Accelerating experiential learning mechanisms

The dismantling of the ‘fourth wall’, i.e. transforming the passive spectator into a ‘spect-actor’, is central to Boal’s theatre of the oppressed. ^{Reference Boal3} Our respondents rated this interactive element highly (mean score: 4.34). When viewed through Kolb’s experiential learning theory, ^{Reference Kolb9} the intervention appears to uniquely compress the learning cycle.

Kolb posits that learning takes place in a four-stage cycle:

1. (1) concrete experience: having an experience;

2. (2) reflective observation: reviewing/reflecting on the experience;

3. (3) abstract conceptualisation: concluding/learning from the experience;

4. (4) active experimentation: planning/trying out what you have learned.

In traditional curricula, Kolb’s stages are often disjointed. ^{Reference Yardley, Teunissen and Dornan10} A student might engage in abstract conceptualisation during a lecture on Monday, but not encounter the concrete experience of seeing a patient until a clinical placement weeks later. Furthermore, active experimentation is frequently curtailed by safety concerns; students rarely lead high-stakes assessments with patients, limiting them to observation. ^{Reference Yardley, Teunissen and Dornan10}

Revolving Door compresses this cycle into a rapid, iterative loop. The play provides the concrete experience; the facilitated discussion drives reflective observation and abstract conceptualisation; and the ‘rewind and replay’ mechanism allows for immediate active experimentation. Students valued the ability to ‘rewrite the ending’ and ‘make mistakes’, suggesting that testing communication strategies in real time is central to the method’s value. This aligns with literature suggesting that drama-based pedagogies allow learners to externalise decision-making, creating rich memory traces through embodied cognition. ^{Reference Arveklev, Berg, Wigert, Morrison-Helme and Lepp11}

Transformative learning as a vehicle for change

Whereas Kolb explains skill acquisition, Mezirow’s transformative learning theory best explains the shifts in perspective highlighted in the qualitative feedback. ^{Reference Mezirow12} Mezirow argues that deep learning requires a ‘disorienting dilemma’ – an experience that challenges the learner’s existing frame of reference. Revolving Door creates this dilemma by presenting the medical system as a potential antagonist, challenging the students’ view of clinicians – and, by extension, of themselves – as purely benevolent healers.

Qualitative data from our study reveal that this cognitive dissonance forced students to grapple with the ‘messy human reality’ of practice. By altering the scenario’s outcome, students engaged in the rational discourse necessary to reintegrate this new perspective, viewing themselves not just as clinicians, but as agents of systemic change. ^{Reference Mezirow and J13} Without the shaking of presuppositions, the experience would be distressing rather than transformative; the interactive nature of the forum ensures that the dilemma leads to growth rather than withdrawal. ^{Reference Mezirow and J13}

Productive anxiety and psychological safety

Respondents frequently highlighted the role of emotion, specifically anxiety, across all qualitative themes identified. Historically, medical education has viewed anxiety as an impediment to clinical reasoning. ^{Reference Merkebu, Soh, Loncharich, Hawks, Costello and Shapiro14} However, our findings suggest a dichotomy: although some felt ‘daunted’, the majority found the emotional engagement (mean score: 4.40) and display of difficult emotions (mean score: 4.58) essential.

This supports the ‘pedagogy of discomfort’, which argues that leaving one’s comfort zone is necessary to recognise hegemonic norms. ^{Reference Boler, Zembylas and P15} Unlike bedside teaching, where anxiety stems from the fear of causing actual patient harm, ^{Reference Peters and ten Cate16} forum theatre shifts risk to the social domain. Here, the ‘patient’ cannot be injured; instead, the primary risk is the performance anxiety associated with acting in front of peers. This allows students to inhabit a space where collective failure is reframed as necessary. Facilitators balanced this by creating a ‘very supportive’ environment, transforming the anxiety of ‘taking the stage’ into productive vigilance.

Restoring epistemic justice

Revolving Door potentially addresses a critical ethical issue: the validation of patient knowledge. Fricker defines testimonial injustice as the downgrading of a speaker’s credibility owing to prejudice. ^{Reference Fricker17} In psychiatry, patient narratives are often subordinated to the clinician’s ‘objective’ assessment. ^{Reference Ballesteros18}

By centring on an authentic narrative, the intervention attempts to restore epistemic agency. Students reported that the play ‘humanises patients’, preventing them from becoming ‘steps on a checklist’. Witnessing the social determinants leading to a crisis forces students to interpret resistance not as pathology, but as a rational response to a frightening system. This counters hermeneutical injustice, defined as the injustice endured by individuals when their experiences do not align with existing popular mental schemas, ^{Reference Ballesteros18} and equips students with the resources to understand the clinical encounter from the patient’s epistemology via the abovementioned transformative learning theory strategies.

Professional identity

Finally, the emotional resonance of the play contributes to the formation of professional identity. Shapiro’s concept of the ‘feeling physician’ emphasises emotional engagement as a clinical skill. ^{Reference Shapiro19} By embodying the psychiatrist during a crisis, students act out ‘becoming a doctor’, moving from passive information gatherers to compassionate practitioners.

Study limitations

Although many found the interactive elements of the intervention empowering, some students reported anxiety around potentially being called on to perform in front of their peers. Such performance anxiety is a recognised challenge in formats such as simulation-based teaching and objective structured clinical examinations. ^{Reference Yu, Chang, Kim, Park, Chung and Lee20} Furthermore, careful thought is required to ensure the psychological safety of the audience. Utilisation of CTFs who have had previous engagement with the students can cultivate safety through familiarity. A play such as this could be potentially anxiety triggering for students, particularly those with lived experience of mental illness. If uncontained, this risks significantly limiting learning. It is the responsibility of facilitators to strike a balance between emotional connection and clinical learning by framing the experience sensitively in the introduction and offering post-production debrief opportunities.

The play highlights how Martin and his family were let down by the healthcare system. This risks reinforcing a binary perception of ‘good’ versus ‘bad’ consultations and clinicians. With experienced facilitation, students can reflect on the systemic pressures and ethical dilemmas faced by clinicians in navigating nuanced perspectives.

Another notable limitation of the study is the lack of longitudinal evaluation to determine whether the use of students’ perceptions is a valid proxy measure for concrete improvement in clinical practice. In addition, to ensure participant anonymity, only the minimum necessary personal information was processed for the study’s specific aims. Without collection of data such as gender and ethnicity, a more granular analysis of how demographic backgrounds may have influenced perspectives on the session could not be undertaken.

Educational implications

This evaluation demonstrates that a forum theatre-based intervention is an effective pedagogical method that supports cognitive understanding, emotional insight and clinical skill development. Its immersive, participatory structure encourages students to practise empathy, navigate uncertainty and reflect on systemic barriers, providing the space to explore professional identity challenges and epistemic injustices. Students are given the opportunity to affirm their shared humanity with the characters in the play, stimulating mutual understanding, which Boal argues is ‘the most powerful weapon’ in catalysing change. ^{Reference Boal3}

The convergence between student feedback and facilitator intent suggests that this model has potential to expedite transformative learning in psychiatric education. As future iterations of medical education increasingly prioritise experiential approaches, forum theatre may offer a powerful template for humanising psychiatry.