Orchestrated Chaos or Chaos Orchestrated?
Anyone who is familiar with residential psychiatric care and especially with working in a psychiatric intensive care unit will know the cacophony of events that can happen at any given point in time: therapy groups need to be run on the unit, a patient needs to be escorted to his or her section 117 meeting, another patient is adamant that she is not going to take her medication, while another patient is seemingly withdrawn from everything. Members of staff need regular breaks, paperwork needs completing and relatives of a patient have unexpectedly turned up for a visit. In the midst of this stream of events, and the defence-barrier between that stream and chaos, is the ‘conductor’ of the unit: the nurse in charge. Often I have entered wards and in my mind admiringly compared the work of a nurse-in-charge with the work of a conductor during an opera.
Opera and Mental Health
Both opera and mental health care, especially mental health care in residential settings, are highly complex and deal with a multitude of factors. In a residential mental health setting there are first and foremost many actors involved: the patient, client or service user; a range of clinical staff (nurses, health care assistants, psychologists, occupational therapists, social workers, psychiatrists, community based professionals) who are directly involved with the patient; relatives of the patient; clinical staff of the setting that the patient may go to after their current placement; commissioners and case managers. And of course in residential care there are the people who work in the background and make it all possible: cleaners, maintenance people, administrative staff etc.
The Concise Oxford Dictionary of Opera (Rosenthal & Warrack, Reference Rosenthal and Warrack1975) consists of 446 pages. Anyone who has attended an opera performance can immediately see the complexity of it all. First there is the music; then there are the voices, the lyrics, the stage, the singers, the orchestra, the conductor and many more aspects that are not immediately visible to the audience, but if not all correct would have an immediate effect (for instance the musical score). Both opera and mental health care depend on the timely and correct interplay of a wide range of factors.
Opera, Badness and Madness
Many operas have engaging and dramatic stories about human misery, badness and madness. A few examples of this are:
• Verdi's Otello, in which psychopathy is eloquently portrayed by Iago, who fuels the jealousy of Otello until this reaches the heights of morbid jealousy and he (Otello) kills Desdemona;
• Britten's Billy Budd, which explores themes of repressed homosexuality, sadism, cowardice and redemption;
• Don Giovanni in Mozart's Don Giovanni displays with perfection the charming psychopath, who given half a chance could sell snow to Eskimos.
‘Opera is fascinated by madness …[,] composers making their characters enact florid psychotic scenes on stage … (Durà-Vilà & Bentley, Reference Durà-Vilà and Bentley2009). Many operas since the late seventeenth century have included an operatic ‘mad scene’. One of the most famous is in Donizetti's Lucia di Lamermoor, when Lucia, after having killed her newly-wed husband Arturo, rejoins the wedding party and completely loses her link to reality. Other ‘mad scenes’ occur in Anna Bolena and Linda di Chamonix (both also by Donizetti); in Bellini's I Puritani and many others. In opera, a mad scene is an enactment of insanity.
Opera has so many things to offer for mental health professionals, from clear-cut examples of evil-doing to examples of irrational thinking. Operas tell stories focused on all of humanity's weaknesses. Operas are full of drama, but the audience at the Metropolitan Opera House in New York got more than it bargained for with the onstage death of one of its greatest stars. In March 1960, while performing Verdi's La Forza del Destino, the great baritone Leonard Warren completed his Act II aria, O Gioia (‘Oh Joy’, which begins ‘Morir, tremenda cosa’ (‘to die, a momentous thing’)), and pitched forward dead. That evening, for one of the very few times in its history, the Met's show did not go on.
Despite the rich representation of madness and badness in opera, it is surprising how few papers have been dedicated to the overlap between opera on the one hand and psychology, psychiatry and psychotherapy on the other hand. In the early 1990s, Mark Jones wrote a few papers on opera and psychiatric problems (Jones, Reference Jones1990a, Reference Jonesb, Reference Jonesc, Reference Jones1991), while Durà-Vilà & Bentley (Reference Durà-Vilà and Bentley2009) wrote an engaging account of madness in Peter Grimes. These studies focused on the representation of mental illness and badness in various operas. The focus of this paper is different: what can clinicians in mental health learn from opera?
What Can We Learn From Opera?
Many operas contain lessons on life as well as helpful hints for practicing mental health clinicians. To illustrate this, I have chosen one of Puccini's grand operas: La Bohème. This is an opera in four acts to an Italian libretto by Luigi Illica and Giuseppe Giacosa, based on Scènes de la vie de bohème by Henri Murger. The world premiere performance of La Bohème was in Turin on 1 February 1896 at the Teatro Regio and conducted by the young Arturo Toscanini.
Five of the main characters of La Bohème are artists: Rodolfo is a poet, Marcello is a painter, Schaunard is a musician, Colline is a philosopher and Musetta is a singer. The two remaining characters are ordinary, non-bohemian people: Mimì is a seamstress and Benoît is a landlord. The story is as follows. In 1830s Paris four arty types (Bohemiens) shiver in their apartment, owing rent but when one of them, the musician Schaunard, earns money they are all set to go for a meal in a nearby restaurant. Rodolpho, the poet, stays behind to finish his writing and is interrupted by Mimì, a seamstress from the next apartment. They are instantly attracted to each other and catch the others up at the restaurant where Rodolpho's painter friend Marcello is re-acquainted with his flirtatious ex-girlfriend Musetta, who dumps her current lover, after getting him to pay everyone's bill. Sometime later Musetta and Alfredo are living together, as are Mimì and Rodolpho, but he is aware that she has tuberculosis and is mean to her in the hope she will leave him for someone who can take better care of her. Eventually she does, Musetta splits from Marcello and the four men resume living together in an apartment. They are visited by Musetta, who has sought out Mimì, now living with a wealthy count, but dying, and has brought her back to die in the presence of her true love and friends. Musetta and Marcello reunite as Rodolpho cries over the dead body of his Mimì.
I have selected four brief excerpts from the opera to focus the mind regarding lessons we can take as mental health clinicians from opera.
ACT 1
This scene occurs during the first act, after about 24 minutes. Rodolfo and Mimì are alone in the apartment, all the candles have been blown out, it is dark, Mimì is about to leave, but before she does Rodolfo takes her hand and introduces himself to her (in the form of a rather beautiful aria). They have been searching for Mimì's key to her apartment. Rodolfo has found the key, but hidden it as he wants to spend more time with Mimì.
This is what he sings:
And how do I live? I live
in my contented poverty,
as if a grand lord, I squander
odes and hymns of love.
In my dreams and reveries,
I build castles in the air,
where in spirit I am a millionaire.
(http://dennisalbert.com/Opera/labohemelibretto.htm)
Reflection points
Even when you are completely in the dark you can find something valuable
Mimì and Rodolfo have been searching in the dark and they still find ‘something’: happiness in meeting. In mental health there is a strong emphasis on evidence based interventions and formulation driven treatment programmes There is a strong emphasis that you really have to know where you are going from the beginning and that clear goals need to be set from the outset. This is all based on the assumption that we always know exactly what we are doing and why it is being done. However in very complex situations (such as when working with patients who have complex needs in a residential setting), it can pay off to apply nature's best approach which in the end always produces results: trial and error (Kellert, Reference Kellert1993). You don't always need to know where you are going in order to get somewhere. With complex and multi-problem patients it may be a good idea to carefully start ‘somewhere’ with interventions, instead of waiting until all the facts are known, evaluated and weighted. In other words, even if you don't have nice polished formulation (i.e. you are in the dark) tentative and careful steps can produce satisfying results (and in a well done performance of La Boheme this is often beautifully demonstrated by the tentative looking for the ‘lost’ key). Basically this is what has to happen in residential settings, especially in psychiatric intensive care units: as a nurse based on the ward, you can't wait for a completed assessment before deciding how to interact with patients: you have to do something right now!
Keep an open mind, even if you have found what you were looking for
Mimì and Rodolfo continue looking for the key, even after Rodolfo has found it. Sometimes the answer is really blowing in the wind and therefore not important. It is the wind that counts and letting the wind dictate where you are heading, even after you have found the answer. This may lead to interesting and uplifting results. In the field of mental health, too often the efforts of a clinician or clinical team come to grinding halt after a diagnosis has been identified or a treatment programme pathway selected. How the patient responds to the specific interventions almost becomes a sideshow (because ‘we know, based on the evidence, how a patient ought to respond and patients responding differently are just difficult…’). Going with the idiosyncratic response of the patient to our interventions has become a ‘not-done’ in this Zeitgeist of protocolised and manualised interventions. From this excerpt, we learn that we can find the key (i.e. follow the protocol) and yet continue to be open to adaptations. Let's face it, if Rodolfo, upon finding the key had said: ‘Oh, found it, here it is, goodbye’, we would have missed a fine opera.
Not all irrational thinking is bad and needs to become the focus of therapy
Rodolfo sings: ‘where in spirit I am a millionaire.’ He is very poor but feels as if he is a millionaire and it makes him happy. In mental health, we frequently behave like the thought police and pursue relentlessly any thought or idea that does not conform to our own perspective of rationality and reality. Reality is simply an option; if a patient chooses to believe in an option of reality that is not shared by us and it does not cause problems, perhaps we should congratulate them on their creative problem solving instead of challenging the ‘incorrect appraisal of reality’. In a PICU setting, addressing all examples of irrationality and delusional thinking would be very much counterproductive.
It is better to lead a life worth suffering for, then to avoid all suffering in life
Rodolfo goes on: ‘Yet sometimes from my safe, all my gems are stolen by two thieves, a pair of lovely eyes’, followed by ‘Beautiful dreams I'd cherished, immediately vanished without a trace’. These phrases indicate that he knows that he is on a path that will bring suffering, but he accepts it as part of life. Too often in the field of psychiatry and psychology suffering is mistaken for pathology. The first noble truth in Buddhism (Bhodi, Reference Bhodi2000) tells us that ‘there is suffering’. Suffering is part of life and we should not teach our patients to avoid suffering but how to lead a life that is so good, that it is worth suffering for. In this sense, a PICU setting where there are no strongly expressed negative feelings and where there are no behavioural problems is probably a setting where patients are overmedicated. Learning new ways of living is painful and difficult for patients and it is not wrong when this shows!
ACT 2
During the second act, at the Café Momus, Rodolfo introduces Mimì to his friends. Marcello's former sweetheart, Musetta, makes a noisy entrance on the arm of the elderly but wealthy Alcindoro. The ensuing tumult reaches its peak when, trying to regain Marcello's attention, she sings a waltz about her popularity (‘Quando me'n vo’’). Sending Alcindoro off on an errand, she falls into Marcello's arms and tells the waiter to charge everything to Alcindoro. The aria ‘Quando me'n vo’’ sung by Musetta reads as follows: ‘When I stroll out alone along the street. The people stop and gaze at me, to seek out my beauty from head to toe. …and then I taste the sly desire that gleams from admiring eyes. They can see all my beauty which lies concealed in my heart, perceived from my outward charms’.
Reflection point
Going beyond the surface and first impressions is essential
In mental health, establishing a diagnosis is often seen as very important. After this song many clinicians will be inclined to see Musetta as a narcissistic personality disorder. This woman clearly has an inflated sense of her personal qualities. However the remainder of the second act shows that Musetta is putting on this show to get Marcellino to notice her (again) and to rekindle his love for her. In other words, her behaviour (the display of narcissism) is fueled by noble and positive intentions (attracting the attention of the man she really loves). In mental health we often see patients with similar problems: the overt behaviour looks bad but the underlying intentions are positive. If we as clinicians solely focus on the behaviour, we may, in a way, reinforce the bad behaviour. If on the other hand we can also focus on the intentions, we might motivate our patients to find alternative behaviours to express their positive intentions. Because (as Musetta and Marcello demonstrate) sometimes it is too difficult to say what we want or need, and we say or do the opposite. This demonstrates two reflection points: The first is that first impressions are not always (or seldom) able to stand the test of time. Unfortunately in mental health we often forget that, and many patients are still followed by diagnostic labels given to them decades ago, by clinicians whose initial assessment was recorded. A brief moment in the consulting room leads to a lifetime in their file! The second reflection point is that behaviour that on the surface looks bad may have positive and even noble connotations.
ACT 3
At the beginning of the third act, at dawn by a tavern on the snowy outskirts of Paris, Mimì wanders in, searching for the place where Marcello and Musetta now live. When the painter emerges, she tells him of her distress over Rodolfo's incessant jealousy (Duet: ‘O buon Marcello, aiuto!’). She says that she believes it is best that they part. When Rodolfo appears from the tavern, Mimì hides nearby, though Marcello thinks she has gone. The poet tells Marcello that he wants to separate from his sweetheart, citing her fickleness; pressed for the real reason, he breaks down, saying that her coughing can only grow worse in the poverty they share; he's desperately afraid she will die from her illness.
When Mimì tells Marcello about her problems with Rodolfo, this is what she says: ‘Rodolfo,… Rodolfo loves me, but flees me, my poor Rodolfo is jealous; he is in torment. The slightest gesture, a smile, a flower will arouse his suspicions. Then he grows vexed and angry. … shouts at me so harshly “You're not right for me, so find yourself another” “You're not right for me” Alas, Alas! What can I do?’
Later on Rodolfo explains the situation to Marcello as follows: ‘Mimì is a minx, she flirts with everyone. A fop of a young Viscount has only to make eyes at her, and she provocatively lifts her skirts and shows off her ankle in a most promising way. (Marcello: Do I have to say it? I don't think you are sincere.) Alright then, no, I'm not. in vain I try to hide my true torture. Mimì means everything in the world to me. I love her dearly, but I'm frightened, I'm so very frightened! Mimì is very sick! Every day she wanes. The poor little thing is doomed to having no life, a terrible cough shakes her chest and weak frame, … My room is a squalid hideout … The fire is always burnt out. The north wind creeps in and whistles around the room… Mimì is a hothouse flower; poverty is making her blooms wither. Love is no longer enough to retrieve her life!’
Reflection points
Bad behaviour can have very noble reasons indeed
After having heard Mimì's account to Marcello, one is ready with a verdict. Rodolfo has the potential for domestic violence: he is a brute and Mimì is making a timely escape from the clutches of this evil man. We want to warn her against the morbid jealousy that clearly is developing and if our base is in forensics, we are inclined to warn her against the possibility of injury and death at the hands of such an evil person. However when we subsequently hear Rodolfo's story our heart melts at such (all be it clumsily expressed) nobility.
Most people have good intentions, but just as in La Boheme, people often express their good intentions with problematic behaviours. It is important to assist people in becoming more consciously aware of their noble intentions and subsequently teaching them pro-social behaviours to make their intentions come true. The two techniques in cognitive behaviour therapy that aim to achieve this increased awareness are motivational interviewing (Miller, Reference Miller1983; Miller & Rollnick, Reference Miller and Rollnick1991) and Socratic dialogue (Padesky, 1993, keynote address at the EABCT Congress, London, 24 September; Vyskočilová & Praško, Reference Vyskočilová and Praško2012).
And if people don't communicate honestly that results in trouble
Rodolfo and Mimì are clearly not the best communicators. As the story unfolds, it becomes clear that she does not even know she is seriously ill. A lot of grief could have been prevented if Mimì and Rodolfo had engaged in some open and honest conversation! Good and open communication is the basis of any productive relationship, whether it is a personal or professional relationship. In a mental health setting effective communication is essential, however just as in La Boheme, too often communication is fudged. Communication between patients and their clinical team during ward reviews and clinical meetings often result in mutual admiration whereby everyone is told they are doing a wonderful job. Afterwards the clinicians wonder why the patient is not developing specific insight into their problems and issues. Miller et al. (Reference Miller, Sovereign and Krege1988) demonstrated that providing objective feedback to problem drinkers was an effective motivation enhancing strategy. As in La Boheme, fudged communication leads to trouble!
If you think someone is not telling the truth, tell them so (in a kind and firm manner)
When speaking to Marcello, Rodolfo attempts to put the blame on Mimì for his bad behaviour. This is a familiar story for people working in the forensic psychiatric sector. Marcello shows us the importance of following our gut-instinct in these situations: ‘You are not being honest with me’. The result is an outpouring of honesty from Rodolfo and our increased understanding of what motivates his bad behaviour. Often this approach is what is needed in a mental health setting: persistent assertive but kind confrontations if we suspect that a patient is not telling us the (whole) truth.
ACT 4
In the final act, now separated from their girlfriends, Rodolfo and Marcello lament their loneliness in their apartment (Duet: ‘O Mimì, tu più non torni’). Colline and Schaunard bring a meager meal. To lighten their spirits they stage a dance, when suddenly Musetta bursts in to tell them that Mimì is outside, too weak to come upstairs. Rodolfo carries her in, while Musetta asks Marcello to sell her earrings for medicine and Colline goes off to pawn his overcoat (‘Vecchia zimarra’). Left alone, Mimì and Rodolfo recall their first meeting and their happy days, but she is seized with violent coughing (Duet: ‘Sono andati?’). The others return and Mimì drifts into unconsciousness. When Rodolfo at last realizes that she is dead, he throws himself despairingly on her body, calling her name.
Reflection points
Good intentions are not always enough
Mimì and Rodolfo sacrificed their love for each other with the aim of providing a healthier and perhaps illness-free life for Mimì. This was not to be. Sometimes, just good intentions are not enough.
In mental health settings, it is often the case that patients and staff lament about their good intentions and that they ‘can't help it that things went bad, and they can't be blamed, because they meant well!’ Good intentions are however only the beginning. Phase 2 would be the behaviour that goes with the intentions.
Don't label people; expect the unexpected
Characters that we previously saw in a negative light (Musetta) or did not notice that much (Colline) shine in this last act because of their kindness. Musetta sells her earrings, while Colline sells his coat to pay for Mimì's medicines. People have different sides to them. The rather self-obsessed Musetta shows her caring and kind side in this last act. In mental health practice we are often so focused on the negative that this defines our patients and our contact with patients. Catching people being positive is important.
Crises can bring people together
The whole group of Bohemians pulls together in this last act, brought together by the crisis of Mimì's illness. A crisis is not always all bad. A challenge in life, a disappointing session with a patient, does not always need to be all bad: we may have to look for the silver lining of the dark cloud.
Lessons from Opera for Practicing Mental Health Professionals
Each opera produces its unique lessons. The story of the Bohemians is just one example, but anyone taking the time to study and enjoy operas like Medea, Rigoletto and many others will be able to distill lessons from these as well. Because viewing opera is almost as individual as performing opera, it is possible that one opera gives different lessons when performed by different conductors, directors and performers.
Opera helps us ‘verstehen’
Besides the unique lessons that each opera can give us, there are a few lessons we can learn from opera in general. I am an opera buff and often the first viewing of an opera does not produce insights as listed above. Opera is the working together of heart, body and mind. During a good performance you can ‘feel’ the music resonate in your body. The mind tries to understand the words, but is also implicitly, going beyond the rational, digital mind by the music, the tone of voice and the visual scenes. Opera forces us into what Max Weber called ‘verstehen’ (Weber, Reference Weber1988). Verstehen goes beyond rational comprehension; ‘verstehen’ refers to understanding the meaning of action from the actor's point of view. It is entering into the shoes of the other, and adopting this inquisitive stance requires treating the actor as a subject, rather than an object of your observations. It also implies that we ‘really’ understand what is going on. Listening to certain operatic arias in Italian, without understanding all the words, one can get the meaning of the song: intonation, musical score, posture on the stage, facial expression all these work together to create a meaning. We sense the meaning and only afterwards, with prolonged reflection, we may be able to deduct how we interpreted the aria in this specific way. In opera you often have to go with your ‘gut’; if you want it all translated and explained, you will lose the real meaning. Perhaps this is what is happening in mental health care, we are in a Zeitgeist where everything is translated in forms, statistics, performance criteria, quality indicators and the like. None of these really result in a real and true understanding what happens on a PICU ward during moments of crisis, on these moments the real ‘verstehen’ of the nurse-in-charge and other attending clinicians is essential. Opera can remind us that the reality is vastly different from the musical score.
The whole is more than the parts
Opera is an experience that only works well if all components work (are orchestrated!) well together: conductor, musicians, and singers. Everything that is on the stage and everything that is behind the stage (all the elements of the ‘artistic milieu’) needs to be in place and work together in a timely fashion. In mental health practice it is exactly the same. When conducting cognitive behaviour therapy one needs to have the right questions, statements and say them at the right moment (to start agenda setting at the end of the session is not really the done thing!); the words need to be spoken with the right emotional tone (to speak to the patient in a sergeant-major type tone: you seem to be very depressed; is not exactly right). In residential mental health settings there are even more components that need to work together in order to create a meaningful treatment programme. Just as in opera, many things that are extremely important may not be immediately visible. In opera, the orchestra is often not visible, the décor designer is not visible on stage, nor are the people who have created the costumes, but it all has an impact on the end product. The same goes for mental health practice: the actual physical surroundings are often taken as a given, the first greeting when entering a service or hospital, these and many more issues often go by unnoticed, but are important factors in the quality of our care.
It is full of emotion but only effective if cool heads prevail
Just like in working on a PICU ward, in opera the emotions ride high. Anyone who has seen a master conductor at work will recognise the emotion that they get out of the performance by rigidly controlling the orchestra with their baton. Emotions may be felt, but are not acted upon during the performance. Similarly in a PICU setting, emotions are often riding high and although patients may act upon their emotions, it is essential for staff to experience the feelings but not act upon them in the moment.
Closing Comments
My first memories of opera are of watching Benjamino Gigli perform ‘Non to scordar di me’, broadcast by German state television to our own Philips TV (no colour yet in 1959). I was five and my dad was the opera lover; while my mother hated it with a vengeance. She won and opera disappeared completely from our household by the 1960s. But even now, too many years later, I still get spine chilling sensations when listening to Gigli perform: the meaning stayed with me. Perhaps this is the most profound lesson we can take from opera. It is not the completed ‘My Shared Pathway’ books, nor the completed daily thought diaries that patients remember when they are confronted by a new crisis. They will remember an implicit meaning, perhaps combined with an image or a sound, which will give them the strength to persist with the path to recovery. I met one of my patients again in a different setting many years after her therapy was completed. She told me that she remembered my voice describing the difference between rational and irrational beliefs in combination with my dog's head which was lying on her lap during many of our sessions (the dog, Mr Percy, would put his head on people's laps when they cried). She explained that the dog's trusting eyes and my voice were an unbeatable combination and during moments of distress she got strength from remembering the combination. Opera teaches us that we need to create moments of positive meaning for our patients, without these moments even a musical score or therapy that looks very good on paper will not be remembered, but with them, even an average musical score or therapy can become the experience of a lifetime.
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Orchestrated Chaos or Chaos Orchestrated?
Anyone who is familiar with residential psychiatric care and especially with working in a psychiatric intensive care unit will know the cacophony of events that can happen at any given point in time: therapy groups need to be run on the unit, a patient needs to be escorted to his or her section 117 meeting, another patient is adamant that she is not going to take her medication, while another patient is seemingly withdrawn from everything. Members of staff need regular breaks, paperwork needs completing and relatives of a patient have unexpectedly turned up for a visit. In the midst of this stream of events, and the defence-barrier between that stream and chaos, is the ‘conductor’ of the unit: the nurse in charge. Often I have entered wards and in my mind admiringly compared the work of a nurse-in-charge with the work of a conductor during an opera.
Opera and Mental Health
Both opera and mental health care, especially mental health care in residential settings, are highly complex and deal with a multitude of factors. In a residential mental health setting there are first and foremost many actors involved: the patient, client or service user; a range of clinical staff (nurses, health care assistants, psychologists, occupational therapists, social workers, psychiatrists, community based professionals) who are directly involved with the patient; relatives of the patient; clinical staff of the setting that the patient may go to after their current placement; commissioners and case managers. And of course in residential care there are the people who work in the background and make it all possible: cleaners, maintenance people, administrative staff etc.
The Concise Oxford Dictionary of Opera (Rosenthal & Warrack, Reference Rosenthal and Warrack1975) consists of 446 pages. Anyone who has attended an opera performance can immediately see the complexity of it all. First there is the music; then there are the voices, the lyrics, the stage, the singers, the orchestra, the conductor and many more aspects that are not immediately visible to the audience, but if not all correct would have an immediate effect (for instance the musical score). Both opera and mental health care depend on the timely and correct interplay of a wide range of factors.
Opera, Badness and Madness
Many operas have engaging and dramatic stories about human misery, badness and madness. A few examples of this are:
• Verdi's Otello, in which psychopathy is eloquently portrayed by Iago, who fuels the jealousy of Otello until this reaches the heights of morbid jealousy and he (Otello) kills Desdemona;
• Britten's Billy Budd, which explores themes of repressed homosexuality, sadism, cowardice and redemption;
• Don Giovanni in Mozart's Don Giovanni displays with perfection the charming psychopath, who given half a chance could sell snow to Eskimos.
‘Opera is fascinated by madness …[,] composers making their characters enact florid psychotic scenes on stage … (Durà-Vilà & Bentley, Reference Durà-Vilà and Bentley2009). Many operas since the late seventeenth century have included an operatic ‘mad scene’. One of the most famous is in Donizetti's Lucia di Lamermoor, when Lucia, after having killed her newly-wed husband Arturo, rejoins the wedding party and completely loses her link to reality. Other ‘mad scenes’ occur in Anna Bolena and Linda di Chamonix (both also by Donizetti); in Bellini's I Puritani and many others. In opera, a mad scene is an enactment of insanity.
Opera has so many things to offer for mental health professionals, from clear-cut examples of evil-doing to examples of irrational thinking. Operas tell stories focused on all of humanity's weaknesses. Operas are full of drama, but the audience at the Metropolitan Opera House in New York got more than it bargained for with the onstage death of one of its greatest stars. In March 1960, while performing Verdi's La Forza del Destino, the great baritone Leonard Warren completed his Act II aria, O Gioia (‘Oh Joy’, which begins ‘Morir, tremenda cosa’ (‘to die, a momentous thing’)), and pitched forward dead. That evening, for one of the very few times in its history, the Met's show did not go on.
Despite the rich representation of madness and badness in opera, it is surprising how few papers have been dedicated to the overlap between opera on the one hand and psychology, psychiatry and psychotherapy on the other hand. In the early 1990s, Mark Jones wrote a few papers on opera and psychiatric problems (Jones, Reference Jones1990a, Reference Jonesb, Reference Jonesc, Reference Jones1991), while Durà-Vilà & Bentley (Reference Durà-Vilà and Bentley2009) wrote an engaging account of madness in Peter Grimes. These studies focused on the representation of mental illness and badness in various operas. The focus of this paper is different: what can clinicians in mental health learn from opera?
What Can We Learn From Opera?
Many operas contain lessons on life as well as helpful hints for practicing mental health clinicians. To illustrate this, I have chosen one of Puccini's grand operas: La Bohème. This is an opera in four acts to an Italian libretto by Luigi Illica and Giuseppe Giacosa, based on Scènes de la vie de bohème by Henri Murger. The world premiere performance of La Bohème was in Turin on 1 February 1896 at the Teatro Regio and conducted by the young Arturo Toscanini.
Five of the main characters of La Bohème are artists: Rodolfo is a poet, Marcello is a painter, Schaunard is a musician, Colline is a philosopher and Musetta is a singer. The two remaining characters are ordinary, non-bohemian people: Mimì is a seamstress and Benoît is a landlord. The story is as follows. In 1830s Paris four arty types (Bohemiens) shiver in their apartment, owing rent but when one of them, the musician Schaunard, earns money they are all set to go for a meal in a nearby restaurant. Rodolpho, the poet, stays behind to finish his writing and is interrupted by Mimì, a seamstress from the next apartment. They are instantly attracted to each other and catch the others up at the restaurant where Rodolpho's painter friend Marcello is re-acquainted with his flirtatious ex-girlfriend Musetta, who dumps her current lover, after getting him to pay everyone's bill. Sometime later Musetta and Alfredo are living together, as are Mimì and Rodolpho, but he is aware that she has tuberculosis and is mean to her in the hope she will leave him for someone who can take better care of her. Eventually she does, Musetta splits from Marcello and the four men resume living together in an apartment. They are visited by Musetta, who has sought out Mimì, now living with a wealthy count, but dying, and has brought her back to die in the presence of her true love and friends. Musetta and Marcello reunite as Rodolpho cries over the dead body of his Mimì.
I have selected four brief excerpts from the opera to focus the mind regarding lessons we can take as mental health clinicians from opera.
ACT 1
This scene occurs during the first act, after about 24 minutes. Rodolfo and Mimì are alone in the apartment, all the candles have been blown out, it is dark, Mimì is about to leave, but before she does Rodolfo takes her hand and introduces himself to her (in the form of a rather beautiful aria). They have been searching for Mimì's key to her apartment. Rodolfo has found the key, but hidden it as he wants to spend more time with Mimì.
This is what he sings:
And how do I live? I live
in my contented poverty,
as if a grand lord, I squander
odes and hymns of love.
In my dreams and reveries,
I build castles in the air,
where in spirit I am a millionaire.
(http://dennisalbert.com/Opera/labohemelibretto.htm)
Reflection points
Even when you are completely in the dark you can find something valuable
Mimì and Rodolfo have been searching in the dark and they still find ‘something’: happiness in meeting. In mental health there is a strong emphasis on evidence based interventions and formulation driven treatment programmes There is a strong emphasis that you really have to know where you are going from the beginning and that clear goals need to be set from the outset. This is all based on the assumption that we always know exactly what we are doing and why it is being done. However in very complex situations (such as when working with patients who have complex needs in a residential setting), it can pay off to apply nature's best approach which in the end always produces results: trial and error (Kellert, Reference Kellert1993). You don't always need to know where you are going in order to get somewhere. With complex and multi-problem patients it may be a good idea to carefully start ‘somewhere’ with interventions, instead of waiting until all the facts are known, evaluated and weighted. In other words, even if you don't have nice polished formulation (i.e. you are in the dark) tentative and careful steps can produce satisfying results (and in a well done performance of La Boheme this is often beautifully demonstrated by the tentative looking for the ‘lost’ key). Basically this is what has to happen in residential settings, especially in psychiatric intensive care units: as a nurse based on the ward, you can't wait for a completed assessment before deciding how to interact with patients: you have to do something right now!
Keep an open mind, even if you have found what you were looking for
Mimì and Rodolfo continue looking for the key, even after Rodolfo has found it. Sometimes the answer is really blowing in the wind and therefore not important. It is the wind that counts and letting the wind dictate where you are heading, even after you have found the answer. This may lead to interesting and uplifting results. In the field of mental health, too often the efforts of a clinician or clinical team come to grinding halt after a diagnosis has been identified or a treatment programme pathway selected. How the patient responds to the specific interventions almost becomes a sideshow (because ‘we know, based on the evidence, how a patient ought to respond and patients responding differently are just difficult…’). Going with the idiosyncratic response of the patient to our interventions has become a ‘not-done’ in this Zeitgeist of protocolised and manualised interventions. From this excerpt, we learn that we can find the key (i.e. follow the protocol) and yet continue to be open to adaptations. Let's face it, if Rodolfo, upon finding the key had said: ‘Oh, found it, here it is, goodbye’, we would have missed a fine opera.
Not all irrational thinking is bad and needs to become the focus of therapy
Rodolfo sings: ‘where in spirit I am a millionaire.’ He is very poor but feels as if he is a millionaire and it makes him happy. In mental health, we frequently behave like the thought police and pursue relentlessly any thought or idea that does not conform to our own perspective of rationality and reality. Reality is simply an option; if a patient chooses to believe in an option of reality that is not shared by us and it does not cause problems, perhaps we should congratulate them on their creative problem solving instead of challenging the ‘incorrect appraisal of reality’. In a PICU setting, addressing all examples of irrationality and delusional thinking would be very much counterproductive.
It is better to lead a life worth suffering for, then to avoid all suffering in life
Rodolfo goes on: ‘Yet sometimes from my safe, all my gems are stolen by two thieves, a pair of lovely eyes’, followed by ‘Beautiful dreams I'd cherished, immediately vanished without a trace’. These phrases indicate that he knows that he is on a path that will bring suffering, but he accepts it as part of life. Too often in the field of psychiatry and psychology suffering is mistaken for pathology. The first noble truth in Buddhism (Bhodi, Reference Bhodi2000) tells us that ‘there is suffering’. Suffering is part of life and we should not teach our patients to avoid suffering but how to lead a life that is so good, that it is worth suffering for. In this sense, a PICU setting where there are no strongly expressed negative feelings and where there are no behavioural problems is probably a setting where patients are overmedicated. Learning new ways of living is painful and difficult for patients and it is not wrong when this shows!
ACT 2
During the second act, at the Café Momus, Rodolfo introduces Mimì to his friends. Marcello's former sweetheart, Musetta, makes a noisy entrance on the arm of the elderly but wealthy Alcindoro. The ensuing tumult reaches its peak when, trying to regain Marcello's attention, she sings a waltz about her popularity (‘Quando me'n vo’’). Sending Alcindoro off on an errand, she falls into Marcello's arms and tells the waiter to charge everything to Alcindoro. The aria ‘Quando me'n vo’’ sung by Musetta reads as follows: ‘When I stroll out alone along the street. The people stop and gaze at me, to seek out my beauty from head to toe. …and then I taste the sly desire that gleams from admiring eyes. They can see all my beauty which lies concealed in my heart, perceived from my outward charms’.
Reflection point
Going beyond the surface and first impressions is essential
In mental health, establishing a diagnosis is often seen as very important. After this song many clinicians will be inclined to see Musetta as a narcissistic personality disorder. This woman clearly has an inflated sense of her personal qualities. However the remainder of the second act shows that Musetta is putting on this show to get Marcellino to notice her (again) and to rekindle his love for her. In other words, her behaviour (the display of narcissism) is fueled by noble and positive intentions (attracting the attention of the man she really loves). In mental health we often see patients with similar problems: the overt behaviour looks bad but the underlying intentions are positive. If we as clinicians solely focus on the behaviour, we may, in a way, reinforce the bad behaviour. If on the other hand we can also focus on the intentions, we might motivate our patients to find alternative behaviours to express their positive intentions. Because (as Musetta and Marcello demonstrate) sometimes it is too difficult to say what we want or need, and we say or do the opposite. This demonstrates two reflection points: The first is that first impressions are not always (or seldom) able to stand the test of time. Unfortunately in mental health we often forget that, and many patients are still followed by diagnostic labels given to them decades ago, by clinicians whose initial assessment was recorded. A brief moment in the consulting room leads to a lifetime in their file! The second reflection point is that behaviour that on the surface looks bad may have positive and even noble connotations.
ACT 3
At the beginning of the third act, at dawn by a tavern on the snowy outskirts of Paris, Mimì wanders in, searching for the place where Marcello and Musetta now live. When the painter emerges, she tells him of her distress over Rodolfo's incessant jealousy (Duet: ‘O buon Marcello, aiuto!’). She says that she believes it is best that they part. When Rodolfo appears from the tavern, Mimì hides nearby, though Marcello thinks she has gone. The poet tells Marcello that he wants to separate from his sweetheart, citing her fickleness; pressed for the real reason, he breaks down, saying that her coughing can only grow worse in the poverty they share; he's desperately afraid she will die from her illness.
When Mimì tells Marcello about her problems with Rodolfo, this is what she says: ‘Rodolfo,… Rodolfo loves me, but flees me, my poor Rodolfo is jealous; he is in torment. The slightest gesture, a smile, a flower will arouse his suspicions. Then he grows vexed and angry. … shouts at me so harshly “You're not right for me, so find yourself another” “You're not right for me” Alas, Alas! What can I do?’
Later on Rodolfo explains the situation to Marcello as follows: ‘Mimì is a minx, she flirts with everyone. A fop of a young Viscount has only to make eyes at her, and she provocatively lifts her skirts and shows off her ankle in a most promising way. (Marcello: Do I have to say it? I don't think you are sincere.) Alright then, no, I'm not. in vain I try to hide my true torture. Mimì means everything in the world to me. I love her dearly, but I'm frightened, I'm so very frightened! Mimì is very sick! Every day she wanes. The poor little thing is doomed to having no life, a terrible cough shakes her chest and weak frame, … My room is a squalid hideout … The fire is always burnt out. The north wind creeps in and whistles around the room… Mimì is a hothouse flower; poverty is making her blooms wither. Love is no longer enough to retrieve her life!’
Reflection points
Bad behaviour can have very noble reasons indeed
After having heard Mimì's account to Marcello, one is ready with a verdict. Rodolfo has the potential for domestic violence: he is a brute and Mimì is making a timely escape from the clutches of this evil man. We want to warn her against the morbid jealousy that clearly is developing and if our base is in forensics, we are inclined to warn her against the possibility of injury and death at the hands of such an evil person. However when we subsequently hear Rodolfo's story our heart melts at such (all be it clumsily expressed) nobility.
Most people have good intentions, but just as in La Boheme, people often express their good intentions with problematic behaviours. It is important to assist people in becoming more consciously aware of their noble intentions and subsequently teaching them pro-social behaviours to make their intentions come true. The two techniques in cognitive behaviour therapy that aim to achieve this increased awareness are motivational interviewing (Miller, Reference Miller1983; Miller & Rollnick, Reference Miller and Rollnick1991) and Socratic dialogue (Padesky, 1993, keynote address at the EABCT Congress, London, 24 September; Vyskočilová & Praško, Reference Vyskočilová and Praško2012).
And if people don't communicate honestly that results in trouble
Rodolfo and Mimì are clearly not the best communicators. As the story unfolds, it becomes clear that she does not even know she is seriously ill. A lot of grief could have been prevented if Mimì and Rodolfo had engaged in some open and honest conversation! Good and open communication is the basis of any productive relationship, whether it is a personal or professional relationship. In a mental health setting effective communication is essential, however just as in La Boheme, too often communication is fudged. Communication between patients and their clinical team during ward reviews and clinical meetings often result in mutual admiration whereby everyone is told they are doing a wonderful job. Afterwards the clinicians wonder why the patient is not developing specific insight into their problems and issues. Miller et al. (Reference Miller, Sovereign and Krege1988) demonstrated that providing objective feedback to problem drinkers was an effective motivation enhancing strategy. As in La Boheme, fudged communication leads to trouble!
If you think someone is not telling the truth, tell them so (in a kind and firm manner)
When speaking to Marcello, Rodolfo attempts to put the blame on Mimì for his bad behaviour. This is a familiar story for people working in the forensic psychiatric sector. Marcello shows us the importance of following our gut-instinct in these situations: ‘You are not being honest with me’. The result is an outpouring of honesty from Rodolfo and our increased understanding of what motivates his bad behaviour. Often this approach is what is needed in a mental health setting: persistent assertive but kind confrontations if we suspect that a patient is not telling us the (whole) truth.
ACT 4
In the final act, now separated from their girlfriends, Rodolfo and Marcello lament their loneliness in their apartment (Duet: ‘O Mimì, tu più non torni’). Colline and Schaunard bring a meager meal. To lighten their spirits they stage a dance, when suddenly Musetta bursts in to tell them that Mimì is outside, too weak to come upstairs. Rodolfo carries her in, while Musetta asks Marcello to sell her earrings for medicine and Colline goes off to pawn his overcoat (‘Vecchia zimarra’). Left alone, Mimì and Rodolfo recall their first meeting and their happy days, but she is seized with violent coughing (Duet: ‘Sono andati?’). The others return and Mimì drifts into unconsciousness. When Rodolfo at last realizes that she is dead, he throws himself despairingly on her body, calling her name.
Reflection points
Good intentions are not always enough
Mimì and Rodolfo sacrificed their love for each other with the aim of providing a healthier and perhaps illness-free life for Mimì. This was not to be. Sometimes, just good intentions are not enough.
In mental health settings, it is often the case that patients and staff lament about their good intentions and that they ‘can't help it that things went bad, and they can't be blamed, because they meant well!’ Good intentions are however only the beginning. Phase 2 would be the behaviour that goes with the intentions.
Don't label people; expect the unexpected
Characters that we previously saw in a negative light (Musetta) or did not notice that much (Colline) shine in this last act because of their kindness. Musetta sells her earrings, while Colline sells his coat to pay for Mimì's medicines. People have different sides to them. The rather self-obsessed Musetta shows her caring and kind side in this last act. In mental health practice we are often so focused on the negative that this defines our patients and our contact with patients. Catching people being positive is important.
Crises can bring people together
The whole group of Bohemians pulls together in this last act, brought together by the crisis of Mimì's illness. A crisis is not always all bad. A challenge in life, a disappointing session with a patient, does not always need to be all bad: we may have to look for the silver lining of the dark cloud.
Lessons from Opera for Practicing Mental Health Professionals
Each opera produces its unique lessons. The story of the Bohemians is just one example, but anyone taking the time to study and enjoy operas like Medea, Rigoletto and many others will be able to distill lessons from these as well. Because viewing opera is almost as individual as performing opera, it is possible that one opera gives different lessons when performed by different conductors, directors and performers.
Opera helps us ‘verstehen’
Besides the unique lessons that each opera can give us, there are a few lessons we can learn from opera in general. I am an opera buff and often the first viewing of an opera does not produce insights as listed above. Opera is the working together of heart, body and mind. During a good performance you can ‘feel’ the music resonate in your body. The mind tries to understand the words, but is also implicitly, going beyond the rational, digital mind by the music, the tone of voice and the visual scenes. Opera forces us into what Max Weber called ‘verstehen’ (Weber, Reference Weber1988). Verstehen goes beyond rational comprehension; ‘verstehen’ refers to understanding the meaning of action from the actor's point of view. It is entering into the shoes of the other, and adopting this inquisitive stance requires treating the actor as a subject, rather than an object of your observations. It also implies that we ‘really’ understand what is going on. Listening to certain operatic arias in Italian, without understanding all the words, one can get the meaning of the song: intonation, musical score, posture on the stage, facial expression all these work together to create a meaning. We sense the meaning and only afterwards, with prolonged reflection, we may be able to deduct how we interpreted the aria in this specific way. In opera you often have to go with your ‘gut’; if you want it all translated and explained, you will lose the real meaning. Perhaps this is what is happening in mental health care, we are in a Zeitgeist where everything is translated in forms, statistics, performance criteria, quality indicators and the like. None of these really result in a real and true understanding what happens on a PICU ward during moments of crisis, on these moments the real ‘verstehen’ of the nurse-in-charge and other attending clinicians is essential. Opera can remind us that the reality is vastly different from the musical score.
The whole is more than the parts
Opera is an experience that only works well if all components work (are orchestrated!) well together: conductor, musicians, and singers. Everything that is on the stage and everything that is behind the stage (all the elements of the ‘artistic milieu’) needs to be in place and work together in a timely fashion. In mental health practice it is exactly the same. When conducting cognitive behaviour therapy one needs to have the right questions, statements and say them at the right moment (to start agenda setting at the end of the session is not really the done thing!); the words need to be spoken with the right emotional tone (to speak to the patient in a sergeant-major type tone: you seem to be very depressed; is not exactly right). In residential mental health settings there are even more components that need to work together in order to create a meaningful treatment programme. Just as in opera, many things that are extremely important may not be immediately visible. In opera, the orchestra is often not visible, the décor designer is not visible on stage, nor are the people who have created the costumes, but it all has an impact on the end product. The same goes for mental health practice: the actual physical surroundings are often taken as a given, the first greeting when entering a service or hospital, these and many more issues often go by unnoticed, but are important factors in the quality of our care.
It is full of emotion but only effective if cool heads prevail
Just like in working on a PICU ward, in opera the emotions ride high. Anyone who has seen a master conductor at work will recognise the emotion that they get out of the performance by rigidly controlling the orchestra with their baton. Emotions may be felt, but are not acted upon during the performance. Similarly in a PICU setting, emotions are often riding high and although patients may act upon their emotions, it is essential for staff to experience the feelings but not act upon them in the moment.
Closing Comments
My first memories of opera are of watching Benjamino Gigli perform ‘Non to scordar di me’, broadcast by German state television to our own Philips TV (no colour yet in 1959). I was five and my dad was the opera lover; while my mother hated it with a vengeance. She won and opera disappeared completely from our household by the 1960s. But even now, too many years later, I still get spine chilling sensations when listening to Gigli perform: the meaning stayed with me. Perhaps this is the most profound lesson we can take from opera. It is not the completed ‘My Shared Pathway’ books, nor the completed daily thought diaries that patients remember when they are confronted by a new crisis. They will remember an implicit meaning, perhaps combined with an image or a sound, which will give them the strength to persist with the path to recovery. I met one of my patients again in a different setting many years after her therapy was completed. She told me that she remembered my voice describing the difference between rational and irrational beliefs in combination with my dog's head which was lying on her lap during many of our sessions (the dog, Mr Percy, would put his head on people's laps when they cried). She explained that the dog's trusting eyes and my voice were an unbeatable combination and during moments of distress she got strength from remembering the combination. Opera teaches us that we need to create moments of positive meaning for our patients, without these moments even a musical score or therapy that looks very good on paper will not be remembered, but with them, even an average musical score or therapy can become the experience of a lifetime.