bauman 1977: 17). They
implicate their audience in active participatory roles, making them
accessory to the display. They blur the boundaries of performance and
life and achieve dramatic characterisation through a combination of
Schechner’s (1985) ‘restored behaviour’ and Goffman’s ‘performers’
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Victor I. Ukaegbu
credulity’ – two performance concepts that require audiences ‘to believe
the character they see actually possesses the attributes he appears to
possess’ (Goffman 1984: 28). As ‘restored behaviour’ the presentations
draw on two related dramatic premises; pretence and role-play, both of
which ritualise social behaviour and transform passive observers into
active participants.
In practice sales acts combine straight performance and presentation
for, as Schechner argues, the ‘difference between performing myself
[…] and more formal “presentations of self” is a difference of degree,
not of kind’ (1985: 37). Schechner’s ‘difference of degree’ underlines
two fundamental features of performed sales. It highlights the retriev-
ability of ‘restored behaviour’ and the reliance of sales on theatrical
pretence in order to achieve real outcomes. Secondly, by insisting that
‘restored behaviour is the main characteristic of performance’ (1985:
35) Schechner highlights the ‘transactional’ (1985: 35) nature of social
drama whilst foregrounding ‘performativity’ as a central element of
performer-audience interaction. Without ‘transactional’ interaction
and the audience’s acceptance of the presentation, the sales perform-
ances I have described here would neither be sustainable nor would
they guarantee results. Schipper (1982), Soyinka (1988), and Bharucha
(1993), among many other writers, have commented on the contract
between performers and audiences in drama, ritual, sporting event,
and informal social gatherings. The successful ‘LOX’ salesman relied
on ‘transactional’ interaction but how did the outcome in the sale of
products impact the status of the presentation as reality and/or as the-
atre? Schechner’s (1994) argues that ‘a performance is called theater
(sic) or ritual because of where it is performed, by whom, and under
what circumstances’ and that ‘one can look at specific performances
from several vantages’ since ‘changing perspectives changes classifica-
tion’ (Schechner 1994: 120). The salesmen did not simply apply drama
to commerce they put on an act without elaborating or distinguishing
between role and actor (Chaney 1993, emphasis added).
The different interests of salesmen and passengers, the proxemic
relationship between them, and the language of transaction provide
the dramatic tension that justifies the theatricality of these perform-
ances. In practice the narrow, restrictive aisles eliminate the neces-
sity for extensive stage business but this deficiency is compensated
for by the verbal and linguistic agility of salesmen. As Rudlin points
out about the commedia dell’arte (which, as I have already indicated,
possesses similar marketplace origins and features as performed sales),
the performer goes wherever ‘a crowd has to be attracted, interested
and then held if a living was to be made’ (1994: 24). His speech and
vocal modulations may be ordinary (although this is rarely the case)
but their deployment in the service of theatrical ‘acts’ requires creativ-
ity and imagination. Salesmen tackle this essential requirement in any
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Performative encounters
number of ways, from gregarious loquacity to banter and witty remarks
deliberately designed to arouse laughter. Dry humour and bombastic
statements are common too, but, irrespective of language preference,
the narrative employed involves ‘an assumption of accountability to
an audience for the way in which communication is carried out, above
and beyond its referential content’ (Chaney 1993: 17).
Salespeople are in ‘direct relationship to’ their ‘public, based on a
humorous sense of collusion’ (Rudlin 1994: 23) but those described
here are involved in more than a straightforward commercial interac-
tion. Limited to the aisles, they interact with passengers that flit from
‘unfocused’ individuals to ‘focused’ gatherings ‘exemplified by occa-
sions of conversation of all sorts’, to ‘jointly focused’ or even ‘multi-
focused gatherings’ (Kendon 1988: 24) exhibiting different levels of
mental presence, alertness and involvement. Verbal language, (but
less so for physical language) is important in how salesmen man-
age passengers’ perceptions of their acts and consequent responses.
Language attracts and then holds the audience’s attention; it frames
the resulting ‘transactional’ interaction as a specialised act with well-
established aesthetic signifiers as well as displaying all the important
features of expressive, meaningful communication:
There is, first of all, contrivance – inventiveness, and a capac-
ity for improvisation, in ‘filling out’ and connecting up familiar
‘pieces of expression’ – which, because they are ‘pieces of expres-
sion’ familiar to his audience (for they too have learned them)
are recognisable and easily understood by them. Second, there is
the meaningful content: the ‘pieces of expression’ – skilled phatic
routines of posture, movement, gesture, and symbolically loaded
formulae of wording, intonation, etc. – which he has learned (by
imitation, practice, experience).
(Burns 1992: 122–123)
In the aisles, the limited standing-room-only space available to sales-
people, stage business and spectacle are compromised; this makes the
performer’s body a physical vocabulary and site of theatrical action in
which language is not only transformed into ‘extra-daily’ (Barba 1999;
Watson 2002) action, it also acquires the status and complexity of a
metalanguage in the sense that it is both verbal and physical. The body
emphasises narrative content, performer’s active involvement, and
modes of delivery in equal proportion. The linguistic content, especially
with respect to the information communicated, structure, and style
of delivery are designed to assault passengers’ attention, to encour-
age their participation, and to channel their attention towards sales.
What salesmen do is ‘enact reality through a drama in which “the
unity of language and way of life” are “both manifested and reinforced
by dramatic argument”’ (Hawkes 1973: 216; in Chaney 1993: 31). In
the diverse ‘gathered’ audience roles change frequently, participatory
interactions are deliberately manipulated, salesmen and passengers go
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Victor I. Ukaegbu
‘in’ and ‘out’ of roles. Without the rich complexity of their language
providing a visual contender or equivalent to images on television and
billboard advertisements, salesmen would hardly sustain their captive
audiences’ interests, let alone direct and manage their actions.
Since the ban ejected salesmen from public transport their presenta-
tion strategies (using language to evoke spectacle and to communicate
effectively in a short space of time in the absence of visual equivalents,
and aligning themselves with the healthcare needs of potential clients)
continue in the marketing of herbal medicine (Adegoju 2008) and
in creative copy-writing in Nigerian media advertising (see Nworah
2007). Performed sales, like ancient shamans and the government-li-
censed herbalists that now dominate the air waves, were driven by
commerce. They all use ‘argumentum ad vercundium’ (Adegoju 2008)
to convince clients that their medicines are not simply panaceas; they
have larger-than-life properties. The aims were, and, in the cases of
herbal medicine and pharmaceutical advertisements, are, to destabi-
lise audiences’ scepticism, establish their ‘sales character’ or integrity,
and to convince audiences that their sincerity and trustworthiness are
synonymous with ‘concern for the well-being of the audience’ (Lucas
1992: 326). Performed sales, herbal medicine and global pharma-
ceutical advertisements use performance to ‘create and make present
realities vivid enough to beguile, amuse or terrify …, they alter moods,
social relations, bodily dispositions and states of mind’ (Schieffelin
1998: 194). The difference is that, unlike herbal and modern medicine
advertising, shamans and sales-performers framed this strategy for the
solo performer without the backing of sophisticated organisations and
professional actors.
Sales-performers devised their routines from unwritten ‘scripts’ to
suit different contexts. Unlike Meyerhold’s inspirational actor who
rejects technique and ‘is content to rely exclusively on his own mood’
(Braun 1969: 129), they used established, tested techniques without
surrendering to character or role as in naturalistic acting. Their train-
ing was mainly by way of Schechner’s (1985) ‘restored behaviour’
which facilitates periodic recalls, retrieval, and the manipulation of
established sequence of actions for new performances. Such retriev-
als may lead to new skills and acts but they essentially allowed these
salesmen to ‘rebehave according to these strips, either by existing
side by side with them’ (Schechner 1985: 36) or by passing them
on to others. Sales performers sustained proxemic relationships with
audiences without the spatial ruptures there are in conventional
communal performances. Despite this the dramatic action ‘is not
limited to one group or to one place exclusively, but rather eddied
through all those present’ (Chaney 1993: 29). There are unrestricted
exchanges among passengers, as well as between them and the
salesmen, resulting in ‘“inclusive” tactile dramatisation’ (Chaney
1993). The acts are not social drama as Turner (1974 and 1986) and
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Performative encounters
Schechner (1994) define the form, but a good salesman creates his
acts to include ‘mundane experience thereby imbuing it with new
levels of meaning’ (Chaney 1993: 28). In effect, what we have is not
only a set of paratheatrical activities which dissolve the audience-
performer opposition (Schechner 1994: 122) but ‘direct theatre’,
that ‘is not “about” something so much as it is made “of” some-
thing. It is actual and symbolic, not referential and representational’
(Schechner 1992: 104).
In the cited examples the acting self and other self differ for, as
Schechner put it, ‘the self can act in / as another; the social or transin-
dividual self is a role or set of roles ….’ (1985: 36). Some activities
in sales presentations happen spontaneously, others are rehearsed
till they become second nature and are stored and retrieved for use
when required. The performative context of performed sales was, and
remains, undeniable. Like many commercial activities in which the
performative intent is non-defined (as in aesthetic theatre), performed
sales functioned on the same socio-theatrical dimension and aes-
thetics as those found in all product advertising and marketing, from
medicine to the most sophisticated electronic goods.
Adegoju, Adeyemi (2008), ‘A Rhetorical Analysis of the Discourse of Advertising
Herbal Medicine in Southwestern Nigeria’, (unpaginated) Linguistik, 33:1,
available at: E:\Review of ARt and Health\Adepoju\A_ Adegoju Discourse
of Advertising Herbal Medicine.htm. Accessed 24 April 2009.
Barba, Eugenio and Savarese, Nicola (1991), The Secret Art of the Performer: A
Dictionary of Theatre Anthropology, London: CPR / Routledge.
Barba, Eugenio (1999), Land of Ashes and Diamonds: My Apprenticeship in
Poland, Aberystwyth: Black Mountain Press.
Barber, K., Collins, J. and Ricard, A. (1997), West African Popular Theatre,
Bloomington & Oxford: Indiana University Press & James Currey.
Bauman, R. (1977), Verbal Art as Performance, MA: Newbury House.
Bharucha, Rustom (1993), Theatre and the World: Performance and the Politics of
Culture, London: Routledge.
Braun, Edward (1969), Meyerhold on Theatre, London and New York: Eyre
Methuen; Hill and Wang.
Burns, Tom (1992), Erving Coffman, London & New York: Routledge.
Chaney, David (1993), Fictions of Collective Life: Public Drama in the Modern
Culture, London & New York: Routledge.
Goffman, Erving (1984), The Presentation of Self in Everyday Life, London:
Grice, Herbert Paul (1999), ‘Logic and Conservation’, in Peter Cole & Jerry L.
Morgan (eds) (1975), ‘Syntax and Semantics’, 3, Speech Acts, New York:
(Academic Press) pp. 41–58.
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Jennings, Sue and Minde, Ase (1993), Art Therapy and Dramatherapy: Masks of
the Soul, London: Jessica Kingsley Publishers.
Jeyifo, ‘Biodun (1984), The Yoruba Popular Travelling Theatre of Nigeria, Lagos:
Nigeria Magazine.
JAAH_1.1_art_Ukaegbu_035-052 49 8/21/09 12:28:17 PM
Victor I. Ukaegbu
Kendon, Adam (1988), ‘Goffman’s Approach to Face-to-Face Interaction’,
in , Paul Drew & Anthony Wootton (eds), Erving Goffman: Exploring the
Interaction Order, Oxford: Polity Press, pp. 14–40.
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Healers in Nigeria’, in Ebenezer O. Olapade (ed.) (1998), Traditional
Medicine in Nigeria, proceedings of the seminar organized by the German
Cultural Centre, Goethe-Institute, Victoria Island, Lagos, pp. 71–75.
Kowzan, Tadeusz (1975), Literature and Spectacle, Texas: Austin University
Lucas, Stephen E. (1992), The Art of Public Speaking, New York: Harper &
Brothers Publishers.
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available at: http://www.sacredearth.com/ethnobotany/medicines/Medicine.
php. Accessed 28 April 2009.
Nworah, Uche (2007), ‘The Shock Therapy In Advertising’, unpagina-
ted, available at: E:\Review of ARt and Health\Nigerian Village Square\
The Nigerian Village Square – The Shock Therapy, in Advertising.htm.
Accessed 24 April 2009.
Ogunshe, A.O. (2007), ‘Who is afraid of Staphylococcus?’, Rural and Remote
Health 7, unpaginated, 826, available at: http://www.rrh.org.au. Accessed
24 April 2009.
O’Hairr, Dan, et al. (1995), Competent Communication, New York: St Martins
Okpewho, Isidore (ed.) (1990), The Oral Performance in Africa, Owerri:
Spectrum Books.
Osofisan, Femi (1991), Once Upon Four Robbers, Ibadan: Heinemann
Educational Books.
Rudlin, John (1994), Commedia dell’Arte: An Actor’s Handbook, London and
New York: Routledge.
Schechner, Richard (1985), Between Theater and Anthropology, Pennsylvania:
University of Pennsylvania Press.
—— (1992), ‘Invasions Friendly and Unfriendly: The Dramaturgy of Direct
Theater’, in Janelle G. Reinelt and Joseph R. Roach (eds), Critical
Theory and Performance, Ann Arbour: University of Michigan Press,
pp. 88–106.
—— (1994) (repr.), Performance Theory, New York & London: Routledge.
—— (2002), Performance Studies: An Introduction, London: Routledge.
Schieffelin, Edward L. (1998), ‘Problematizing Performance’ in Felicia Hughes-
Freeland (ed.), Ritual, Performance, Media, ASA Monograph 35, London &
New York: Routledge. pp. 194–207.
Schipper, M. (1982), Theatre and Society in Africa, Johannesburg: Ravan Press.
Soyinka, Wole (1988), Art, Dialogue and Outrage: Essays on Literature and
Culture, Ibadan: New Horn Press.
Spencer, Julius S. (1990), ‘Storytelling Theatre in Sierra Leone: The Example
of Lele Gbomba’, New Theatre Quarterly, 24:6, pp. 349–356.
Tell Magazine (2005), 35, 29 August.
Turner, Victor (1974), Drama, Fields and Metaphors: Symbolic Action in Human
Society, Ithaca: Cornell University Press.
—— (1986), The Anthropology of Performance, New York: PAJ Publications.
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Debate, Manchester: Manchester University Press.
JAAH_1.1_art_Ukaegbu_035-052 50 8/21/09 12:28:17 PM
Performative encounters
Ukaegbu, V. I. (2010), ‘Performative encounters: Performance intervention in
marketing health products in Nigeria’, Journal of Applied Arts and Health
1: 1, pp. 35–51, doi: 10.1386/jaah.1.1.35/1
Dr Victor I. Ukaegbu is a Senior Lecturer and Course Leader for Drama at
The University of Northampton. He has written on African and intercultural
theatres, postcolonial performances, gender, black British theatre, applied
theatre, including a book; The Use of Masks in Igbo Theatre in Nigeria: the
Aesthetic Flexibility of Performance Traditions. He is Associate Editor of African
Performance Review and a member of the Editorial Board of World Scenography
(Africa /Middle East).
Contact: Division of Performance, School of The Arts, The University of
Northampton, St George’s Avenue, Northampton, NN2 6JD, United Kingdom.
E-mail: victor.ukaegbu@northampton.ac.uk
JAAH_1.1_art_Ukaegbu_035-052 51 8/21/09 12:28:17 PM
The Poster
ISSN 2040-3704 (1 issue | Volume 1, 2010)
Aims and Scope
L`]Hgkl]j ¦s a ío:um ío: oeba¹es abou¹ ¹he ways ¦¤ wh¦ch v¦sua¦ oev¦ces a:e useo ¹o ío:m
oµ¦¤¦o¤, sway, µe:suaoe, µ:ovoke, u¤¦¹e a¤o o¦v¦oe us The [ou:¤a¦ ¦¤v¦¹es a¦¦ scho¦a:s a¤o
µ:ac¹¦¹¦o¤e:s oí v¦sua¦ cu¦¹u:e ¦¹s soc¦a¦ oµe:a¹¦o¤, a¤¹h:oµo¦ocy, µh¦¦osoµhy, h¦s¹o:y, µo¦¦¹¦cs
a¤o c:ea¹¦o¤ ¹o [o¦¤ w¦¹h us ¦¤ a¤ oµe¤ oeba¹e abou¹ ¹he e¹h¦cs, aes¹he¹¦cs, eííec¹ a¤o
oµe:a¹¦o¤ oí v¦sua¦ :he¹o:¦c ¦¤ ¹he µub¦¦c sµhe:e L`]Hgkl]j a¦ms ¹o b:¦¤c oµe¤¤ess a¤o c¦a:¦¹y
¹o ¹he sea oí v¦sua¦ µe:suas¦o¤ ¦¤ wh¦ch we a:e a¦¦ subme:ceo
Call for Papers
L`]Hgkl]j seeks subm¦ss¦o¤s í:om v¦sua¦ µ:ac¹¦¹¦o¤e:s, ¹heo:e¹¦c¦a¤s a¤o :esea:che:s |¦¤c¦uo¦¤c
¹hose í:om ¦¤ous¹:yì o¤ ¹he ío¦¦ow¦¤c
Why a¤o how ¹he µos¹e: s¹a¤os as a µ:¦v¦¦eceo s¦c¤¦íe: oí :he¹o:¦c, ove: a¤o above eve:y ·
o¹he: ¦¤s¹a¤ce oí ¹he v¦sua¦ wh¦ch a¦so µe:suaoes o: aííec¹s behav¦ou:
Wha¹ a:e ¹he ¤ew ace¤¹s oí v¦sua¦ :he¹o:¦c` ·
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[o: ¹he íu¦¦ ¦¦s¹ oí succes¹eo subm¦ss¦o¤ oues¹¦o¤s µ¦ease see ¹he [u¦¦ Ca¦¦ o¤
Subm¦ss¦o¤s may be íu¦¦ µaµe:s, sho:¹ µaµe:s co¤¹ex¹ua¦¦z¦¤c v¦sua¦ subm¦ss¦o¤s, µos¦¹¦o¤
µaµe:s, :eµo:¹s oí successíu¦ v¦sua¦ :he¹o:¦cs oeµ¦oyeo ¦¤ ¹he íe¦o, a¤o :ev¦ews oí :e¦eva¤¹
co¤íe:e¤ces, ¦¤ous¹:¦a¦ eve¤¹s a¤o exh¦b¦¹¦o¤s
Louchbo:ouch U¤¦ve:s¦¹y
U¤¦ve:s¦oaoe oe /ve¦:o
Louchbo:ouch U¤¦ve:s¦¹y
U¤¦ve:s¦¹y oí New Sou¹h Wa¦es
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Louchbo:ouch U¤¦ve:s¦¹y
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JAAH_1.1_art_Ukaegbu_035-052 52 8/26/09 8:38:37 AM
JAAH 1 (1) pp. 53–61 Intellect Limited 2010
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.53/1
Northampton General Hospital and
The University of Northampton
Best foot forward: An
orthopaedic odyssey
through the world
of dance
This article reviews the musculoskeletal problems of dancers. An over-
view of the benefits of dance is given and background problems increasing
injury risk explained. The article follows dancers from infancy to retirement
through the ‘five orthopaedic ages of a dancer’ and highlights some of the
orthopaedic problems commonly encountered at each age. The specific prob-
lems of a major ballet company are discussed and the requirements for a
multi-disciplinary team of healthcare professionals to support the organisa-
tion outlined.
From early times, almost every civilisation has embraced dance in one
form or another. Dance has fulfilled many roles including an inte-
gral part of courtship, a means of passing stories from generation to
1. A version of this
paper was originally
presented as a key
note address by the
author at Inspiring
Transformations: Arts
JAAH_1.1_art_Ribbans_053-062.indd 53 8/21/09 12:33:20 PM
Bill Ribbans
generation, a form of thanksgiving, an invocation of the gods, a wel-
come to guests and a preparation for battle.
Two hundred years ago, the poet, Lord Byron (1788–1824), wrote
glowingly of its charms in Childe Harold’s Pilgrimage (1812):
On with the dance! Let joy be unconfined;
no sleep till morn, when youth and pleasure meet.
To chase the glowing hours with flying feet.
Who knows this might have been the first description of an all night
With the advent of films, our forbears flocked to the cinemas and
amongst their matinee idols were dancers such as Fred Astaire, Ginger
Rogers and Gene Kelly. More modern cinema audiences have been
entertained by dance and musical blockbusters such as Saturday Night
Fever, Grease, and Dirty Dancing. Not to be outdone, BBC television in
the United Kingdom has screened its own dance-themed programmes,
such as Come Dancing and Fame, providing escapism and promoting
participation for all ages. More recently, vivid images of David Brent’s
grotesque disco dancing routine in The Office, and attempts by stars
of sport and screen to master routines in Strictly Come Dancing have
attracted massive television audiences for the same broadcaster.
Dance is accessible to all ages, for example: ballet classes for pre-
school toddlers; Jive, Ballroom and Ceroc classes for adults; and Tea
Dances and Line Dancing for the even ‘younger at heart’. The benefits
of dance for its participants’ health should be self-evident. It provides a
reasonable degree of cardiovascular training and respiratory exercise. It
improves coordination and balance – an important protection against
falls in the elderly – and builds and maintains muscle and bone mass
to counter osteoporosis. The calories consumed can form one strand
of a weight-control programme. Less easily measured benefits include
the feeling of wellbeing that accompanies regular exercise, the forma-
tion and maintenance of social skills in the young, participation in team
building, and, for the elderly, helping to offset feelings of isolation (Fiske
1997; Lobo 2006; Matarsso 1997; McHenry 2009).
Noel Coward was clearly aware of the benefits of dance when he
wrote the lyrics to Dance Little Lady in 1928: ‘Dance, dance, dance little
lady, leave tomorrow behind’ (Coward 1928). However, by 1935, his
views had changed for reasons unknown to this author. He implored:
‘Don’t put your daughter on the stage Mrs Worthington, Don’t put
your daughter on the stage.’
Clearly a seven-year itch!
It has been my fortune to be involved as the Honorary Orthopaedic
Surgeon for The English National Ballet (ENB) for many years. The ENB
medical team comprises a full-time physiotherapist and a part-time
and Health Conference
at The University
of Northampton in
September 2007.
2. There were seven years
between the songs
and he had clearly
changed his mind
about ladies dancing
on the stage!
JAAH_1.1_art_Ribbans_053-062.indd 54 8/21/09 12:33:20 PM
Best foot forward: An orthopaedic odyssey through the world of dance
masseuse and general practitioner. A Pilates instructor and remedial
coach also provide sessions twice a week. In addition to an Honorary
Orthopaedic Surgeon, the company calls upon the services of a stable of
other consultants in many disciplines, as well as other healthcare practi-
tioners including podiatrists, sports scientists, and psychologists.
My role with The English National Ballet involves seeing dancers
during routine clinics, undertaking surgical procedures, and providing
telephone advice when required. On occasions it involves visits to
the ENB Headquarters at Jay Mews, London, for clinics and rehearsals,
and attendances at performances to provide ‘Interval Clinics’. The
orthopaedic surgeon brings to the company his or her experience of
musculoskeletal disorders to facilitate diagnosis, appropriate inves-
tigations and guidelines on management. As well as undertaking
surgery, one has to be supportive of the company physiotherapist
and physician. However, being slightly distant and not intimately
involved in the day-to-day activities of the company can be advanta-
geous at times of critical decision-making.
Clinicians involved in ‘sports and dance medicine’ are called upon
to display qualities additional to those utilised in your normal daily
practice. The orthopaedic surgeon needs to be aware that his or her
role is more than ‘just putting in the knife’. First and foremost is the
requirement to be a team player. The ability to watch, listen, learn and
communicate in a multi-disciplinary team setting is mandatory.
An awareness of the technical aspects of the sport or dance with
which you are involved, and an up-to-date knowledge of the indi-
vidual athlete’s past achievements and forthcoming events are also
Frequently, you are called upon to act as advocate for the athlete,
and decisions regarding appropriate treatment are often coloured by
such non-medical issues as contract situations. The orthopaedic sur-
geon must never forget that his or her primary duty of care is to the
athlete and this can create difficulties of patient confidentiality within
the context of a team or dance company. The relationship between
an employer and athlete is at times almost feudal and one must be
aware of the difficulties that arise through the natural inquisitiveness
of coaches, trainers, artistic directors and the media.
Additional are the psychological aspects that are integral to any
‘changing room’. Training and performing together, whether as part
of a sports team or dance company, inevitably produces strong bonds
and tensions. As a surgeon or physician, it is easy to lose the con-
fidence of the ‘changing room’ and the oft-quoted surgical phrase
‘you’re only as good as your last operation’ is never as true as within
the field of sports and dance medicine.
The demands on a company such as The English National Ballet are
enormous. Every year the company travels the length and breadth of
JAAH_1.1_art_Ribbans_053-062.indd 55 8/21/09 12:33:20 PM
Bill Ribbans
this country and abroad performing. They are required to learn, prac-
tice and execute up to eight different dance productions per year.
Despite being The English National Ballet, 48 of the present sixty-six
performing in the ensemble (73 per cent) are from overseas. By itself this
can produce difficulties for the treating medical staff. New recruits may
have language barriers when discussing medical problems, detailed past
medical notes are not always available, cultural differences are inevita-
ble and a suspicion of ‘all things foreign’ is not confined to the British!
As in many sports, dancers may have a preference for home physicians
or for ‘alternative therapy’. In addition, the spectre of home sickness for
the young dancer can lie barely hidden just beneath the surface.
So what does the ‘ugly duckling’ have to go through to become the
‘beautiful swan’? Brinson and Dick published their survey into danc-
ers’ health in 1996. It revealed that 83% of ballet dancers were likely
to have sustained injury in the previous twelve months and 58%
of professional dancers require time out each year to recover from
such problems. The Australian Dance Council Survey (Geeves 1990)
revealed that 65% of professional dancers carried long-term injuries.
By the age of 25, 75% had chronic problems and only 5% of all pro-
fessional dancers were over 35. Similar injury patterns are seen in all
forms of dance and, regionally, the back, knee, foot and ankle were
amongst the most common areas of concern.
In my experience, there are five ‘orthopaedic ages for a dancer’. The
first extends from infant to young adolescent, the second covers the
teenage years, the third the young adult, the fourth the mature dancer,
and the fifth the retired dancer.
The young dancer attending local dance schools and performing at
festivals is prone to a number of different problems. Like any young
child, they can be subject to a number of specific paediatric injuries
caused by either acute damage or chronic overuse. At times, poor
teaching in local dance schools may embed technical faults that can
lead to injury and, as the child grows and develops, the changing
body shape puts altering demands on the musculoskeletal system.
In addition, the varying physical demands of other sports frequently
undertaken by a gifted young dancer may cause conflicting strains and
predisposition to injury.
By the time the aspiring dancer has reached his or her teens, they are
usually enrolled into a dance college or ballet company school. This
JAAH_1.1_art_Ribbans_053-062.indd 56 8/21/09 12:33:20 PM
Best foot forward: An orthopaedic odyssey through the world of dance
is a common time for presentation to orthopaedic clinics with various
problems. As daily classes become the norm, the increased physical
demands can create over-use injuries and subtle biomechanical and
technical weaknesses are highlighted.
The problems of weight issues and nutrition are a concern in our
society for a significant minority of teenage females. For the young
dancer, it brings with it the added concern of susceptibility to injury
and subsequent problems in recovery from such injury. In common
with many sports such as horse racing and gymnastics, many young
dancers have to be careful regarding their dietary patterns.
Finding a dietary balance, often at a time when a young dancer is
living away from home for the first time, is difficult. Walking the line
between being too thin and too heavy, coping with an evolving body
shape, and replenishing the calories burnt during rehearsal and per-
formance are difficult for a dancer to tackle alone.
Abraham’s Australian study, in 1996, demonstrated that ballerinas
had almost double the prevalence of eating disorders of control groups
and developed strategies to control weight often leading to amenor-
rhea. Rivaldi et al. (2003) looked at the problems of eating disorders
and body image disturbances in non-professional dancers. The study
concluded that, in those sports and activities emphasising thinness or
muscularity, there was a high degree of body uneasiness and inappro-
priate eating attitudes and behaviours.
Brinson and Dick’s extensive study in 1996 showed that dancers’
diets were poorly balanced compared to other athletes. They took
a higher percentage of calories from fat and a lower percentage of
calories from carbohydrates. They concluded that a paucity of anti-
oxidants in their diets, such as selenium and vitamins A, C and E, may
contribute to the common findings of immune system depression and
increased susceptibility to viral infection. Problems with nutrition can
manifest themselves in a number of different ways including problems
with wound healing and adverse reactions to soft-tissue injections
that may be required to help treat various musculo-skeletal problems.
Once the teenager has progressed from ballet and other dance schools
to professional companies, there is another incremental step in work-
load and increased emphasis on fitness maintenance. In addition, there
are the further challenges from frequent travel, both home and abroad,
and learning to accommodate different performing venues. The English
National Ballet, as previously mentioned, travels widely and is called to
perform in many different venues. On occasions the performing surface
can be less than optimal. Venues staging ballet ideally require specifically
laid wooden sprung floors. Sadly, many of these venues lack optimal
conditions increasing the risk of injury, particularly stress fracturing.
Stress fractures are a particular concern to ballet dancers. The sur-
vey in 1992 by Kadel, in North America, revealed that of the 54 dancers
JAAH_1.1_art_Ribbans_053-062.indd 57 8/21/09 12:33:20 PM
Bill Ribbans
reviewed, seventeen had sustained a total of 27 stress fractures during
their careers, with 63 per cent occurring in the metatarsal region of
the foot. Identified risk factors included the number of hours per day
spent training and dancing and a tendency to amenorrhoea. Frusztajer
et al. (1990) reviewed ten New York ballerinas with stress fractures and
matched them against a similar number of ballerinas without stress
fractures and ten matched controls. Those with stress fractures had a
higher prevalence of eating disorders and weighed less than the other
groups. However, the numbers in each group were too small to reach
statistical significance.
After a period within a professional dance company, the ballet dancer
will be asked to take on increasingly more demanding roles. Their
prime position within the company makes it increasingly difficult to
time any surgical interventions because of their busy schedules. Their
bodies, as has previously been noted, accumulate various stress inju-
ries and years of maintaining optimal body shape for dancing may
begin to produce metabolic bone problems. Like many sports, elite
ballet dancers are prone to ‘burn out’ when subjected to a remorseless
schedule of training and performing without proper rest to recover
mentally and physically from the inevitable fatigue that occurs.
Undoubtedly, osteoporosis in ballet dancers has been, and will
remain, a cause of concern and thus the subject of several studies.
Karlsson et al. (1993) looked at a number of Swedish dancers; their
study suggested that regular dance maintained the bone mineral den-
sity in the lower limbs. Tsai et al. (2001) reported a similar finding in
Chinese dancers. However, Cuesta et al. (1996) found, in a group of
Spanish dancers, significantly lower bone mineral content in the arms
of female dancers and in the trunks of both male and female dancers.
This suggests that these areas may be at risk of later osteoporosis.
When tested on such parameters as speed, power and strength
testing, dancers have fared poorly in comparison to other elite ath-
letic groups. Female dancers compare less favourably, with a relative
lack of strength and body weight associated with a greater incidence
of back and lower limb injuries. When comparing dancers with other
sports groups in terms of aerobic fitness measured by respective VO

max (maximal oxygen uptake), the average aerobic fitness is only just
above that of sedentary controls. Brinson & Dick (1996) found that
British dancers were less aerobically fit than their North American
and Russian counterparts. Once again a reduced fitness correlated
with increased risk of lower limb injuries and it was appreciated that
traditional barre and floor work were not, in themselves, sufficient to
improve aerobic fitness and that overwork and traditional training
methods may be at fault.
Most dancers will decide to end their careers at their own volition
or, possibly, coinciding with the end of a company contract. Frequently,
JAAH_1.1_art_Ribbans_053-062.indd 58 8/21/09 12:33:20 PM
Best foot forward: An orthopaedic odyssey through the world of dance
however, the long-term strains of accumulated injury will reach an
intolerable point or the dancer may sustain a single, career-ending
injury. The value of a team approach to such decision-making cannot
be over emphasised and frequently the orthopaedic surgeon’s opinion
is required. A dancer having to finish their career ‘ahead of sched-
ule’ requires tact and understanding. Frequently the decision-making
involves parents, teachers, spouses and partners. Surprising reactions
from the dancer can be encountered; relief that a decision has been
taken out of their hands, often through fear of letting down their fam-
ily or teachers, is occasionally witnessed. At the end of a dance career
other issues come into focus, such as future career choices and the
financial implications of loss of income.
Once the dancer has moved into the post-performing stage of their
lives, difficulties can be encountered in adjusting to ‘a fresh start’,
whether that is in a dance-related profession or elsewhere. The dancer
can be prone to the development of degenerative changes within joints
as a result of their career, at an earlier stage than normal, and the
change in fitness and weight, having stopped such an active career,
can only add to these problems.
In my career as an orthopaedic surgeon, I have taken a particular
interest in foot and ankle problems. The extreme positions required of
an ankle and foot in classical ballet positions such as plié, pointe and
demi-pointe put enormous stresses and strains on joints and soft tis-
sues. Problems such as bunions and arthritis at the base of the great
toe (first metatarsophalangeal joint) are common. The lesser toes are
subject to the development of deformities such as hammer toes, mal-
let toes and dislocations. Small nerves can become swollen causing
conditions such as Morton’s Neuromata. The ankle is a frequent area
of concern with development of ligamentous sprains. Tendons around
the ankle are frequently swollen and painful and bony spurs may
occur at both the front and back of the ankle as well as on the heel.
Male dancers in particular place massive strains on their Achilles ten-
dons and are subject to conditions associated with swelling, pain and,
even occasionally, rupture. The frequent problem of stress fracturing
has already been highlighted, particularly in the midfoot as well as the
ankle and shins.
It is clear that major companies such as The English National Ballet
need to put into place measures of preventative care. The ENB has put
into place a comprehensive programme of screening and prophylac-
tic measures such as six-monthly formal fitness reviews, four-monthly
Pilates reviews, regular technical correction sessions, and bi-annual
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Bill Ribbans
DEXA scans (‘dual energy x-ray absorptiometry’) for bone densitome-
try and the detection of osteoporosis. Initial medical, orthopaedic and
podiatry assessments are followed by regular reviews throughout the
dancer’s time with the company.
Galen (130–200 AD), sometimes known as the ‘Father of Anatomy’,
said over two thousand years ago that ‘the best exercises are those
that train the body and delight the mind’ (reference unknown).
Dance fits both of these criteria. Ballet gives pleasure to millions
of people every year around the world. However, the stresses and
strains experienced by student dancers and professional performers
are enormous. To maintain a healthy body and mind that allows a
dancer to enjoy a long and, hopefully, comfortable career, and enjoy-
ment of their post-performance life, requires expert input from many
medically-related disciplines.
Abraham, S. (1996), ‘Characteristics of eating disorders among young ballet
dancers’, Psychopatholog, 29:4, pp. 223–229.
Brinson, P. and Dick, F. (1996), Fit to Dance? Calouste Gulbenkian Foundation,
Byron, Lord (George Gordon). (1812), Childe Harold’s Pilgrimage.
Coward, N. (1928), Dance little lady. Song Lyrics. From Album of Eight Songs.
Publisher Chappell & Co.
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(1990), ‘Nutrition and the incidence of stress fractures in ballet dancers’,
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(Australia Dance Council), Jamison, A.C.T. Australian Association for Dance
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Best foot forward: An orthopaedic odyssey through the world of dance
Rivaldi, C., Vannacci, A., Zucchi, T., Manucci, E., Cabras, P. L., Boldrini, M.,
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‘Bone mineral density in young female Chinese dancers’, International
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Ribbans, B. (2010), ‘Best foot forward: An orthopaedic odyssey through
the world of dance’, Journal of Applied Arts and Health 1: 1, pp. 53–61,
doi: 10.1386/jaah.1.1.53/1
Professor Bill Ribbans Ph.D., FRCSOrth, FFSEM (UK) is a Consultant
Orthopaedic Surgeon at Northampton General Hospital and Visiting
Professor at The University of Northampton. He is Honorary Orthopaedic
Surgeon to the English National Ballet and involved with many profes-
sional sports organisations, particularly involving rugby union, association
football, cricket, athletics and badminton.
Contact: Pavilion Clinic, 500 Pavilion Drive, Northampton, NN4 7YJ, United
E-mail: billribbs@uk-doctors.co.uk
JAAH_1.1_art_Ribbans_053-062.indd 61 8/21/09 12:33:21 PM
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Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.63/1
JAAH 1 (1) pp. 63–80 Intellect Limited 2010
University of Southampton
Inspiring transformations
through participation in
drama for individuals
with neuropalliative
Purpose: The aim of the service evaluation was to use an occupational sci-
ence focus to describe the effects of drama with variable levels of sensory
content and a potentially active, rather than a passive, participant role on
engagement by individuals with neuropalliative conditions.
Method: The service evaluation involved time sampled observations of
engagement during a single session for each of the fourteen participants
during a passive spectator role in the audience at a live drama, a potentially
active interactive performance and a control condition.
Results: The observations of engagement showed a significant difference
between the engagement scores for the control condition and the drama.
Conclusions: Whilst drama appears to be satisfying their engagement it
depends on the role offered to them (e.g. potentially active versus passive),
JAAH_1.1_art_Fenech_063-080.indd 63 8/21/09 1:57:10 PM
Anne Fenech
on the level of sensory stimulation offered and on the supporter to partici-
pant ratio available to facilitate their engagement.
Neuropalliative conditions (Turner-Stokes et al. 2007) are usually caused
by brain damage, and include rare conditions such as Locked
in Syndrome (Krasnianski et al. 2003) or Huntington’s disease
(Huntington 1872). They also include common conditions in their
advanced stages such as Parkinson’s disease (Hudson et al. 2006) or
Multiple Sclerosis (Multiple Sclerosis Society 2007). Their complex-
ity is derived from a combination of physical, cognitive, perceptual,
communication, sensory gating and awareness limitations; the con-
sequence of these limitations can be profound levels of disability
(Fenech 2009). This can result in Barthel scores (Shah et al. 1989)
in the region of 0 out of 100, (e.g. individuals in a minimally con-
scious state), to 30 out of 100 (e.g. individuals with late stage Multiple
Sclerosis). Such profound disability complicates the achievement of a
good quality of life because as the complexity of disability increases
the options for satisfying occupational engagement decrease, which
can lead to a passive/spectator role (Stanley & Dolby 1999; Farrow &
Reid 2004), and because the disability is outside the individual’s
control, this can lead to a state of occupational deprivation (Wilcock
1998; Whiteford 2004).
Sensory gating deficits such as those found in Huntington’s dis-
ease (Uc et al. 2003) and Head Injury (Kumar et al. 2005; Arciniegas
et al. 1999) are where the Reticular Activating System is damaged
and unable to filter out irrelevant and excessive information. Sensory
deprivation on the other hand results from under-stimulation,
and sensory overload from over-stimulation: both also impact on
participation. Therefore several similar concepts have been devel-
oped such as the sensory diet (a selection of individualised sensory
stimuli offered across a range of sensory receptor organs), sensory
regulation (the limitation of the level of sensory stimuli encoun-
tered at any point in time) and sensory integration (combinations
of sensory stimulation tailored to increasing physical and cognitive
The terms ‘leisure occupation’ and ‘occupation’ are used through-
out this paper. Human occupations have been defined as ‘any activity
in which a person is engaged’ (Webster 2003), and as ‘an activity in
which one engages’ (Webster 2003) and this is a study of engage-
ment. The difference therefore between an activity and an occupation
is the degree of engagement by the participant. Human occupations
include everything that people do to occupy themselves, including
looking after themselves (self-care), enjoying life (leisure), and con-
tributing to the social and economic fabric of their communities
(productivity) (CAOT 2008). However for individuals with neuropalli-
ative conditions, opportunities for engaging in human occupations
JAAH_1.1_art_Fenech_063-080.indd 64 8/21/09 1:57:10 PM
Inspiring transformations through participation in drama …
are limited by their performance capacity, motivation, interest, or
sense of wellbeing (Nilsson 2006). Occupational science (the basic
science which underpins occupational therapy) postulates that occu-
pational deprivation (Wilcock 1998) and its negative effects on health,
are the opposite of (and therefore can be reversed by) engagement
in occupations (Whiteford 2004) such as leisure. Occupational dep-
rivation has been defined as a state of long-lasting exclusion from
meaningful and necessary occupations due to factors that may be
outside the control of the individual (Whiteford 2000). The negative
effects which can result from it may include spending time in longer
periods of sleep, having a lower mood (potentially leading to suicide),
a lack of social acceptance and social status. Atrophied occupational
capacities lead to a diminished sense of self-efficacy and thus a loss
of self-identity and a completely altered pattern of activity and time
use. Other effects of occupational deprivation include social isolation,
enforced dependence/lack of control and limited hand or tool use.
The profound disability experienced by the participants render them
unable to ‘participate’ and therefore occupationally deprived, because
their permanent or progressive disability is beyond their control; and
because they rely entirely on assistive technology and supported
facilitation. Their self-care is supported by others and they are unable
to find paid employment: therefore leisure appears to provide a major,
and perhaps their only opportunity, for occupational engagement.
However, at present, occupational science only acknowledges pro-
found disability as a ‘special case’ (Whiteford 2004) of occupational
deprivation. This article reports one of a series of studies which com-
pare a control condition (frequently experienced by participants when
not facilitated) with casual leisure activities with an increasing level of
sensory content.
Engagement is the involvement in an occupation which can pro-
vide a sense of self identity and so has strong links to the meaning-
ful nature of occupations. It is an observable phenomenon (Suto
1998) that is affected by performance capacity, motivation, interest,
and wellbeing (Nilsson 2006). Kishida & Kemp’s (2006) measure of
engagement was designed for use with individuals with profound and
multiple developmental disabilities, but is applicable to individuals
beyond this clinical group. Observations of engagement could indi-
cate whether an occupation has been suitably adapted in order for an
individual to participate rather than inducing sensory overload or sen-
sory under-stimulation, which reduces the likelihood of engagement
Leisure may satisfy many needs (Beard & Ragheb 1980), and
appears to be a major factor in re-establishing pre-disability quality
of life; if not experienced, this places individuals at risk of disen-
gagement (Neulinger 1990). Therefore this service evaluation will
focus on leisure being an opportunity to experience participa-
tion in meaningful occupations to enhance the quality of life of
individuals with profound disabilities. Leisure is a self-determined
JAAH_1.1_art_Fenech_063-080.indd 65 8/21/09 1:57:10 PM
Anne Fenech
and enjoyable use of an individual’s free time, rather than being a
default situation enforced through having nothing else to do (Suto
1998; Lobo 1999). What is important about a leisure occupation
is not what it is but why it is carried out. Leisure occupations are
generally socially ‘time-out’ or achievements orientated (Passmore
2003) and contribute to self-identity (Pound et al. 1998). However,
individuals with disabilities are reported to spend considerable
time in passive activities such as TV viewing and listening to music,
radio, audio books etc. (Nelson & Gordon-Larsen 2006). This may
be because others perceive this as what is suitable for them or what
is available to them (Laliberte-Rudman et al. 2006). Casual leisure
occupations tend to be immediately, intrinsically rewarding and
relatively short-lived pleasurable experiences requiring little or no
skill to enjoy them (Stebbins 1997).
Leisure based relationships can lead to the development of social/
cultural roles and values (Molineux & Whiteford 1999; Franke &
Engle 2001; Wilcock 1998) contributing to self esteem, social approval
and self-identity (Christiansen 1999; Passmore 1998). Perceptions of
health and wellbeing are either self-orientated or orientated around
others (Wilhite et al. 2004). Occupations that provide the individual
with a sense of achievement may do so through personal challenge
(Passmore & French 2003; Lobo 1999; Farnworth 1998) or widen-
ing experience (Drummond & Walker 1996). However Lockwood &
Lockwood (1991) proposed that individuals with high support needs,
whose awareness of their limitations and desire to prevent further
dependence on others, may lead a high proportion to engage in spec-
tator occupations rather than being active physical participants (with
facilitation and support).
Drama offers opportunities for a passive (spectator) role or for
a potentially active (participant) role to be taken. To date the only
article published about interactive drama with individuals with neu-
ropalliative conditions was written by the author (Fenech 2009).
However, the use of drama has been reported in healthcare educa-
tion (Fursland 2001 & 2004), and as a therapeutic medium in speci-
alities such as developmental disability (Price & Barron 1999; Green
& Reinhard 1995; Ineland 2005), mental health and homelessness
(Rowe 2004; Yonge 2005). Drama has been found to make a positive
contribution to adjustment to disability (Mckenna & Haste 1999),
providing individuals with opportunities for escapism, creativity,
spontaneity and enjoyment (Mckenna & Haste 1999), improving
assertiveness and motivation (Price & Barron 1999).
This service evaluation seeks to discover whether participants
are more likely to engage in dramatic leisure occupations with a
high sensory level content and a potentially active rather than a
passive participant role. The reason for selecting the sensory focus
is to counter the profound disability resulting from neuropalliative
conditions, i.e. it is accessible to individuals with physical/cognitive
JAAH_1.1_art_Fenech_063-080.indd 66 8/21/09 1:57:10 PM
Inspiring transformations through participation in drama …
This study was conducted as a service evaluation, i.e. it was
designed to observe and describe current clinical practice without
allocating participants to intervention groups and therefore did not
require Research Ethics Committee approval (NHS Research and
Development Forum 2006) however, permission for the service
evaluation to take place was granted following the local research
governance procedure. The majority of the participants had cognitive
dysfunction and therefore it was important to consider the ethical
implications of including them in the service evaluation. No indi-
vidual was excluded from, or included in, live performances because
of the service evaluation. The participants’ written consent to partici-
pate in the service evaluation was sought.
Using a study design, which allocates individuals to a specific
experimental group by any means other than their own choice, would
negate a key principle which turns an occupation from just something
to be carried out into a leisure occupation, i.e. freedom of choice.
Therefore there are ethical issues about comparison trials in case an
individual is allocated to an occupation which is not of their own
choosing. As such a series of single case studies may be more appro-
priate with comparison to a control condition through time sampled
data being gathered.
Other satisfaction studies published have used levels of engage-
ment as reported by third parties (Delle Fave & Massimini 1988
& 1991) or standardised self-reporting tools such as the Leisure
Satisfaction Scale (Di Bona 2000). However, as a result of the dif-
ficulties in expressing preferences and feelings caused by cogni-
tive dysfunction and communication difficulties, self-reporting has
limited data collection to participants who can express their own
opinions consistently.
Observation of engagement (using a single marginal partici-
pant observer and a structured observation format) is an appropriate
method of observation given the facility’s philosophy of non-intrusion
and protection of vulnerable adults (Protection of Vulnerable Adults
Policy, POVA). This limits the number and type of observers who can
be used and precludes the use of video recording (where the indi-
vidual could be identified). Kishida & Kemp’s (2006) simple measure
of observed engagement is designed for use in practice and with indi-
viduals who cannot report their own experience and so is ideal for use
with this population.
Single-case methodologies can establish the effect of an interven-
tion on a single group by focusing on a particular behaviour such as
engagement with the intervention (in this case leisure occupations)
being altered (Robson 2002), i.e. present or absent. The number of
observations for each single group study is guided by the concept that
JAAH_1.1_art_Fenech_063-080.indd 67 8/21/09 1:57:10 PM
Anne Fenech
casual leisure occupations can realistically be assessed in terms of lei-
sure satisfaction after each isolated experience (Stebbins 1997). The
uniquely profound nature of the participants’ disability and the small
sample size mean that the findings are likely to be specific to neu-
ropalliative conditions.
Are participants more likely to engage in dramatic leisure occupations
with a high sensory level content and a potentially active rather than a
passive participant role?
The service evaluation involved:
Time sampled observations of engagement during a single •
Comparison of engagement between a control condition, a live •
spectator performance and an interactive drama performance;
A momentary time sampling (every five minutes) methodology •
(Powell et al. 1975) was selected. The observations were of sin-
gle cases/occupations, i.e. a control condition, a live spectator
performance and an interactive drama performance rather than
allocating participants to one condition or another for compari-
son. No individual comparison of a participant across all the
occupations was drawn, only grouped comparisons were made.
The observer recorded the participants’ engagement throughout
the session using instantaneous recording, and did not take part
in the session.
The same fourteen participants were observed during the control con-
dition, the live drama and the interactive drama performance.
The service evaluation participants were residents of a long-term
care facility (specialising in the care of individuals with neuropallia-
tive conditions) who have been reported by the Residence Manager
as able to discuss their opinions consistently. Participants who did not
consent or have the capacity to consent to be part of this evaluation,
who are unwell or are under the age of eighteen were excluded from
the service evaluation.
Data Collection tool used was the Kishida & Kemp (2006) measure
of observed engagement. Kishida & Kemp (2006) reported mean
inter-observer agreement of 87.95% (range 71.79 – 100%) when
validating their measure. Following a similar time sampling meth-
odology (one minute’s observation every five minutes) to Fenech
JAAH_1.1_art_Fenech_063-080.indd 68 8/21/09 1:57:10 PM
Inspiring transformations through participation in drama …
(2009), the engagement behaviour of each participant was observed
during a control condition, a live spectator performance and an
interactive drama performance, over a limited time period in order
to ensure that the observer had a consistent definition in mind of
each level of engagement. The observation format used included a
brief description of the signs of sensory overload and usual behav-
iour for each participant as a reflective guide during the observa-
tions. The small number of participants included meant that any
statistical analysis of consistency would be limited because of the
weak statistical power.
Kishida & Kemp (2006) use five engagement codes that the
observer selects from; these are based on the following definitions of
‘Active engagement’ – participates actively by interacting with the •
environment appropriately/manipulating materials or vocalising,
excluding repetitive and/or inappropriate behaviours.
‘Passive engagement’ – interacts with the environment without •
manipulation or vocalisation.
‘Undifferentiated engagement’ – interacts with the environment •
automatically, i.e. in a repetitive manner.
‘Passive non-engagement’ – does not interact with the environ- •
ment/does what is expected during the activity.
‘Active non-engagement’ – interacts with the environment in an •
inappropriate manner by manipulation/movement and/or vocali-
sation (see Appendix 1).
The consistency of results across the sessions observed is an impor-
tant factor which would enhance the reliability of the results. The
small sample size and the use of a single observer without video
recording backup will compromise their reliability whilst complying
with the facility’s POVA policy and reducing the intrusion into par-
ticipants’ use of free time. A solution was to ensure that the observer
was trained to criterion and had used the measure of observed
engagement with other leisure opportunities (Fenech 2009) prior
to commencing the data collection. In order to ensure the reliabil-
ity of the time interval, the observer using a preset vibrating alarm
checked against the British Telecom speaking clock (1–2–3) prior to
each observation.
Setting the scene for the observations of engagement
The observations were conducted by a single observer who was
seated (facing the group) in order to be able to see the participants,
whilst trying to be as unobtrusive as possible. Each observation
JAAH_1.1_art_Fenech_063-080.indd 69 8/21/09 1:57:10 PM
Anne Fenech
lasted for 45 minutes, which suited the average length of concentra-
tion and sitting tolerance of the participants. Apart from the control
condition, the participants were accompanied by staff members from
their residence in case they required physical assistance, modelling,
gesturing or verbal direction, and to facilitate their engagement and
support the actors.
Here the participants were awaiting the arrival of a live performer in
a familiar room with dimmed lighting and no TV or radio on in the
background. The potential sensory stimulation included seeing and
hearing only and no performance components (motor or processing)
were required.
Watching a live performance (whether musical, drama or dance) is
a regular part of the lives of this group of participants. The perform-
ances observed were both offered by the same theatre company, who
specialise in bringing drama into health and care settings. The per-
formances occurred in a large public room, which was laid out with
a large space for the actors in the centre of the room, for them to
perform in the round.
The performance offered participants opportunities to experience
hearing, visual and, for some, touch/temperature stimulation in a
passive spectator role. On the occasion that the observations were
conducted the author was seated (facing the group) in order to be
able to see them all, and in order not to detract from the perform-
ance. The occupational performance components for each participant
included: tolerating/maintaining sitting position, watching and lis-
tening to the performance, and understanding the performance in
order to follow the plot. The actors were not experienced in gauging
the responses of the participants with neuropalliative conditions and
so, at times, were communicating inappropriately or were answered
but did not realise it.
Interactive drama is a particular form of drama in which audiences
participate as ‘Spect-Actors’ (Green & Reinhard 1995), with their
interventions being used as part of the performance. The charac-
ters treat everybody the same – engaging participants, supporter
and family members in their world, and listening and responding
in character to whatever they have to say in return. This offers
audiences the opportunity for active participation. The characters
regard everyone’s stimulation as valuable and so accept every-
thing they’re told and use it to develop their story, activities and
JAAH_1.1_art_Fenech_063-080.indd 70 8/21/09 1:57:10 PM
Inspiring transformations through participation in drama …
For some participants the occupation included elements of pro-
prioceptive stimulation, and taste and vestibular stimulation. While
all participants experienced degrees of hearing, seeing and touch/
temperature sensation. The performance components of the occu-
pation included accepting, holding or using props, responding to
the character visitors appropriately, and self or attendant-propelled
movement about the stage area. The participants’ role when partici-
pating in the interactive drama was to stimulate the characters and
influence the performance.
In order to test the statistical significance of the differences in
engagement, a Friedman test and a series of Wilcoxon signed-rank
tests were conducted. Both tests are non-parametric and suitable for
repeated-measures (related samples) ordinal data. Statistical sig-
nificance does not necessarily mean that the finding is clinically or
practically significant. As well as using stars to denote the degree
of statistical significance, Table 2 has presented a higher and lower
value between which the reader could be confident of the result in
relation to the wider population.
The results from the Friedman test confirmed that there was a
significant difference between the engagement scores across the two
conditions (x
=74.8; df=7; p<0.001). The Wilcoxon test results are
presented in Table 2 (figures given are for Z and significance level
is indicated by coloured stars). The live performance has a signifi-
cantly higher engagement level than the control condition (with a
confidence interval of p<0.01). The interactive drama performance
has a significantly higher engagement level than the control condi-
tion (with a confidence interval of p<0.001). The difference between
the live performance and the interactive drama performance is not
The mean levels of patient engagement in the live performance,
interactive drama performance and the control condition were calcu-
lated, based upon the median scores of each participant from each
45-minute session observed. The live performance and interactive
drama performance had significantly higher engagement levels than
the control condition as can be seen in Table 1.
T-tests were carried out on the same data, but means were cal-
culated rather than medians. T-tests help to highlight whether the
means of engagement across the different occupations are statistically
different from each other. This was carried out because the data were
Control 2
Live Performance 4
Interactive Drama 4.5
Table 1: Mean engagement for each occupation at each time sample.
JAAH_1.1_art_Fenech_063-080.indd 71 8/21/09 5:01:06 PM
Anne Fenech
considered to be part of a continuum but not necessarily equidistant.
The difference in engagement levels between live and interactive drama
performance and the control condition was again found to be signifi-
cant. However, due to the more conservative assumptions of the non-
parametric tests, they were felt to be most appropriate to use. The
results are significant at the 0.01 per cent level, therefore type 1 errors
are unlikely.
Drama appears to offer individuals with neuropalliative conditions
an engaging way to use their free time. The anticipated reduction
in engagement at the higher levels of sensory stimulation (given the
effects of sensory overload, and sensory gating deficits) did not occur.
In fact engagement with the three conditions appeared to increase as
the sensory stimulation levels increase. Additionally there is a slight
difference between the engagement levels in potentially active and
passive occupations. The potentially active occupations were also
the ones which had the higher supporter to participant ratios and
therefore the higher potential for supporters to facilitate participant’s
engagement. Participant engagement may therefore be influenced by
a three-part combination of supported facilitation, the sensory stimu-
lation level of the occupation, and the potential for active as opposed
to passive participation.
The supporters were observed to use techniques such as physi-
cal assistance, modelling, gesturing or verbal direction in order to
keep the participants attention on the performance and enable their
participation and engagement. This 1:1 facilitation may have added
additional sensory stimulation and therefore had the potential to
overload the participants (and so may have added further to the
engagement if sensory overload had not been a factor). Supported
facilitation appeared to have the desired effect of maintaining and
encouraging engagement given that the higher-supporter participant
Live performane Z 3.25**
Lower bound sig.
Upper bound sig.
Interactive drama Z 3.44*** 0.95
Lower bound sig.
0.000 0.435
Upper bound sig.
0.001 0.460
Monte Carlo 99% Confidence Intervals
*<0.05; **p<0.01; ***p<.001 (more stars = more
confidence in significance of difference)
Table 2: Signed-rank differences between occupations.
JAAH_1.1_art_Fenech_063-080.indd 72 8/21/09 5:01:06 PM
Inspiring transformations through participation in drama …
ratio was reflected by higher engagement scores; whilst the control
condition (where there was no supported facilitation occurring) had
significantly lower engagement scores.
An important difference between the live performance and the
interactive drama performance appears to be the potential to take
an active role in the interactive drama performance. The control
condition and the live performance (spectator role) were totally pas-
sive roles, whereas the ‘Spect-Actor’ role of the interactive drama
performance gave the participants the choice to take a passive or
an active role, with supported facilitation. The opportunity to take
part was reported anecdotally as being highly valued by the partici-
pants. However the results show a slight but not significantly differ-
ent level of engagement between the spectator and the interactive
drama role.
The apparent disparity between the findings of Lockwood &
Lockwood (1991) and Nelson & Gordon-Larsen (2006), and others,
about preferring to undertake a passive role, rather than an active
one with support appears to have been countered in this profoundly
disabled group by adding in the rare opportunity to experience signifi-
cant personal challenge (Passmore & French 2003), novel experiences
(Drummond & Walker 1996) and therefore a sense of achievement
(Fenech 2009).
The major difference in engagement between these two similarly
engaging occupations and the control condition includes the 0:1 sup-
porter to participant ratio when compared to the 00.5:1 & 00.5:1 supporter
to participant ratios (respectively) of the live performance and interactive
drama performance as shown in Table 3. The supporter plays a vital role
in facilitating the participant’s engagement above and beyond the par-
ticipant’s daily use of assistive technology. It appears that a supporter to
Control Group
at a live
Supporter to
resident ratio
0:1 0.5:1 0.66:1
Supporter to
resident ratio
low high high
Physically active/
passive passive potentially active
Maximum senses 2 3 4
Table 3: Comparison of minimum and maximum sensory involvement,
supporter to resident ratios and the passive or potentially active status
of each occupation.
JAAH_1.1_art_Fenech_063-080.indd 73 8/21/09 5:01:06 PM
Anne Fenech
participant ratio of 0.5:1 is all part of the mix of enabling engagement
with such profoundly disabled individuals.
Additionally, the greater sensory stimulation level of the interactive
drama performance, as opposed to the passive audience role of the live
performance, may have contributed to the higher engagement level of the
former. The three conditions varied in the sensory stimulation level pro-
vided: the control condition stimulating a maximum of two senses; the
live performance stimulating a maximum of three senses; and the interac-
tive drama performance stimulating a maximum of four senses. This may
imply that there is an optimal sensory level which enhances engagement,
before the increasing sensory content of the occupations and the sup-
porter facilitation overloads the individual.
The limitations of the leisure satisfaction evaluation related to the
characteristics of the sample, to the data collection, to the data gather-
ing techniques, to the data analysis techniques and to the reliability of
the results. Many of these limitations are compromises which have to
be made to protect these vulnerable adults.
The participants represented a particular sub-group of individu-
als with neurological disabilities, i.e. those with a very high depend-
ency level. The sample size was limited by the participants’ capacity
to express consent and the small population of individuals with such
profound levels of disability. The sample size limitation was inevitable
given the small size of the sub-group of individuals with neurological
disabilities studied; it could be enlarged by conducting a multi-centre
trial, however this would bring with it the issues associated with data
collection by a group of observers. It is recognised that in all qualita-
tive evaluations the perceptions of the observer will affect the inter-
pretation of the data to some extent. The small number of participants
in the observation study was partly countered by the large amount of
data collected using a time sampling methodology.
The use of a single-case methodology study was felt to be appro-
priate given that the conditions being observed were casual leisure
occupations. Ideally the observations should have been conducted
by more than one observer and then compared for inter-rater objec-
tivity; however this would have been inconsistent with the facilities
Protection of Vulnerable Adults Policy (POVA) and more intrusive
to participants, and so would have heightened the likelihood of
altering their behaviour in response to being observed. It may also
have lead to issues around the translation of the behaviour observed
into the measure of observed engagement used, as it relied on many
years of experience with this clinical group as well as the specific data
about sensory overloaded behaviour gathered from the Residence
Ideally, a measure of engagement designed specifically for use
with participants with neuropalliative conditions, which included an
JAAH_1.1_art_Fenech_063-080.indd 74 8/21/09 1:57:11 PM
Inspiring transformations through participation in drama …
element of sensory integration/overload measurement, would have
been used. However to date there is no such outcome measure avail-
able. The presence of the observer may have drawn attention away
from the occupations since the observer neither attempted to hide or to
actively join in the sessions preferring to take the role of an observer-
as-participant (Robson 2002). The marginal participant observer role
involved a conscious effort to distribute her attention widely and
evenly by literally observing and noting each participant in turn every
five minutes throughout the occupations (Robson 2002). The service
evaluation involved a subjective interpretation by the observer about
whether the participant was engaged or not. Videoing of all partici-
pants might have given an opportunity for more detailed observation
but was classed by the facility’s policy (on the use of technology to
capture data in research) as obtrusive and possibly intrusive. The use
of video would have been helpful in determining whether the engage-
ment was with the occupation rather than other factors, e.g., a vehicle
arriving outside a window. However the use of video for research pur-
poses may be regarded as an intrusion into participants’ privacy and
has not been welcomed during other projects at the facility as a result.
The use of a single marginal observer offered no possibility of inter-
rater reliability comparison.
Kishida & Kemp (2006) report participants who demonstrated diffi-
cult to code behaviour for a large proportion of the study forcing them
to take into account preceding and successive behaviour in order to
select an engagement code. McWilliam & Ware (1994) acknowledged
this as an innate difficulty when measuring engagement in individu-
als with disabilities which impact upon their observable behaviour.
During the current leisure satisfaction evaluation there were no par-
ticipants’ responses that were difficult to code.
Participation in drama appears to offer individuals with neuropalliative
conditions an engaging leisure experience. However the occupations
need to be adjusted/adapted in order for individuals to research their
optimal level of engagement. Sensory barriers to participation have
long been acknowledged in the domain of occupational therapy.
However the effect of the long term preclusion from occupational
engagement experienced by individuals with profound disabilities
does not appear to have been fully acknowledged. It is therefore
likely that the personalisation and enabling of leisure occupations,
such as drama participation, may not be taken as seriously as these
individuals deserve.
The results of this service evaluation show that the factors to take
into consideration when doing this include the individuals’ sensory
processing capacity, the level and type of support offered by others in
order to facilitate their engagement, and whether the individual feels
that they have a choice to watch or participate actively.
JAAH_1.1_art_Fenech_063-080.indd 75 8/21/09 1:57:11 PM
Anne Fenech
Appendix 1: Observation Template.
Active non-
– interacts with the environment in an inappropriate manner by
manipulation/movement and/or vocalisation.
























Passive non-
– does not interact with the environment and does not do what is expected
during the activity.
ated engage-
3 – interacts with the environment automatically/repetitively.
4 – interacts with the environment without manipulation or vocalisation.
– participation with the environment appropriately/manipulating materials
or vocalising.
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JAAH_1.1_art_Fenech_063-080.indd 79 8/21/09 1:57:11 PM
Anne Fenech
Anne Fenech is currently a Lecturer at the University of Southampton School
of Health Sciences. Her background is in management (MBA), gerontology
(MSc) and occupational therapy (DipCOT).
Her career history has included several Head Occupational therapist posts
before moving into general/policy management and more recently a research
fellowship. She is currently the English Board Member for the South East
Region of the College of Occupational Therapists and also a Registration
Assessor for the Health Professions Council.
Contact: 41 New Elms Cottages, Firle, Lewes, East Sussex, BN8 6NA.
E-mail: annemfenech@aol.com
JAAH_1.1_art_Fenech_063-080.indd 80 8/21/09 1:57:11 PM
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.81/1
JAAH 1 (1) pp. 81–92 Intellect Limited 2010
The University of Northampton
Emotional responses to
music listening: A review
of some previous
research and an original,
five-phase study
The paper firstly reviews four studies on the power of music to generate emo-
tional responses in the listener. Using scientific methodology, the research
comprised experiments with sacred versus secular music, the effect of differ-
ent modes and rhythms in hymn tunes, music and task performance, and
the respective influences of nature and nurture on musical ability. Secondly,
the paper describes the five phases of a research programme to assess the
frequency and nature of peak emotional experiences generated through lis-
tening to music. This study made use of surveys, laboratory experiments
and EEG measurements in its investigation. Whilst the combined outcomes
add to the knowledge and understanding of the role of music, many oppor-
tunities for further work remain.
peak experiences
JAAH_1.1_art_Lowis_081-092.indd 81 8/21/09 2:00:04 PM
Michael J. Lowis
This paper firstly reviews four earlier studies on the nature and effects
of music, before describing the five phases of a research programme
on peak emotional experiences triggered by music, carried out at The
University of Northampton.
Music is universally enjoyed, and it has survived since the dawn of
civilisation when there is little evidence of a good evolutionary reason
for doing so. Musical sound has been described as energy in vibrating
motion, which is produced by beating, blowing, plucking, striking, or
frictionising with a bow (Bernstein 1976). Bernstein adds that, unlike
random ‘noise’, music is structured into time and space, forming the
components of melody, rhythm, tone colour (timbre), and harmony.
Music is found in every known culture and historical period for which
there are records (Trehub et al. 1993). The Guinness Book of Records
(1994) stated that bone flutes have been discovered that date back
some 27,000 years, whilst Hawkes (1997) writing in The Times sug-
gested that more recent finds may be from 43,000 to 67,000 years old.
This was a time when Neanderthals as well as Homo sapiens inhabited
the earth, and when humanoids were still in the hunter-gather stage
of development. However, the origins of music may extend much
further back in time, and Storr (1993) speculated that it might have
predated speech, originating from vocal exchanges between mothers
and babies.
Music is a non-verbal form of communication, associated with emo-
tion and feelings (compared with speech, which communicates facts
and ideas), being processed predominantly in the right cerebral hemi-
sphere (Garland & Kuhn 1995), whilst speech is processed mainly in
the left hemisphere. For this reason, to investigate the effects of music
per se, vocal selections should be avoided as they add the confound-
ing variable of verbal communication to the equation. Unless there are
specific reasons to the contrary, the items used should be sufficiently
complex to require cognitive processing, for example classical compo-
sitions, rather than superficial background music.
(1) Can music impart spirituality to the listener?
According to Combarieu (cited in Alvin 1966), in all known civilisa-
tions music has been held to have a divine origin – perhaps the only
particle of the divine essence that humans have been able to capture.
This notion would concur with the sentiments of Nieman (cited in
Priestly 1975) that music is a bridge for us to the inner (spiritual) world.
Many great composers, especially of the pre-Baroque and Baroque
periods (up to about 1765) were primarily church musicians, and their
compositions probably were, at least in part, spiritually inspired and
intended to enhance the spirituality of both performers and listen-
ers. Examples are Palestrina (ca. 1525–1594), Bach (1685–1750), and
Handel (1685–1759).
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Emotional responses to music listening
To try and explore this, a controlled experiment on a compari-
son of the effects of sacred and secular music on elderly people was
carried out by Lowis and Hughes (1997). The participants com-
prised a convenience sample of 22 women and eight men, aged 62
to 90 (mean 76.7 years), Caucasian, and living in the community.
Four 30-minute audiotapes were prepared, two being designated
‘sacred’, for example: Adorate Deo (a Gregorian chant) and Variegated
Maria (Dukov). Two were control or ‘secular’ selections, superficially
similar to the above, but believed not to be spiritually inspired, for
example ‘Concerto for two trumpets, RV 537’ (Vivaldi) and Abschied
(Schubert). A pre-test seven-item INSPIRIT scale (Kass et al. 1991)
was administered as a measure of spirituality (a way of being and
experiencing that comes through awareness of a transcendent
dimension – Elkins et al. 1988). Participants were randomly allocated
to ‘sacred’ or ‘secular’ groups, and listened to one of the relevant
tapes under controlled conditions, before completing a short ques-
tionnaire on their reactions to the music. At subsequent weekly
intervals the procedure was repeated, with the two tapes of the same
type of music being alternated. Finally, in the fifth week, the spir-
ituality measure was repeated. The scores from the four repetitions
were combined for statistical analysis.
Although no significant difference between the effects of sacred
and secular music were found, when results for both were combined
a positive correlation was revealed between the INSPIRIT scores and
the ratings of the pieces for reverence and spirituality (p = <.01). This
implies that the more spiritually inclined a person is, the more he
or she will perceive the music to have religious or spiritual qualities.
Significant and positive correlations were also found between enjoy-
ment of the selections and familiarity with them (p = <.001), and with
familiarity and degree of participants’ musical training (p = <.01). This
hints at differences between musicians and non-musicians in cogni-
tive processing during music listening.
(2) Emotional responses to hymns
Dowling and Harwood cited research showing that major musical
modes convey feelings of happiness, merriness, sprightliness and
playfulness, whereas minor modes were more likely to suggest sadness,
dreaminess, tenderness and yearning. They defined rhythm as a ‘tem-
porally extended pattern of durational and accentual relationships’
(1986: 185). Bruner (1990) referred to studies showing that music
written in triple form (3/4 time) tends to be perceived as smooth-
flowing and relaxed, whereas duple (2/4) and quadruple (4/4) forms
are regarded as controlled or firm, and are said to be more sacred and
serious. Batson et al. (1993) stated that music facilitates religious expe-
rience, which is why it has been included in religious ceremonies for
as long as we have records.
A study by Hughes & Lowis (2002) to investigate the emotional
responses to hymns in different modalities was carried out during four
JAAH_1.1_art_Lowis_081-092.indd 83 8/21/09 2:00:05 PM
Michael J. Lowis
services in Anglican churches. Hymns were selected on the basis of
their combined mode and rhythm. Examples: ‘O for a thousand songs
to sing’ (quadruple/major), and ‘Let all mortal flesh’ (quadruple/
minor). Following each hymn, members of the congregation rated it
for emotional/spiritual impact on an original five-item questionnaire,
examples: ‘The music was very enjoyable’, and ‘I felt that the music
brought me closer to God’, using a five-point Likert response scale.
The scores from the five questions were totalled to give an estimate
of ‘emotional impact’ per hymn, and results from all the services were
The findings revealed that hymns with triple rhythms had a signifi-
cantly higher impact than did quadruple (p = .034), and there was a
trend for minor mode to rate higher than major. There were no signif-
icant gender differences, but the findings could have been confounded
by other aspects of the services, and the fact that the words of the
hymns were involved as well as the tune. Triple time, unlike quad-
ruple, is neither rooted in nature, nor our neurological and biological
makeup (for example breathing and heart beat): nor is it rooted in our
walking (Epstein cited in Robertson 1996). Thus triple rhythms might
free the listener from formality and allow greater freedom to identify
with the music. Hymns in quadruple time and major mode may be
cheerful and uplifting, but might not facilitate contemplation and feel-
ing closer to God (by those prone to such experiences) as readily as do
the more gentle modes and rhythms.
(3) Music mode and task performance
In a seminal study that has stimulated much related research,
Rauscher et al. (1995) reported a short-term enhancement in spa-
tial reasoning following listening to Mozart: a phenomenon later
dubbed the ‘Mozart effect’. One such follow-up study was under-
taken by Sutton & Lowis (2008) to investigate the effect of musi-
cal mode on task performance. A participant pool of 24 men and
24 women were exposed to either a piece of music in F-major by
Handel, or the same item digitally converted to the minor mode,
whilst they completed written speed tests of both verbal and spatial
reasoning. Following rating of the music on an eleven-point happy-
sad continuum for emotional impact, and a short break, the partici-
pants repeated the exercise with parallel tests whilst being exposed
to the alternative musical version. Results showed that the music
in the major mode was rated more emotionally positive (all par-
ticipants combined) than was the minor (p = <.0005). Performance
by females on the verbal task only was significantly enhanced with
the major mode music compared with the minor (p = .0175); there
were no such significant findings for males. With music in the major
mode there were, however, trends close to significance for females
to score the highest on verbal tasks, and males on spatial tasks,
which is in keeping with previous research on gender differences.
JAAH_1.1_art_Lowis_081-092.indd 84 8/21/09 2:00:05 PM
Emotional responses to music listening
The contrast between this latest finding that music in the major
mode had the highest emotional impact, and the outcome of the
study by Hughes & Lowis (2002) where the trend was for hymns in
the minor mode to have the highest rating, adds weight to the notion
that there are two types of emotional impact: arousal (latest study)
and introspective/spiritual (hymn study).
(4) Musical ability – nature or nurture?
In 1883, Francis Galton theorised that if talented people only inter-
bred with other talented people, the outcome would be ‘measur-
ably better offspring’ (cited in Black 2003: 13). A polar opposite view
was expressed by John Watson in 1930, when he stated: ‘Give me a
dozen healthy infants […] and I’ll guarantee to take any one at ran-
dom and train him (sic) to be any type of specialist I might select’
(cited in Atkinson et al. 2000: 70). Current opinion would generally
place the influences of nature and nurture on a more-or-less equal
Goldman & Lowis (2007) were interested to find out if musi-
cal ability was influenced more by the environment, for example by
exposure or training, than by genetic inheritance. Thirty-two chil-
dren, aged 14–26 (mean = 19.3 years), and both their parents, were
given Gordon’s (1989) Advanced measures of Musical Audiation
(AMMA) test (GIA Publications, Chicago). This does not require any
prior musical knowledge or training, but needs judgments on pairs of
recorded musical ‘statements’ as to whether they are the same or dif-
ferent, tonally or rhythmically. The children alone also completed an
original sixteen-item measure for environmental influences on their
musical skills (examples: ‘Have you ever played a musical instrument?’
‘Do you attend music concerts?’), scored on a five-point Likert scale.
Multiple regression analysis yielded a significant relationship between
children’s scores on the AMMA and the environmental measure (p =
<.0005), suggesting that the environment plays the largest role in the
development of this aspect of musical ability. When tonal and rhyth-
mic ability were separately analysed, however, there was a significant
and positive correlation between scores from fathers and their chil-
dren on rhythm alone (p = .002).
The finding of an apparent link between the rhythmic ability of
fathers and their children is intriguing: could this be a case of a domi-
nant genetic component passed only through the male line? Rhythm
is not only an essential component of music, but it is also evident in
marching, chanting, drumming and other warlike behaviours such
as hunting and fighting the enemy, that could be linked with tribal
survival. In most cultures, prowess in such pursuits would tradition-
ally be the prerogative of the male: there would be an evolutionary
advantage in such behaviour being preserved. These spatial skills are
predominantly controlled by the right cerebral hemisphere, held to be
more dominant in males than in females (Gorski 1998); this side of
the brain is also involved in music processing.
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Michael J. Lowis
The research at The University of Northampton on ‘peak emotional
experiences’ (PEEs) triggered by music extended through five phases.
Experiences that appear to elevate the recipient to an altered or higher
plane of consciousness, with attendant feelings of profound joy, revela-
tion, insight, or of being at one with the world, have probably occurred
since the dawn of civilisation (Lowis 2003). Psychological interest in
such phenomena was stimulated by Maslow (1962), who regarded the
ability to achieve ‘peaks’ as being one of the characteristics of self-
actualisation (highest level of functioning). In subsequent writings he
cited a variety of triggers, including music, adding that PEEs were quite
common although these are not always recognised for what they are.
Phase one – how common are peak emotional
Method: All members of staff at The University of Northampton were
sent a pack comprising an original Personal Experiences Questionnaire
(PEQ) and the Tellegen Absorption Scale (TAS) (Tellegen & Atkinson
1974). The PEQ described peak experiences in Maslow’s terms, and
asked if the participant had encountered one: (a) whilst performing some
task, and (b) whilst in a passive state. The TAS was originally employed
to measure hypnotic susceptibility, and Tellegen & Atkinson believed
that the tendency to become totally immersed in events resulted in a
heightened, and altered, sense of reality. Roche & McConkey (1990)
noted that absorption was correlated with musical enjoyment.
Results: From the 364 responses received, 74.6% recorded at least
one experience in the active condition, and 76.2% in the passive con-
dition (85.8% combined). ‘Creating’ was the most frequent active trig-
ger, with playing a musical instrument being cited by 11.8% of the
participants. Listening to music was the most frequent passive trig-
ger (55.1%). When triggers for both conditions were combined, music
was found to be the most frequent. There was a significant and posi-
tive correlation between TAS scores and PEE incidence (p = <.001),
suggesting a link between the ability to become totally absorbed and
the tendency to experience ‘peaks’ (Lowis 2003).
Phase two – how important is music?
Method: One hundred and two of the initial participants completed
an original Musical Involvement and Reaction Questionnaire (MIRQ),
with sections on the importance of music in one’s life, and Smeijster’s
(1995) list of 41 statements headed ‘When I listen to music …’.
Examples: ‘I would like to cry’, ‘It reminds me of things from the past’,
‘I experience something beautiful’. Participants tick as many of these
statements as they deem relevant.
Results: The findings showed that musical involvement was sig-
nificantly correlated with any trigger (data from Phase one) under the
JAAH_1.1_art_Lowis_081-092.indd 86 8/21/09 2:00:05 PM
Emotional responses to music listening
passive condition (r = .008), but only with playing a musical instru-
ment under the active condition (r = .013). In general, the most fre-
quently rated statements were ‘it reminds me of things from the past’,
‘I sing, hum, or whistle along’, ‘I experience pleasure’. In comparison,
the high musical involvement participants ranked most frequently:
‘I can feel it in my stomach’ (p = .0005), ‘I try to understand the
composition’ (p = .0006), and ‘It is like I am addicted’ (p = .0007).
This suggests that, those for whom music is important experience
reactions that may be physical, analytical and transpersonal, com-
pared with the cheerful and motor reactions of the less involved lis-
tener (Lowis 2002).
Phase three – can PEEs be triggered by music under
laboratory conditions?
Method: Two 25–30 minute audiotapes were prepared with the help of
a professional musician and musical director. One selection, designated
‘Gentle’, comprised pieces by composers such as Elgar and Mozart; the
second ‘Upbeat’ tape contained a selection of more rousing items by
Wagner, Stravinsky and others. A comfortable room was used contain-
ing high quality audio equipment, and a computer fitted with a hand-
held button device and with a custom-written software programme that
registered elapsed time whenever the button was pressed. Seventy-four
of the original participants (41 women, 33 men) were seen individu-
ally, and instructed to press the button every time they experienced a
PEE during the music. The tapes were randomised, and the participants
returned after a mean interval of 65 days to repeat the procedure with
the alternative selection. A short post-test questionnaire on the feelings
evoked by the music was completed after each session.
Results: A total of 67.6% of the participants pressed the button at
least once during the gentle music, and 62.9% during the upbeat (77.3%
combined). A comparison of the mean button pressings revealed that the
upbeat music resulted in significantly more responses (7.20, range zero
to 42) than did the gentle (3.81, range zero to 30) (p = .01). There were
significant correlations between frequency of button pressing and the feel-
ings evoked by the music, for example joy, love/tenderness, and longing.
There were no significant gender differences (Lowis & Touchin 2002).
Phase four – can musical triggers for PEEs be identified?
Method: There is debate on whether or not music can actually con-
vey emotions to the listener and, if so, to what extent this is due to
‘cook book’ compositional techniques. Gregory & Varney (1996) com-
mented that there is no general agreement on whether relationships
between musical forms and emotional feelings are due to inherent
qualities of the music, or to learning and associations. In this phase
of the study, and using the data obtained from the laboratory studies,
two researchers attempted to identify specific points in the music that
coincided with particular clusters of button pressings. From the
JAAH_1.1_art_Lowis_081-092.indd 87 8/21/09 2:00:05 PM
Michael J. Lowis
computer records, the total number of ‘hits’ for each 20-second period
of the music was noted, and then the musical scores of the pieces were
scrutinised for events that coincided with high incidences of PEEs.
Results: Examples identified for the gentle music included the start
of a climax sequence, the entry of a different solo instrument, the
change to a ‘dark’ minor section, and a first significant fortissimo. For
the upbeat music, there was the start of a rousing piece, the impacts of
gong and bass drum, again a fortissimo and start of a crescendo, and
a powerful ensemble. The highest cluster of peaks for either selection
was the stirring conclusion of Stravinsky’s ‘Firebird’ music. Most of the
examples identified can be regarded as rousing, and Berlyn (1971) sug-
gested that there was a relationship between the complexity of an art
form (including music) and hedonic value, adding that novelty, surprise
and ambiguity can cause arousal.
When clusters of peaks were totalled and plotted for each piece
of music, an interesting pattern was revealed for the gentle selection.
The highest incidence was for the first piece, but this was followed
by a pattern of alternating low and high clusters but with an overall
downward trend (See Figure 1).
A possible explanation for this is that each item had similar num-
bers of potential triggers, but the listener experienced emotional
saturation that could not be sustained, requiring a refractory period
as does a muscle or nerve fibre. Full recovery, however, could not be
attained before the exposure to more emotional triggers occurred.
Further studies, with varied orders of presentation of the music pieces,
are required to confirm this (Lowis & Touchin 2002).
Figure 1: Total number of peaks per gentle music item.
JAAH_1.1_art_Lowis_081-092.indd 88 8/21/09 2:00:05 PM
Emotional responses to music listening
Phase five – can the occurrences of PEEs be detected
in the brain?
Method: Goldstein (1980) stated that the brain area involved in the
perception of what he called ‘thrills’ in response to music must have
bilateral representation, and Shuter-Dyson & Gabriel (1981) opined
that, for successful listening, there is a working together of the two
hemispheres. A pilot study was carried out at Northampton to inves-
tigate the hemispherity of PEEs, utilising a Medilec® Profile multi-
media EEG (Oxford Instruments, UK, Ltd). This apparatus comprises
a 21 channel EEG input coupled to a computer loaded with custom-
designed software to amplify, record and digitally process the cortical
impulses. From these recordings, head maps can be produced show-
ing profiles of activity levels. Eight participants from the original pool
agreed to repeat the process of music listening and button pressing,
but this time when fitted with electrodes following the standard 10/20
placement pattern. Following the tests, the times of the PEEs were
manually inserted into the EEG recordings.
Results: Evidence of arousal could sometimes be gleaned from the
tracings themselves, such as ‘heat sways’ that could indicate galvanic
skin response. Head map displays were generated from ten-second seg-
ments of relaxation, and a composite of as many segments as possible of
ten-second periods leading up to and including the peaks. From these,
the areas of major activity could be compared, and were most useful in
the alpha (8–13 Hz) and beta (13–30 Hz) bands. The outcome was very
mixed: two participants only registered one PEE between them, which
was insufficient for processing. Of the remainder, two (33 per cent)
showed the hypothesised result, namely right hemisphere activity only
when relaxed, but both right and left activity during peaks. The tracings
of the four remaining participants showed evidence of strong arousal,
which sometimes coincided with the recorded peaks, but the head
maps did not reveal significant evidence, partly due to ‘noise’ interfer-
ence (Lowis 2000). See Figure 2 for illustration of one example.
Figure 2: Differences in brain activity: relaxed (left) and peak (right).
Head viewed from above, with nose at the top. The narrow, light strip between the ear region and
dark inner banding indicates an area of high activity in this monochrome image.
JAAH_1.1_art_Lowis_081-092.indd 89 8/21/09 2:00:06 PM
Michael J. Lowis
The outcome was sufficiently encouraging to merit further tests
with many more participants. In addition to being time consuming
and requiring specialist equipment, however, these trials were replete
with variables difficult to control. In particular, participants need to be
relaxed enough to keep extraneous EEG noise to the minimum, and to
experience PEEs despite the experimental conditions.
This paper set out to review a range of studies that utilised scientific
methodology to investigate why and how music can have a pro-
found emotional effect on the listener. Taken together, some fasci-
nating, albeit sometimes tentative, findings have been revealed. There
appears to be significant differences between casual music listen-
ing, and listening by those who have had some musical training or
are otherwise musically involved. The latter are more likely to listen
(subconsciously) analytically, probably involving dual hemisphere
processing, which thus increases the likelihood of peak emotional
experiences. The ability to become totally absorbed in an activity is
also linked to PEEs. Attempts to identify aspects of music that can
have an emotional impact revealed mostly arousing triggers, and the
major modality rated higher in emotion than did the minor in the task
However, music may also trigger another variety of powerful
emotion: the introspective, wistful, spiritual, and sad. The experi-
ment with sacred and secular music seemed to impart such an
emotion to those who were susceptible, and the high rating for
hymns in triple time and minor mode also provided evidence, as
did the PEEs with the gentle music even though of lesser frequency
than with the upbeat. An intriguing additional finding was the
indication of a genetic link through the male line for rhythmic
ability. This, and other outcomes cited in this paper, merit further
However, despite much research effort, many aspects of music
remain enigmatic, and do not adequately explain its all-pervading
influence throughout history and amongst all cultures. In fact, it might
be that the ‘scientific method’ will never reveal satisfactory answers.
In one theoretical study, a novel methodology utilising a philosophical-
deductive approach was used to address the proposition: ‘music is an
innate gift’. Instead of trying to prove this, the technique was to try
and disprove it in favour, firstly, of music being a learned phenom-
enon and, secondly, that it conveyed an evolutionary advantage. In
neither case could evidence be found that conclusively negated the
original premise, and there is much testimony to confirm that music
has aesthetic qualities that serve the sole purpose of generating tingles
of delight and even peak emotional experiences. So far, using such a
methodology, the notion that music is an innate, perhaps a divine, gift
has survived attempts to discount it (Lowis 2004).
JAAH_1.1_art_Lowis_081-092.indd 90 8/21/09 2:00:07 PM
Emotional responses to music listening
I am extremely grateful to Oxford Instruments, UK, Ltd who, at
no cost, provided two Neurophysiology Support Specialists and a
Medilec® Profile multi-media EEG apparatus for a day. Without this
help, the EEG tests could not have been accomplished.
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nal response to hymn tunes’, The Mankind Quarterly, 42:4, pp. 441–454.
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(1991), ‘Health outcomes and a new index of spiritual experience’, Journal
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music’, Transpersonal Psychology Review, 4:1, pp. 43–49.
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Michael J. Lowis
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staff population’, Creativity Research Journal, 14:3 & 4, pp. 351–359.
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secular music on elderly subjects’, Journal of Psychology, 131:1, pp. 45–55.
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and Health 1: 1, pp. 81–92, doi: 10.1386/jaah.1.1.81/1
Dr Michael Lowis is a chartered psychologist, and currently Visiting Fellow,
Occupational Sciences, The University of Northampton. His research interests
include the psychology of music, the psychology of humour, and life satisfac-
tion in the later years. He is the author of over 70 academic papers and con-
ference presentations, and is called upon by the media from time to time for
specialist opinion. He is also an amateur musician.
Contact: 47, Allard Close, Northampton NN3 5LZ, United Kingdom.
E-mail: mike.lowis@virgin.net
JAAH_1.1_art_Lowis_081-092.indd 92 8/21/09 2:00:07 PM
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.93/1
JAAH 1 (1) pp. 93–110 Intellect Limited 2010
City University London
You don’t have to like
them: Art, Tate Modern
and learning
The context for the article is a workshop that takes place at Tate Modern
in London, with a focus on exploring violence. The material is drawn from
two small-scale research projects. The participants, who come from a vari-
ety of occupations, observe and deal with violence in their work in varying
degrees. The rationale for the art gallery based session is that ‘live’ visual
works of art stimulate engagement in cognitive and emotional processes
whilst exploring societal phenomena relevant to professional knowledge and
There are two main themes: the first focuses on the art gallery visit
as a means of learning, and the second is to consider the impact on stu-
dents and whether learning in an art gallery might give insight into their
Whilst there has been a growing interest in using art as an educa-
tional medium the following rather strong reactions still reflect the
art museum
JAAH_1.1_art_Weir_093-110.indd 93 8/21/09 2:05:37 PM
Hannele Weir
apprehension, or a sense of distance, that museums and art galleries
can generate in the public:
“When I was young museum was the most boring shit mum
could take me to. I’m turning twenty on Saturday and this visit
made my soul better.” (Graffiti on the wall of a Tate Modern lava-
tory 2007)
‘I couldn’t believe I was getting into this.’ (Mature student)
Whilst both comments express suspicion of museums and what they
might represent they also convey surprise and satisfaction that seem-
ing ‘effort’ of getting engaged with art may be beneficial.
This article reflects on a small-scale piece of research following
students’ discussions during a workshop held at Tate Modern as part
of an inter-professional Master’s level sociology module ‘Historical,
Cultural and Social Perspectives of Violence’. Additional material
is drawn from an earlier research conducted by one of the curators,
Alison Cox, with students during a similar workshop in 2006, within
the same module.
Collaboration with Tate Modern has developed a particular
way of exploring violence in the context of the module. The overall
purpose of the article is to consider how consciousness of com-
plex and difficult issues that surround violence can be explored
by experiencing the ‘live’ contact with works of art; how viewing
art may reveal depths that spoken words in a lecture may not do;
and how such an experience might impact directly or indirectly on
approaches to practice. In order to address art in education and
learning in an art gallery I will consider arguments that address the
‘getting involved’ in art aspects; describe and give examples of the
content of one session; report on the comments made by students
and finally consider what impact the viewing and discussion has
made on the participants.
The session, the last in the module programme, in Tate Modern falls
under the auspices of the ‘Art into Life’ workshop programme, which
aims to encourage visits from a variety of groups, and whilst ‘widening
participation’ is not a conscious part of the curricular aims – indeed it
would not be relevant as such – the visit may generate further interest
in art in general as an unintended consequence. The participants, who
are nurses, police officers and other professionals, work in settings that
involve contact with people who have suffered intentional and uninten-
tional violence.
Why art – in education?
There is accumulative evidence of ‘use’ of art in teaching (see
Blomqvist et al. 2007; Simons & Hicks 2006), which indicates a variety
of reasons and outcomes, for example, Blomqvist et al. refer to art as a
JAAH_1.1_art_Weir_093-110.indd 94 8/21/09 2:05:38 PM
You don’t have to like them: Art, Tate Modern and learning
skilful interpreter of emotions (2007: 89); Simons & Hicks argue that
the use of different art forms in teaching facilitates trust, confidence
and the expression of emotions (2006: 80).
Whilst these writers appear to prioritise emotions in the use of art
in learning they also make reference to reflective thinking (Blomqvist
et al. 2007: 92) and integrating the emotional level with the intellectual
and cognitive aspects (Simons & Hicks 2006: 85). We might expect
arts to generate such processes, in addition to the aesthetic apprecia-
tion of the work created by artists, but the increasing utility of muse-
ums as places of teaching and learning within a formal curriculum is
less obvious. However, I want to emphasise the point of engagement
in and with art. Whilst ‘using’ art is often seen as the shorthand way
of describing how artworks increase our insight and comprehension
in an educational or therapeutic context, the attempt here is to con-
vey how focused viewing of art compels engagement, and draws into
some depth of exchange between the viewer and the piece in ques-
tion. ‘Use’ therefore may refer to a more transient impact; and argua-
bly devalue the energy and emotion invested by the artist in the piece.
In our case the engagement is guided and enhanced by the specialist
facilitation and group work.
For novice viewers there are inevitable questions about the pur-
pose of educational visits to an art gallery, as it might turn out to be
seen as just a nice idea and a mildly interesting afternoon. The con-
cern of the type and extent of engagement is to do with how art could
challenge our thinking and emotions, and reveal something that was
hidden; expose something about the way we construct explanations
about events and the world around us.
The claim that art is not only an aesthetic experience but also ‘the
consciousness of the world’ (Doran 1978, quoting Cezanne’s thoughts
on ‘the stages of man’ cited in Marion 2007) leads us to academic
debates about the purpose and value of art. There are sophisticated
academic arguments about art and its value both as art and as an
investment (see, for example Berger 1972), the skills and choice of top-
ics by artists, and whether galleries should purposefully widen their
doorways to the public. We may also draw attention to learnt assump-
tions about art, and ways of looking at art, to which Berger (1972) in
Ways of Seeing refers, and that the way we see things is connected to
what we believe or know (1972: 8).
The understandable scepticism that viewers may feel and express
is rooted in larger domains than just those of personal prefer-
ences. Elitism still surrounds art galleries and artworks that appear
obscure to the majority of people. For example, Bourdieu (Savage
& Bennett 2005: 8) has observed that the art museum serves as a
site of cultural and social distinction and that there are significant
inequalities of access to works of art and participation in cultural
activities. After Wolff (1993) it could argued that art can be effec-
tive not only in enlightening viewers politically and historically but
it could also be a tool in learning about the other societal issues
JAAH_1.1_art_Weir_093-110.indd 95 8/21/09 2:05:38 PM
Hannele Weir
relevant to professional knowledge; although that depends on how
professional knowledge is conceptualised and its function defined.
Art offers a means of exploring life events and organised activity
of society, and facilitates a commentary on life events by way of
symbolism and the visual impact viewers experience in engaging in,
looking, seeing, feeling and thinking.
What difference does viewing and discussing art make to our com-
prehension of life events? In this article it is argued that visual art can
help to deconstruct and reconstruct meaning, presentation and repre-
sentation of conflict, aggression, violence and subtle sense of unease
and discomfort as depicted in a small selection (five to six) of artworks
on which the session focuses.
The participants in all participating groups so far are not regular
visitors to art galleries. The underlying purpose is that complex and
difficult issues that surround violence, and seeking to understand
how violence, by which we are touched in one way or another daily,
can be explored in relation to visual works of art, rather than, for
example viewing television news. Whilst television presents a reality
that is image perfect in that the images are a direct presentation of
an event and people as we might see it, almost, if we were present.
Art involves a process by the artist, in terms of planning, thinking
and the execution of the work. The end result is a representation
that may be visually more complex than news footage shot with a
camera; it presents layered meanings that are not obvious by a cur-
sory and fleeting viewing.
The important factor in working in the gallery is the live impact
of the art, a point emphasised by Liz Ellis, curator, who leads the
session. It is to do with the directness and nakedness of the work
without a camera lens in between mediating the image. The col-
ours, texture, the presence of the work, even the size can be fac-
tors forming the relationship with the viewers. A specific personal
example concerns Picasso’s Guernica (completed in 1937), a depic-
tion of the destruction of the Basque town of Guernica, during the
Spanish civil war. I had seen many pictures of the painting, but I
was quite unprepared for the impact that the real work impressed
on me when viewed some years ago in the Museo Nacional Centro
de Arte Reina Sofia in Madrid. The magnitude of the painting in
terms of the subject, composition, colours and the horror palpable
in it represents the incomprehension and suffering of the people in
the picture, and thereby people of Guernica, more powerfully than
many television images might do. My experience oddly concurs with
David Hockney’s point about Picasso’s cubist paintings when he
says that they better represent figural reality because he paints his
subjects from different angles (1993, cited in Hatch & Yanow 2008:
26); Hockney notes ‘only if you think of one particular way of seeing’
Picasso’s paintings may appear as distorted (Hatch & Yanow 2008:
27). Art, then, compels us to see things in different ways, in which
reality has many sides.
JAAH_1.1_art_Weir_093-110.indd 96 8/21/09 2:05:38 PM
You don’t have to like them: Art, Tate Modern and learning
A painting, collage or constellation presents a multitude of aspects
and possibilities to the senses of the viewer and, in doing so, mirrors
the complexity of violence in real life. As we work towards compre-
hension of the artistic presentation of events, such as Picasso’s and the
artist’s expression of their experience and observations of the world,
we also are invited to appraise our experiences and the way we see
things and feel the effect with constantly changing scenes and events.
Therefore ‘beautiful’ pictures (apologies to Monet and various other
flower arrangements), which we ‘like’, do not necessarily encourage us
to look beyond the obvious. In contrast, it is the potentially more unset-
tling works – which, of course may be subjective – that make us turn
away. If we dare engage, they may probe the areas that are aspects of
the reality in life.
Learning in an art gallery context is likely to be a new experience
for many participants, and may feel socially and emotionally threaten-
ing. It also challenges what Bourdieu (1977, cited in Layder 2006) calls
‘habitus’, the basic cultural stock of knowledge we carry in our heads.
Sharing a stock of knowledge, cultural environment and social class
background eases social encounters and gives us the premise from
which we can anticipate the encounters and interpersonal relations
with other people. An art gallery as a case example here, challenges
the ‘stock of knowledge’ with which we are familiar, in a strange
environment, and presents us with an ‘other’ cultural experience. It is
easy to understand the apprehension some people feel if their cultural
background does not include art and museums as either concepts or
places. The implication, we can surmise, is that engaging with art as a
way of learning may make more immediate sense to people who are
familiar with the symbolism that art often uses to express emotions
or life events and issues. Therefore the artworks may be more readily
‘read’ by those who not only consider art as an aesthetic experience,
but also as a commentary on the social world.
Wolff (1993) has noted that where only a small minority or a domi-
nant group have access to culture, the potential effect and transforma-
tive power as a social force is ‘extremely limited’. However, the drive
for widening participation in, for example, accessing art galleries may
lead to a transformation in a variety of ways, which is to extend learn-
ing opportunities and methods. In a pedagogic sense – and to justify
viewing art as a teaching and learning method – other people have
argued that participation in the arts is beneficial to personal develop-
ment (Matarasso 1997), or as Simon & Hicks (2006) argue that the
power of creative art enhances opportunities for learning through
trusting participants’ intelligence and imagination. One fundamental
aim is also to do with the encouragement for creative thinking rather
than instruction-based approach (Lindblom-Ylanne et al. 2006). To
put it simply, the aim is to give art the chance to take intellectual and
emotional space in our thinking, and present violence from an unfa-
miliar perspective in a context that occupies participants visually, and
support the use of metaphors in reflection.
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Also, my arguments do not exclude the appreciation of artistic
merits in an academic sense, for example, how well the artists have
executed their works, in their use of colours and material. Aesthetically
pleasurable pictures are not excluded; rather it is the focus of their
subject matter that may not express the power and control that under-
score aggression and violence. That is not to say that the selection of
works for the workshop consists of obvious violent scenes as such; but
they are more complex than still life pictures.
The module learning outcomes cover the intended learning for all
the sessions, building meaning and insight between theoretical think-
ing and practice. The workshop is intended to tap into free associa-
tion in a sense that the participants can articulate an understanding
of the link between the academic and the artistic. My argument has
been that the viewing cannot be tied down too much to detailed
learning outcomes. Setting prescriptive outcomes for the gallery visit
would encourage ‘observation rules’ that would, from the outset, limit
the exploration and impact made on the viewer. Rather, the purpose
is to engage with art as a means of creative (as in seeking different
meanings and insights) and educational dialogue. Therefore the agreed
learning outcomes are tied to the opportunity and the psychosocial
space that Tate Modern offers for the participants: with focused atten-
tion on pieces selected for the session with questions that lead the
discussion on each selected work; contained reflection on each work
viewed; and further reflection and discussion immediately after the
session. The learning outcomes have been formulated as follows:
Students will have had an opportunity to participate and learn in a •
qualitatively different experience at Tate Modern.
Students will have gained another way of exploring issues that sur- •
round violence.
Students will have engaged with each other as a shared experi- •
ence, and communicated on different levels.
The session would have expanded the students’ insights by looking, •
thinking and reflecting on the ‘live’ visual contact with works of art.
Each work of art is accompanied by other activities that tie in with the
piece and help the association between our world experience and the
work on view.
The methodological approach is underpinned by the experience gained
from the previous sessions that have taken place within the module
programme at Tate Modern. The session format is always the same
and starts with a brief introduction before touring the gallery, dur-
ing normal opening hours, and concentrating on between five and six
pieces of art, around which discussion and some activities take place.
Following the viewing the group meets in another room in the gallery
for feedback and reflection.
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You don’t have to like them: Art, Tate Modern and learning
The session is preceded by a discussion between the module leader
and the curator, Liz Ellis, leading the session. The discussion is impor-
tant as it enables a dialogue about the artworks selected for the session,
and gives an opportunity to consider the relevance of the works to the
student participants. The preparation has also facilitated an understand-
ing and agreement about each other’s work and roles besides ensuring
that the works are accessible without demanding overt effort and sophis-
ticated theoretical understanding (Wolff 1993). It also functions as a point
of information exchange about the students’ work context and the rest
of the module content. Furthermore, it becomes integral to the students’
sense of safety, and confidence in the proposed activity. The methodo-
logical approach to capturing the discussion during the session and for
the purpose of the research is mainly descriptive for the reasons that the
context presents. Hence the reality revealed and the nature of the knowl-
edge (Crotty 1998) created is tied to the dynamic and flowing essence of
the session (amongst the rest of the public visiting the gallery).
The study was based on ethnographic method as a ‘situated activ-
ity’ (Denzin & Lincoln 2000) where the module leader was a partici-
pant observer, thus ‘located in the world’, as Denzin & Lincoln note
(2000: 3), recording discussions as we went around the gallery. The
data was written down simultaneously. The reflection session after the
tour was audio-recorded, but due to equipment failure the feedback is
based on simultaneously made notes.
Alison Cox, a curator at Tate Modern, accompanied the group in
2006 for her research. Her conclusions, based on the reflection and
discussion after the session, and the interviews she conducted after-
wards with three participants are integral to the research. As the
format was exactly the same for both groups the data from 2006 is
considered alongside the content for 2008 group, which adds strength
to the (tentative) conclusions.
Before the session the participants were asked to give a brief bio-
graphical history on their age, gender, occupation and current work.
They were also asked if they had previously visited Tate Modern, or
any other art gallery. The group in 2008 consented to attending two
sessions at Tate Modern, with a six-month interval, in order to recall
any thoughts or impact gained from the first visit.
The outline of the research was as follows:
Documentation of discussion and reflection during and after the ses- •
sion at Tate Modern, which charts the first impressions and impact.
Reflective narrative/ diary of thoughts, charting decisions and events •
that in any way can be connected with the session at Tate Modern.
Thematic analysis of feedback from participants, and consideration •
of the link between the learning in a gallery and practice.
Ethical approval
Approval was sought and granted by City University London and all stu-
dents were given written and verbal explanations of the session format; all
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Hannele Weir
signed a consent form according to the university regulations. All mate-
rial collected was anonymous and the students understood the nature
of confidentiality in the discussions and recording of the discussions. All
participants have also given their consent for the use of the material.
The biographical data for the group in 2006 was similar to the group in
2008 in terms of a mix of participants and with reference to age, occupa-
tion and ethnicity. The age range in both groups was from late 20s to 49
years of age. The groups consisted of nurses, police officers and people
working for voluntary organisations; and people from different ethnic
groupings. Four out of six students in the 2008 cohort had visited Tate
Modern before the session and two had not, but only two said they
visited museums more than three times a year, the others did so infre-
quently. This was close to the visiting pattern of the 2006 group.
The data is not strictly organised into themes. The insights and
contributions made by the participants concern firstly the initial reac-
tions and surprise that they found the workshop interesting, useful
and enjoyable. A second theme was formulated from the comments
that were to do with the artworks themselves, the discussion and
insights generated in the discussion, and how connections were made
with other aspects of life. The third area focuses on the comments that
could be linked with work life and practice. In the narrative that fol-
lows these themes are enmeshed in the reported discussions.
Session content and discussion on the works viewed
The selection of artworks is based partly on what discussion could be
built around it that gives participants the opportunity to explore rela-
tionships, various phenomena in society, including some difficult issues.
The session is expertly led and facilitated by Liz Ellis, with the works
of art in the centre of the learning. The works can represent different
things to different people, whilst there may be a particular theme.
The following section includes examples of some works viewed and
discussed during a session. The responses are reported here verbatim as
captured by me, as a participant observer taking part in the discussion.
The intention is mainly not to comment on them as they are the real
responses to the works and, as such, describe the impact and sense gen-
erated in the members of the group. It will give an idea how the session
unfolds and how the words give that sense of exploration and connec-
tion; trying to make sense and meaning of what we see and how differ-
ent the observations may be. The exhibits viewed in 2008 were: Salcedo:
Shibboleth; Rothko room; Kuitca: Untitled 1992; and Bacon Triptych.
Liz Ellis explains: ‘Shibboleth’ – a political word, borders, deliberate,
about poverty, justice.
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You don’t have to like them: Art, Tate Modern and learning
Four participants look at the crack that runs the length of the Turbine
Hall. Five observed how they reacted and generally how the audience
walked around and reacted to the crack.
Discussion: could be all kinds of things; ripped into; could be pushed back
together; mouse trap – we could be trapped.
There are remarks about divisions in society, and how powerful it felt
seeing it in concrete (no pun intended) terms, and which you could
not escape as it commanded the whole length of the hall.
How was it all made
Liz explained: Salcedo wants to keep all of it secret.
Debris dropped into it – how deep is it; one student got onto the floor
and put her arm into it; one did not want to move from their spot;
child friendly like a sand castle that cracks; peaceful.
Rothko room
We were instructed to keep certain words (below) in mind as we look.
Again the discussion took place in groups.
Meditation: not brightly lit; compare to the other environment outside the
room; cool down zone; painting on the back wall: easier to look at – others
are more offensive; womb like; bodily sense.
Fluid: physicality of the paintings; like dried blood; first on the left ‘drizzling’;
colour; extremes of experience.
Trapped: not uncomfortable; the paintings pulse.
The paintings polarise people – we have diverse and opposite views; and
different feelings were generated as reflected in the words.
As the Rothko room generated rather diverse views and feelings, some
referring to rather personal feelings, Liz Ellis explained: ‘What we do
here is never therapy, but we are thinking of a way into art works.’
The point is important as otherwise the impact of the works could be
diminished to consist only of the introspective reaction rather than
exploring what is on view and opening oneself to wider considera-
tions and social interpretation.
Guillermo Kuitca: Untitled 1992
Before the viewing of the work we were given crumpled balls of paper
to examine and discuss in groups. The paper balls opened into maps.
The physicality of the crumpled though smoothed out paper gener-
ated different comments:
feels like mountains; crumpled paper cannot un-crumple – once violated
you cannot go back, the violence is always there; cannot heal crumples.
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Hannele Weir
What we saw as we entered the room: small beds covered in fabric
with maps. We looked at the beds and sat down to discuss: one par-
ticipant turned her back to the beds as she could not bear to look at
them due to the connection with the finds in the Jersey children’s
home – damp, grey, dusty cellar, children’s beds.
Eastern European orphanages; roses: there was a happy time once;
mapping the body on the bed; clinical; slave ships-bodies packed
together; deliberate…?
The beds were placed in a roped off area (for security and protection of
the works), but that became also symbolic of a quarantine; the whole
work was troubling physically and mentally.
As the maps on the beds were a mix of different places (not
geographically correct) they could have been representations of
migration or being a refugee as the beds appeared to have been
bunched together in an austere gallery, suggesting regimentation
and a lack of space. So we had a number of visual messages pre-
sented to us that appealed to our previous knowledge: displaced
people, who did not know where they were, possibly children as
the beds were child-size; discrepancy between part of the material
covered in pretty flowers but soiled, and white painted bed frames,
that made the beds look quite nice and conventional. Thus view-
ing the beds was quite difficult for us, as it brought out so many
issues to do with poverty, migration, displacement, loss, possibly
abuse. We could tap into a number of personal and societal issues
and feelings.
The engagement with the beds is an example of leading partici-
pants to focus on uncomfortable areas of life. In this instance the beds
reflected particular types of violence. The fact that maps could be read
in so many different ways is like a metaphor on education and how
people can be led to read what is presented in more than one way.
Maps show you roads, places, perhaps terrain – if we can read maps
and understand the symbols. And we take for granted how maps
should be read as a direction to places you want to visit; surely it is like
reading a book – except that you can view them in different, focused
ways, as the beds suggested.
Bacon: Triptych
Started 1948, finished 1988. In three groups looked at the three parts.
My notes read:
1. Physical form; incomplete; deformity; hate content, love the colour; broken
rule about body; put on a mask when sees disabled body.
2. Image of life; seed – to survive; body that could snap; incomplete; stains
just outside the painted area of canvas: were they deliberate?
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You don’t have to like them: Art, Tate Modern and learning
Liz Ellis observed: Bacon would be delighted at the effect on the
3. Difficult to see where head and neck differ;
Liz Ellis: there is a response to Belsen 1948, but he still had it
in mind in 1988.
There are the extremes of emotion; getting at you, attacking
you with the deformity.
One participant noted: for me too much – us being part of
this – is being complicit.
The group in 2006 also viewed the Triptych, which is an example of
an artist presenting his interpretation of events in personal circum-
stances, but in the context of the wider society. The work baffled most
of the viewers by its obscurity, apparent deformity of the figures and
strong colour; it also disturbed the students, as noted above.
Can the art gallery be a place of learning that is meaningful to the stu-
dents? The reactions by the participants in the beginning of the article
reflect reservations that move from disbelief: ‘I couldn’t believe I was
getting into this’, to relief: ‘It’s OK not to like art works’. One partici-
pant observed that ‘art is elite’, and another seeing it as something ‘for
posh people’, but ‘beginning to make sense of art’ and ‘appreciate it’.
The comments link with the earlier point about the stock of knowl-
edge, but they also demonstrate, in their way, continuity in the accu-
mulation of knowledge, which, of course, is the purpose of education.
The pedagogic principle here is also driven by the moral and
social notion in development of the whole person and acknowledg-
ing socio-holistic contexts of learning (see MacNeill et al. 2005), and
applying the principles also in the work context as all practitioners’
work involved contact with people in vulnerable situations.
Impact on students
This section of the report will draw data from the discussions with the
group in 2006 and the group who participated in the session in 2008.
The reasons for this are that the two groups (2006 and 2008) reflect
the impact that learning in an art gallery may produce, and therefore
reporting on the combined data gives a more extensive idea of art in
teaching and learning.
It has become clear that many students are initially apprehensive
about the session, partly due to the unfamiliar space and the sense
that they do not understand art, and there is anticipation that they
should like what they see.
Once in the gallery the important point for the students was to
realise that stopping and looking, ‘taking time to look properly’, as
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Hannele Weir
one participant put it, was rewarding. It meant going beyond the
observations about beauty, ugliness, like and dislike dichotomies
and also giving pointers for subsequent discussion. Because of the
juxtaposition of the pleasure of beauty and the challenge of the dis-
turbing and violent, the message at the beginning of the session that
we do not have to like the works we are going to view, put aside
the issues about assumed sophisticated or educated appraisal of the
works. The approach rests on the premise that art is like a text and
can be read, with ‘seeing’ (after Berger), as a symbolic text, in which
signs and works mediate our self-knowledge (Ricour 1981, cited in
Solheim & Borchgrevink 1993), and I would argue that as part of that
process, viewing art mediates understanding of other people. That
leads us to consider art as mediated ‘lived experience’. For example,
violence observed on the canvas or in an artefact is, as Solheim &
Borchgrevink note, what the artist has objectified through signs and
expressions. What we come to ‘know’ about that experience is one
side of the knowledge, and what we gain in self-knowledge by look-
ing and absorbing the work/exhibit is the result of how it resonates
in us and in our understanding. Cezanne referred to ‘an abyss into
which the eye plunges, a voiceless germination’ (Doran 1978, cited
in Marion 2007: 60), which serves as a withdrawal from a literal-
minded approach and confusing ‘symbolic imagination with fantasy’
(Tacey 2004: 161).
‘Symbolic’ refers to an understanding that experiences and phe-
nomena can be presented by symbolic signs, images and words
whilst referring to real observations and events. Cezanne exhorts
us to ‘lose consciousness, descend with the painter into the dark,
tangled roots of things’ (Doran 1978, cited in Marion 2007: 60). But
unlike Cezanne, who resurfaces with colours, we may find that the
visual presents discomfort that dredges up the hidden within us. On
the other hand, Tacey (2004) sees the role of arts as bringing new life
or ‘making new’ of tradition and linking it to contemporary aware-
ness and experience.
Looking at conflict and turmoil of life with the eyes of the artist, as
artists “represent the world through their eyes” (Tate Modern 2007),
adds to the comprehension of how we feel about, and approach, vio-
lence, and how it may help our dealing with it. One participant offered
her experience in the following contribution:
I work with survivors of human trafficking, with people living
with HIV/ AIDS and/ or psychiatric disorders. I see pain and suf-
fering very closely in the work I do. This is the dark side and yet
I know that the only way to work through this is to understand
it. That was how I felt about the art we saw. Yet the most signifi-
cant learning for me was that from time to time we need to allow
ourselves to feel our emotions, we need to come out of our com-
fort zone and recognise that we are like everyone else, human.
(See Weir 2007: 387)
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You don’t have to like them: Art, Tate Modern and learning
The words reflect a variety of comments and emotions when the par-
ticipants viewed Francis Bacon’s work: for one participant it was ‘too
much’ with the sense of ‘being complicit’ in viewing it, whilst someone
else appreciated the colours Bacon had used. Thus we can see how one
work, as an example, resonated in different ways between the viewers.
The way artists construct their view of social reality encourages us
to engage with ourselves, and the wider world, using our creativity and
interpretation. For example, Paul’s (2006) comment on Kandinsky’s
work (Tate Modern exhibition in 2006) is useful when she notes that,
‘it is the mood of violence and chaos that is more important than the
literal interpretation of objects or narrative’ (2006: 9). It echoes what
some students found liberating in that personal meaning and inter-
pretation was possible and acceptable, as in the following quote by a
participant on the meaning of the viewing: ‘It doesn’t matter what the
artist intended and that is revelatory… it is how you interpret it that is
important and I didn’t know that before.’
The following extract from ‘random musings’ by a Mental Health
Nurse taking part in the session go straight to the point about paral-
lels between the art and the personal:
I found myself interacting with events or for that matter with a
piece of art based on my experiences and assumptions about the
world. In that respect I see art as an interpretation of an event
by the artist based on his/her interactions with the world and
his/her assumptions about the world. The risk then lies in these
experiences we carry within ourselves, experiences that are pri-
vate and at times repressed. Experiences that we might not want
to be made aware of and that no one can predict.
The following comments also indicate a shift in thinking that began to
take place during and following the session: ‘It made me take a bit of
a step back and look at things a bit differently’ or that attending and
engaging was worth it: ‘I would have walked past the ones we looked
at were it not for the workshop’ (Weir 2007).
The observation that the session was ‘thought provoking in a way
that made you think more about previous class sessions’ begins to take
the benefit of the Tate session beyond the gallery and, in this instance,
extends the experience to other learning. The process also involves
risk; that diversifying a teaching session into a relative unknown area
for students can be risky, and requires trust between all collaborators
(see da Costa 2006). Therefore placing the session last in the module
allows both for building up trust and theoretical exploration.
Impact on practice: very tentative observations
It is difficult to draw anything conclusive about learning with and experi-
encing art in the gallery context that could be said to impact on practice,
apart from some indications included in the preceding quotations.
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Yet, the comments by six participants some months after the ses-
sion give pointers, and sometimes surprising connections, to the
potential change on a personal level with influence on practice situa-
tions. One participant gave a concrete example:
As a consequence of the Tate session experience and the work
done during the module has resulted in a collaboration with
journalists to accompany me to observe the work of the traffic
officers dealing with traffic offences and emergencies.
Another police officer made the following point: ‘As policemen we
can become institutionalised – sessions like this help us to think out-
side the box to do some lateral thinking, which is very good and valu-
able’ (Weir 2007).
The participants also began to make connections between the
exhibits and life outside the gallery; how the metaphors between art
and real life observation make sense and which might not have been
so powerfully experienced, and expressed, in words: ‘Art and life in
many ways are similar in the response they elicit from us. We want to
see the pretty and the hope and look away from the rest.’
The group in 2008 met for a second session six months later to
report on their thoughts on the first session and participate in another
session. Although they had been asked to write down reflections fol-
lowing the initial session, none of the four (out of six) who were able
to attend the second session had made any notes. As no specific expla-
nations were offered it was left for speculation what the reasons might
have been: the activity asked of them was additional to the module
content; time constraints were also likely to be a factor due to other
course assignments and work demands; it is also likely that making
reflective notes about connections with work after one session was
premature and difficult to articulate, that is, the spheres of artworks
and the linkage between daily life was not easily made (Weir 2008).
The points that emerged during the session indicate, firstly, a
growing sense of anticipation of working with the pieces of art linked
with the analytical way of approaching the works (for example, link-
ages between the conscious and unconscious), and secondly, what the
gallery can offer as a space for reflection and thinking, which is not
easily achieved when at work.
Three students from that group also took part in a videoed session
(as part of the dissemination of the project results) at Tate Modern a
year later. Their discussion elicited further insights into the meaning
of art and art gallery visits. It was felt that art offers a valid way of
learning as it encourages listening to other people. There is a paral-
lel between expressions in art and discussing the different views on a
piece of work and listening to each other, and patients, in daily work
and life. For example, exploring the strong instinctive reactions to
paintings and how you need to keep them in check at work; or should
you sometimes let clients know how you feel? It was concluded that
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You don’t have to like them: Art, Tate Modern and learning
there is a place for art when you work with violence; that generating
different ideas and considering so many sides and perspectives pre-
sented by participants has parallels to working in teams, and opens up
a way of looking at real life.
Simons & Hicks (2006) have pointed out that using art in education
facilitates trust, confidence and the expression of emotion. The above
participants’ contributions also communicate the dilemmas between
our perceptions of reality and the way we try to cope with it. Yet, if we
dare to look, it is a challenge, but I would argue that it also locates our
fears and hope into a more realistic place in which engagement with
art provides a revelatory reflection. For one group of students the ses-
sion offered a space to think and think differently – a point that should
be applied to practice more regularly. Further links with work was the
observation that there are so many boundaries in everyday life, and
coming to a space like Tate Modern frees us from those barriers.
The participants engaged in a fairly complex process that is not nec-
essarily limited to the one occasion. With reference to the particu-
lar socio-cultural antecedents, as discussed earlier, a more in-depth
research would start with a pre-session interview or some attitu-
dinal measurement in order to gage previous experience of styles
and expectations of teaching and learning. Thus the results as such
are descriptive and may remain, in terms of understanding, on the
level of discovery rather than validating the explanation of behaviour
(Martin 1994), especially in the case of impact on practice.
However, what can be reported here is that the impact of the ses-
sion on the participants has been varied, as could be expected given
the various professional, but fairly consistent social class background.
It was anticipated that many might not have been familiar with works
of art. The fact that many participants had not been to Tate Modern
before, and were uncertain of what it might offer in an academic
course, present a certain risk for teaching and learning in such a way:
can it be expected that relevant and desired knowledge is acquired
and that it is relevant to practice? The results are encouraging but not
confirming. There is sufficient evidence to suggest that class and cul-
tural boundaries became less inhibitive as the connection with works
of art became less threatening, and Tate Modern began to feel more
familiar and less of a hallowed ‘arty’ ground.
The responses have indicated that something ‘happens’. It may be
that there is a transformation of attitude, even impacting on practice,
or an appreciation that an art gallery offers a space that allows dif-
ferent kinds of thinking, or restores a sense of connecting with crea-
tive aspects of the self; and the creative side of the human brain. The
constitution, development and transmission of knowledge could then
be approximating cross-disciplinary and cross-sectoral interactions
(Crossick 2006: 11) firstly as demonstrated in the collaboration between
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Hannele Weir
the university and Tate Modern, and secondly involving experienced
practitioners from other sectors. Certainly the engagement with art
supports the idea that learning is a multidimensional rather than lin-
ear process (Weir 2007, cited in Chamberlayne & Smith 2007: 265).
The impact reported here is based on students’ feedback but fur-
ther relevance is difficult to discern, let alone measure, in the time
frame available. The group who attended in 2008 and who subse-
quently met two more times (outside the module requirement) has, to
some extent, demonstrated how engaging with art can support mak-
ing sense of work-related organisational and interactional processes.
In almost every group, since the beginning of the collaboration
between Tate Modern and the module, one participant has been scep-
tical of the method. The apprehension and scepticism is to be expected
given the background, context and differences in the way people learn.
The comments by those students have been an important contribu-
tion, as they encourage further exploration of the hidden and obvious
in the artworks, and how to link that with everyday life.
A reflection period after the workshop has implications for the
expectations of impact in terms of immediate learning and later
insights. The group of 2008 have confirmed that one visit may be only
the beginning of the process where art could become a resource, not
only for leisure time but also connecting with different phenomena,
many of which have relevance to work.
The results of the art gallery experience cannot be restricted to
learning outcomes that promise a definite transfer of knowledge in
the conventional pedagogic sense. Crossick (2006) has, to some extent,
problematised the term and provides a useful critique of how arts and
creative industries have been forced into models of knowledge trans-
fer devised for science and technology. Indeed, the original idea for the
session was not constructed with such a model in mind, rather it was to
have learning outcomes that facilitate different kinds of learning, which,
to a degree, are student dependent, and which we have seen in some
of the above comments. However, we have examples of knowledge
transfer in that focused thinking can be transported between learning
in different ways and places – the classroom and art gallery in our case,
or between an art gallery and an organisation – demonstrating aspects
that are important to personal development and approaches to work.
The session appeared to have generated new insights into art and
its place in the commentary on social and personal experience. Our
students’ feedback has suggested that viewing art presented chal-
lenges and possibilities, which may develop into influential insights in
varying levels of experience and some of that experience is encapsu-
lated in how emotions can be provoked by the lived experience of art
rather than be expressions of art ‘appreciation’. What we can report
in this article are some participants’ responses to the session and the
works of art. How that experience is connected to work and practice
depends on their work and biographical background and situation,
and willingness to further engage in visual thinking.
JAAH_1.1_art_Weir_093-110.indd 108 8/21/09 2:05:39 PM
You don’t have to like them: Art, Tate Modern and learning
What can be emphasised is the enhancement of collaboration and
group work between all those who take part, which is evident during
the tour of the gallery, in the feedback and reflection.
I would like to thank the students who took part in the module ses-
sions in 2006 and 2008, and especially those students who enthusias-
tically came back for two more sessions in 2008 and 2009. My heartfelt
thanks to Liz Ellis and Alison Cox, both curators at Tate Modern, with-
out whom none of the work would have been possible; and thank you
to Tate Modern for the use of the facilities. The project was made pos-
sible with the help of a grant from the Learning Development Centre,
City University London.
Berger, J. (1972), Ways of Seeing, London: BBC and Penguin Books.
Blomqvist, L. Pitkala, K. and Rautasalo, P. (2007), ‘Images of Loneliness:
Using Art as an Educational Method in Professional Training’, The Journal
of Continuing Education in Nursing, 38:2.
Bourdieu, P. (1977), Outline of a Theory of Practice, Cambridge: Cambridge
University Press.
Chamberlayne, P. and Smith, M. (2007), ‘Editorial’, Journal of Social Work
Practice, 21:3, pp. 263–270.
Cox, A. (2006), A qualitative study of the ‘Art into Life’ workshop programme at
Tate Modern, unpublished mini research project.
Crossick, G. (2006), Knowledge transfer without widgets: that challenge of the
creative economy, lecture to the Royal Society of Arts, 31 May.
Crotty, M. (1998), The Foundations of Social Research: Meaning and Perspective in
the Research Process, London: Sage.
Da Costa, J. L. (2006), ‘Changing adult learning environment as viewed from
a social learning perspective’, International Electronic Journal for Leadership
in Learning, 10:1, pp. 1–17.
Denzin, N. K. and Lincoln, Y. S. (2000), ‘The Discipline and Practice of
Qualitative Research’, in N. K. Denzin & Y. S. Lincoln (eds) (second
edition), Handbook of Qualitative Research, London: Sage Publications.
Hatch, M. J. and Yanow, D. (2008), ‘Methodology by Metaphor: Ways of see-
ing in painting and research’, Organization Studies, 29, pp. 23–44.
Layder, D. (2006) (second edition), Understanding Social Theory, London: Sage.
Lindblom-Ylanne, S., Trigwell, K., Nevgi, A. and Ashwin, P. (2006), ‘How
approaches to teaching are affected by discipline and teaching context’,
Studies in Higher Education, 31:3, pp. 285–298.
MacNeill, N., Cavanagh R. F. and Silcox, S. (2005), ‘Pedagogic Leadership:
Refocusing on learning and teaching’, International Electronic Journal for
Leadership in Learning, 9:2, pp. 1–13.
Marion, E. (2007), ‘The Phenomenology of Art: the site of the work of art, the
place of the collection’, Museum, 59:3.
Martin, M. (1994) ‘Another look at the doctrine Verstehen’, in M. Martin and
L. C. McIntyre (eds), Readings in the Philosophy of Social Science, London:
The MIT Press.
JAAH_1.1_art_Weir_093-110.indd 109 8/21/09 2:05:39 PM
Hannele Weir
Matarasso, F. (1997), Use or Ornament? The social Impact of Participation in the
Arts, Stroud, Glos: Comedia.
Paul, K. (2006), Kandinsky: The Path to Abstraction, London: Tate Modern.
Savage, M. and Bennett, T. (2005), ‘Editors introduction’ in ‘Cultural capital
and social inequality’, The British Journal of Sociology, 56:1.
Simons, H. and Hicks, J. (2006), ‘Opening Doors: Using the creative arts in lear-
ning and teaching’, Arts & Humanities in Higher Education, 5:1, pp. 77–90.
Solheim, J. and Borchgrevink, T. (1993), ‘A Rotten text? Gender, Food and
Interpretation’, in V. Broch-due, I. Rudie & T. Bleie (eds), Carved Flesh/Cast
Selves: Gendered Symbols and Social Practices, Oxford: Berg Publishers.
Tacey, D. (2004), The Spirituality Revolution: The emergence of contemporary spi-
rituality, London: Routledge.
Tate Modern (2007), ‘Art into Life’ leaflet: Tate Modern.
Weir, H. (2007), ‘Representations of violence: learning with Tate Modern’,
Journal of Social Work Practice, 21:3, pp. 377–390.
Weir, H. (2008), Learning with art at Tate Modern, unpublished research report,
London: City University.
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Weir, H. (2010), ‘You don’t have to like them: Art, Tate Modern and learning’,
Journal of Applied Arts and Health 1: 1, pp. 93–110, doi: 10.1386/jaah.1.1.93/1
Hannele Weir is a Lecturer in Applied Sociology, City University London,
Department of Interdisciplinary Studies in Professional Practice, School of
Community and Health Sciences.
Contact: City University London, Department of Interdisciplinary Studies in
Professional Practice School of Community and Health Sciences, Northampton
Square, London EC1V 0HB.
E-mail: H.H.Weir@city.ac.uk
JAAH_1.1_art_Weir_093-110.indd 110 8/21/09 2:05:39 PM
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Article. English language. doi: 10.1386/jaah.1.1.111/1
JAAH 1 (1) pp. 111–126 Intellect Limited 2010
Centre of Applied Theatre Research, University of Manchester
Creating a space
for the individual:
Different theatre and
approaches to sexual
health communication
in South Africa
Sexually transmitted infections such as HIV are illnesses that affect both a
person’s physical health as well as their mental and social wellbeing. Yet,
the global development of public health responses have, for the most part,
remained focused on the physical wellbeing of people with little attention
paid to the individual’s emotional wellbeing. With the highest number of
HIV positive people worldwide, South Africa requires ‘a new and positive
approach to the pandemic’(Ross 2008). This article aims to bring attention
theatre and
applied theatre
sexual health
South Africa
JAAH_1.1_art_Low_111-126.indd 111 8/21/09 2:26:45 PM
Katharine Low

1. Margaret Silberschmidt
(2004) has considered
male sexuality and HIV
transmission in East
Africa, Gregory Herek
(1991) has studied the
impact of stigma on
people living with AIDS
and their families, and
Paul Flowers and
colleagues (2002)
have examined the role
of relationships in gay
men’s sexual decision
making within the
context of AIDS.

2. This is not the WHO’s
official definition of
sexual health but it was
developed following
a 2002 WHO-
convened meeting of
international experts to
discuss sexual health.
For more information:
to practice, in this instance, theatre and performance-based work, which
considers the people and communities affected and afflicted by HIV, and
other sexual health concerns, as individuals with individual thoughts and
emotions, for greater inclusion in a more positive approach to tackling
AIDS. This article will consider three examples of such practice, namely the
Themba HIV/AIDS Organisation, the Etafeni Centre and ‘our place, our
stage’ (OPOS) project.
The past eight years – or even longer – of AIDS denialism in
South Africa have been tragic and have cost many lives, but
the time has now come for a new and positive approach to the
(Ross 2008)
Sexually transmitted infections such as HIV are illnesses that affect
both a person’s physical health as well as their mental and social
wellbeing. Since the emergence of AIDS, there have been numerous
studies which have explored the effects of sexuality, stigma and rela-
tionships on an individual’s response to the syndrome and their emo-
tional health.
Yet, the global development of public health responses
have, for the most part, remained focused on the physical wellbeing
of people. As Tony Barnett and Alan Whiteside describe in their book,
AIDS in the Twenty-First Century, ‘[the] effects of disease are rarely con-
sidered [by governments and other leaders] beyond the clinical impact
on individuals’ (2006: 5). Although it is comprehensible that the speed
of infection and the scale of the AIDS epidemic may make it difficult
for public health programmes to consider the multiple outcomes of
the disease, bar the effect on a person’s physical health, this approach
remains one-sided. Furthermore, considering a working definition, as
noted on the WHO website, where sexual health is described as ‘a
state of physical, emotional, mental and social wellbeing in relation
to sexuality and the aforementioned research’,
it appears essential to
also focus on the social health of those affected by AIDS and other
sexual and reproductive health (SRH) issues and not to view those
infected as simply being statistics.
However, as Barnett & Whiteside have acknowledged ‘[it] is hard to
measure things – quality of life, quality of relationships, pain of loss – for
which measures are partial or non-existent. If it is hard to see these
things, it is all the easier to deny them’ (2006: 6). This perceived dif-
ficulty in calculating such effects may explain Andrew Irving’s view
that ‘[for] a literature concerning a blood-borne disease, much of it is
surprisingly bloodless; the person’s thinking, emotions, and dilemmas,
their very flesh and being, are reduced to statistics, the biological body
or social structures. Surprisingly few people inhabit these texts’ (2007:
204, emphasis in the original). Irving is not alone in drawing attention
JAAH_1.1_art_Low_111-126.indd 112 8/21/09 2:26:46 PM
Creating a space for the individual

3. Didier Fassin’s When
Bodies Remember:
Experiences and
Politics of AIDS in
South Africa (2007)
provides an excellent
commentary on the
lack of governance
over AIDS and the
mismanagement of the
Health Department,
as does Mamphela
Ramphele in her
monograph Laying
Ghosts to Rest:
Dilemmas of the
Transformation in
South Africa (2008),
Chapter 13.
to the lack of focus on the individual; Bolton & Wilk (2003) and Thomas
(2007) have also done so, arguing that this does not provide a rounded
response to the epidemic, especially in developing counties. In the fight
against AIDS, it is vital to consider the wellbeing of the individual, pro-
viding a space in which they can speak, share and discuss their dilem-
mas and where they can be heard.
Speaking about South Africa’s response to AIDS, Mamphela
Ramphele remarks on the limited research into the psychological
wellbeing of childbearing women living with HIV and proposes that
a public health approach ‘would do well to factor psychological sup-
port into the comprehensive care of people living with HIV/AIDS’
(2008: 239). Ramphele’s suggestion could be one aspect of the ‘new and
positive approach’ that Ross describes, providing a more comprehen-
sive response to the epidemic. In addition, this new approach has the
potential for a greater scope of different methods and is an opportunity
to include more arts-based work that places the individual’s experience
at the forefront of their practice. While arts-based work in health pro-
motion is not a new approach in South Africa, this is a chance to bring
more attention to practice, in this instance, theatre and performance-
based work, which considers the people and communities affected and
afflicted by SRH concerns as individuals with individual thoughts and
emotions, for greater inclusion in tackling AIDS. Thus, this article exam-
ines three examples of theatre and performance-based work in South
Africa: the Themba HIV/AIDS Organisation, the Etafeni Centre and the
‘our place, our stage’ (OPOS) project. Set against a background of using
theatre-based approaches for sexual education in Africa, the examples
will be considered in terms of the performance forms employed and the
focus on the individual by the organisation.
AIDS has been and remains one of the most contentious subjects in
South African politics, during both the apartheid era and the current
democracy. During the 1980s, AIDS was used as a tool in the racial
politics of apartheid South Africa where the National Party claimed that
the liberation movements were using it as a ‘weapon’ against South
African society by ‘importing’ it into the country through the ANC’s
‘cadres’ (Fourie 2006: 98, 175–6), while the ANC charged the ‘[National
Party] government and Western powers of developing the virus in their
laboratories to act as a weapon against blacks’ (Fourie 2006: 98, with
reference to van der Vliet 2004: 50). During the first years of democ-
racy, stabilising the economy and ensuring a peaceful transition of
power were more pressing needs than tacking the growing epidemic
(Cameron 2005: 123).
In later years, the government began to pay more attention to
managing AIDS, albeit in a seemingly haphazard manner, issuing
contradictory plans and statements. This mismanagement of the
AIDS pandemic has been discussed in depth elsewhere,
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Katharine Low
the lack of governance over this issue has resulted in a situation
where an estimated 5.7 million (4.9 million – 6.6 million) people
are infected with HIV in South Africa, the greatest number of infec-
tions worldwide. Of those millions of individuals infected, only
approximately 460’000 (398’000 – 520’000) are receiving antiretro-
viral therapy, a response which falls significantly short of the 1.7
million (1.3 million – 2.1 million) citizens whom UNAIDS considers
should be receiving antiretroviral treatment (UNAIDS/WHO 2008a,
2008b). Although the appointment of a new Minster for Health in
September 2008 has re-energised the fight against HIV and other
sexual health issues, prompting comments such as Ross’, both the
public health service and the citizens of South Africa have been
neglected for a long time and any changes will take time to come
into effect. Thus, there is all the more reason to examine organisa-
tions that focus on individuals, providing them with opportunities
to speak and be heard.
Current theatre groups in Africa, which use theatre as an educative
medium to transmit public health messages to the population, owe
much of their present working methodologies to the travelling univer-
sity theatres of the 1960s. Many of the universities in Kenya, Malawi,
Nigeria, Uganda, and Tanzania had travelling theatre troupes which
would travel to rural areas and workshop devising plays in the local
languages in an attempt to address the community’s problems. This
manner of working has become a framework for today’s Theatre for
Development (TfD) (Epskamp 1989; Kerr 1998; Kidd 1984).
the history of TfD has been well documented and critiqued elsewhere
(Mlama 1991; Kerr 1995; Salhi 1998; Pompêo Nogueira 2002; Boon
and Plastow 2004), it should be acknowledged that TfD, alongside
the broader educational theatre field, has had a significant influence
on current performance-based responses to SRH issues. Indeed,
Esiaba Irobi argues that the AIDS pandemic in Africa has resulted in a
‘Theatre of Necessity’,
where practitioners across the continent have
employed song, music, drama, dance, and television and radio dra-
mas to educate and support people, thereby creating a theatre that is
‘about survival’ (2006: 34–38).
One of the first examples of this was in 1988 in Uganda, where
AIDS education was approached through a School Health Education
Programme initiated by UNICEF and the Ministry of Education, using
‘dramas’ as a means of ‘sensitizing’ the children about sexual health. In
a subsequent interview, one of the leaders of the project, Rose Mbowa,
described how the performers used an improvisational style in order
to involve the audiences more in the performances, emphasising how
‘it is important in community-based theatre to leave the tool, the solu-
tion, with the people’ (Mbowa cited in Sicherman 1999: 111–117).

4. Laedza Batanani, a
theatre group from
Botswana, who used
popular theatre in
combination with
traditional forms
to educate their
participants, was
the main forerunner
to TfD. The Laedza
Batanani group called
their performances
popular ‘because
they are aimed at the
whole community,
not just those who
are educated’
(Kerr 1995: 151).
Laedza Batanani had
developed many new
manners of working,
and one of the most
important additions
to their techniques
was an ‘organised
discussion at the end
of the performance in
order to facilitate a
process of community
education and
mobilisation’ (Byram
and Kidd 1978).
5. Irobi acknowledges
Werewere Liking, a
Cameroonian theatre
practitioner working in
the Côte d’Ivoire, as
the creator of the term.
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Creating a space for the individual
Facing competition from the more visual and vocal anti-apartheid
theatre and lacking in resources due to the international donor’s
restrictions during apartheid, the development of educational thea-
tre in South Africa was slower than that of its neighbours. However
the arrival of AIDS swiftly spurred the growth of a large, developing
field of ‘reform[ed]… social actors’ (Kruger 1999: 206–207) with AIDS
awareness becoming a fundamental topic in educational theatre prac-
tice across South Africa (Blumberg 1997: 160). Two examples of this are
the ‘arepp: Theatre for Life’ programme and ‘DramAidE’, both long-
standing theatre organisations who have worked in the field of SRH
since 1987 and 1992. These projects, along with others, use a multi-
tude of different media, cultural performance forms and approaches to
tackle SRH issues by focusing on life-skills education to provide the
youth with the life-skills necessary to enable them to make informed
decisions about their wellbeing. For example, arepp performs plays
and puppet shows and facilitated discussions for schoolchildren coun-
trywide. Each play is written for a specific age group and uses current
sayings, ideas and music to both encourage identification with the
characters and to ‘foster thought and debate’ over key topics including
HIV, relationships and violence (Schultz & Bilbrough 2006).
Viewing art-forms (plays, songs, poetry and dance) as a means of
enabling interpersonal communication, DramAidE runs a number of
projects including Act Alive, which is aimed at peer-education and
developing healthy schools. A recent evaluation of this project found
that ‘it provided opportunities for young people to express themselves
in ways that they found authentic and culturally relevant’ (Dalrymple
2006: 205–210). Another strand of educational theatre frequently
employed in South Africa is Entertainment-Education (edutainment).
Based on a number of cognitive behavioural change theories, edutain-
ment is the placement of educational content within popular forms
of entertainments such as television, radio and magazines (Singhal
& Rogers 2002: 117). First broadcast in 1992, Soul City is one of the
largest health promotion edutainment programmes in South Africa
and its numerous television and radio dramas have helped to improve
health literacy countrywide (Scheepers et al. 2004).
It is within this context that I would like to consider the proposed
examples of performance-based practice by examining the forms used
and the opportunities created in the work for considering and validat-
ing the individual’s ideas and experiences. These examples have been
chosen because they illustrate different manners of approaching HIV,
while maintaining a focus on individuals. For example, Themba focuses
on HIV information dissemination, aspiring to ‘influence behaviour
change to prevent the spread of HIV/AIDS’, while Etafeni’s music and
dance programme is viewed as a support mechanism for HIV positive
people, and, finally, OPOS aims to use theatre and performance to cre-
ate spaces for the individual to discuss their views on SRH matters.
However, before undertaking this examination, it is important to
acknowledge that ‘individualism’ is a somewhat western concept and
JAAH_1.1_art_Low_111-126.indd 115 8/21/09 2:26:46 PM
Katharine Low
6. The term ‘community’ is
used here to describe
the gathering of people
within a theatrical
event. For example,
the schools in which
Themba perform could
be described as
7. For more information
about Themba: http://
hence to query if this is a notion that is appropriate for the South
African communities in question. In her monograph, Steering by the
Stars: Being young in South Africa, Ramphele argues: ‘[t]oo much indi-
vidualism leaves you overly focused on the self and denies you the
enrichment that comes from relationships with others’ (2002: 102).
This creates a conundrum as the representational projects chosen for
analysis all focus on the individual in a society which has traditionally
been community-focused. Yet, if we consider the medium of thea-
tre and performance, its basis lies in communication and it requires
some form of interaction with others in order to exist. Thus, although
these projects all provide an arena for the individual to speak and be
heard, it is within an existing ‘community’ or group; the individuals
are not isolated from others, rather they are in dialogue with oth-
ers and are reflecting on, or responding to, their own communities.

It can thus be argued that theatre and performance practice helps
to enable ‘the enrichment that comes from relationships with oth-
ers’ (Ramphele 2002: 102). Furthermore, considering recent research
conducted in Uganda, which concludes that increased social commu-
nication and a greater acknowledgement of the existence of AIDS in
the community has had an impact on HIV prevalence (Green 2003;
Low-Beer & Stoneburner 2004), it is possible to propose that theatre
and performance-based projects that have a particular focus on the
individual can be part of a more positive response to the AIDS pan-
demic in South Africa.
Set up in 2002, Themba HIV/AIDS Organisation is an interactive the-
atre company that creates performances predominantly for schools
but also performs for companies, community-based organisations and
corporate events in and around Johannesburg. They have a number of
HIV-related plays in their repertoire and use a variety of theatre tech-
niques, including a style of interactive theatre that they have developed,
which is influenced by forum theatre, theatre games, improvisation,
psychodrama and drama therapy. They also make use of short ‘cameo’
scenes or ‘duologues’ which they suggest help to ‘demonstrate a vari-
ety of possible responses to situations involving sexual encounters
and to stigma and discrimination at work’ (Themba 2006). In order to
ensure clarity and greater understanding, they employ colour-coded
visual aids ‘to impart clear messages about sex using popular terms
and language’ (Hope 2005: 241).
In April 2007, I accompanied a team
of Themba performers to a secondary school in Soweto to watch
one of their performances. My analysis of their work is based on this
performance as well as interviews with the actor-educators and the
Managing Director, Eric Richardson. However, it should be acknowl-
edged that my familiarity with Themba is not as comprehensive as the
other two projects and my presence at the performance may have had
an effect on the event that I am unaware of.
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Creating a space for the individual

8. One such project is
Lucky the Hero!, a
‘mini-musical’ run by
the Africa Centre
Management, based
at Stellenbosch
University. Developed
in 2004, the musical
delivers a high-
energy performance,
portraying the process
of being tested for HIV,
to farm workers across
the Stellenbosch area.
Each performance is
followed by a
question and answer
session. For more
information about this
project: http://www.
Themba’s interactive performance approach, which is more than the
usual question and answer session that other projects describe as being
their interactive element,
utilises a content based on differing indi-
vidual experiences of HIV. In his editorial to African Theatre: Youth,
Michael Etherton concludes from the different accounts of practice that
the communication of messages is much more powerful when there is
more space for audience interaction and when it is the youth them-
selves who have devised and created the dramas (2006: xii). Although
Themba does not involve the schoolchildren in devising the play, it does
provide numerous opportunities for the students to involve themselves
in the performance. The different interactive opportunities for the audi-
ence include voicing their own opinions on a topic, giving suggestions
of what the protagonist (Tumelo) could do next, and trying out a scene
from the play to see ‘how it feels’ (a form of role-play). This approach
involves the audience in a twofold manner: firstly, individuals are invited
to share their ideas and thoughts from the safety of their seats, and sec-
ondly, for those who desire it, they can get up and physically be in the
scene, trying out a particular response. In the performance I watched,
the audience of schoolchildren, aged between 13 to 15 years old, were
extremely eager to participate and to communicate their ideas, giving
many suggestions to anyone who went onstage.
In his recent overview of educational theatre, Anthony Jackson
explores the role of the aesthetic experience in the making of mean-
ing, proposing that theatre can help to dramatically heighten under-
standing of a subject. In particular, he argues that ‘the meaning has
to be made and experienced within the drama,’ explaining that the
aesthetic and ‘ludic’ (or ‘playfulness’) qualities of the drama have a
greater impression on participants and audiences than ‘overtly seri-
ous, message-driven elements’ (2007: 175, 198). Considering Jackson’s
argument, it is possible to propose that Themba has developed an
approach that trusts that the meanings embodied within the aesthetic
experience can be understood without making the meanings explicit
at the end of the performance. Themba employs both aesthetic and
‘playfulness’ qualities in its theatre techniques to embed messages in
the performance. One example of this is the stylised cameo scenes,
which portray three homosexual and heterosexual couples who have
different responses to HIV. Each cameo presents a different possible
response to the threat of HIV in a relationship, thereby providing an
opportunity for the audience to both observe different reactions and
decisions that individuals can make, and to discover for themselves
the diverse meanings and ideas embodied in the performances.
In addition to this, Themba uses the security of an already estab-
lished character through whom the audience members can express
their individual opinions and thoughts. Through the use of speech
and discourse within the theatrical moments, Themba is encouraging
the beliefs and notions of the individual in a safe environment – an
approach that was very well received at the performance I observed. It
is a model of theatre that is suitable for the community Themba works
JAAH_1.1_art_Low_111-126.indd 117 8/21/09 2:26:46 PM
Katharine Low

9. At the time of the
interview, in May
2007, Richardson
explained that Themba
was in the process of
developing teaching
materials, which they
hoped to leave with
the teachers to enable
them to provide
support for the students.
in, as it provides a means of generating and stimulating important dis-
cussions in environments like schools or correctional facilities, which,
as Themba have stated, sometimes ‘have cultures which tend to ostra-
cise people who are HIV positive’ (Creative Exchange 2007).
The performance at the school raised issues about sharing your sta-
tus and living with HIV; it challenged the young people to think in
different ways as well as demonstrating that opinions can be differ-
ent, which in turn raised many questions. At the end of the perform-
ance and interactive process, the actor-educators were swamped with
students asking questions and the performers strived to ensure that
everyone had had an opportunity to speak, even continuing the con-
versations in the car park. Furthermore, as some of the teachers also
watched the performance, there was the implicit suggestion that stu-
dents are able to continue these conversations with their teachers and
that they can turn to their teachers for support in the first instance.

Yet, it is important to recognise that the school environment may have
had some bearing on the students’ responses, as within schools chil-
dren are supposed to behave in a particular way.
One drawback of Themba’s approach is that apart from the train-
ing it offers to businesses, prison services and schools, it has little
engagement with other services which could support Themba’s work,
such as the local clinics. Moreover, Themba’s interactive performances
are only a few hours long and thus it does not have a continuous
involvement with its participants, unlike Etafeni or OPOS. Although
this is, in part, due to financial considerations and the large number
of schools Themba works with, it seems unlikely that without long-
term involvement and support from other services that Themba will
be able to achieve its aim of influencing behavioural change. Perhaps
if Themba’s aim to start conversations about HIV and sexual health
could be combined with mobile VCT clinics and the establishment of
peer-education programmes similar to the ones DramAidE has imple-
mented, supported by the local clinics, it could then form part of the
‘new’ approach required in South Africa.
Nevertheless, Themba does have long-term engagements with
people from the disadvantaged communities it works in: the actor-
educators themselves. Actively recruited because of the importance of
using appropriate languages when communicating with the audience,
the actors are trained by Themba and given yearly contracts, thereby
creating a sense of longevity and commitment as well as an oppor-
tunity for those individuals to be heard and have their experiences
validated. One actor-educator mentioned how, before they came to
Themba, they would not talk openly about sex or relationships but now
they do feel free to do so. This description of feeling free to speak, and
thus to be heard, is an extremely important example of what happens
when an individual is given the attention and the chance to share, try
out and discuss her or his ideas with others. I would suggest that this
is one of Themba’s underlying aims within both the performances and
the support and development offered to its staff.
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Creating a space for the individual
The second project to be examined is the Etafeni Day Care Centre,
which is an example of an approach that supports and enhances the
emotional and physical wellbeing of individuals infected or affected by
HIV. Etafeni is an organisation aimed at assisting people living with
HIV in the Nyanga township in Cape Town, one of the most vola-
tile townships in South Africa. The national crime statistics for 2008
demonstrate that Nyanga has highest murder rate in the country and
is rated third nationally for attempted murder, seventh for rape and
fourteenth for assault (de Vries et al. 2008). It has an HIV prevalence
of 28.8% and the rate of unemployment is over 56% (City of Cape
Town 2006). Originally established in 1983 as a small playgroup run
by women from Nyanga, since 2001 Etafeni has become a centre of
holistic care, support and training, offering opportunities for creative
income-generating work and provides a preschool, after-school care
and a clinic for its users.
As noted in the introduction, it is crucial in the care and support of
HIV-positive individuals and their families to provide a well-rounded
approach that caters for both physical and emotional health. In her
study of HIV-positive individuals in Namibia, Felicity Thomas argues
‘that living with long-term and stigmatized illness can play a cen-
tral role in shaping people’s identity, self-worth and wellbeing.’ Her
research highlights the importance of also considering the emotional
wellbeing of people living with HIV, as this has an effect on a person’s
sense of purpose and their desire and capability to take on familial
and financial responsibilities (2007: 81).
Considering Etafeni as an organisation, I would like to argue that
through the provision of a dance and music therapy programme,
Etafeni is caring for both the physical and emotional wellbeing of its
service users. For the past two years, the music and dance therapy
programme has been run at Etafeni, working with the preschool and
after-school children and the HIV positive women who are part of
the income-generating project. It is this programme’s work with the
women that will be considered here. When the project began, each
week one of the women would bring a song to the group that was
important to her, usually a traditional song from ‘home’. The musician
would then improvise with the group using the song and its melody.
The purposes of the practice are celebratory, to have fun, to have
some exercise, to recall and validate local traditions, and to encourage
sharing – the individual brings something of hers to the group who
validate it and reinforce it by engaging in the music session based on
her song. More recently, the women have included traditional danc-
ing into their weekly workshop, which is a performance-form that
Themba employs as well. In July 2008, the women choreographed a
performance of their dances for an audience at Etafeni in July 2008.
The after-school children’s group joined them at this event with a
music and dance recital, as did the OPOS participants performing a
series of short plays.
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Katharine Low
Interviewing some of the women a week after their performance, it
was apparent that while the dancing is appreciated for both personal and
emotive reasons, it is also enjoyed for its health benefits as it makes them
‘feel fit’. Incidentally there is a significant body of research (Stringer et al.
1998; Spierer et al. 2007) that demonstrates that exercise improves the
quality of life of HIV positive people. During the interviews, the women
emphasised how important the dancing was to them because it reminded
them of their ‘culture’ and their ‘tradition’. All the women referred to
their youth in the Eastern Cape and some of them told stories of past
events and experiences with family when dancing, becoming animated
and smiling at the memories. One woman described the following:
It also remind me of…my culture and my grandmother was also
a witchdoctor. Ya. We used to dance, […] we would have to stay
for the whole night, until 5 o’clock. If you were sleeping, they
would, what do you call that [makes a whipping gesture]? […] So
no one is supposed to sleep if it is a dance day. So it reminds me
a lot about my grandmother.
These responses from the women emphasise how strongly they feel
about the dancing and singing: how it provides them with an oppor-
tunity to express themselves, reconnect with their culture and provide a
physical break from their stationary work of beading or sewing. Taking
part in these dances together means that the women are able to recollect
and share their experiences while also building strong links with other
group members, who share similar experiences. In addition, these links
and interactions between the individuals can create avenues for sup-
port between them. This is similar to findings described by Irving in his
account of using ‘fieldwork performances’ (a type of photo elicitation and
social drama) to draw upon the emotions and memories of people liv-
ing with HIV in order to better understand the experience of HIV/AIDS
in Uganda. Describing one particular performance, Irving explains how
conversations about the experiences of HIV-positive people in Europe
and North America enabled one participant to diminish his ‘sense of
isolation and abnormality and allowed him to understand himself as
part of a wider cosmopolitan experience of HIV/AIDS’ (2007: 196).
Regarding the performance-forms used in this approach, the songs,
which come directly from the women, and the dances, which many of
them know from their childhood, do ‘fit’ in the community at Etafeni.
Furthermore, these art forms help to create communication channels as
the women are interacting through the music, dances and songs. This
work here at Etafeni is both self-focused (as the individual’s contribu-
tion of her song is reinforced) as well as strengthening bonds within the
Etafeni group. Although Etafeni describes this programme as ‘therapy’,
it is actually much more focused on celebration, and on promoting the
emotional and physical wellbeing of the women and children who are
part of the Etafeni community. However, within the dancing workshops
there seems to be few opportunities for the participants to devise their
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Creating a space for the individual

10. It is important to note,
however, that the field
of SRH is extremely
complex and that the
topic of ‘rape’ does not
stand isolated from HIV
or crime, hence all the
proposed issues were
touched upon during
both projects.
own dances, as they tend to practice traditional dances or ones which
the facilitator has choreographed. Nonetheless, the interactions within
the groups and between the groups, through the performance, help to
foster a sense of being part of a community of support, something which
Etafeni strives for. Moreover, Etafeni as a model centre of holistic care
and support is being replicated in the Vrygrond community, located in
another part of Cape Town. This indicates that, as a whole, Etafeni is
already viewed as a ‘new and positive approach’ for South Africa.
The final example for consideration is the OPOS project, which forms
the basis of my Ph.D., examining the role of applied theatre in sexual
and reproductive health communication. The concept of OPOS is based
on the aforementioned research in Uganda, which suggested that direct
and personal communication could play a vital part in limiting the spread
of AIDS. In addition to this, OPOS aims to redress the lack of focus on
the individual’s emotional response to a sexual health crisis by using
theatre to create spaces where individuals can be heard and to explore
how such community-led work may have an impact on communica-
tion between individuals and their community. OPOS was developed
after observing both the Themba and Etafeni approaches and thus it
could be argued that it is an approach that fills the gap between the two
projects. OPOS achieves this as it places the individual, and dialogue
between the individual and the community, more firmly at the centre
of its approach, as well as locating the project within a larger organisa-
tion that can provide additional support. During 2008, OPOS ran two
projects, each lasting two months, at the Etafeni Day Care Centre with
unemployed young people who were part of Etafeni’s ‘Fit for Life, Fit
for Work’ employment programme.
Influenced by applied theatre practice and prior knowledge
of theatre-based health promotion projects in South Africa, OPOS’
theatre-based approach has employed a variety of theatre techniques
which are similar to the ones that Themba utilises, particularly improv-
isation, interactive theatre, and dance work. Each project began with
theatre games and improvisation techniques, gradually moving into
image and sculpture work in order to create opportunities for discus-
sion. This is an organic way of bringing about discussion as it can bring
up a variety of issues which the participants can decide they need to
discuss. It is an important part of the project’s focus on the individual,
as it provides a space where the individuals can suggest SRH issues
and topics that they feel are important to explore and discuss.
For example, during the first week of one project, the image work
raised ideas around teenage pregnancy, HIV, rape, child abuse, the recent
xenophobic violence and the high levels of crime, which the group then
narrowed down to rape and teenage pregnancy, exploring these two
topics in greater depth.
This initial work was followed by more improv-
isation, dance and object-based exercises where the participants used
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Katharine Low
11. The participants’ names
have been changed.
12. Community meetings
are meetings organised
by the various street
and community
committees in most
townships. The
community meets in the
community hall when
there is something
important to discuss.
the fictional worlds created through theatre practice to explore different
ways of protecting their SRH health. Similarly to Themba’s audiences,
the participants tried different roles in scenarios that explored teenage
pregnancy and the boundary between unprotected sex and rape as a way
of better understanding how and why these situations come about, dis-
cussing how they could be avoided. In addition to this, the participants
also devised short scenes and interactive dramas which they presented
to different audiences at Etafeni, which, recalling Etherton’s aforemen-
tioned conclusion, can lead to better communication of information.
An important feature of this work has been the opportunity to work
in the supportive, community-based environment that is provided at
Etafeni. This positioning, combined with the theatre workshops provision
of opportunities to reinforce and validate each individual’s experience and
opinions, has meant that some of the participants have felt more inclined
to discuss SRH within their community. Nkosazana is one example:
ing a follow-up visit she described how she spoke to her younger sisters
and her neighbour’s young daughters about teenage pregnancy, which
resulted in her taking one of the young girls to the clinic, explaining:
Since because I am easily talking to them, they are free to come
and talk to me, ask something to me. I also think […] I have some-
thing to tell to someone, something good. I can advise someone.
The notion of having something to tell, of being able to share her
opinion, is echoed by Thandiwe, a woman in the second project who
shared with me in an interview how, during the OPOS project, she
started to stand up and speak out at the community meetings held in
her neighbourhood,
something she had never done previously:
[…] before, I want to talk to them but I, I afraid to stand in front
of them and tell them. […] But now, I am proud of my [laughs
and points to herself] because I am going and talk. I am going to
the [community] meeting, I raise my hand and tell them.
However, there were a few in the group who did not feel able to speak to
their community, for reasons outside their control. Vuyiswa, in response
to a question asking her if she would discuss the topics they examined
during the workshops with her community, replied that she would not as
she would be too afraid of their reaction to her, explaining ‘I would rather
just keep it to myself and my family.’ Vuyiswa was a strong and confi-
dent member of the group, always contributing and sharing her views,
frequently getting up to participate in a scene. It could be suggested that
within the theatre space, she felt safe and comfortable and thus was able
to share her opinion and discuss things that she would not feel comfort-
able or safe doing outside of that space. This demonstrates the impor-
tance of providing such space where people can debate, discuss and
share, without fear of recrimination or being at risk. However, there are
some limitations in this approach, mainly because it is a research project,
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Creating a space for the individual
which continuously redeveloped its approach as the projects unfolded,
and because it is significantly shorter than the Etafeni project.
Considering these three examples, a number of things are apparent:
firstly, providing space for individuals to discuss and share their fears
and emotions concerning HIV and other sexual health matters is essen-
tial as it is part of a rounded response that considers the physical and
emotional health of the individual. Secondly, theatre and performance-
based projects work well as part of a larger structure. For example, both
the music and dance therapy programme and OPOS are located within
the holistic Etafeni centre where onsite clinic staff, counsellors and social
workers are available, providing physical and extended emotional and
mental healthcare if the participants require it. Finally, longer projects
have more time to focus on the individual and provide prolonged peri-
ods in which individuals can develop relationships with other group
members. This creates opportunities for the individuals to try out their
ideas, recollect and share past experiences and, perhaps, feel that they
have ‘something good to tell someone’. Furthermore, more time means
that the discussions of the issues can be more detailed, which may lead
to communication outside of the theatre space – an aim that is shared by
both Themba and OPOS. However, while the OPOS projects were rel-
atively short in comparison to the music programme at Etafeni, they still
provided additional time to focus on the individuals than the approach
taken by the Themba programme. Moreover, there were some exam-
ples of external communication, as was the case with Nkosazana.
To conclude, the greater inclusion of performance-based work in the
field of SRH communication and AIDS prevention is vital as it helps to pro-
vide a more complete response, considering both the physical and emo-
tional health of individuals. With theatre and performance-based work it is
possible to focus in on the individual’s particular experience and substanti-
ate it as valid and important. It provides spaces for people to discuss con-
cerns and ‘try out’ situations safely and it can encourage communication
between individuals and the community. Nonetheless, it is also important
to recognise the complexities of the work; for example, the different forms
of practice (interactive theatre, music and song, speech and discourse) are
multiple, nuanced and have differing agendas and purposes in their man-
ner of use. The three examples have demonstrated this through their differ-
ing aims and the groups of individuals they focus on, who all have different
needs. For example, the HIV positive women at Etafeni require a different
approach than the young people the OPOS project worked with.
In their discussion of the Afro Reggae project in Rio, Patrick Neate
and Damian Platt note the founder’s argument that ‘Afro Reggae is
not a franchise and you can’t just drop Afro reggae anywhere like
McDonald’s. We can’t just come in and create an illusion and then
leave, it has to be a considered and continuous process’ (2006: 61). This
is true too for the examples described here. Each of the approaches
have many positive qualities, however what works in one community
or location, may not work in another. Thus, developing a ‘new and
positive approach’ to the AIDS pandemic in South Africa needs to be
JAAH_1.1_art_Low_111-126.indd 123 8/21/09 2:26:46 PM
Katharine Low
a ‘considered and continuous process’. This article forms part of this
considered process, serving to illustrate the different means of using
theatre and performance forms to place the individual and their emo-
tional and physical wellbeing, at the forefront of an approach that
aims to tackle the AIDS pandemic in South Africa.
Many thanks to the participants in the OPOS projects, to all at Etafeni
for their help, and finally, thank you to James Thompson, Jenny
Hughes and Zoe Zontou.
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Low, K (2010), ‘Creating a space for the individual: Different theatre
and performance-based approaches to sexual health communication
in South Africa’, Journal of Applied Arts and Health 1: 1, pp. 111–126,
doi: 10.1386/jaah.1.1.111/1
Katharine Low is a practice-based Ph.D. student in the Drama department
at the University of Manchester, supervised by James Thompson and Jenny
Hughes. Through her research project, ‘our place, our stage’ (OPOS), she is
exploring the role of applied theatre in sexual and reproductive health com-
munication in the Nyanga township in South Africa, focusing in particular on
concepts of spatiality, risk-taking and resistance.
Contact: c/o our place, our stage, Centre for Applied Theatre Research, University
of Manchester, The Martin Harris Centre for Music and Drama, Manchester,
M13 9PL, United Kingdom.
E-mail: katharinelow@gmail.com
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JAAH 1 (1) pp. 127–129 Intellect Limited 2010
Journal of Applied Arts and Health | Volume 1 Number 1
© 2010 Intellect Ltd Review. English language. doi: 10.1386/jaah.1.1.127/4
London: Jessica Kingsley Publishing UK, 336 pp.,
ISBN 9781843109747, Paperback, RRP £17.99
Reviewed by Hayley Singlehurst, The University of Northampton
Transforming Tales – How Stories Can Change People
The strap line ‘How Stories Can Change People’ indicates the value of
Rob Parkinson’s latest contribution to illustrate the impact of stories
on our everyday lives, alongside the therapeutic potential of storytell-
ing. Transforming Tales illuminates the author’s focus on how stories,
used therapeutically, can instigate change in people’s lives. In this book
Parkinson neatly guides the reader through the uses of stories that are
hidden in cultures and everyday social interactions, before revealing
an odyssey of examples to put into practice to help the reader under-
stand how stories can be embraced further than just bedtime routines
and spirited tales around a fire on a cold winter’s night. He reveals
how we make sense of our own life worlds through the stories we
construct, each second and minute of each day. Parkinson also reveals
how stories are embedded in our everyday lives and are used by vari-
ous sources to manipulate or stimulate our way of thinking and pro-
vide benchmarks of who we are and what we should or could be.
Parkinson recognises reframing and story trance as a main
source of change and draws on the writings of Milton Erikson, the
American psychiatrist often noted for his unconventional approach
JAAH_1.1_rev_Singlehurst_127-129.indd 127 8/21/09 2:49:51 PM
to psychotherapy, who specialized in medical hypnotherapy and
who developed the extensive use of therapeutic metaphor and
story. Parkinson extends this further by referring to imagination
as being a source of helpfulness and hindrance. Encouraging the
use of imagination through the art and craft of storytelling is what
Parkinson aims to do by taking the reader on a journey of its uses
across cultures and throughout time.
The most useful chapters are 3 and 4, entitled ‘It’s the way you tell
‘em’ and ‘Traditional ways of storytelling’ respectively. Chapter 3 offers
practical tips on techniques of storytelling, from familiar techniques
such as pacing, preamble, energy, and eye contact to less familiar
skills such as the use of ‘resistance and confusional language’. This is a
technique that can be used in order to get the listener’s creative areas
of their brains working. The sub-section called ‘The attention bargain’
also gives an interesting insight into the levels of attention that are
needed in the practice and art of telling stories. Within it Parkinson
provides a summary of what is at the heart of storytelling: keeping
it simple, knowing the story well and trusting it to do its job. Within
Chapter 4, ‘Traditional Ways of Storytelling’, Parkinson draws on
two traditional ways of storytelling: the fable and the dilemma tales.
Using many familiar fables and tales such as ‘The boy who cried wolf’,
Parkinson illustrates the effect and meaning of the context in which
stories are told and the intention with which they are told, touching
on the use of metaphor and multiple meanings.
It order to stretch and further stretch stories it gives license to the
narrator to fib in order for it to fit the context in which it is being told.
This is not only fun but also feels quite natural, and by that one should
ask, ‘When was the last time you told a story about an everyday
occurrence without even the slightest of embellishment?’ This adds
weight to Parkinson’s claims that humans are natural storytellers and
that story is central to our everyday lives. These chapters provide con-
siderations from both storyteller and listener perspectives; explaining
how the teller can immerse themselves within the story, and become
the story in order to bring it alive and captivate audiences of different
sizes and backgrounds.
The use of language throughout the book is interesting, stimulat-
ing and thought provoking. The extensive use of fables, stories, shorts,
narratives, and vignettes, enables Parkinson to share the tools and
techniques of the storytelling trade in a unique way. His clever uses of
drama and cliffhangers within the illustrations also draw the reader in,
helping he/she move through the book more smoothly and enthusias-
tically than if one had an academic textbook.
As with the illustrations it is clear that the author has drawn
from a wide range of sources of theory regarding the claims he
makes about the impact of stories, yet the referencing is sporadic.
As a result it is not always clear whose view is being expressed,
whether these view are credible evidence or whether Parkinson’s
own speculations are being aired. This will be an important aspect
JAAH_1.1_rev_Singlehurst_127-129.indd 128 8/21/09 2:49:51 PM
for those wishing to perform the art of storytelling in settings where
evidence-based practice continue to support and influence choices
of therapeutic interventions. It is also clear that the author is an
experienced storyteller who has practiced as a performer and a ther-
apist in a variety of settings. His writing reflects this, but it may
be slightly unrealistically optimistic about the competence of others
who wish to follow in his footsteps. This is more prominent in the
chapter regarding guided imagery and the inner storytelling process.
It describes how the technique can be used for those suffering from
Post-Traumatic Stress Disorder (PTSD). Although it explores the
work and successes of ‘therapists’ using the techniques, it is imme-
diately followed with ‘Four relaxation techniques’ to use in order for
the reader to know how to relax themselves, and others, in order for
guided imagery to work best. This raises the question regarding the
level of competence needed to carry out the techniques. Working
with people who experience PTSD requires in-depth knowledge of
the condition and, in the majority of cases, training within the sub-
ject area in order to practice ethically and minimise further trauma
being experienced. However, Parkinson makes no reference to the
prior expertise needed or the collaborative working necessary to
carry out this particular technique; it is implied rather than explicit.
Taking into consideration one’s own limits, expertise and potential
growth, this book can act as a manual to anyone interested in using
stories therapeutically. It is surprisingly and ultimately a story about
the power of stories and storytelling and will appeal to many profes-
sionals and anyone interested in the capacity, the power, and the use
of stories as a potential vehicle for change.
E-mail: hayley.singlehurst@northampton.ac.uk
JAAH_1.1_rev_Singlehurst_127-129.indd 129 8/21/09 2:49:51 PM
Journal of Applied Arts and Health (JAAH) is the academic
journal for scholars from around the world whose research
interests focus on the interplay between arts and health.
Research articles for peer review should seek to evidence
the effectiveness of applying arts to health practices and are
grounded in the relevant literature. In addition, book reviews,
article abstracts, conference reports, interviews, obituar-
ies and key documents, all contribute to JAAH’s mission to
stimulate scholarly interest in the field. JAAH only publishes
in English. The views expressed in the journal are those of
the authors, and do not necessarily reflect those of the Editor
or Editorial Board. The following notes are intended to assist
contributors in preparing papers for consideration by the
editor. Regrettably non-compliance with the requirements
set out here is grounds for rejection. Papers and contributions
accepted for publication become the copyright of the publisher,
Intellect, unless otherwise agreed.
1.1 Research articles will be evaluated by double-blind peer
Research articles should:
• Contain original research or scholarship.
• Not be under consideration by any other publication.
• Usually be between 3000–6000 words in length.
• Be written in a clear and concise style.
• Conform to the instructions outlined below in particular
the use of the Harvard referencing system.
1.2 Review pieces will not be subject to peer review but
require approval by a reader other than the editor or
reviews editor.
Review pieces should:
• Should usually be between 600–2000 words.
• Be written in a clear, concise, readable style while avoiding
colloquialisms unless explained.
• Not be under consideration by any other publication.
• Submissions to JAAH should be sent as an attachment to
an e-mail message to the editor: ross.prior@northampton.
• The attached article should be ‘anonymised’, and contain
an abstract and up to six keywords. This is to maintain
confidentiality during peer review. You should delete the
‘File properties’ or ‘Summary info’ of your document (see
file menu) that reveal your name and institution. Be sure
to add your full name and address in the e-mail message
to the editor.
Articles accepted for publication cannot be sent to the
publishers (Intellect) until they contain:
– Correct Harvard system references (see below for
details; however this is very similar to APA)
– Author name and institutional affiliation.
– Abstract (max. 150 words) in English.
– Keywords (max. 6) in English.
– Author biography (c. 50–100 words) in English.
– A list of References containing only works cited in the
• Font should be Times New Roman 12 one-and-a-half
line spaces and left aligned, not justified.
• Margins should be 1 inch/2.5 cm all round.
• Pagination should be continuous with numbers applied
top right.
• Images – tables, photographs, graphs, and graphics –
should all be entitled ‘Figure’; be numbered consecutively;
and be clearly legible. The source must be indicated
below each. If images are less than half a page in size,
they may be inserted into the text according to the place
of insertion. If larger, they should be placed on separate
pages at the end of the article. In this case, ensure that
an indication has been given as to where they should be
placed in the text, e.g. Insert Figure 3 here.
• Quotations should be used sparingly and be identified
by ‘single’ quotation marks if they are embedded in the
text. Longer quotations (i.e. longer than 40 words) should
be indented on both sides, without quotes. Both should
be referenced using the Harvard system (see below). The
page number(s) must be included.
• Foreign words and phrases inserted in the text should be
in italics.
• ‘Explanatory notes’ should be kept to a minimum: they
will appear in the outside left or right margins of the text.
They should not contain publication details; submit all
these as references. Please use the Word (or equivalent)
‘note’ facility and ensure that they are submitted as end-
notes, not footnotes.
• Place endnote marks outside the punctuation (after the
comma or full stop). The note mark must be in super-
scripted Arabic (1, 2, 3), not Roman (i, ii, iii).
• Bibliographical references should use the ‘Harvard style/
system’ (author + year: page), e.g. (Taylor 2003: 29)
inserted into the text. Note that punctuation after the
author’s surname and between the year is not used)
All references must identify an author (surname or institu-
tion name) for all documents, whether found in archives,
newspapers, the Internet, etc. The ‘author’ for a law or bill
will be the legislative body/parliament of a country, e.g.
Department of Health. The author of a poll or survey is
the polling organisation. The author of a news item is the
journalist (his/her by-line) or the news agency, not the
• Each Harvard-style reference should be fully sourced in a
list of ‘References’ at the end of the text.
Author surname, Initial (year), Title in italics, Place of publi-
cation: Publisher.
e.g. Taylor, P. (2003) Applied Theatre: Creating Transformative
Encounters in the Community, Portsmouth, NH: Heinemann.
Note the use of a comma after the book title.
Author surname, Initial (year), ‘Title in single quotation
marks’, Name of journal in italics, volume number: issue
number (and/or month or quarter), page numbers (first and
last of entire article),
e.g. Prior, R. (2007) ‘Understanding actor trainers’ articula-
tion of their practice’, Studies in Theatre and Performance, 27:
3, pp. 295–305.
JAAH_1.1_rev_Singlehurst_127-129.indd 130 8/26/09 7:56:01 AM

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