In this essay, we outline and discuss the possibilities of Forum Theatre as an educational method for healthcare professions; specifically for skills that are based on social, psychological and relational competencies. We believe the approach can inform educators, teachers and facilitators looking for methods to create a high level of learner engagement, with potential to embody learning points. We also hope to attract readers who may be reluctant to try Forum Theatre because such methods may be perceived as only being for drama specialists. First, we outline the origins of Forum Theatre and how it has made its way into the broad field of education. Second, we offer three examples of how we have used Forum Theatre. Finally, we share additional reflections drawing directly on our experiences.
Forum Theatre is a powerful interactive, improvisational theatrical technique [1] that has gained recognition as an effective educational approach activating both reflection-in and reflection-on action [2] as learners are invited into situations that foster embodied learning.
Augusto Boal (1931–2009), was a Brazilian theatre practitioner who developed the concept of the Theatre of the Oppressed during the 1970s, as Brazil was being ruled by a military fascist regime. He observed that the farm workers had not learned how to speak up against oppression or exploitation, nor had they been empowered to do so. Theoretically, Boal was deeply influenced by the ideas of the Brazilian educator, Paulo Freire, and his seminal work, the Pedagogy of the Oppressed (first published in Spanish in 1968 [3]). Broadly speaking, Freire advocated for a participatory model of learning with learners as co-creators of their knowledge. Boal translated this theory into practice through the Theatre of the Oppressed.
Boal acted as a political activist and sought to empower individuals and foster social change through theatre, to empower the oppressed to stand up and liberate from the oppressor. The Theatre of the Oppressed aimed to dismantle oppressive structures and engage the audience as spect-actors in a democratic theatrical experience [4]. The word spect-actors is a combination of spectator and actor; hence spectators are encouraged to get involved in the acting.
Within the Theatre of the Oppressed framework, Boal introduced Forum Theatre as a specific technique. It provides an interactive platform where spect-actors can intervene and explore different perspectives. By staging a difficult or challenging situation with actors, the participants are given a mutual point of departure to co-explore and co-create ways to address and improve the situation by proposing alternative actions to those that unfold in playing out the scenario. These actions are intended to be constructive, productive and ethically acceptable. Since the staged situation (the scenario) should be relatable to the audience, the experience may foster transfer to daily life. The technique emphasizes active participation, enabling individuals to reflect on societal issues and envision alternatives. The goal is to empower individuals to become agents of change [5].
The Joker (a facilitator) is a central figure. They are bridging the involvement in the action; introducing and enforcing the rules of the game; and steering the session. They oversee the playing out (by actors), of a short, scripted scenario featuring a complex problem. At first, the actors will play the full scene for the spect-actors to experience. A second round will be introduced, and then, at any point, the spect-actors or the Joker can stop the action and make suggestions about how the actors should proceed. The spect-actors can even jump in and interact by taking the place of one of the actors. The scenario can be played out multiple times using this process, with outcomes that reflect the wishes of the spect-actors.
Boal’s international workshops, publications and collaborations led to the spread of Forum Theatre across diverse contexts and communities to address specific issues and challenges faced by different groups. The participatory nature of Forum Theatre allowed for flexibility and relevance in various cultural and social settings [5]. In response to technological advancements, Forum Theatre has been further developed and applied in all kinds of digital and online settings [6].
The term Forum Theatre and especially the phrase it is connected to – Theatre of the Oppressed – is not always suited to how educators and facilitators draw from the Boalian work today. Many scholars prefer terms like post-Boalian drama and theatre, applied drama techniques [7] or Improvised Participatory Theatre (1). More recent changes to Forum Theatre methodology include shifting from working with an oppressor to working with perplexing situations that feature challenging interactions between people who have different agendas, aims, resources, hopes and wishes. In this context, actions and interactions focused on the why and the what of the situation are explored [7,8]. A modern adaptation developed by David Diamond (2007), has moved beyond binary notions of oppressor and oppressed, by approaching living communities as complex, living entities [9]. And also, as educators, we perceive the scholars as vulnerable. And to quote from literature: We believe the culture of medicine and medical education may be oppressive for some learners, precluding their development into the physicians they want to be (p. 1193) [10].
Videos showing variants and adaptations of Forum Theatre
In healthcare education, Forum Theatre has found a meaningful place for the development of awareness and skills related to communication and relationships. Healthcare professionals often face complex ethical dilemmas requiring critical thinking and decision-making skills. Forum Theatre offers a space to explore and discuss these issues through interactive scenarios. Through role-playing in these scenarios, participants can practise active listening, effective communication and empathy. Participants can engage in ethical reasoning, analyse different perspectives and develop strategies to navigate challenging situations. This training may cultivate patient-centred care and improve interactions with patients and their families [11]. Forum Theatre also provides an opportunity for interprofessional collaboration and collective reflection by providing scenarios that require coordinated efforts. Through these scenarios, healthcare trainees and professionals can develop skills in effective communication, creative problem solving, conflict resolution and decision-making within a team [8].
In this section, we provide a description of the elements that we recommend in developing an educational session using Forum Theatre. For most elements, there is a direct line back to the original Boal way, but there are adaptations for contemporary education settings.
Like most educational activities, a needs analysis will identify the need, purpose and participants of your proposed session. We suggest spending as much time as possible in the scope of your project to observe and interview members of the actual target audience to gain an understanding of the challenges at hand. Use all the data sources you have at hand. It is important to ensure that participants will relate to the content. The closer you can get to how work unfolds for real, the more the scenes will speak to the audience. Also, when you introduce Forum Theatre as a method to teach professional communication and interaction with patients and relatives, it is important to study the perspective of the “other party”. Reading the human psychology literature and patients’ narratives – both in general and specific within the subject of attention – for example, motivational interviewing. Scenario authors should aim to construct a meaningful and respectful scenario and for the actors and the joker to be prepared and able to engage in the experiment in a truly developing way. Keeping focus on both the groups of vulnerable subjects: The learners (our spect-actors) who are present in the room, but also the patients that we stage by having an actor simulate this part, and who are for our learners their subjects of care and attention.
Building on the needs analysis, a short, scripted scenario is developed with relevant characters. For example, a scenario in healthcare might be focused on a challenging conversation between a patient and a healthcare professional, who serves as the alter-ego for the healthcare learners in the audience. This scripted scenario is the basis for the ground play – the first version of a scenario that is played out. Missed opportunities are built into the scenario so that the ground play does not end in an optimal outcome. While the scenario may play out in its entirety, it may also stop amidst an unsolved situation or conflict. In this case, What happens next? prompts dialogue with learners regarding the agendas of those within the staged scenario.
The actors are those who play the characters in the scenarios. They may be actors or other colleagues. Professional actors can be ideal for these roles, by virtue of their training. However, colleagues who know the topic may also function effectively. In our experience, they can even be more engaging for the learners, as they have tacit contextual knowledge that informs their behaviour in the interaction.
In any case, it is important for the actors to be able to step into the character they are portraying, be open to learner suggestions and be able to improvise the implementation of these sessions in character as the play is unfolding.
Another essential element is The Joker. As we stated earlier, this character is basically a kind of facilitator. When we embrace the word, it is a strong reference to the origins of Forum theatre. The Joker sets the ground rules, explains the process and steers the learners (the spect-actors) to engage in the scene. The Joker role is inspired by the medieval fool at the King’s Palace. The Joker can help address taboos and steer a stuck conversation. The Joker can call out observations that nobody else dares or sees. The Joker (facilitator) must be alert, attentive, playful and courageous. It is their job to keep a playful and engaging atmosphere, often quite different from the classical teacher role. The Joker does not know the answers – nobody does, which is an important point since we are exploring and expanding. The Joker is allowed to ask all the questions [12]. On the one hand, The Joker (facilitator) encourages learners to reflect, engage and bring ideas to the discussion. On the other hand, they must be aware of whether the focus of the learners aligns with the learning objectives. If not, they must address this misalignment, reflect on it and get the process back on track – with great respect to the learners’ perspectives and vulnerabilities. They keep an eye on the actors as well, checking the progress of the action and observing that the actors are fulfilling the suggestions of the learners. The Joker (facilitator) steers how many corrections of the ground play can and should be made and finds the balance between fine-tuning of interaction details, progress throughout the whole scene and meeting the learning objectives.
Although there is a specific methodology related to facilitating a Forum Theatre session, a person already skilled in facilitation is likely to be suited to the task. Although there is a specific methodology related to facilitating a Forum Theatre session, a person already skilled in facilitation is likely to be suited to the task. The Joker should be someone with some knowledge of the subject and while it is beneficial to have some Applied Drama and Forum Theatre experience, it is not essential.
We use the term learners or participants to depict what Boal originally called spect-ators as the audience. The learners are actively involved as the audience making suggestions to influence the course of the staged scenario. As a highly interactive method, this may place learners at risk of vulnerability. Facilitators need to foster a safe psychological space – to articulate and show the need for a kind and respectful atmosphere. It helps to have a warm-up activity before the play. Small exercises, sharing thoughts and reflections are usually helpful.
When introducing Forum Theatre to learners it is important to set the stage by explaining what is going to happen and what is expected from them. In Box 2, we outline how a facilitator can introduce Forum Theatre with guidelines for engagement.
Facilitator guidelines for engagement in Forum Theatre
The first example focuses on a faculty development activity using the role of the health professional as a health advocate [13]. The example was created for and presented at the International Meeting for Simulation in Health Care (IMSH) in Orlando, FL, USA, in 2023.
We chose the role of health advocate as the topic since it crosses many professional disciplines. It is a role that healthcare professionals are obliged to fulfil but might not feel comfortable with or competent for. The role of health advocate is considered highly complex [14], and we found it meaningful to voice this complexity and allow doubts and difficulties to come to light, to raise the level of competence and reflection in this area. At a mandatory communication course for new doctors in Copenhagen, the experience is, that the learners struggle with this role and that engaging in Forum Theatre, as part of the theme of motivation and lifestyle, seems very helpful and eye opening for them. The struggle revolves around how to manage the role as medical expert while – at the same time – engaging in the role as health advocate. As medical experts, they have knowledge that they think they should share. Thinking that this is how the medical expert and the health advocate emerge, not realizing that this can be quite counterproductive if you wish to ‘get anywhere’ with the patient [15]. Patient-centred communication can get lost in navigating these two competencies. The Forum Theatre brings this into the light so to speak.
In the workshop, the scenario that was presented involved a patient visiting the doctor to ask for more medicine while not willing to discuss root causes and lifestyle changes as an alternative approach to the presented medical problem. CT took on the role of the Joker/ Facilitator (she holds an MA in psychology, is an experienced facilitator, and has over 20 years of experience working with Applied Drama, including Forum Theatre in healthcare educational settings). The two Actors were both experienced role players. CS, who has a PhD in drama, is a professional actor and a simulation educator, portrayed the doctor while PD, a psychologist, simulation educator and psychodrama director, played the role of the patient. The audience was comprised of about 20 attendees from various countries, many with first languages other than English.
We made a slight modification to the Forum Theatre approach by initially using a technique that Boal invented and termed ‘simultaneous dramaturgy’ [4]. After we portrayed the scenario one time through, the Facilitator engaged with the audience and asked them to reflect on what they thought had happened. The Facilitator then asked them to offer their suggestions that would then be enacted by the doctor (CS). The scenario started up again and the Facilitator invited the audience to call out ‘STOP’ and to make suggestions to the actor playing the doctor about what to change or what to continue doing. In this way, the actor playing the doctor functioned as the proxy for the audience. The Joker/facilitator checked in with the audience members after each enactment to confirm that the doctor’s actions had been portrayed as intended. We made this choice to start with simultaneous dramaturgy to foster psychological safety, for both the participants and ourselves. We were meeting one another for the first time, and we were uncertain about the audience’s background and comfort level with role playing. We wanted to keep the focus on the learning objectives of the session. Although we offered the audience the option to step into the role as the session progressed and we gained greater familiarity with each other, they chose to keep offering suggestions that the actor played out. This modified approach has also been described in other published accounts of Forum Theatre activities related to educational sessions with health trainees [6,12]
Participants were very engaged, and the debate regarding the doctors’ professional obligations and options was lively. The international factor of the participants brought diverse and sometimes unexpected comments and ideas to the discussion. Another interesting outcome was that even though the workshop was framed as focusing on training professionalism in the role of health advocate, and even though the participants were largely experienced educators, they tended to focus on the medical aspects of the scenario. This required CT to manage the balance of acknowledging suggestions, guiding the progression of the scenario and redirecting participants back to the learning objectives.
The whole experience of planning and giving the workshop showed us how important it is to steer the process and to bring the learners attention to another perspective, namely the importance of creating connections to the patient if you as a health professional wish to help. To discuss and reflect on how to create this relation is of great importance for making meaningful treatment plans. Creating a staged scenario where the biomedical content does not distract from the learning objectives but remains relatable is challenging.
Our second example focuses on how Forum Theatre was modified to be used as part of an online patient history session for Year 1 students at Imperial College School of Medicine (ICSM) in the academic year 2021–2022 as part of their Clinical Communication training.
Exploring a patient’s lifestyle seemed well suited to using Forum Theatre because it offered ample opportunities for students to recognize issues that patients may find difficult to disclose, to identify strategies that aid communication around these issues and to recognize how students’ own world views may impact a consultation.
During COVID-19, this face-tο-face session was transformed into online using Zoom. It was delivered by the three core members of the Clinical Communication team (AB and the two academic leads) with the contribution of two actors (playing the roles of a doctor and a patient) to the Year 1 cohort (approximately 360 students); it included a PowerPoint presentation, followed by a staged scenario with Forum Theatre, using the chat function to enable learner participation. The staged scenario was created by the Clinical Communication team based on real patient encounters and reflected relevant curriculum goals on enquiring about patient lifestyle; it covered several components of a social history similar to those in a real doctor-patient encounter, giving the students the opportunity to witness a realistic scenario that they will often encounter in clinical practice.
During the Forum Theatre, one of the facilitators would pause at certain intervals to ask the learners for their input on the scenario, regarding the way questions were asked, what and how was asked, etc. The Zoom chat function was used to receive learners’ suggestions. The learners posted their own ideas and reactions to other suggestions. As the staged scenario evolved, AB was monitoring the chat, feeding the suggestions/comments live to the facilitator who then fed back to the two actors. Similarly, following the scenario, the learners were encouraged to ask questions by posting them in the chat and the presenters would answer them.
There was a high engagement in the session. The use of the chat function provided an easy and safe platform for learners to shape the scenario, perhaps even encouraging reticent learners to participate, as indicated by the large number of contributions and answers to the facilitators’ questions.
Modifying Forum Theatre online provided a basis to roll out subsequent sessions online and to use the chat function to promote participation. However, it highlighted the need to account for online disruptions and potential challenges in recognizing cases of personal resonance, guiding the Clinical Communication team to add an introductory ‘safety-netting’ slide (explaining that the session would be exploring certain topics and that if any students felt uncomfortable with any of the content, they could reach out to the Clinical Communication Team) in all teaching materials going forward.
This third example focuses on using Forum Theatre face-to-face to teach about barriers to communication to the Year 2 cohort at ICSM in the academic year 2022–2023.
We used Forum Theatre to help students recognize some of the barriers to communication and identify ways that these may be overcome. Using Forum Theatre enabled us to raise students’ awareness of the potential impact of self on communication and identify personal strategies to address this.
The Year 2 cohort lecture (approximately 350 students) comprised didactic and interactive components, including a PowerPoint presentation followed by staged scenario with Forum Theatre, with a professional actor as the patient and two volunteer students acting as a medical student. According to the scenario, the patient was speaking basic English and the students had to initially talk to the patient about their symptoms (first volunteer student) and then explain to the patient how to use an albuterol inhaler (second volunteer). At certain points of the staged scenario, AB would pause to invite learners’ comments, feedback to the volunteers and suggestions, which were then incorporated into the scenario.
This session was very well received, which was evident by the group’s lively participation and comments. Due to the nature of the interaction portrayed in the scenario, with language being a major barrier, the learners were creative in their suggestions, trying to find ways to communicate in the absence of an interpreter or an online/telephone support.
Using Forum Theatre to raise awareness of barriers to communication made the session interactive, dialectic and enjoyable for the learners. However, given the nature of this scenario which involved students as volunteers, it required careful planning and script preparation to account for possible contingencies and an experienced actor as the patient. It also required quick reflexes and swift handling by the facilitator, so that it could be paused at the right intervals for the teaching goals to be achieved.
We hope that we have described some of the potentials that Forum Theatre has in an educational context. Even though Forum Theatre has existed for more than 50 years, and is to some extent widely known, we believe that it could be involved much more in training programmes for all professionals in need of communication and relation-building skills.
Challenges in the uptake of Forum Theatre might be a lack of knowledge and uncertainty about how to use it, and a lack of resources for training in its application. It is also a method that leaves quite a bit of control to the participants, potentially generating insecurity for facilitators. It may also be that facilitators are comfortable with their own approach and so may be reluctant to learn a new one. Facilitators, and to some extent, the actors, need to be able and willing to improvise. Facilitators might not be trained in providing feedback during the unfolding scenario. There might also be a fear on the part of facilitators of steering too much, of manipulating, and of triggering emotions. In our experience, those who like experienced-based learning and facilitating it (as many simulationists already do), can easily begin working with Forum Theatre, following the steps above and taking care of actors and learners. Selecting scenarios that are not too intense can be a good start (although any scenario has the potential to trigger old traumas – just like any simulation as well). Also, asking learners to be kind and careful with each other and each other’s ideas can help. Agreeing on a time-out word can also help in sharing control of the development of the scene (e.g. The time-out/safe word or sentence should be something out of context like “banana” or “I need to call a taxi”).
Learners might be reluctant to engage in Forum Theatre. They might fear to be exposed or judged and therefore might not feel psychologically safe. Learners might also not know the method and might feel a lack of specific guidance on how to do it right, on top of potential doubts about the actual subject matter (e.g. effective health advocacy or communicator). Learners are asked to suggest changes to the scenario and those ideas are tested and re-tested by other people, who might not fully understand the details of their ideas. Still, the value of every idea becomes obvious. Involving the interplay of different persons, the situation may be uncertain and ‘muddy’ and that can trigger fears. Sometimes if a learner feels insecure about a task, a psychological reaction can also be to ridicule the set-up, to question its values and to disengage.
Forum Theatre is a form of learning ‘in the moment’, combining actions, and reflections in action and on action (2) Pässila (6) describes the learning that takes place as ‘… reflection organized by embodied action of various applied drama techniques is a stage towards practical reflexivity’ (6). It draws on age-old insights of theatre – actors and spectators learn – partly by katharsis. Actors can try different roles, can experience different contexts on stage and can learn a lot about their professional and personal roles. Learners can participate in the scene by being active observers, partly feeling and thinking, what the figures they observe feel and think. Further, Forum Theatre draws on human empathy and the ability to learn from observed experiences. This can also be done in scenarios that focus on topics that insiders in the system might not even dare to raise. The ‘elephants in the room’ can show up on stage without the need for any of the learners to show themselves as experiencing them personally. It is the actors and the figures they portray that have the responsibility, they show the tensions and even taboos, not the learners (the oppressed). The learners can comment on what they see, they can draw real and relevant insights from the observations and discussions without the need (but still with the possibility) to reveal how they as persons think. In this regard, Forum Theatre offers learners a lot of control, how much about themselves they want to reveal in their comments and suggestions about the scene. We see this as a rich potential of the method that is hard to achieve in different formats.
Forum Theatre typically does not need special places: A stage can be defined anywhere, even virtually. It might be a good idea to have simple props that help actors into and out of their role. As long as those involved agree to experiment, a lot is possible with simple physical set-ups. Forum Theatre is highly activating and combines experiences with reflections and discussions and therefore allows discussions of a range of topics, also, as described above, the difficult ones.
When engaging in learning settings as interactive as Forum Theatre, there are several vulnerabilities. As educators, you must be ready to hold the room. To take responsibility for really trying to foster a psychologically safe space. You must be attentive to tension and address it. The facilitator must be very aware of hierarchy and power in the audience to avoid victim-blaming or individualizing the problems in general (7).
When writing a staged scenario, be aware that you do not reproduce or support prejudice or stereotype beyond what is acceptable and necessary. The same goes for taking suggestions from the learners. This is a trickier part since it is quite counterproductive to critique what is suggested. Draw on all your facilitator skills to make it a productive learning opportunity. If not aware of this responsibility, you might violate the objective of Forum Theatre, and instead be part of reproducing structural oppression of vulnerable groups of people.
When combining the use of Forum Theatre with certain learning goals, we set limitations on where the suggestions are allowed to go, and on which impulses you can pursue. In a classical Forum Theatre, it could be considered oppressive in itself. It is important doe an educator to be open about the agenda. Even though we say – we explore in an open manner – it is in the power of the facilitator to ask the questions that set the limits of what we talk about [16] and it might provoke some participants. Using Forum Theatre in a pedagogical context as we describe it here, we submit that it is about balancing fulfilling learning needs with the wishes and interests of the audience and the Joker, It is very important that the facilitator is aware of their power and reflects frequently about how and with what intent it was used.
We hope that we have made the case for Forum Theatre and that it can have a place in different educational settings to address topics that might be difficult to achieve otherwise. Based on the brief historical sketch, we hope you have gained insight into the goals with which the method was developed and how those shifted over time. Our discussion of the processes, the examples, and our reflections can hopefully help to decide in which setting the method can be useful for you and how you can put it into practice. In our view, the method can contribute value that supplements other forms of learning. The special strengths we see concern the possibility to address sensitive or taboo topics and to explore power structures. Forum theatre also offers the possibility to productively engage large groups of learners.
None declared.
None declared.
None declared.
None declared.
The authors declare no conflict of interest.
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Using Forum Theatre techniques in teaching and learning about professionalism and communication in healthcare
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