Dangerous deviation or creative responsiveness?

In the age of evidence-based therapy and the associated treatment manual, what of the evocative imagery of the 'swampy lowlands' of clinical practice described by Donald Schön (1983) more than 30 years ago? When the firmness of what appears 'high, hard ground where practitioners can make effective use of research-based theory and technique' (p.42) gives way to the mess of the swamp, do we hold the manual tighter – a float should we start to sink – or is it time to let go of what will be the weight that pulls us under?

Observing professionals' work, Schön found that when faced with the inevitable 'surprises' of the mess of real-world practice, they would use 'reflection-in-action', enabling an improvised response. This response, drawing on previous knowledge and experience, developed a practice open to constructing a new theory unique to each case. The development of the 'reflective-practitioner' role from this work is now central to applied psychology practice (Health Professions Council, 2010).

The manualisation of therapy has more of the hopes of those on the high hard ground with its evidence-based interventions. But, even for Improving Access to Psychology Therapies (IAPT) services focused on applying these interventions, training recognises the need to be able to respond to 'complex and unpredictable situations' (Department of Health, 2008, p.10).  

All therapists improvise to some degree in their practice, and much of the skill in this is developed over time through reflection-on-practice, such as retrospective supervision and reflective journals. But can therapists further develop this responsive ability, by learning from specialists in improvisation outside of therapy? The following thoughts are based on my exploration of theatrical improvisation training with therapists (Selman & Wheeler, 2014).

What is improvisation?

What does it mean to improvise? You may think of TV comedy, jazz, the horrific news reports of Improvised Explosive Devices (IEDs) in Iraq, and in day-to-day conversation as people get by in less than ideal circumstances – 'We ran out of… so I improvised.'

Dictionary definitions of 'improvise' identify two areas: 'to speak or perform without preparation', and 'to make or create (something) by using whatever is available'. Neither particularly inspires a desire to embrace a deliberately improvisational approach in therapy; who would want a psychologist who comes unprepared or seemingly makes do with whatever is at hand? There are a variety of definitions in the arts but most focus on the act of 'spontaneous creation' (e.g. Nachmanovitch, 1990).

Some analyses of improvisation come to the conclusion that it is something that is part of life through activities like conversation (Sawyer, 2001). There is a risk of losing a distinction between the everyday and a deliberate approach where the practitioner develops the necessary skill to enable it. Berliner (1994) argues most definitions of improvisation in jazz overemphasise the spontaneous creative act as coming from an 'intuitive' performer, which he sees as diminishing the importance of experience and extensive practice that are needed to perform well. Certainly, anyone can 'improvise' something on a musical instrument, but not everyone is Miles Davis.  

Learning from theatrical improvisation

While the metaphor of the jazz musician is helpful, it does not offer an immediate link for therapists in how to develop this skill. However, the mindset and techniques that enable improvisational theatre performers to creatively collaborate do lend themselves to the therapist (Selman, 2015).  

For the actor working from a script, whom we might compare to the manualised therapist, there are times within a performance where they may need to go off script; this could be that they or another miss a piece of the text and need to bring it back to a level of coherence, or a prop is missing so the script at this point does not match what is happening on stage. We could equate these times to the unexpected – a client is late and now we have 20 minutes for the session. How best to go on? Then there is the skill of the actor responding to the timing, intensity and body language of the other actor as they play their role, so that each line delivered is a unique response to this whole. This makes a play appear to the audience as if the words are spoken for the first time, that these characters are people interacting. The therapist too needs a responsiveness that reflects the 'in the moment' relationship if they are to be experienced as genuinely 'there' for the client. While a therapeutic intervention may have been done many times before, this response is to this unique person and not simply a 'going through the motions'.

We also have improvisational theatre where the performance is entirely unscripted, created 'on the spot' (Frost & Yarrow, 2007). This could be equated to those therapies (or therapists) that have an approach and associated methods and techniques, but session content and structure is not planned.

The influence of theatrical improvisation as metaphor, and also at levels of method and technique, has been touched on as guiding principles in psychoanalytic practice (Ringstrom, 2001), through the incorporation of improv exercises as a form of couples and family therapy intervention (Wiener, 1994), and even as inviting the development of a unique therapeutic approach for each practitioner in Keeney's (1990) Improvisational Therapy.

The difference from the reflection-in-action of Schön is the active incorporation and development of a creative act. The obstacle, mistake or novelty can, like a philosophy problem to Wittgenstein, 'dissolve' as we treat this as part of the creative process.

Training in improvisation

To give the reader an idea of what therapists may experience in improvisational training we will explore the practice of 'Yes and…', which is central to improvisational theatre (Johnstone, 1981).  

Most initial training is done through playing games, enabling people to step outside of the success/failure, approval/disapproval mindset that stifles our spontaneity (Spolin, 1999). In this playful atmosphere we practice recognising whatever happens as an offer; the words fellow improvisers say, their body language, an unexpected sound off stage, etc. For therapists their clients' narrative and what is happening in the moment – relationally, environmentally – are all like the offers the improviser looks out for. For the manualised practitioner many of these offers will fit, or can be fitted, within the prescribed practice. However there will always be offers outside of this for example, the home visit where a family dog sniffs around ominously at your leg, or a client says 'I brought my best friend James. Can he join the session? He knows what I'm like.'

Once offers are recognised we will introduce the idea of saying 'Yes!' – literally at first and figuratively later in performance. People starting out find that even in the apparently low risk activities in a workshop, perhaps telling a story together, they will habitually block their own and others' ideas. Improvisation trainers view much of this as due to anxiety (Johnstone, 1981; Napier, 2004), something psychologists can offer a range of theories to support.

Although it might seem counterintuitive we might play games where people deliberately block ideas. 
A: 'We enter our spaceship'
B: 'No! We're climbing a tree' (or perhaps) 
B: 'Unfortunately it's out of fuel so we have to leave.'

In doing so, people come to recognise their own and others' blocking, the disheartening effect of having ideas killed off and the difficulty in keeping a positive relationship when doing this. Therapists might reflect on what it is like for the client whose offers are knocked back without even acknowledgement '[No] 
We only see people individually here!'

Having experienced 'No!' we practice saying 'yes and', where 'yes' is accepting the offer and the 'and' is our own contribution that builds on this. However, if the responses are said unenthusiastically with an attitude of 'If I have to!', the energy will be low and the willingness to make offers is less. So we train with responding to each other with enthusiasm. With the enthusiastic 'Yes and', the process becomes enjoyable and it is easier to make offers when you experience them as fully accepted. 
A: 'We enter our spaceship.'
B: 'Yes and as the door closes we take our seats and start the engines.'
A: 'Yes and we blast out into space heading towards the international space station.'
B: 'Yes and we come to the space station and see purple tentacles poking out of the landing bay.' 
A: 'Yes and …'

Once people engage with this creative process the workshop tends to become filled with laughter, a sense of energy, engagement… adventures become interesting. People take more risks with their offers and, because working cooperatively is fun, are willing to make mistakes. What would it be like to experience a therapist willing to set aside the manual and embrace the unexpected as an opportunity? How much might your practice alter with the option to say 'yes' and explore where this takes you both?

These broad process skills offer an approach to the unexpected – saying 'yes' opens the possibilities and the 'and' is where experience, current context, theory, and evolving understanding of the client determine the therapist's offer.  

A new adventure

Therapy, like all of life – aside from Benjamin Franklin's famous pronouncement on death and taxes – is uncertain. Regardless of our preferred, or required, way of navigating the swampy lowlands of clinical practice, there is a need for some degree of improvisation. The active development of this through training seeks to further what experienced therapists do with 'knowledge-in-action'. It serves to enhance not replace practice; an uninformed purely spontaneous improvised Dadaesque version of therapy would be as oppressive as an automaton-like following of theory and technique when it is not working. Ultimately, engagement with improvisation training offers the practitioner options and possibilities. So, will you say 'yes' to the idea of an improvisational stance, knowing that it brings the possibilities of creative responsiveness but also the uncertainty of not always being able to open the manual and say 'See, I did it right'?

- Matt Selman is a principal clinical psychologist at Northumberland, Tyne and Wear NHS Foundation Trust 
[email protected]

References

Berliner, P.F. (1994). Thinking in jazz: The infinite art of improvisation. Chicago: University of Chicago Press.
Department of Health (2008). Improving Access to Psychological Therapies - Implementation plan. Available at tinyurl.com/jdvcavp. 
Frost, A. & Yarrow, R. (2007). Improvisation in drama (2nd edn). Basingstoke: Palgrave.
Health Professions Council (2010). Standards of proficiency: Practitioner psychologists. London: Author.
Johnstone, K. (1981). Impro: Improvisation and the theatre. London: Methuen.
Keeney, B.P. (1990). Improvisational therapy. New York: Guilford Press.
Nachmanovitch, S. (1990). Free play: Improvisation in life and art. New York: Penguin Putnum.
Napier, M. (2004). Improvise. Portsmouth, NH: Heinemann.
Ringstrom, P. (2001). Cultivating the improvisational in psychoanalytic treatment. Psychoanalytic Dialogues, 11(5), 727–754.
Sawyer, R.K. (2001). Creating conversations: Improvisation in everyday discourse. Cresskill, NJ: Hampton Press.
Schön, D.A. (1983). The reflective practitioner. New York: Basic Books.
Selman, M. & Wheeler, J. (2014). Whose reality is it anyway? Context, 134, 12–15.
Selman, M. (2015). Getting 'withness'-thinking through theatrical improvisation. Context, 138, 32–34.
Spolin, V. (1999). Improvisation for theater (3rd edn). Evanston, IL: Northwestern University Press.
Wiener, D.J. (1994). Rehearsals for growth. New York: Norton.