SciELO - Scientific Electronic Library Online

 
vol.17 número1Mentes brillantes (2018): una odisea para conseguir una plaza en medicinaCerebros, mentes y robots: una aproximación a través del cine del siglo XXI índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Indicadores

Links relacionados

  • En proceso de indezaciónCitado por Google
  • No hay articulos similaresSimilares en SciELO
  • En proceso de indezaciónSimilares en Google

Compartir


Revista de Medicina y Cine

versión On-line ISSN 1885-5210

Rev Med Cine vol.17 no.1 Salamanca ene./mar. 2021  Epub 29-Mar-2021

https://dx.doi.org/10.14201/rmc20201714147 

ORIGINALES

Cinema and Psychiatry's relationship through time and its role in current medical education

La relación entre el cine y la psiquiatría a través del tiempo y su rol en la educación médica actual

Adriana Marcela Arenas-Rojas1 

1Universidad Industrial de Santander. Bucaramanga. Santander (Colombia)

Abstract

Cinema has been a source of entertainment and recreation for decades, and usually the themes depicted in films have roots in society itself. Films featuring psychiatrists and the mentally ill abound. Most early interpretations tended to be negative contributing to the stigmatization of mental illness, or overly positive furthering misinformation among the general public. Fortunately, nowadays there is an increasing number of films able to provide realistic depictions of psychopathologic disorders, being reasonably accurate and therefore suitable for psychiatric teaching purposes. Over the last three decades, psychiatry trainers have attempted to use films as an educational tool for teaching medical students and psychiatry residents for a number of mental health conditions. Films can be used to engage students' attention, emphasize learning points in lectures and illustrate symptoms of a disorder. Cinema constitutes not only an important source of entertainment, but also an educational tool and a significant influence on people's attitude towards mental illness.

Keywords: medical education; psychiatry; cinema

Resumen

El cine ha sido una fuente de entretenimiento y recreación durante décadas, y generalmente los temas representados en las películas tienen raíces en la sociedad misma. Las películas con psiquiatras y enfermos mentales abundan. La mayoría de las primeras interpretaciones tendían a ser negativas, lo que contribuía a la estigmatización de la enfermedad mental, o a ser demasiado positivas aumentando la desinformación entre el público en general. Afortunadamente, hoy en día hay un número creciente de películas capaces de proporcionar representaciones realistas de trastornos psicopatológicos, siendo razonablemente precisas y, por lo tanto, adecuadas para fines de enseñanza psiquiátrica. Durante las últimas tres décadas, los profesores de psiquiatría han intentado usar películas como una herramienta educativa para enseñar a los estudiantes de medicina y residentes de psiquiatría sobre una serie de condiciones de salud mental. Las películas se pueden utilizar para atraer la atención de los estudiantes, enfatizar los puntos de aprendizaje en las conferencias e ilustrar los síntomas de un trastorno. El cine constituye no solo una importante fuente de entretenimiento, sino también una herramienta educativa y una influencia significativa en la actitud de las personas hacia las enfermedades mentales.

Palabras clave: educación médica; psiquiatría; cine

«The screen is a magic medium. It has such power that it can retain interest as it conveys emotions and moods that no other art form can hope to tackle.»

Stanley Kubrick

Cinema has been a source of entertainment and recreation for decades, and usually the themes depicted in films have roots in society itself, portraying several issues regarding culture, religion, health, and mankind. The combination of images, dialog, sound effects, and music in a film makes it particularly well suited for depicting psychological states and mental illnesses. Thus, psychiatry has a long and deep history in cinema1,2.

Films featuring psychiatrists and the mentally ill abound. Over the decades, movies have portrayed a wide range of psychiatric conditions, being the most popular: suicide, substance use disorders, multiple personality disorder, and schizophrenia1,3. The depiction of psychiatry-related subjects in cinema has evolved over the years. The first portrayal of a psychiatric hospital was in 1020 on the German film Das cabinet des Dr. Caligari, directed by Robert Wiene and written by Hans Janowitz and Carl Mayer. Nonetheless, if any film has become the prototype representation of asylums, it must be One Flew Over the Cuckoo's Nest (1975), directed by Milos Forman and based on the novel by Ken Kesey. The film was a blockbuster and received recognition in the form of 5 Academy Awards1,3,4.

Since the beginning of cinema, psychiatric hospitals have caught the attention of directors, producers, and the general public, as clearly shown in the amount of films whose plot develops in such place; one could even state that the hospital plays a role as important as the protagonists in the telling of the story3,4,5,6. Bedlam (1946) by Mark Robson, The Snake Pit (1948) by Anatole Litvak, La tête contre les murs (1958) by Georges Franju, Shock Corridor (1963) by Samuel Fuller, Shock Treatment (1964) by Denis Sanders, Hombre Mirando al Sudeste (1986) by Eliseo Subiela, Twelve Monkeys (1995) by Terry Gilliam, Girl, Interrupted (1999) by James Mangold, Quills (2000) by Philip Kaufman, Shutter Island (2010) by Martin Scorsese, and others, are among the list of the most popular and representative films portraying asylums and psychiatric hospitals from a dramatic point of view3,6,7.

Most early interpretations of hospitals were rather negative, showing sadistic psychiatrists who used emotional or psychological manipulation by hypnosis or deception. Horror films have a tendency to portray mental institutions as dark, tenebrous places, with cold, high walls, harboring diabolical nurses and demented directors. This is the case of Das cabinet des Dr. Caligari, which is arguably the first true horror film and it is known for setting a brilliantly high bar for the genre, remaining terrifying nearly a century after it first appeared on the screen2,3,6. However, it is not only horror movies that have used this formula; in general, the majority of movies based on such institutions tended to present them in such a light. Psychopathic psychiatrists who inflict emotional wounds were depicted in films such as A Fine Madness (1966) by Irvin Kershner and Bad Timing (1980) by Nicolas Roeg. The use of cruel and aver- sive behavioral techniques is seen in A Clockwork Orange (1971) by Stanley Kubrick, where they attempt to condition a sadistic murderer against violence, and two brutal procedures are depicted in One Flew Over the Cuckoo's Nest (1975), where they use unmodified electro-convulsive therapy and lobotomy as treatment for the main character's illness3,8,9,10,11,12,13.

One of the downsides of using psychiatry-related topics in films has been the fact that the majority of depictions tended to be negative and to perpetuate myths and stereotypes, thus contributing to the stigmatization of mental illness. On the other hand, portrayals too could be overly positive, suggesting that a mental illness can be easily cured, thus furthering misinformation among the general public. There was a lack of detailed studies into film techniques used in the representation of mental illness. As said by M. Anderson, «contemporary cinema has a difficult task on its hands in attempting to depict the experience of mental illness»4,8,9,10,11,12,13,14.

Fortunately, times are changing from the films being criticized for the negative portrayal of psychiatrics and psychiatric conditions to the current times when an increasing number of them are able to provide realistic depictions of character styles and psychopathologic disorders, as well as personal and family dynamics, being reasonably accurate and therefore suitable for psychiatric teaching purposes. Cinema constitutes not only an important source of entertainment, but also an educational tool and a significant influence on people's attitude towards mental illness7,8,16.

Over the last three decades, psychiatry trainers have attempted to use films as an educational tool for teaching medical students and psychiatry residents for a number of mental health conditions and scenarios, that range among personality disorders, assessment of mental state, response of others to the mentally ill, and the relationship between the therapist and the patient; especially on issues of transference and counter-transference7,8,10.

Although such depictions may not always be completely accurate, they may however be good enough to use as an example to understand and analyze some aspects of a mental disorder. Even negative images can be used to generate discussion and promote critical thinking. It is unavoidable that films are made for entertainment, different from documentaries which are meant for education, nonetheless commercial films have an artistic richness that is rarely matched by documentaries. Films are well produced, interesting, entertaining, accessible, well-liked by students, and there are no concerns over patient confidentiality, all of which constitutes an advantage when using them for teaching7,8.

In films, characters experience their symptoms in the context of their lives, not in an isolated clinical encounter, which offers multiple perspectives on illness not usually seen in short psychiatry placements. Likewise, they can offer an opportunity to observe the long-term course of an illness, which is no usually possible in short training posts8,12,17.

From a practical perspective, another advantage is the fact that films can be paused to deal with a discussion point. This allows students to express their honest opinions and feelings about film characters in situations when they may feel inhibited to do so about patients8,9. Also, films can be viewed repeatedly to emphasize specific learning objectives, being particularly helpful when learning about clinical examination, given that it offers an opportunity for the students to notice things they may have overlooked the first time, such as behaviors, mannerisms, expressions or any other information useful to determine the proper diagnosis, prognosis and treatment of an illness.

Psychiatry practice requires skills such as critical and reflective thinking, clinical ethical reasoning, values-based practice and narrative skills, which can be aided by cinemeducation since it offers trainees a vicarious experience of mental illness and the opportunity for reflective observation, thus a deeper understanding of the subject8,9,14,15,16.

An example of the use of cinemeducation is the introductory lecture in psychiatry for students at the University of Nottingham, UK, which provides an overview of the ICD-10 classification with the diagnostic criteria of the major psychiatric disorders by using a range of films that include As Good as It Gets (1997) by James L. Brooks, The Madness of King George (1994) by Nicholas Hytner, Some Voices (2000) by Simon Cellan-Jones, Mr. Jones (1993) by Mike Figgis, Rainman (1988) by Barry Levinson, The Lost Weekend (1945) by Billy Wilder, among others8,17,18,19,20,21.

According to particular learning objectives, entire films or selective clips can be used. The clips can be watched before and after discussing the diagnostic criteria, which enables students to correlate the criteria with the audio-visual representation. Zazulak24 recommends asking the following questions after presenting a film clip: «what did you see? What did you hear? What did you feel? What did you think? What impact might this have on your clinical practice?», thus creating starting points for guided discussion8,21,22,23,24,25.

Films can be used to engage students' attention, emphasize learning points in lectures and illustrate symptoms of a disorder, being particularly helpful when learning about mental state examination, how to reach a diagnosis, doctor-patient interactions, and treatment formulation skills. Trainers should encourage students to discuss a character's appearance, behavior, abnormal experiences and perceptions, which they can consider in the context of the other characters in the film. One of the difficulties of using films to illustrate psychopathology is that the diagnoses are not always clear, therefore it is important to consider ICD-10 or DSM-5 categories, as well as differential diagnosis9,21,26.

Additionally, film clips can be useful in prompting role-play by providing a set of ready-made characters and circumstances for students to incorporate into their enactment. The Psychiatry Teaching Programme at Derby Medical School, UK, uses this method regularly to teach aptitudes such as interviewing, diagnostic and therapeutic skills1,8,17.

Trainees can learn as well about doctor-patient relationships, transference and countertransference, therapeutic boundaries, and professionalism. One of the strategies is to ask trainees to look at the reasons why doctor behaves in an arrogant manner, so introducing them to the notion that insensitivity to the patient is created by the doctor's defense mechanism. M.A.S.H. (1970) by Robert Altman offers a terrific setting for looking at how doctors deal with working under stress. Ordinary People (1980) by Robert Redford displays an overly involved patient, which can encourage discussion about the boundaries of therapeutic relationships1,8,9,17.

Films can help illustrate the course of a disorder, for example, the features of substance misuse may be clearer in a film than in a patient interview and it may be easier to identify different personality disorders or more subtle psychological impairments thanks to the longitudinal perspective of some films1,8.

There are hundreds of films available as teaching materials. There are many resources that trainers can use to identify films suitable for teaching psychiatry, some authors have compiled lists of movies that meet the criteria. Alexander et al.26 list film clips with questions related to some psychiatric disorders and treatments. Wedding et al.27 provide a detailed bibliography of films illustrating psychopathology. Robinson28 compiles film portrayals of many conditions, usefully cross-referenced with DMS-IV or ICD-10 diagnostic criteria. And the Association of Directors of Medical Student Education in Psychiatry has listed a summary of more than 100 feature films depicting various psychiatric disorders29.

The author's personal choice of films for teaching the topics mentioned above is shown in Table 1 and Table 2. The list is not comprehensive, and readers may have their own preferences.

One of the main challenges of cinemeducation is managing to integrate films into the existing curriculums. The first step is to identify the learning objectives, then to determine the purpose of the film or clip and how it aids to achieve those goals. Films are an additional tool to help facilitate learning rather than replacing any other learning activity. The material should be used selectively, and the educational context should be explicit. Trainers should prepare lead-in questions for active watching, such as those suggested by Zazulak25 which are mentioned above. As well as follow-up questions as resources to further motive active discussion among trainees8,22,23.

Cinema and psychiatry interact in many ways and have a complex relationship though history. Films represent an entertaining and informative device in the current clinical educator's set of teaching tools, as they can be easily integrated with existing formats of teaching such as lectures, role-play or small group discussions.

Table 1.  List of films suitable for teaching1,8,29

Films for specific disorders

Schizophrenia

Some Voices (2000) by Simon Cellan-Jones

A Beautiful Mind (2001) by Ron Howard

Devrai (2004) by Sumitra Bhave – Sunil Sukthankar

Obsessive-compulsive disorder

As Good as It Gets (1997) by James L. Brooks

Attention-deficit hyperactivity disorder

Dennis the Menace (1993) by Nick Castle

Borderline personality disorder or psychotic depression:

Girl, Interrupted (1999) by James Mangold Somatic complaints

Hannah and Her Sisters (1986) by Woody Allen

Hypomania, bipolar disorder

Mr. Jones (1993) by Mike Figgis

Autism

Rainman (1988) by Barry Levinson drug.

Mental state examination

The Lost Weekend (1945) by Billy Wilder

The Snake Pit (1948) by Anatole Litvak

Harvey (1950) by Henry Koster

Frances (1982) by Graeme Clifford

The Glass Menagerie (1987) by Paul Newman

The Madness of King George (1994) by Nicholas Hytner

Twelve Monkeys (1995) by Terry Gilliam

Lone Star (1996) by John Sayles

She's So Lovely (1997) by Nick Cassavetes

As Good as It Gets (1997) by James L. Brooks

Requiem for a Dream (2000) by Darren Aronofsky

Silver Linings Playbook (2012) by David O. Russell

Still Alice (2014) by Richard Glatzer and Wash Westmoreland

The Skeleton Twins (2014) by Craig Johnson

Table 2.  List of films suitable for teaching1,8,29

Diagnosis

Harvey (1950) by Henry Koster

Betty Blue (1986) by Jean-Jacques Beineix

The Naked Lunch (1991) by David Cronenberg

Jerry Maguire (1996) by Cameron Crowe

Lone Star (1996) by John Sayles

Trainspotting (1996) by Danny Boyle

Fight Club (1999) by David Fincher

A Beautiful Mind (2001) by Ron Howard

The Aviator (2004) by Martin Scorsese

Black Swan (2010) by Darren Aronofsky

Silver Linings Playbook (2012) by David O. Russell

Doctor-Patient interactions

Frances (1950) by Graeme Clifford

M.A.S.H. (1970) by Robert Altman

One Flew Over the Cuckoo's Nest (1875) by Milos Forman

Ordinary People (1980) by Robert Redford

Still of the Night (1982) by Robert Benton

What about Bob? (1991) by Frank Oz

Personality disorder

Strangers on a Train (1951) by Alfred Hitchcock

The Caine Mutiny (1954) by Edward Dmytryk

Play Misty For Me (1971) by Clint Eastwood

A Clockwork Orange (1971) by Stanley Kubrick

Taxi Driver (1976) by Martin Scorsese

King of Comedy (1982) by Martin Scorsese

Zelig (1983) by Woody Allen

Fatal Attraction (1987) by Adrian Lyne

Single White Female (1992) by Barbet Schroeder Swimming with Sharks (1994) by George Huang

Bullets over Broadway (1994) by Woody Allen

The Talented Mr. Ripley (1999) by Anthony Minghella

Girl, Interrupted (1999) by James Mangold

Thus, cinema constitutes not only an important source of entertainment, but also an educational tool and a significant influence on people's attitude towards mental illness.

Referencias

1 Bhugra D. Teaching psychiatry through cinema. Psychiatric Bulletin. 2003;27(1):429-30. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/7A01CA02703E42217CA847F8554E751E/S0955603600003433a.pdf/teaching_psychiatry_through_cinema.pdfLinks ]

2 Vera B. ¡El asesino era yo! o el trastorno de identidad disociativo en el cine. Rev Med Cine. 2006;2(4):125-32. https://revistas.usal.es/index.php/medicina_y_cine/article/view/193Links ]

3 Vera B. Asylums for the insane in the cinema: the representation of mental institutions and their procedures on the wide screen. J Med Mov. 2007;3(2): 57-67. http://campus.usal.es/%7Erevistamedicinacine/Vol_3/3.2/ing.3.2.pdf/manic_ing.pdfLinks ]

4 McGinty E. Cinema's Sinister Psychiatrists: From Caligari to Hannibal. Am J Psychiatry. 2014;171(4):472-3. https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2013.13101403 [ Links ]

5 Cappelletti GL, Sabelli MJG, Tenutto MA. ¿Se puede enseñar mejor? Acerca de la relación entre el cine y la enseñanza. Rev Med Cine. 2007;3(3):87-91. https://revistas.usal.es/index.php/medicina_y_cine/article/view/141/238Links ]

6 Cogollo SN. Cine y locura: momentos de una atracción. Revista Psicoespacios. 2010;4(4):81-8. http://revistas.iue.edu.co/revistasiue/index.php/Psicoespacios/article/view/48/558Links ]

7 Byrne P. Now this won't hurt a bit - Psychiatry in the movies. BJP. 2010;196(5):411. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/B8D3B9014D45C87946D45CE7E41BEEFD/S0007125000252562a.pdf/now_this_wont_hurt_a_bit.pdfLinks ]

8 Dave S, Tandon K. Cinemeducation in psychiatry. Advances in psychiatric treatment. 2011;17(4):301-8. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/746204949B9AADA0EDFE0C1C9C75C42A/S135551460001422Xa.pdf/cinemeducation_in_psychiatry.pdfLinks ]

9 Hankir A, Albazi M, Nguyen NT. The Portrayal of Mental Illness in Film and its Application as a Learning Tool in Medical Education. WJMER. 2011;1(1):87-90. https://www.wjmer.co.uk/downloads/old/JOURNAL_FLIP_BUK/individual_pdfs/WJMER_Vol1_Article_9.pdfLinks ]

10 Lappan NC, Van't Hooft F. Cinema e Psiquiatria: Filmes para o estudo do autismo. R Enferm Cent O Min. 2011;1(3):313-23. http://www.seer.ufsj.edu.br/index.php/recom/article/view/5/208Links ]

11 Kalra G. Psychiatry movie club: A novel way to teach psychiatry. Indian J Psychiatry. 2011;53(3):258-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221185/ [ Links ]

12 Castaldelli-Maia JM, Pereira H, Guerra A, Lotufo-Neto F, Bhugra D. Using selected scenes from Brazilian films to teach about substance use disorders, with-in medical education. Sao Paulo Med J. 2012;130(6):380-91. http://www.scielo.br/pdf/spmj/v130n6/v130n6a05.pdfLinks ]

13 García LM. La naranja mecánica (1971): ¿padecía Alex DeLarge un trastorno antisocial de la personalidad? Rev Med Cine. 2012;8(2):53-8. https://revistas.usal.es/index.php/medicina_y_cine/article/view/13725/14079Links ]

14 Hernández P, Peña F. El cine como herramienta en la docencia de Psiquiatría. Humanidades Médicas. 2013;13(1):244-65. https://www.medigraphic.com/pdfs/hummed/hm-2013/hm131n.pdfLinks ]

15 Gramaglia C, Jona A, Imperatori F, Torre E, Zeppegno P. Cinema in the training of psychiatry residents: focus on helping relationships. BMC Med Educ. 2013;13(1):90. https://bmcmededuc.biomedcentral.com/track/pdf/10.1186/1472-6920-13-90.pdfLinks ]

16 Middleton C. The use on cinematic devices to portray mental illness. Etropic. 2013;12(2):180-90. https://journals.jcu.edu.au/etropic/article/view/3341/3281Links ]

17 Sharma N, Sharma S, Ghai S. Psychiatry Movie Club: An innovative way to Teach Psychiatry. Delhi Psychiatry Journal. 2013;16(2):335-42 [ Links ]

18 Hernández P, García L. El uso del cine en la enseñanza de la psiquiatría: una propuesta metodológica. Ética y Cine Journal. 2013;3(3):55-61. http://journal.eticaycine.org/IMG/pdf/jeyc_nov_2013_hernandez_cine.pdfLinks ]

19 Padhy SK, Khatana S, Sarkar S. Media and mental illness: Relevance to India. J Postgrad Med. 2014;60(2):163-70. https://www.jpgmonline.com/article.asp?issn=0022-3859;year=2014;volume=60;issue=2;spage=163;epage=170;aulast=PadhyLinks ]

20 Graf H, Abler B, Weydt P, Kammer T, Plener PL. Development, Implementation, and Evaluation of a Movie-Based Curriculum to Teach Psychopathology. Teaching and Learning in Medicine. 2014;26(1):86-9 [ Links ]

21 Leistedt SJ, Linkowski P. Psychopathy and the Cinema: Fact or Fiction? J Forensic Sci. 2014;59(1):167-74 [ Links ]

22 Müller-Vahl KR, Riemann L, Krämer H, Münchau A. Can Tics be Performed Convincingly by an Actor? Behavioural Neurology. 2014;2014(1):893859. https://downloads.hindawi.com/journals/bn/2014/893859.pdfLinks ]

23 Law M, Kwong W, Friesen F, Veinot P, Ng ST. The current landscape of television and movies in medical education. Perspect Med Educ. 2015;4(1):218-24. https://link.springer.com/content/pdf/10.1007/s40037-015-0205-9.pdfLinks ]

24 Zazulak J (2002). Let Hollywood help you teach. The College of Family Physicians of Canada. Section of Teachers (SOT) Updates. Newsletter 10:6. https://www.cfpc.ca/en/member-services/for-teachersLinks ]

25 Shier AM, Williams D. An Evaluation of the Use of Problem Based Learning and Film as a Method of Teaching and Assessment for Social Care Students. European Journal of Social Education. 2016;26/27(65):8-27. https://arrow.tudublin.ie/cgi/viewcontent.cgi?article=1075&context=aaschsslartsLinks ]

26 Alexander M. A review of the literature. In: Alexander M, Lenahan P, Pavlov A. Cinemeducation: A comprehensive guide to using film in medical education. 1st. ed. Oxford: Radcliffe Publishing; 2005. p. 3-7 [ Links ]

27 Wedding D, Boyd M, Niemiec R. Movies and Mental Illness. Using Films to Understand Psychopathology. 4th. ed. Boston: Hogrefe and Huber; 2005 [ Links ]

28 Robinson D. Reel Psychiatry. Movie Portrayals of Psychiatric Conditions. 1st. ed. Port Huron: Rapid Psychler Press; 2003 [ Links ]

29 Levine R. Specific Films Which Demonstrate Specific Pathologies or Symptoms. Association of Directors of Medical Student Education in Psychiatry [Internet]. 2009. https://www.admsep.org/film.php?c=specificLinks ]

Received: March 18, 2020; Accepted: May 08, 2020; pub: February 17, 2021