Interaction Rituals and Jumbled Emotions Among “Relative Strangers”

Learning games such as role-play (which we refer to as “simulated interaction rituals”) are commonly used as social tools to develop trainee health practitioners. However, the effect of such rituals on individual and group participant emotions has not been carefully studied. Using a heuristic approach, we explore the experiences of complementary therapy practitioner trainees (and their trainers) participating in a personal development course. Ten trainees and two tutors were interviewed, observational notes taken, and a secondary qualitative analysis undertaken. Participants and tutors described a medley of disparate emotional and moral responses to group rituals, conceptualized in this article as “jumbled emotions.” Such emotions required disentangling, and both trainees and staff perceived participating in unfamiliar rituals “with relative strangers” as challenging. Front of stage effects are frequently processed “backstage,” as rituals threaten social embarrassment and confusion. Concerns around emotional triggers, authenticity, and outcomes of rituals arise at the time, yet trainees can find ways to work through these issues in time.


Introduction
Group activities known as social and emotional learning (SEL) games, such as sharing personal experiences, imagination games, and role-play have been used in child and adult education for decades (Hromek & Roffey, 2009;O'Sullivan, 2003). However, the theory underpinning SEL, as elaborated in this article, is a more recent development. From the 1970s, sociologist Mezirow developed his theory of transformative learning for adults returning to education (Kitchenham, 2008). In the 1990s, SEL theory was formally developed by the Collaborative for Academic Social and Emotional Learning (CASEL) in the United States (Hromek & Roffey, 2009). SEL has since become a cornerstone of Western education.
Experience-based learning (EBL) and problem-based learning (PBL) activities are increasingly featured in health care training programs (Chaturvedi & Chandra, 2010;Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005;Kenaszchuk, MacMillan, van Soeren, & Reeves, 2011;Nikendei et al., 2007;Oflaz, Meric, Yuksel, & Ozcan, 2011;Wilkie & Burns, 2003), although their value is only now being more fully examined (Kenaszchuk et al., 2011). Believed to act as vehicles for personal development and transformation of mental habits, attitudes, and values, the advantages of "experiential" (Hromek & Roffey, 2009) and "transformative" (Mezirow, 1997) learning activities are extensively reported (Durlak, Weissberg, & Pachan, 2010). SEL games for children have been associated with positive emotions leading to more creative problem-solving capacities and reducing stress (Hromek & Roffey, 2009). PBL activities, where students work in small groups on scenarios they may encounter in vocational practice (Wilkie & Burns, 2003), are thought to activate tacit knowledge and facilitate both comprehension and memorability (Schmidt, Rotgans, & Yew, 2011). The emotions these activities evoke in differing cultural settings, however, are likely to be more complex (Brownlie, 2011;Keville et al., 2013), particularly when participants have the added stress of being assessed for professional competencies (Chandavarkar, Azzam, & Mathews, 2007). As social rituals, these activities are intriguing in their own right, yet have not been interpreted dramaturgically, as we intend to do in this article.
The last few decades have witnessed an explosion of interest in the study of emotions in groups and organizations (Collins, 2004;Filipowicz, Barsade, & Melwani, 2011;Kelly & Barsade, 2001;Wiley, 1990). However, with the exception of psychology (Keville et al., 2013) and counseling (Lane & Rollnick, 2007), the study of group emotion work in health practitioner education and training has been somewhat neglected. In our article, we examine the accounts of a culturally diverse cohort of complementary therapy trainees and their tutors who participated for 2 years in a university-based personal and professional development course. Regular sessions consisted of group activities incorporating a variety of games and dramatic techniques comparable with those described in transformative learning literature. Written reflections based on these activities constituted part of the course assessment. Using a secondary qualitative analysis approach and direct observations, we examine interviews and observations with participants, focusing on their affective experiences during group work. To interpret the data, we draw on theory about types of ritual and the emotional energy they generate (Collins, 2004) as well as emotion and performance in contemporary organizations (Alexander, 2006;Brownlie, 2011;Ng & Kidder, 2010).

Social Interaction Ritual Theory
"Sub-cognitive ritualism" traces its roots back to the work of Émile Durkheim for whom rites and rituals were perceived as sites of "collective effervescence," wherein the very fact of congregating to perform actions together was thought to generate creative energy and collective emotion, thus giving reinforcement to beliefs and moral dispositions. Goffman was the first to use the term social interaction ritual, ascribing similar attributes to mundane interactions of the everyday as Durkheim attributed to formal religious rituals (Durkheim, 1912;Goffman, 1959;Hausmann, Jonason, & Summers-Effler, 2011). Assuming a dramaturgical perspective, Goffman (1959Goffman ( , 1972 focused on the unspoken norms played out socially, including managing the impressions we make on others to save face and avoid social embarrassment, and the distinctions between social etiquette front of stage (such as in the presence of a tutor) and back of stage (such as in the cafeteria with one's peers). One quandary of impression management in the context of the group is that a person's individual performance depends not only on his or her own performance, but also on the role-playing of other "actors" in the unfolding social drama.
In his recent work on social interaction rituals, Randall Collins (2004) introduces the notion of "interaction ritual chains," depicting individuals as strategic pursuers of "emotional energy," constantly feeling their way through situations (p. 3), but generally seeking moral cohesion within the group. For Collins, it is this emotional energy that individuals seek from interaction rituals that determines success or failure. Outcomes of successful rituals are increased emotional energy (such as feelings of courage and enthusiasm), a sense of moral rightness, and adherence to the group and its symbols (Collins, 2004). In contrast, failed rituals are those that feel forced or flat, lack a sense of shared emotion or group solidarity, and that result in feelings of anxiety, embarrassment, or alienation from the group. Interaction rituals can be informal and spontaneous, formal, or ceremonial (Collins, 2004, p. 50). Broadly, people are also stratified into "insiders" and "outsiders" and, within the ritual, into leaders and ritual followers.
Collins's theory involves the view of collective emotions as generated by a medley of individual actions and emotions in specific circumstances (Kelly & Barsade, 2001;J. H. Turner & Stets, 2005). The unique emotional tendencies that individuals bring to the group interaction produce emotional "heat" (Barsade, 2002) or "energy" (Collins, 2004) that can vary in intensity. Emotional responses become incorporated into the individual's perception of self and relationship (Game, 2008) and provide a bank of emotional resources for subsequent interaction rituals chains.

Ritual and Emotion
Researchers in the field of social interaction suggest that the "performed to an audience" aspect of rituals can render them intensely meaningful, challenging, and memorable for those taking part (Ng & Kidder, 2010;V. W. Turner, 1987). During a group performance, the simultaneous arising and expression of emotions in players and the audience potentially create a "collective effervescence" that can transform the way people feel (Collins, 2004). Nevertheless, the quality of the felt experiences depends on the nature and purpose of the ritual. Generating or managing emotions can be perceived as stressful, such as when participants are expected to put on a show for commercial purposes, and simulate enthusiasm for a product or service without truly feeling it (Hochschild, 1983;J. H. Turner & Stets, 2005). At some level, people in these types of ritual have an awareness of trying to deliberately change emotions, as opposed to participants feeling spontaneously charged with emotion (Collins, 2004;Ng & Kidder, 2010).
Simulation techniques, such as role-play and soliloquy (talking to oneself aloud to reveal inner thoughts) to rehearse before real-life scenarios, are applied in psychodrama for therapeutic purposes (Moreno, 1985;Wiley, 1990) and used as vehicles for skills training of health practitioners (Wilkie & Burns, 2003). Role-playing of patient-practitioner relationships by trainee medical practitioners, for instance, has been shown to be beneficial in terms of increasing trainee understanding and skills with patients (Issenberg et al., 2005). Yet, empirical evidence on the processes embedded in simulation activities  and their ability to improve health professional skills is lacking. In addition (Kenaszchuk et al., 2011), performing in front of others in educational settings can be personally challenging, involving emotional and impression management (Thoits, 1996), resulting in anticipatory anxiety, emotional and impression management, and conflict with other players (Fixsen & Ridge, 2012). In medical training scenarios, the role of the patient is often taken by trained actors or volunteers trained to take on a role (Wilkie & Burns, 2003). Even trained actors can experience a degree of stress from acting out psychiatric roles (Bokken, Van Dalen, & Jan-Joost, 2004;Mitchison & Khanna, 2010).

Group Emotions and Power Relations
During group encounters, the emotional state of individuals and groups can converge over time to create group emotions (Kelly & Barsade, 2001). As participants get "caught up" in each other's emotions (Collins, 2004, p. 149), the mood becomes stronger and has more impact on behaviors (Barsade, 2002). Collective feelings within the group (such as empathy and altruism) can increase emotional energy and solidarity within the group (Collins, 2004) or, alternatively, lead to discord or resistance when things go wrong. The reasons why certain groups work more effectively than others has been ascribed to both individual personalities and leadership styles (Niven, Holman, & Totterdell, 2012), and to the ways in which group emotional and cultural competencies can together influence the generation and expression of emotion (Koman, Wolff, & Howard, 2008). A dominant group member, who commands respect and whose sentiments are shared by other members, can add to the emotional energy and moral solidarity. However, if members feel coerced, they might use defensive strategies to avoid loss of emotional energy (Summers-Effler, 2004). In cooperative teamwork, shared leadership is commonly adopted; however, dominating or extrovert personalities can still seek front of stage attention, whereas introverted peers fade into the background (Collins, 2004). Either way, over-participation or non-participation can give rise to emotional tensions and conflict within the group. In our study, we examine the experiences of complementary therapy trainees and tutors, focusing our analysis on the various types of group rituals enacted, emotional patterns generated at individual and group level, and the role and influence of the stage, as well as facilitators.

Method
Interview data and observations were originally collected as part of an initial study to explore trainee and tutor responses to participation in a complementary therapy reflective practice program. Some broadly ethnographic studies choose to use one-to-one interviews as the sole or principal method of data collection (Leverentz, 2010;Nenga, 2011). For this study, one-to-one interviews that elicited personal accounts and stories were considered the most cost-effective way of gaining insight into the meanings that participants' attributed to their experiences and thought processes (Minichiellow, Madison, Hays, Courtney, & St. John, 1999). Such personal accounts and narratives provide an overarching framework for the way that people construct-and then transmit-meanings about themselves and their social world (White, 1987). As Frank (1995) points out, "the truth of stories is not only what was experienced, but equally what becomes experience in the telling and its reception . . ." (p. 22). Thus, along with our participant-observer tutor, and steering group that included the observer, our methods are consistent with ethnography.
To ensure wider aspects of the study were considered, such as observations of the groups in action, and power implications of the interview process (Hoffman, 2007), a steering group of experienced tutors and researchers (including a participant observer of the teaching program who made notes about, and reflected on, the program, and also discussed observations at group meetings) was closely involved in the original study design, data collection, and the current analysis. The steering group met on three occasions in person, and was also in regular e-mail contact. The participantobserver member shaped the study from the beginning and reviewed the drafts of the manuscript for the current secondary analysis; his observations and comments have fully informed our final analysis.
The program was a mandatory part of a professional development course delivered to trainees studying a range of complementary therapies (such as Chinese medicine and Western herbal medicine). Central to the program were regular small group activities facilitated by a team of staff. Trainees on the courses were expected to attend regular sessions and complete written assessments involving reflections on their experiences. We subsequently used these data to conduct a secondary qualitative analysis; that is, we used existing qualitative data to answer a research question, which differed from that asked in the original research (Hinds, Vogel, & Clarke-Steffen, 1997). For the secondary analysis, the participant observer (whose experience of the training program pre-dated the cohort under study) and the other authors approached the data from a dramaturgical perspective, concentrating on the emotionally charged and interactive components of the program under review.
Our focus was on investigating the preclinical rituals (and the emotional upshots) that are part of preparing trainees for initial patient work. Our first study in the area focused on the emotion work done by graduating practitioners (Fixsen & Ridge, 2012). To answer our new question, we looked at participants' (trainees and tutors) responses to the group work undertaken as part of preparing trainees for patient work. The data consisted of 12 semi-structured interviews conducted by one of the authors, Alison Fixsen, lasting on average 1 hr, and observations from the participant observer on the team. Our rationale for the study was to build on theory about emotion work and performance in the area of complementary therapy trainee experiences, which remain both underresearched and untheorized.
Participants in the study had all completed 2 years of the reflective group-work program. Ethical approval for the research was granted through the University of Westminster ethics committee and covers our subsequent use of interview data for secondary qualitative analysis. Prospective participants were invited to participate in the study by e-mail. Interested trainees were provided with an information sheet explaining the study and its ethical safeguards, including confidentiality, the research independence from teaching, and removal of identifying information from transcripts to safeguard identities. The final trainee sample of 5 male and 5 female participants included trainees from each of the 10 tutor groups, and represented a range of ages (22-42 years) and complementary therapy modalities. In addition, two interviews were carried out with staff teaching on the program with similar safeguards. The interviewer was a senior qualitative researcher, with no previous relationship to participants, and who assured participants of confidentiality. Interviews were conducted within the university grounds, excluding one interview that was carried out in a participant's home. The interviews, which ranged from 40 to 60 min, were audio recorded and later professionally transcribed. Topics covered in the interviews included perceptions of the teaching and facilitation, views on the activities undertaken, feelings generated within groups, and reflections on subsequent personal impacts. A recognized limitation of the sample was that only trainees who were available to take part in interviews during the limited interviewing time frame (10 weeks) could be included.
There are strengths and limitations to secondary analysis. When applied to qualitative data, secondary analysis has several advantages, such as potentially adding to existing knowledge (Thompson, 2000), while reducing the costs of research and burden on respondents by removing the need to recruit and interview further participants. Nevertheless, epistemological problems with secondary analysis can potentially limit interpretation of data. For example, the new researcher cannot recover the context in which data were gathered, and the relationship between researcher and participant is missing. In contrast, the distance between new researcher and research can arguably assist explanation of data (Fielding, 2004). For our analysis, the original members of the research team were included on the new team to bridge the gap between the original and secondary analysis. Thus, we were confident our analysis would be sufficiently rich and faithful to the data to allow for a useful interpretation (Denzin & Lincoln, 2000).
We used a heuristic approach to encourage the process of examining data afresh. Described by Moustakas as "swimming against an unknown current," our approach involved attempts to immerse ourselves in the data at an emotional and practical level (Moustakas, 1990, p. 19). The goal was discovery, and therefore, anything that helped to make sense of data was tested and utilized (such as comparing the group work with "reality" television formats, examining the humor in the accounts of group work). Using phases of analysis outlined by Moustakas (1990), in the initial engagement phase of analysis, we considered the story behind the original study and examined our rationale and interest in conducting secondary research. In the immersion phase, the first author studied the original transcripts one by one, in their entirety, noting down any thoughts, feelings, and metaphors that came to mind. The first author then discussed her initial impressions with the second author, face-to-face and at length. The second author (who was also on the original research team) then sampled a single transcript and fed back his ideas and feelings, and challenged the first author to refine her impressions and find an overall metaphor to explain the findings. At a later stage, the author who had collected the original data (along with other authors on the original team) provided detailed feedback on the entire secondary analysis to ensure that the new interpretation remained true to the ways in which interviewees had presented their accounts. In addition, observational data were used to check and shape the final write-up of the article.
We used a modified constant comparative approach, focusing on inductive coding (coding emerging from direct examination of the data) at open level (labeling and defining raw data) and axial level (connecting of open codes). We then cross-referenced emerging concepts with existing theory and literature (Strauss & Corbin, 1998). The first author re-read the transcripts, comparing words and phrases used by participants to build upon emerging codes and themes, and debated their relevance with the second author. We developed a coding system (such as challenge, acting out, roleplaying, safety, cohesion, support) to apply across interviews with both trainees and staff. Manual coding of interviews continued until we were confident that the main themes had been captured. Significant quotes from the transcripts were then cut and pasted in Microsoft Word, and sorted electronically under themed headings (such as conflict and resistance, spirituality and values, mix of people, group games) for analysis.
As we worked on the data, it became clear that the dramaturgy of games and techniques in which participants engaged was the focus of the narratives. In writing up the analysis, the analyses focused primarily on participants' accounts and views of class work activities undertaken, feelings they generated within groups and how they were managed, and changes in participants' perceptions over time. There were limitations to this study. The study sample was small, and caution needs to be exercised in generalizing beyond this sample. Any conclusions we make in our article are, therefore, tentative. Interesting questions emerged, however, concerning the nature and context of rituals performed by participants and emotion work involved, which we explore in our results.

Results
Participants in the study described a variety of activities and games performed during class sessions. These included soliloquy, discussions, imagination games, guided group meditation, group games, and role-play. For the purposes of our study, we will refer to the activities as "simulated interaction rituals." In the "Results" section, we examine the experiences of participants under the following headings: multidisciplinary work, game playing, and challenge, resistance, and revelations.

Multidisciplinary Work: Thrown Into the Mix
As participants were studying different complementary therapy modalities, at the beginning of the program, they did not necessarily know one another. The deliberate mixing of participants from a wide range of cultures and backgrounds was hoped to broaden trainee experience and prepare them for work in the real world. As one tutor remarked, "they don't know who's [that is, the clientele] going to come through that door as a complementary therapist." But establishing a good working relationship between group members was not easy, and participants advanced their own theories as to why this was the case. At the beginning, it could "feel quite awkward" for participants who did not know anyone. Not having a chance to bond, to "laugh and chat with each other" in the early weeks, meant people were hesitant to share their personal information. Meeting up on alternate weeks for the teaching groups was not enough to "break down barriers," so trainees were "still just all strangers to each other." One participant said, "People were feeling very, very closed . . . I think it really did close a lot of people off." As groupings were preselected, whether you were in a "good" group or not was regarded as accidental.
A general mood or collective "emotional energy" (Collins, 2004) pattern within a group was established early on in the year. A taciturn mood, once established, could promote prolonged silences and a general holding back among group members. In other cases, the collective feelings generated within the group brought a sense of intimacy, "I liked the idea that, very early on, our group got quite close." Experiences could also change as people gradually got to know and trust one another. One participant recalled how in the first year no one was keen on the program; however, at some point, people began to speak more honestly, and "the dynamic in the group changed." In terms of encouraging group cohesion, the role of the facilitator was seen as pivotal. Some facilitators were described approvingly: "He was an incredibly aware chap, a very nice bloke who facilitated his group extremely well." One participant explained how fortunate they were to have a "democratic" facilitator who was "very open and really wanted to create a discussion rather than pinning people down." Others reported poor facilitation, complaining that their group had been "left just to get on with role-plays, to try and just work out how we can do it ourselves." One participant felt that their facilitator did nothing to encourage people to open up: "We did have several sessions where you'd just sit there." Another said, "When the facilitator actually left the room at one point, we got on great. We had . . . a really good discussion." In other instances, the facilitator's approach was perceived as overly directive or even confrontational: He was trying to provoke people, myself included, and it was just a totally negative experience . . . He was very, very confrontational . . . You got the idea that maybe he'd learnt a few things about psychology and he was going to then practice on you.

Game Playing
In the first year of the program, the emphasis was on values and beliefs. Some participants described topics, such as "compassion," as interesting whereas others found them pointless and boring. Debates around spirituality or moral values led to "some interesting clashes"; "you've got a mix of people who are religious and follow a faith, and then you've got those of us who aren't." Some participants enjoyed the spiritual-based rituals such as meditation and found them "quite therapeutic." Others felt that they already had established beliefs and did not want to review them. One participant spoke at length against what they regarded as "blatantly religious practices," which ran contradictory to their own beliefs. Group relaxation techniques, in contrast, appeared to be viewed more neutrally as they "did not cross the [secular-religious] line." A range of imagination games was also played out during these practical sessions. One game required a group of participants to act out an activity in silence, such as going shopping or sitting by a river, while another group of participants tried to work out what these participants were miming. Several participants expressed confusion over the purpose of these games, and what they were supposed to get out of them. Some were highly critical: One of the first things that we did was . . . we had to pick out (a card) that we were drawn to and then analyze why we were drawn to that particular card . . . And it's like, "well it's a nice picture . . . what does it mean to you?" . . . I wasn't at all used to looking at life in that way, and I found it a bit of a load of bollocks.
During such games, some participants reported facilitators ascribing unconscious psychological processes to their actions, which could be especially jarring: There was a lot of postcards on the floor and we had to go and pick one that we felt attracted to and then describe to a small group why we liked them . . . I only found one, that was a man sitting on like a handmade wooden chair . . . When [the facilitator] said, "Well why did you pick it?" I said, "Because I really like wood, I'm really attracted to natural wood things." . . . And [the facilitator] was going, "It wasn't anything to do with the man in it?" And I just said, "No, I really didn't take that into consideration." And he took that to mean that I had a problem with my father figure. Speaking or acting untypically in social situationsincluding personal disclosures-creates a distinct risk of embarrassment and losing face (Goffman, 1972). Another learning activity discussed in detail by trainees and generating strong feeling was the "mutual appreciation" exercise.
Participants were asked to sit in two lines of chairs and then move around so that they got to face the whole group in turn. As the line facing participants moved, they were requested to shut their eyes, count to five, and then just open them for a few seconds. After this, each person was meant to say something positive to the other person. One participant felt that it helped people to get to know one another, whereas others found the forced disclosure uncomfortable or "fake." We did this thing where . . . you had to praise someone [a fellow participant] in some way. And if you couldn't do it, I think, I'm not sure if there was an out or not. But basically, everyone was so uncomfortable doing it.
In professional work, the "correct" presentation of self is intimately tied to credibility (Goffman, 1972), "gaining face," and establishing a relationship of trust with one's client. In the second year of the program, students engaged in clinic-oriented role-play, working in "triads" consisting of two "actors" and one observer. Participants described roleplay as good practice for how you should "present yourself" and "come across" to patients. For instance, during mock consultations, you could have it pointed out to you if you were not using open questions or your body language was "shut off." Some participants were "really open to it" and found the role-playing sessions tremendously helpful: For others, role-play "pushed buttons," where acting out emotions during role-playing meant entanglement in uncomfortable feelings, such as artificiality: I think I have a problem with . . . the role-play idea, of a false environment . . . because it doesn't seem to be real to me; well it's not real. I find it very difficult to pretend, or to project those emotions that I might feel in a different situation. Some participants expressed confusion over real and simulated feelings developed in role-play. One student complained, for instance, that there was "was no structure or understanding of what was the actual pretend situation as it were."

Challenge, Resistance, and Revelations
The ethos behind the program was expressed by a tutor as one of "high challenge and high support" to encourage participants to develop and "grow." Nevertheless, aspects of the course that some people experienced as stimulating and "nurturing" were just uncomfortable for others. Although one tutor thought it most challenging for the younger participants who had never been asked to express their reflections and opinions in this way, some mature participants described it as "patronizing," or "too much gazing at your own navel." One participant expressed strongly negative feelings about the program: I can't really put my finger on what it was that I really hated but . . . I found it really false . . . A room full of people that you don't know . . . a bit like pseudo counseling, it was awful.
If group members feel coerced into performing, they may use defensive strategies to avoid loss of emotional energy (Summers-Effler, 2004), including group resistance (Collins, 2004). Negativity was said to spread easily within a group: "In my particular group, people were really hesitant to interpret or share personal information." Whereas participants spoke in terms of group resistance, one tutor attributed dissidence to ring leaders dominating the mood within the group. When this tutor met with resistance from a participant, the tutor challenged it and ascribed this negativity to experiences in the past. One defense tactic, according to the tutor, was "not to turn up, or leave halfway through the group." However, the mandatory elements of the course, which required completion of in-class logbooks, encouraged resisters to attend classes.
An issue of concern to participants was the degree to which participation in the various rituals felt safe or appropriate. Although the tutors assured participants that "this is a [safe and] healthy space for you to share," according to one participant, "you could see on some people's faces they weren't comfortable." One participant felt that the activities in the first year had led to the raking up of a lot of negative emotions. Another compared it with Alcoholics Anonymous: I recall them [the facilitators] talking about how . . . you can talk about these personal things and that's a safe environment and stuff, but it didn't sound like a safe environment. I mean I've never worked in any kind of group and stuff like that before, so maybe . . . You've got to take a certain kind of risk, but I particularly didn't feel like opening up to these people.
A specific issue raised concerned help available to allow participants to work through emotional issues that (re)surfaced during group work. One participant said they personally had no major issues from the past but nevertheless imagined that for some people it might be "a bit dangerous really if they're expected to explore these issues and look at themselves, and then [were] left in limbo land": I seem to remember one individual . . . there was kind of awakening in her that maybe this [her "face"] was a front . . . I wondered [if] . . . there is a supportive network in place for people . . . What happens afterwards and how does she deal with her peers and tutors after that event?
Although acknowledging the issue of emotional vulnerability for participants, the tutors believed that such issues diminished with time and experience. There were a number of ways in which issues were dealt with, including sharing your (the tutor's) own experiences to show you were "just as vulnerable as the rest." Time permitting, tutors "facilitated closure" at a penultimate moment to help process any outstanding concerns ahead of the class breaking for lunch. In addition, safety mechanisms were embedded in the course such as information in the handbook, and opportunities to discuss issues with the module leader, a personal tutor, or a participant counselor.
Simulated activities, which break social or cultural conventions, can arouse strong emotional energy (Collins, 2004) or emotional "heat" (Barsade, 2002) between comparative strangers. Participants described a medley of emotional feelings these interactions generated, including empathy, disappointment, anger, and shock. Managing one's own and others' feelings could feel uncomfortable within the classroom, and some games involved quite intimate exchanges between players. An example of this (as described by an overseas male participant) took place during an activity that required one player to physically support another for 2 min. When the passive female player began to cry, the male player felt compelled to physically support her and was therefore unable to move, to the point where he experienced pains in his hands for several days. He retained complex feelings about this experience and expressed doubts as to whether it should have happened: Sometimes the line between training and group therapy could feel blurred: At times it felt like therapy, there was people bursting into tears and, yeah people sharing issues and . . . expressing themselves maybe for the first time . . . that needs to be clarified . . . that therapeutic environment, how far do you go down that road?
The acting out of complex emotions in the presence of an audience (the group) could become an "emotional jumble" that required work to resolve: She (another participant) was obviously really upset that I hadn't said that she was a wonderful person or something and so she was really gutted and upset. And then I was really upset that I'd upset her . . . And then it upset me that she like attacked me in front of the group for basically saying something nice about her. Such a jumble of emotions takes time to sort through, such as in the group itself, or during debriefings, or out of class. Over time, transformative outcomes were reported by participants, with challenges frequently judged to be "worth it" in hindsight. One tutor felt that "some really powerful things" could come out as a result of the group work, producing revelations similar to therapy: There was [one] participant who . . . came to the session and she'd . . . had a real issue with her husband . . . you could see she was upset . . . and the group . . . really supported her. And at the end she said it helped her to see that there were other ways at looking at the situation. And she went home and she dealt with it and she's back with her husband.
For both participants and staff participating in the program, "backstage chat" (Goffman, 1972) was used as a way of "sorting through" jumbled emotions and developing insights. For instance, during the interviews, participants repeatedly referred to informal conversations they engaged in or overheard about the "moods" of other groups, comparing them with their own groups. Stories relating to emotive scenarios or power struggles were relayed between participants: Well, from some of the stories that I hear, the fact of really appalling behavior on the part of the facilitators . . . Yeah, different stories, just about the way that people had maybe established [their] role or . . . their power in the group or something, they said was a bit juvenile.
Although participants mostly debriefed informally, the tutors explained how facilitators were expected to formally participate in hour-long meetings after each class and attend staff supervision sessions "where we support each other and bring own experiences of teaching and trying to help each other and learn from and with each other." Staff members working on the program were qualified in a variety of disciplines (nursing, psychotherapy, body work, nutritional therapy, and so on). Although operating within the same educational context, there were varying views among the trainers as to the precise genre of the program, which could sometimes lead to tensions and disagreements between tutors:

Discussion
For this article, we focus on the experiences of complementary therapy trainees and tutors who participated in an undergraduate personal development course. We use the term simulated interaction rituals to describe the various group activities and games (soliloquy, discussion, group meditation, interpersonal games, role-playing) that formed part of the training program. Performing in these various rituals generated a range of emotional responses for participants in our study, which were expressed both front (such as in formal groups) and back of stage (such as in the café afterward). Although activities were not always experienced as "safe" in our study, establishing a safe environment in which students can express themselves in their own time and style can be beneficial to the group as a whole (Keville et al., 2013). Partaking in rituals was for some trainees an emotionally satisfying experience with enjoyment, support, and respect reported between group members and facilitators. For other trainees, similar rituals felt flat, false, or forced, with complaints made about lack of clarity as to the purpose and "rules of the game," as well as concerns about lack of acting skills and facilitation/support needed to undertake activities that trigger challenging emotions. Scenarios, in which resistance and emotional outbursts were acted out and witnessed, were features of both trainees and staff accounts.
We draw on theories of simulated interaction ritual and emotions, and performance in organizations, to consider factors likely to have influenced these experiences, including types of ritual, group emotion, and style of leadership. Although sharing characteristics of the rituals described by Durkheim, Goffman, and Collins, we argue that the rituals designed to develop health practitioners have a propensity to generate moral and emotional confusion and unease in players, due to simulation, difficulties in understanding the purpose of the rituals, distinguishing between authentic and artificial sentiments and, subsequently, the need to disentangle emotions. Finally, we consider the broader implications of our findings.

Ritual Games
During the first part of the program, there was more emphasis on personal values, with a significant time spent working in pairs. Feelings such as shyness and embarrassment arose when participants were expected to reveal personal information with people perceived as "relative strangers." During everyday interaction rituals, people use avoidance measures such as discretion and physical distance to prevent social embarrassment (Goffman, 1972). As both parties share obligations and expectations of the other, when a rule of conduct is broken, both actor and observer run the risk of becoming discredited (Goffman, 1972). We suggest the articulation of emotions and intimacy required during participation in simulated interaction rituals (for instance, the "mutual appreciation" and physical support exercises) risks contravening cultural conventions such as social distance (Brownlie, 2011;Goffman, 1972), potentially creating uncomfortable feelings. In addition, the ambiguity and deeply psychological nature of some imagination games described by participants could trigger sudden and strong emotions, which participants in our study at times struggled to manage.
In the second year of the program, as the focus shifted to the practitioner-patient relationship, role-playing was introduced. The acting out of patient-practitioner role-plays was perceived as less confusing and more relevant to professional needs than imaginary games. As actors are in "role," there is less personal disclosure; hence, loss of face is less likely. Nevertheless, performing in front of others can cause anxiety and other difficult feelings, the more so when one is potentially being assessed (Chandavarkar et al., 2007). In addition, some participants felt insufficiently briefed on their role prior to performing in improvised therapy scenes, suggesting a need to clearly explain the nature of games and roles to prospective players. Unlike professional actors trained to access emotion and who may easily switch between deep to surface acting (Bergman Blix, 2007), for participants in our study, acting out emotion or distinguishing between real and simulated feelings in others were not straightforward. Heightened feelings generated during these performances (such as embarrassment) could be difficult to process and many times lingered. We suggest that although students largely recognized the difference between real acting and role-play, the heightened feelings generated during these performances such as excitement, embarrassment, and anticipatory anxiety could be similar to, and sometimes intruded into, their ordinary life. Method actors have reported similar psychological and emotional effects, even by performing complex medical roles (Bokken et al., 2004;Mitchison & Khanna, 2010).
Our previous study of trainee health practitioner experience brought to light the importance of formal peer group work as an emotional coping mechanism for final year trainees undertaking clinical practice (Fixsen & Ridge, 2012). The peer group conversations reported by the participants in this study were mostly informal, outside of class, and often concerned memorable scenarios or comparisons between groups and facilitators. Such "backstage" conversations (Collins, 2004;Goffman, 1972) provide a means by which order takers can vent their feelings away from tutors. In addition, as informal rituals, backstage reviews are helpful settings in which to share emotional and moral sentiment, increasingly emotional synchronicity, and group solidarity. "Order givers" (Collins, 2004) also needed coping strategies, and facilitators met together after each class to formally discuss issues in confidence. We suggest that formal and informal debriefing should be recognized as a vital adjunct to group learning activities, both serving a different purpose to formal group work or written reflections: processing feelings and establishing insights.

Leaders, Values, and Emotions
Interpersonal affect regulation describes the deliberate attempt to change or influence the emotions of others (Niven et al., 2012). In describing group interactions, participants in our study identified a range of affect regulation strategies from extending emotional support to the use of verbal incitement of emotions (Niven et al., 2012;Thoits, 1996). As described in the literature (Cai & Fink, 2002;Thoits, 1996), definite preferences were expressed for a more integrative rather than dominating style of facilitation. Facilitators portrayed as helpful, supportive, democratic, and emotionally aware were regarded as agents of group cohesion and positive emotion. Staff and trainees were critical of facilitators who appeared to impose their views or provoke responses. In contrast, some participants complained about ineffective facilitators leaving the group to "get on with it," although our findings suggest that leaving trainees to work it out themselves (such as backstage) may be better than poor facilitation. These findings indicate that participants broadly evaluate the skills of facilitators including their ability to appropriately interpret emotions, regulate their own and others' emotions, and encourage cohesion in groups (Niven et al., 2012). Open and honest expression of personal issues and emotions in a group requires clarity of purpose, freedom from coercion, and feelings of personal safety (Wiley, 1990). For some participants in our study, not understanding the point of practical or reflective activities led to uncertainty that stifled expression. The safety and intimacy of certain activities were also questioned, and some negative comparisons were made to psychotherapy. Nevertheless, many participants ultimately acknowledged gains in personal and professional learning as a result of the program, with some expressing strong enthusiasm for the kinds of simulated interaction rituals employed.

"Jumbled Emotions" and Simulated Interaction Rituals
Collins describes how the momentary but meaningful encounters acted out in social arenas generate an emotional energy that is perpetuated through interaction ritual chains. The success or failure of a ritual is measured by the emotional energy transmitted and shared within the group (Collins, 2004). Although we agree that emotional energy motivates social interaction (Collins, 2004), describing and interpreting the ways in which participants responded during emotionally charged moments outside of their "ordinary experience" proved more difficult (Ng & Kidder, 2010). A successful social performance calls for a particular cultural script with shared rules, agenda, and ethos (Goffman, 1959). As society becomes increasingly complex and entangled, so the elements required for successful performances grow more difficult (Alexander, 2006). The cultural and social rules governing the performance of emotion, for instance, may not be readily interpreted (Ng & Kidder, 2010). As our findings indicate, participants from diverse multicultural backgrounds do not necessarily share the metaphors and narratives through which to interpret new rituals and their symbols, hence, designing and facilitating inclusive and culturally diverse SEL activities is a challenging task (Taylor, 1997).
Managing multiple identities (such as trainee/practitioner/ actor/confidante) can lead to contradictory and ambivalent emotions (Rothman & Wiesenfeld, 2007), or stresses at personal and organizational levels (Westring & Ryan, 2010), with implications for well-being. The inharmonious energy produced during certain rituals may be more akin to an emotional traffic jam than the rhythmic synchronicity suggested by Durkheim and Collins. For the purpose of this study, we use the concept of "jumbled emotion" to describe this tangle of multifarious feelings and reactions that participants felt compelled to sort through. Even highly intense and emotionally complex experiences can lead to positive outcomes as they spark a process, are highly memorable, and can retrospectively be untangled and recast as developmental.
Simulation games feature imaginary scenarios requiring a mixing of real responses and simulated role-play. In addition, face-to-face interactions require the management and acting out of emotions in the presence of others, thus taking on a greater theatrical dimension. Unable to find a suitable term to fully describe these activities in the social interaction literature, we chose the idiom simulated interaction rituals to describe rituals that combine a real role (such as trainee practitioner) and a contrived role (such as patient) with intentional simulation of emotions for therapeutic (Wiley, 1990) or educational purposes (Issenberg et al., 2005;Kenaszchuk et al., 2011). Not to be confused with virtual simulation games, face-to-face simulated interaction rituals lie somewhere between theatrical imagination and reality, and have become strongly featured in personal and professional development programs. We suggest that the popularity of "simulated interaction rituals" as learning devices in health education lies in encouraging players to act out challenging emotional scenarios with peers and rehearsing the "correct" presentation of a professional self (Goffman, 1972) within a supervised environment.
The outcome of any interaction ritual is uncertain; however, our study indicates simulated interaction rituals to be arenas of difficult emotional intensity and entanglement. We suggest that the openness and intimacy required between group members encourages spontaneous expression of feelings such as affection, sadness, or anger (Wiley, 1990). Such emotional disclosure can feel risky (Brownlie, 2011) and, in educational or professional settings, feel at odds with institutionally sanctioned conduct such as politeness and emotional reserve (Goffman, 1972). The result can be a tangle of unpredictable emotional responses that, although ultimately developmental, can be uncomfortable. To further complicate matters, in the program we examined, the jumble of emotions expressed by trainees may also have been linked to the somewhat jumbled intentions of the training staff. To help sort out this emotional jumble, a number of devices could be brought into play, including written reflective work, recognition of backstage chat, and use of peer debriefing sessions such as those used by tutors on the program. In the meantime, jumbled emotions are an issue program designers and facilitators are yet to come to grip with.
In rounding up our study, SEL games, such as dialoguing, imagination games, and role-play, are now well established in health education (Erichsen, 2011;Hromek & Roffey, 2009). Other studies have considered the effects of "problem-based learning" activities and role-play on health care students from the skills training perspective (Lane & Rollnick, 2007;Smith, 2009). However, with the exception of some psychologybased studies (such as Keville et al., 2013), few have examined the emotional aspect of face-to-face simulations and none using an interaction ritual interpretation. In this article, we examined experiences of complementary therapy trainees and tutors participating in early health practitioner development involving facilitated group activities. We used the terms simulated interaction ritual and jumbled emotions to conceptualize what trainees go through.
The rationale for the use of EBL tools rests on their propensity to facilitate self-awareness, underpin resilience, and develop healthy relationships between learners (Hromek & Roffey, 2009;Mezirow, 1997). SEL with games can add enjoyment and meaning to health care. Studies suggest that SEL is associated with increased academic and professional performance (Zins & Elias, 2007), reduced stress, and improved coping abilities (Slaski & Cartwright, 2002).
From an interactionist perspective, activities such as sharing and role-play permit players to "loosen up" with strangers, share sentiments, and potentially create a "collective effervescence," thereby forming strong interaction ritual chains and reinforcing group/institutional values and symbols (Collins, 2004, pp. 48-49). In contemporary multicultural settings, however, the elements required for a successful social performance are increasingly complex and multidimensional (Alexander, 2006). Emotions generated by SEL activities may not always be straightforward or comfortable. Opening up and connecting with others in learning situations may feel highly risky (Keville, 2013). The process of roleplay, for example, activates not only thinking but also a variety of feelings that can be difficult and even distressing and that can challenge the adult learner and their tutors. Although some adults enjoy role-playing, for those who have long abandoned imaginative play, acting out face-to-face simulations may be disagreeable.
Our analysis shows that SEL games can challenge deeply held beliefs, generate moral unease, and evoke powerful emotional responses that require careful management and clarity as regards their purpose as educational assessment tools. In this article, we suggest that not understanding or misinterpreting emotions can result in an emotional "jumble." Feminist scholarship suggests that, ultimately, professionals and patients will have varying levels of emotional investment in health care, and emotions are important to process in terms of reflexively caring for patients (Fisher & Byrne, 2012). Thus, the evocation of professional emotionswhether simulated or in real life-will continue to be used to assist professionals in their reflections on patient care. This point about the centrality of emotional considerations for adequate reflection is also being made in other arenas of social life (King, 2006). However, due to a limited budget, our study is small; for the future, we recommend larger ethnographic studies, using additional observation methods to gather extensive data from group work, including the types of role-play and learning games discussed in the interviews.