Medicine and Society
Jul 2020

Improvised Caregiving or How a Famous Comedy Theatre Found Itself in Health Care

Kelly Leonard and Anne Libera
AMA J Ethics. 2020;22(7):E619-623. doi: 10.1001/amajethics.2020.619.


For more than 60 years, The Second City has used the techniques of improvisation to train some of the world’s funniest and most famous people—among them Bill Murray, Tina Fey, Amy Poehler, Jordan Peele, John Belushi, and Joan Rivers. The same skills that generate laughter are just as powerful and potent in any situation that requires human beings to navigate complexity, solve problems in group settings, and listen with the intent to hear. Collaborating with Caring Across Generations, Cleveland Clinic, and other organizations, The Second City has developed training modules that give individuals and groups more agency in the health care space. This article details how the program was developed, provides key insights into the benefits of such training, and offers takeaway exercises readers that can use with their teams and students.

Development of The Second City’s Partnership With Caring Across Generations

In August 2015, The Second City (the famed comedy theatre and school of improvisation) in Chicago almost burned to the ground. A grease fire in the restaurant below the theatre sent flames shooting up to the roof of the facility in Chicago’s Old Town neighborhood that has been home to The Second City for more than 50 of its 60 years. The firefighters were able to save the actual theatre venues, but a good chunk of the corporate offices was destroyed. The office of the first author (K.L.) was one of those destroyed. K.L. had worked at The Second City for more than 30 years and had moved to that office a week earlier. We begin this story with the fire for a reason. We and our colleagues at The Second City have long believed that our best work comes from mining very uncomfortable places. We contend that innovation is, in fact, born in discomfort. It turns out, of course, that the behavioral sciences tend to agree with this point of view. When Nobel Prize winner Richard Thaler and co-author Cass Sunstein claim that “People have a strong tendency to go along with the status quo or default option,”1 they’re noting the difficulty that people have in leaving their perceived comfort zone. In improvisational practice, exercises based on the yes, and concept provide a way to eschew the default option and instead explore and heighten unusual ideas that generate humor as a vital dynamic in the process of creating. The Second City teaches improvisers to “follow the fear,” “see all obstacles as gifts,” and “make mistakes work for you” in order to spark innovative practices.2 Nobel Prize winner Daniel Kahneman touches on these teachings when he notes that “an inability to be guided by a ‘healthy fear’ of bad consequences is a disastrous flaw.”3

Displaced to a sad coworking space in downtown Chicago that we and our colleagues at The Second City dubbed the “beige palace,” K.L. was sitting in a cramped office that he shared with 3 colleagues when the phone rang. On the line was Adam Grant, a professor at the Wharton School of the University of Pennsylvania who has written a host of bestselling books, including Give and Take, which presents the science behind the success of people who give more and take less.4 When Grant calls with a favor, you do it, lest you wish to be cast as the villain in his next New York Times bestseller. A friend of his by the name of Ai-jen Poo, who is associated with the nonprofits Caring Across Generations and the National Domestic Workers Alliance, was moving to Chicago, and he thought K.L. should meet her. A lunch was set.

Meeting Poo sparked a years-long journey that would become more valuable and important than either of us ever could have guessed. At lunch, not knowing much about each other, K.L. offered to share with Poo the work that he and the second author, A.L., had done that morning. A.L. and K.L. were codeveloping a program at the Center for Decision Research at the Booth School of Business at the University of Chicago with the Center’s then-executive director, Heather Caruso. We called our program The Second Science Project. In short, this program looked at behavioral science through the lens of improvisation and vice versa. In developmental labs and executive education programs, we linked evidence-based science on self-regulation, gratitude, and individuation to existing improvisational exercises, such as the “Yes, and” exercise, and created exercises with new experiential learning formats to bring new behavioral science findings to life.5

Poo then explained that in her roles with Caring Across Generations and the National Domestic Workers Alliance (which seek support and policy change for home caregivers and domestic workers), she was trying to change the national conversation around aging, care, and caregiving. Within seconds, we saw the overlap between the exercises we had been creating and the kind of skill building that the caregiving community needed. Within weeks, we were collaborating on creating a live workshop that could help home caregivers develop personal resiliency, improve their communication skills, and create ensembles of support with patients, friends, and family members. Within a few months, we presented our ideas during the Spotlight Health portion of Aspen Ideas Week (the opening segment of the annual summit that convenes experts and innovators in the health and medicine field). Ruth Almen from the Cleveland Clinic Lou Ruvo Center for Brain Health-Las Vegas was one of the participants in our inaugural workshop. She became our champion and commissioned the development of a 6-week program called Improvisation for Caregivers.

Skills Explored and Related Exercises

The following skills are among the many explored and developed through associated exercises as part of the Improvisation for Caregivers curriculum.

Skill 1: Creating a caregiving ensemble. In improvisation, an ensemble is a group of people that works to create something greater than what each person could have created alone. We think of ensembles as a practice or behavior. As a practice, ensemble is a way of working with others that acknowledges their contributions and strives to make it easy for everyone to contribute at their best level. At The Second City, we and our colleagues say that if you make your partner look good, then you will look good.

Exercise 1: “Pass the Clap.” A simple improvisational exercise that we taught to illustrate the idea of ensemble is called “Pass the Clap.” The group is brought into a circle, and each member’s task is to clap at exactly the same time that the person next to them turns in their direction and then to turn to the person next to them in the circle, such that the group members continue to pass the clap around the circle. It is not easy for everyone to do, and, in the debriefing, we talk about the many ways that participants truly need to focus on others in order for the group activity to become seamless. Such intense focus does not come naturally to people, and it is rarely practiced as a skill.

Skill 2: Sharing and listening (“yes, and”). One of the basic concepts in behavioral economics is that human beings have a default setting to do nothing or to say no.1 Recognizing this tendency, the founders of The Second City created the concept yes, and—the idea that, in order to tap the full creativity of any ensemble, space must be created for each person in a group to collaboratively build upon everyone else’s ideas, whether innovating new processes or products, problem solving, or working in crisis mode. The yes, and concept fosters an orientation towards openness to change rather than the status quo.

Exercise 2: “Plan a Party.” The “Plan a Party” exercise pairs individuals whose “job” is to plan a party. In round 1, person A offers planning suggestions and person B offers as many different ways of saying no as possible. In round 2, person B offers suggestions for the party, and person A begins responses to all of the suggestions by saying “yes, but.” In round 3, both person A and person B offer suggestions that are enthusiastically accepted and built upon by using the words yes, and in response to every idea.

Skill 3: Embracing mistakes and change. The caregiving space is filled with stress and uncertainty; therefore, it is even more vital that individuals enter that space with a heightened understanding of what it feels like to operate in that uncertainty. Caregivers need to have practice in finding alternative solutions when faced with a situation that doesn’t turn out as expected. A certain level of mindfulness and flexibility is required when navigating the complexity of the caregiving experience.

Exercise 3: “New Choice.” The “New Choice” exercise provides a fun and potent way to practice being more agile in the moment. In groups of three, participants are given a situation and a location (for example, friends having brunch or coworkers hanging decorations for an office party). At any point during the improvised conversation, the facilitator rings a bell and the participant who most recently spoke has to make a new choice of what to say. This kind of rapid ideation is difficult to do when participants are fixated on or anchored to their original idea. It becomes easier when individuals allow themselves to exist in a state of flow.6 Because people often underestimate their ability to handle new information, this exercise encourages the understanding that playfulness and achieving flow can support our capacity  to deal with the unplanned or the unexpected.


When K.L. is asked by others why The Second City provides training for such a wide variety of organizations—from health care providers to financial institutions—he asks if their business involves human beings interacting with other human beings, because improvisation bolsters the skills of individuals working in teams and team environments. Although we are still in the early stages of developing the Improvisation for Caregivers curriculum, attendees of the first few workshops overwhelmingly found that they were better able to deal with their burdens after completing the 6-week program.

In an ensemble, if you make your partner look good, then you will look good. 

Improvisation is a pedagogy. The reason why so much comedy arises from the teachings of improvisation is that it is rooted in the essence of human behavior. People laugh at the things they recognize; they laugh at the things they share with other human beings; they laugh at things because those things are surprisingly true.

In an early meeting with Poo and her team at Caring Across Generations, we talked about fighting the robot narrative. In a world that is becoming increasingly reliant (hooked?) on technology, the skills that will become the most valuable are the skills of an improviser: storytelling, divergent thinking, problem solving, and innovation. Our work gives individuals a space in which they can explore their own discomfort to discover all their untapped agency. In her recent book, Rebel Talent: Why It Pays to Break the Rules at Work and in Life,7 behavioral scientist Francesca Gino writes, “When we challenge ourselves to move beyond what we know and can do well, we rebel against the comfortable cocoon of the status quo, improving ourselves and positioning ourselves to contribute more to our partners, coworkers, and organizations.”

Bringing improvisational training to the caregiving community has implications for the well-being of all caregivers. In Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference, Stephen Trzeciak and Anthony Mazzarelli write:

Decades of rigorous research has identified 3 hallmarks of burnout: emotional exhaustion (being emotionally depleted or overextended), a lack of personal accomplishment (the feeling that one can’t really make a difference) and depersonalization. Depersonalization is the inability to make that personal connection.8

These concepts are exactly what lay at the heart of the Improvisation for Caregivers program. Our society needs to give everyone in the caregiving space—be it doctors, nurses, administration, patients, or family members—practice in becoming more resilient, engaged, and connected. These skills don’t appear like magic. They have to be honed, developed, and practiced over time.

There is another improv adage that counters the idea that “your team is only as good as its weakest member.” We and our colleagues at The Second City say that an ensemble “is only as good as its ability to compensate for its weakest member.” In our version, the onus is put on the team, not on the individual, because at some point each person will be the weakest member of some group. When that inevitably happens, won’t all of us want the team to pick us up in those moments rather than leave us behind? In any case, any clinical team’s patient or loved ones probably would.


  1. Thaler R, Sunstein C. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press; 2008.

  2. Libera A. The Second City Almanac of Improvisation. Evanston, IL: Northwestern University Press; 2004.

  3. Kahneman D. Thinking Fast and Slow. New York, NY: Farrar, Straus & Giroux; 2011.

  4. Grant A. Give and Take: Why Helping Others Drives Our Success. New York, NY: Penguin; 2014.

  5. Shelton L. The surprising power of “thank you because.” Chicago Booth Women Connect Conference. Accessed May 11, 2020.

  6. Csikszentmihaly M. Flow: The Psychology of Optimal Experience. New York, NY: HarperCollins; 2008.

  7. Gino F. Rebel Talent: Why It Pays to Break the Rules at Work and in Life. New York, NY: HarperCollins; 2018.

  8. Trzeciak S, Mazzarelli A, Booker C. Compassionomics: The Revolutionary Scientific Evidence That Caring Makes A Difference. Pensacola, FL: Studer Group; 2019.


AMA J Ethics. 2020;22(7):E619-623.



Conflict of Interest Disclosure

Kelly Leonard is a full-time employee of The Second City and Second City Works, Inc. Anne Libera had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.