Original article

The use of mainstream movies in psychiatric training

DOI: https://doi.org/10.4414/sanp.2022.w10125
Publication Date: 18.09.2022
Swiss Arch Neurol Psychiatr Psychother. 2022;173:w10125

Gerard Calzada, Stéphane Rothen, Ariella Machado, Louise Penzenstadler, Gabriel Thorens, Daniele Zullino

Department of Psychiatry and Psychotherapy, Geneva University Hospitals, Geneva, Switzerland

Summary

BACKGROUND: Psychiatry has been represented in films since the beginning of the 7th art. Many of the films aim to render mental suffering more understandable and to advocate for more humane treatment. Films can be used as an interesting teaching tool in medical education, making learning fun and enjoyable, while promoting motivation and learning effectiveness. This study examines the relevance of mainstream films for teaching psychiatric diagnostic criteria.

METHODS: A university course on psychopathology and social representations of psychiatry in cinema was created. The course is structured in ten sessions, each based on a film dealing with a specific disorder, allowing students to gain a comprehensive overview of the main psychiatric disorders. During the session, after watching a film, participants rate the character depicted in the movie according to DSM-5 criteria and evaluate their ability to recognise typical symptoms of the specific psychiatric disorder, the film’s ability to depict the key elements of this disorder, and how easily they relate and empathise with characters suffering from the presented disorder.

RESULTS: Self-perceived ability at the beginning of the session, the percentage of symptoms exhibited and the possibility to empathise are positively associated with self-perceived ability at the end of the session, whereas the movie quality as measured by the IMDb score was not statistically associated. Furthermore, the ability to feel confident in recognising the symptoms increased over the course of the sessions.

CONCLUSIONS: The present study demonstrated the feasibility of implementing a structured course in psychiatry based on movies. It shows that cinema is a suitable instrument to teach psychopathology

Introduction

Psychiatry, and especially characters presenting mental disorders have been present in movies since the beginning of the 7th art. The first known film to contain a psychiatry-related theme, Dr Dippy’s sanitarium, was made as early as 1906. Psychiatry, psychiatric patients and psychiatric caregivers have subsequently been among the most successful characters in cinema’s history. Among movies winning the Academy Award between 1990 and 1996, almost half featured disabilities and two-thirds of those focused on psychiatric disorders [1].

The reasons for this keen interest may be curiosity, fascination or even voyeurism. However, many of the most enthralling movies have rather aimed at rendering psychic suffering more understandable and plead for more humane treatment of psychiatric patients.

Movie scenarios tend to depict outstanding characters and situations, and they may depend largely on stereotypes exceeding everyday normality. On the one hand, mental illness with its potentially “dramatic” manifestations may therefore be particularly suitable, as viewers may experience strong feelings and sympathy for the depicted characters and therefore evoke their emotional attention [2]. On the other hand, portraying the more frightening aspects of mental illness may solidify stereotypes and stigmatisation. Although in real life, persons suffering from mental illness are more likely to be victims rather than perpetrators of violence, many movies may, for dramaturgic reasons, suggest the contrary.

A further connection between the two domains, psychiatry and moviemaking, is their ambition to understand humans, their behaviuors, characters, motivations, relationships and life paths.
 

The interest of mainstream movies for psychiatric education



When viewing movies, psychiatrists could be interested in depictions of psychiatric symptoms (semiological analysis) and psychological explanations of behaviours or attitudes (psychopathological analysis). They may try to classify behaviur of movie characters using diagnoses (taxonomical analysis). Finally, they may appraise interview techniques, doctor/patient boundaries, and stigmatising representation of patients, families, caregivers or institutions.

Movies have been suggested as an interesting teaching aid in undergraduate and postgraduate medical training, particularly in psychiatric education [3–7]. Rendering the learning process entertaining and enjoyable supports motivation and therefore effective learning. Using video material also appears to increase students' ability to visualise and remember phenomena [8].

The benefits of teaching with films are multiple. Movies makes it possible to depict behaviours in realistic situations, somewhat “in vivo” (e.g., alcohol abuse, violence problems, behavioural problems). The longitudinal nature of psychiatric diseases, including their psychopathological development can be presented over periods as long as the lifetime of a movie character. Screenplay and cinematographic techniques allow the illustration of complex ideas in a short period of time, to show otherwise covert psychological phenomena (e.g., merging real and hallucinated perceptions, reality and delusions, "split" behaviour where the person is blameless in the eyes of society but behaves aggressively in private), to represent the characters through time (e.g., the protagonist’s childhood), and in different places. Finally, unlike psychiatric teaching with patients, the use of movies prevents any problem of confidentiality.Movies may be an appealing learning medium, but the use of movies in teaching presents some possible limitations. Artistic license may be overused to sacrifice facts for stories. Portrayals of mental illness may sometimes be unrealistic, reinforcing negative stereotypes, confusing diagnoses (e.g., schizophrenia and dissociative identity disorder), as well as simplifying aetiology and psychopathology. Therefore, rigorous theoretical teaching and, possibly, discussion on social representations and stereotypes must be used to accompany the use of movies for teaching purposes.

There have been descriptions of the use of movies in teaching activities, but no study has, to our knowledge, examined the suitability of mainstream movies for teaching psychiatric diagnostic criteria.

The aim of this study was to assess the relevance of using films for teaching psychiatric semiology.

Relevance was defined with five hypothesis regarding confidence in recognising a psychiatric disorder:


  1. The more confident students feel before the course, the better they feel more confident to determine a psychiatric disorder (hypothesis 1).

  2. The more symptoms are present in the film, the more students will improve their confidence in recognising the typical symptoms of a psychiatric disorder (hypothesis 2).

  3. The better the quality of the film (according to the Internet Movie Database [IMDb] score), the more students will improve their confidence (hypothesis 3).

  4. The more the film allows students to empathise with the character suffering from the disorder depicted, the more the students increase their confidence in diagnosing correctly (hypothesis 4).

  5. Over time and through participation in the various sessions of the course, students improve their confidence (hypothesis 5).

Method

The course "Psychiatry in movies" is an optional course offered every year since 2014 to undergraduate students from the University of Geneva. The course is limited to 20 students per year and is open to all faculties. Although most students are medical students, students from social science and nutrition science regularly attend the programme.

The learning objectives of the course are: basic psychiatric semiology and psychopathology, and the analysis of social representations of psychiatry.

Movies are chosen according to several criteria: the specific psychiatric disorder to be analysed is explicitly illustrated, at least one of the main characters suffers from this disorder, at least one character is a healthcare professional or caregiver and the movie must be considered good enough, with an IMDb score greater than 6.5. 



The course is structured in 10 sessions, each one dealing with a specific and different disorder, allowing students to gain a comprehensive overview of the main psychiatric disorders. The films chosen during the research period (between 2016 and 2019) illustrated the following disorders:

  • Alzheimer's (Still Alice, Tête en l’air)
  • Autism (Mary and Max, Rain Man)
  • Gambling (Owning Mahowny, Rounders),
  • Hypersexuality (Nymphomaniac)
  • Obsessive-compulsive disorder (The Aviator)
  • Anxiety Disorder (What about Bob)
  • Generalized anxiety disorder (Les émotifs anonymes)
  • Bipolar Disorder (Mad World, Silver linings playbook, The Dark Horse, Touch in Fire)
  • Antisocial Personality Disorder (Sexy Beast)
  • Borderline Personality Disorder (Girl Interrupted)
  • Delusional Disorder (Lars and the Real Girl)
  • Depressive Disorder (Blue Jasmine, Cake, Harold and Maude, The Beaver)
  • Substance Use Disorder (Limitless)
  • Alcohol Use Disorder (The lost weekend)
  • Opiate use disorder (Gridlock’d, Trainspotting)
  • Psychotic disorder (K-PAX, The Voices)

Each session is divided into five stages.

  1. The session begins with a theoretical presentation (30 min) which involves the cinematographic aspects of the film (context, cast, production, reception by critics) and the specific disorder (epidemiology, aetiology, psychopathology, diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders [DSM-5], prognosis and treatment)
  2. Afterwards, the participants watch excerpts of the movie. In order to make the teaching compatible with copyright requirements, parts of the film are selected, without exceeding 60 minutes in total. Cut sequences are replaced by intertitles. The movies are screened in their original version with French subtitles.
  3. After watching the film, all participants (students and teachers) complete the ”diagnostic evaluation” (10 min), a series of questions that assess a film character by choosing whether each of the DSM-5 diagnostic criteria for the disorder concerned is present or absent.
  4. During the next stage, the teacher leads a discussion about the semiology and social representations of patients and caregivers in the movie. In addition, the participants discuss the relevance of the film for the teaching of the chosen disorder (75 min).
  5. At the end of each session, students fill in the "evaluation survey" and rate their ability to recognise typical symptoms of the specific psychiatric disorder (before and after attending the session), the film’s ability to depict the key elements of this disorder, and how easily they relate to and empathise with characters suffering from the presented disorder. The survey is composed of four questions, every question is answered on a five-point Likert scale:a. Before this session, how confident were you in recognising the typical symptoms of the disorder depicted in this film? (Q1)b. After this session, how confident are you in recognising the typical symptoms of the disorder depicted in this film? (Q2)c. Does this film allow you to observe the key elements that characterise the disorder represented in this film? (Q3)d. Does this film allow you to put yourself in the place of people who suffer from the represented disorder? (Q4)

All the participants in the sessions answered the questionnaires. Forty-nine students were female (71%) and 20 male (29%). Their mean age was 20.7 years (standard deviation [SD] 1.1). The experts were the course teachers, specialists in psychiatry or psychology. As far as possible the course requires two experts per session. Since some films were used multiple times during the research period, several expert assessments were made per film.

Statistical analyses



In order to evaluate the perceived quality and utility of the course, the evaluation questionnaire described above was analysed. First, descriptive statistics of the course participants as well as the course evaluation were computed. Then, due to the discrete nature of the scales, a Wilcoxon signed rank test was performed on the improvement (the score after the session minus the score before the session) of the perceived ability to recognise the typical symptoms of the disorder in question.

In order to assess our five hypothesis, linear regression was performed as follows:.The outcome (dependent variable) is the improvement. The improvement was calculated as  confidence score after the session (Q2) minus confidence score before the session (Q1).
According to the five study questions, predictors of improvement (independent variables) are perceived ability before the question (hypothesis 1), the movie quality regarding the presence of symptoms measured as the percentage of symptoms exhibited evaluated by an expert (hypothesis 2), the IMBD movie quality evaluation (hypothesis 3), the self-perceived movie quality regarding the capacity to empathise (hypothesis 4) and the session number within the semester (session 1 being the first course and the session 9 being the last one) (hypothesis 5).

Moreover, alLinear mixed model [9] was also used in order to take into account the lack of independence of the data, since data were clustered (student within movie within year). The results of both strategies led to identical results, therefore only the simplest model, the linear regression, is presented.

Results



The mean number of evaluations per session across years was 13.2 (SD 3.1). There were between 5 and 19 evaluations per session. This corresponds to the number of students attending the session.

The mean number of experts per movie across years was 2.2 (SD 1.2). There were between one and five expert evaluations.

The median score of the perceived ability to diagnose a specific disorder at the beginning of the session was 3 (mean 2.9, SD 1.1) and about 4 (mean 4.3, SD 0.6) at the end of the session. The standard deviation is smaller after the session suggesting higher homogeneity around the mean. The Wilcoxon signed rank test on the improvement was statistically significant (W = 67180, p <0.001) and led to the conclusion that the perceived ability improved.

Table 1 shows the results of the multiple linear regression predicting perceived ability at the end of the session.

The self-perceived ability at the beginning of the session (hypothesis 1, b = 0.21 p <0.01), the percentage of symptoms exhibited (hypothesis 2, b = 0.32 p = 0.04) and the possibility to empathise (hypothesis 4, b = 0.06 p = 0.01) were positively associated with the improvement of the self-perceived ability, whereas the movie quality as measured by the IMDb evaluation (hypothesis 3) was not statistically significant (b = –0.09, p = 0.156). Furthermore, the ability to feel confident in recognising the symptoms increased over the course of the sessions (hypothesis 5, b = 0.03 p <0.01).

Table 1: 

Linear regression to predict improvement

 EstimateStd. Errort valuePr(>|t|)
Perceived ability before the session0.210.038.24<0.001
Percentage of symptoms present in the movie0.320.162.030.043
IMDb grade–0.090.06–1.420.156
Movie quality regarding the capacity to empathise0.060.032.460.014
Session0.030.012.74<0.01

Discussion



The present study was, to our knowledge, the first to investigate the suitability of mainstream movies for teaching diagnostic criteria in psychiatry. The research question was to evaluate the relevance of the use of films in the teaching of psychiatry using five hypotheses.

The improvement of the perceived ability to recognise symptoms before and after each session can be interpreted as a positive impact of teaching during the course. The quality of portrayed symptoms, as explained earlier, may have impacted the students’ ability to recognise them. The more accurately symptoms are depicted, the easier it may be for students to understand and feel confident to recognise them in real situations.

The results also show the importance of the number of symptoms presented, as their recognition was facilitated by an increased number of symptoms in each film. The confidence in recognising specific symptoms improved with the students’ progress over the course.

The chosen movies show an overall good quality regarding their representation of symptoms. This contrasts with the expectation that portrayals of mental illness would likely be unrealistic for dramaturgic purposes. Possibly, directors and viewers have become more critical, requesting more realistic portrayals of characters. The choice of the movies, however, may also have influenced these results as they were suggested by the course teachers, who were experienced clinicians. However, the movies chosen by the students confirmed the results.

The analysis showed that putting oneself in the character's place and showing empathy with the main character did not improve the students’ ability to recognise psychiatric symptoms. However, even if having empathy with the character does not seem to improve students’ capacity to recognise psychiatric symptoms, it may help to create less stigmatising views of people with mental disorders among future medical doctors. This is an important aspect of medical training.

There were various limitations to this study. Firstly, the small number of 20 students enrolled per year may make the results difficult to generalise. The results are valid for the course participants (who were interested in film and psychiatry and who had chosen the course) but are not representative for all students. Secondly, the movies were sometimes chosen by the teachers and sometimes by the students. This could also have impacted the learning quality of the different films as the teachers were likely more aware of the specificity of the depicted symptoms. Thirdly, the surveys used were self-assessments and not theoretical tests that would have assessed students’ skills.

Conclusions



This article illustrates how cinema can help to teach psychiatry to students who are new to the field. As everyone is familiar with movies, use of this well-known medium can help teachers and students to illustrate the core of psychiatric symptoms more vividly and rapidly. Using mainstream movies has many advantages, as described in the introduction, and can help students reduce stigma for psychiatric patients and psychiatric symptoms. However, it is important to choose films with as many symptoms as possible and not just films with a high IMDb score. The heterogeneity of the portrayal of psychiatry in movies can also broaden students’ representation and help them to apprehend the psychosocial dimension of psychiatry.

The present study demonstrated the feasibility of implementing a structured course in psychiatry based on movies. It showed that cinema is a suitable instrument to teach psychopathology. This study tested the ability to recognise the principal symptoms of mental disorders; however, we did not test learning ability. Also, the long-term effect of this course was not investigated. Therefore, future iterations of this study could be to test the acquired short- and long-term knowledge.

In future research, knowing that cinema can mobilise strong emotions, it would be interesting to add an emotional dimension that could possibly better explain why one film has a greater impact on students than another (e.g., because of fascination, fear, rejection, disgust, etc.) as well as adding the assessment of improvement by diagnostic categories.

It would also be interesting to develop self-learning between sessions with online courses, using entertaining teaching tools such as participation in friendly competitions on diagnoses between students with tools such as Quizlet, making quizzes or watching other films or series, in order to further facilitate learning.

Disclosure statement: 






No financial support and no other potential conflict of interest relevant to this article was reported.

Correspondence

Gerard Calzada, MD

HUG: Hopitaux Universitaires Geneva

Département de psychiatrie et de psychothérapie

CAAP Arve

CH-1227 Geneva

Gerard.Calzada[at]hcuge.ch

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