Question: How many mental health carers are there in the UK? Do you know? Or would you have to guess?

Answer: 1.5 million people in the UK are currently caring for someone with a mental health problem. On average, a carer’s role involves 60 hours of unpaid work a week.

In the context of under pressure services and funding cuts across the board – such as the £800,000 taken from the annual budget of the Glasgow Association of Mental Health (GAMH) earlier this year – the role of carers has recently shot up the political agenda. With the Scottish Government’s mental health strategy up for revision in January 2016, this is a crucial time to pay heed to this unseen and unheard workforce, and to give them the visibility and voice they deserve.

Enter Headtorch – an innovative group founded by Amy McDonald (who has already addressed the issue of mental health at work with The Cynthia Show). Now, in collaboration with GAMH and funded by Greater Glasgow and Clyde NHS and Care Information Scotland, they have devised a new project, The Guessing Game, that focuses attention on the role of carers in mental health.

What emerges, then, is a timely call for action. Based on research by GAMH and carers’ first-hand accounts and participation in a Headtorch drama group, this is an interactive drama that puts into performance a much-needed shift in approach. Rather than following a traditional linear model – where carers and professionals stand either side of the service user and never get to meet – the drama introduces us to the holistic ‘Triangle of Care’ (see this PDF for more information), a ‘therapeutic alliance’ in which all three come together to address acute mental health care as a team.

This collaborative approach towards mental health treatment is mirrored by the collaborative approach to the The Guessing Game itself. After all, as the character of Derek says in his opening speech to the audience: ‘This could be anyone’s story, this could be your story’. We’re all already involved and implicated, right from the start. Engagement takes centre stage so that, rather than passively watching, those who witness also get to co-produce. The play is therefore interrupted, altered, edited, rewound and rerun by suggestions shouted out by audience members, a back and forth that disrupts the usual theatrical experience and draws everyone in.

The three Headtorch actors, Amy, Steve and Kate, play the roles of Jane, a woman whose mental health issues gradually worsen throughout the performance; Derek, her husband and carer; and Sophie, Jane’s sister; as well as a series of professional figures: boss, GP, Community Psychiatric Nurse and Registered Mental Health Nurse. Scenes from Jane’s life are interspersed with song excerpts with lyrics that play on the actors’ lines, piecing together a story of how a woman’s mental decline affects her husband and children and how their encounters with service providers risks aggravating the crisis rather than resolving it.

However, while ‘narrative disruption’ is often seen as a negative consequence of mental health and disability issues, in which the flow of ‘normal life’ is radically thrown off course, in the context of The Guessing Game, it is disruption which provides a positive space and opportunity for change and intervention to take place.

Intermittently, McDonald ‘presses pause’ on the performance, steps out of character, turns to the audience and invites them to engage. An unsuccessful early encounter between Jane and a harassed and dismissive GP is opened up for analysis, with audience members talking directly to the characters involved, asking the GP about her avoidance of eye contact and distractedness, while the GP in turn has the chance to say how much pressure she is under and how unable she feels to cope.

At other times, the audience are able to shout out the names of characters so that they can freeze-frame the action and gain privileged access to their inner monologues, a crucial insight into all that goes unsaid beneath the surface of everyday conversations and the miscommunication that so often results.

Later, we witness a fraught conversation between Derek and a Registered Mental Health Nurse on the psychiatric ward where his wife has been sectioned, with the consequences of bad practice vividly enacted before us. The scene is then replayed, but this time with the audience able to intervene, voicing advice and instructions about how to proceed. From a heated and dramatic confrontation, the scene is transformed into an empathetic encounter between two people dealing with a difficult situation the best they can. The critical insights and suggestions of audience members effectively rewrite the script, re-choreographing the on-stage dance so that the outcome is radically different.

The stop-start, jigsaw pieces of the play are united in part by Macdonald’s role as mediator, and in part by the thread of the ‘6 standards’ taken from the Triangle of Care model and identified on cards held up at key moments. The 6 principles are therefore woven into the action on stage, taking what might have felt like a dry list of criteria and bringing them to life before us:

Taken from the Royal College of Nursing website, the six key principles are:

• Carers and the essential role they play are identified at first contact or as soon as possible thereafter.
• Staff are carer aware and trained in carer engagement strategies.
• Policy and practice protocols re confidentiality and sharing information are in place.
• Defined post(s) responsible for carers are in place.
• A carer introduction to the service and staff is available, with a relevant range of information across the acute care pathway.
• A range of carer support services is available along with a self-assessment tool.

While respecting confidentiality and the rights of the service user, the Triangle of Care nevertheless brings the carers into the picture, recognising them as an important asset. At one crucial moment, there’s a long pause when the audience are invited to question Derek directly. Voices that had been forthright in their condemnation of poor medical practice are momentarily silent. There’s a discomfort, perhaps, at coming face-to-face with the struggles and realities of life as a carer, the stigma and isolation that can arise, the lack of respite from living with increased suicide risk and unpredictable behaviour, the toll this daily work takes on the carer’s own physical and mental health. But it is precisely this dialogue that needs to take place, and it does eventually unfold, as audience members dare to ask the questions that only a carer can truly answer.

While we start off by realising how little we know, entering into the ‘guessing game’ with our feelings of confusion mirrored by Derek – ‘It’s like being in a land of mystery’ – we gradually move towards a greater sense of understanding. Through new scenes that emerge from audience participation and dialogue, we begin an open conversation, adding fresh perspectives into the ongoing debate around mental health care.

Ultimately, then, this is a profoundly empowering experience for all involved – especially for the diverse audience made up of professionals, service users, members of the public and carers themselves. In drawing the focus back to the 6 standards, the play leaves us with a challenge to assume collective responsibility for how things develop from here. Julie Cameron, Programme Manager for the Mental Health Foundation, talked in the after-show panel about how the project is being used with Mental Health Nursing students at Glasgow Caledonian University, as well as with staff in psychiatric clinics, showing how transformative drama can be when incorporated into training.

As Rosemary Nicolson, GAMH Carers Development Worker, put it, this is very much a ‘work in progress’ in which we all have a part to play. Asked what she hoped would be the take-home message of the event, she called for greater awareness and acknowledgement of carers: ‘Please include family and carers. Don’t exclude them. Listen and respect them…. They just want to be heard and to know how to help. Instead of a burden, they should be seen as a precious resource and as trusted members of the team.’

Rather than treating the problem in isolation, the Triangle of Care and the creative outreach of projects such as The Guessing Game invite us to take a holistic and collaborative approach to what is a problem that affects us all, reminding us how we all stand to gain when guesswork makes way for debate.

Written by Clare Blackburne

The Guessing Game was performed at Gorbals Parish Church as part of the Scottish Mental Health Arts & Film Festival, featuring a post-show panel discussion with Amy Mcdonald (founder and CEO of Headtorch); Rosemary Nicolson (GAMH); Julie Cameron (The Mental Health Foundation); Derek Ferguson (Triangle of Care steering group); Steven (volunteer actor with Headtorch); and Shelley Paterson (GAMH).