“Once more unto the breach…”

A scene from the play “Our Trojan War,” which is a collaboration between Aquila Theatre and combat veterans of the Warrior Chorus (Credit: Richard Termine)

I love theatre.

When I was conducting some research as a medical student at Great Ormond Street Hospital in London, I would have really long “theatre days.” They started early with a neurosurgical round followed by several hours in the operating theatre observing brain surgery on children with severe intractable epilepsy. Then I’d head back to my Air BnB to get changed before heading out to the West End to watch a play.

So you can imagine how I was gripped by Bessel Van der Kolk’s chapter on theatre in his seminal work on trauma, “The Body Keeps the Score.” He suggested that theatre can act as a catalyst for personal understanding of trauma. He provided a number of case studies of the use of theatre in groups of people with a history of trauma, suggesting that this is an effective embodied means of processing trauma.

Representing trauma

Trauma is widely represented across cultural practices. It is a major theme in ancient Greek tragedy, and tragedy with traumatic themes extends along a rich vein through Western theatre until today.

Tragedy today is expressed across a wide variety of mediums from theatre, to dance, performance art, to film. Alex Mangold writes that tragedy has a “decisively psychological purpose because it defines and provokes a split subjectivity we all share.” He argues that tragedy does this by creating inexplicable instances of human trauma.

Other scholars have observed that tragedy is a way in which society can attempt to understand and contextualise trauma. This is certainly Van der Kolk’s perspective of the potential for theatre in people with a history of trauma. In fact, this is the basis of treating Posttraumatic Stress Disorder (PTSD) with trauma-focused Cognitive Behavioural Therapy. It attempts to make sense of the trauma by creating a narrative of the trauma. It makes sense why Van der Kolk would see the potential for theatre in this way.

Mangold counters by suggesting that tragedy acts as a call to action. I like the way that Mangold thinks, but the pragmatic therapist in me has to side with Van der Kolk. Regardless of where the needle falls, our own human experience would have to concur that theatre has a powerful potential to represent trauma.

Where is the evidence?

But there is surprisingly very little clinical evidence in the academic literature on the impact of theatre on trauma despite the rich field of dramatherapy; to date the only published review found no clinical benefit in PTSD. Perhaps this is because the question seems so obvious because of the deep cultural roots of the catharsis from representing trauma in theatre.

Look at the work of the Warrior Chorus from the image above. It is powerful, it is relevant, it is cathartic. It is veteran-led and assisted by artists and academics so that they can explore how contemporary issues connect with classical literature. Through reading Greek plays and historical texts, the participants frame a discussion about democratic themes and develop a public programme.

It makes sense that this will work and anecdotally it does. So why does the academic literature have so little evidence? Perhaps there’s another reason why there is such a limited amount of literature.

When I and a couple of colleagues sat down to look at the literature, we realised that the limited evidence was focused on participants with a formal diagnosis of PTSD. So we asked ourselves whether this clinical lensing limited the search for what evidence is there.

We broadened our search so that a diagnosis of PTSD was not required. And we found five studies, all of them with promising results but not without some significant limitations.

Reframing the evidence

I think that this is actually an indication that we’re looking at this the wrong way. I think that theatre is an immensely powerful cathartic engine for working through trauma. Why else would tragedy run so deep across so many traditions?

Also, look to therapy for other clues as to why the clinical evidence is so scant. After all, therapy - especially psychodynamic psychotherapy - is a kind of theatre played out in the darkly unsconscious worlds of two (or more) individuals. When anybody confronts their demons for the first time in therapy, they will experience a set back. Uncovering the unconscious is hard. Catharsis is hard. Integrating trauma is hard. And psychometric scores are too crude to detect the deep changes from tackling trauma.

Healing and growth can follow from takcling one’s demons. This is a fundamentally human struggle. But each individual needs to find their own pathway through the undergrowth. If that is played out on the stage, then who are we to suggest it lacks any evidence? To quote Oscar Wilde: “I regard the theatre as the greatest of all art forms, the most immediate way in which a human being can share with another the sense of what it is to be a human being.”