Technologies
Doc Hollywood North:
Part I. The Educational Applications of Movies in Psychiatry
Harry Karlinsky, MD, MSc, FRCPC
Clinical Professor and Director, Continuing Medical Education and
Professional Development, Department of Psychiatry,
University of British Columbia; Faculty Associate,
Office for Faculty Development and Educational Support, Faculty of Medicine,
University of British Columbia, Vancouver, British Columbia harryk@telus.net
Summary: Despite their formidable societal presence, movies appear to be underused as instructional tools. However, more medical educators are beginning to use this popular medium to teach about psychiatry in creative and engaging ways. Although we still need evidence of their instructional efficacy, the most formidable obstacles to wider utilization appear to be the current cumbersome copyright prohibitions.
Résumé : Docteur Hollywood North : L’application des enseignements du cinéma en psychiatrie (1re partie) Malgré leur forte présence sociétale, les films semblent être sous-utilisés comme outils pédagogiques. Toutefois, un nombre croissant d’éducateurs en médecine commencent à utiliser ce média populaire pour enseigner la psychiatrie de façon inventive et attrayante. Même s’il faut encore prouver leur efficacité pédagogique, les obstacles les plus importants à leur utilisation répandue semblent être les encombrantes interdictions de droits d’auteur.
Key Words: movies, psychiatric education, public performance rights
The affinity between psychiatry and the movies has existed since their coinciding gestations in the early 20th century. Numerous articles and texts have been written on the relationship—often focused on stereotypic or inaccurate depictions of psychiatrists, psychiatric subjects, illnesses and treatments. For example, as one labour of love, Rabkin has compiled The Celluloid Couch, an extensive filmography of the mental health professional in the movies and television “from the beginning to 1990” (1). Psychoanalytically informed movie criticism is another popular and long-standing endeavour that often provides a helpful perspective on a particular movie’s audience impact (2). Conversely, others have argued that “the great contribution of psychoanalysis has been to provide a new alibi for the structure of the American narrative film” (3). Unfortunately, psychological explanations for characters’ otherwise implausible behaviour continue to be a filmmaker’s plot device of last, albeit still-frequent, resort.
Interestingly, educators and clinicians are now using movies in more practical ways. This paper (Part I) examines how “Hollywood” feature-length films can be used to understand and teach aspects of psychiatry. Part II will look at the clinical implications of movies, including prescribing movies for therapeutic purposes.
Educational Applications
In Movies and Mental Illness: Using Films to Understand Psychopathology (4), Wedding and Boyd provide a convincing rationale for the successful use of movies to teach psychopathology. The arguments include the widespread popularity and familiarity of the medium, the experiential power of movies, their relatively low cost, the fact that recommended movies can be watched in the privacy and safety of one’s own home, and the absence of confidentiality issues (a movie that vividly depicts a psychiatric disorder circumvents the ethical issues associated with discussing actual cases and interviewing patients).
For Zazulak (5), the major advantage of “cinemeducation”—a term coined by Alexander and others (6)—is that it allows learners to explore personal responses to situations, without clinical responsibility. Zazulak cites other advantages, including the opportunity for learners to practise their observational skills and the opportunity for medical educators to expose their students to areas not covered in their personal practices.
As a teaching tool, movies lend themselves to various instructional approaches. The most basic approach is simply to encourage students to watch a movie before or after a lecture or clinical experience. Alternatively, selected vignettes from a relevant movie or, time permitting, the entire movie, can be shown during a lecture or rounds—an approach that has been systematically used throughout an entire curriculum (4,7).
A scene from G.W. Pabst's Secrets of a Soul (1926). This German silent film was written under the supervision of three of Freud's students and was the first film to depict psychoanalysis.
However, watching films collectively, outside a theatre, actually raises an important caveat that is not always appreciated. In brief, unlike U.S. copyright law, there is no exemption in the Canadian Copyright Act for educational use of videotapes or DVDs. This means that films exhibited in the classroom or during hospital rounds normally require a Public Performance Licence. An apparent exception is the use of “insubstantial,” short, selected clips: the Copyright Act appies to performances of entire works or “any substantial part thereof” (but check with your librarian!). In general, however, videos or DVDs borrowed from a retail outlet or public library should not be shown for educational purposes (8).
Fortunately, many universities and colleges have a special institutional Feature Film Public Performance Licence. This allows any legal copy of a feature film that is covered by the licence, including videos and DVDs rented from the local video store, to be legally shown on the campus in question without any further payment. Even in the absence of an institutional licence, many libraries associated with teaching institutions will purchase an “educational licence” for most, if not all, of their individual holdings that allow for educational presentations. When neither option is in place, movies can be still shown for educational purposes if a licence is purchased for each showing. Unfortunately, this can be a cumbersome and expensive process; it involves contacting the relevant distributor and obtaining a “per showing” licence that may cost over a hundred dollars. The practical approach is to establish a (positive!) relationship with your library’s media acquisition services and to beg their assistance, including convincing them to purchase those films you require for teaching purposes. For those campuses with an “institutional” licence, it would be prudent also to ensure (or lobby!) that the licence includes public performance in off-campus teaching hospitals.
With that caveat addressed, and hopefully now overcome, teaching with movies involves the following three essential steps, regardless of which instructional approach is used.
Selecting the Appropriate Film
Movies appear to be most used to teach the symptomatology, etiology and treatment of mental illness, but virtually every other topic, including psychological processes and the doctor–patient relationship, can be imaginatively addressed. The first obvious challenge is to find the appropriate movie. Fortunately, various filmographies related to psychological processes and psychopathologies have now been constructed. For example, Wedding and Boyd’s text contains a comprehensive filmography organized by diagnostic category (4). Each film is rated from 1 to 5, primarily based on its utility as a teaching tool. Another significant resource is Gabbard and Gabbard’s alphabetical list of more than 450 films (2). Anthologies of movies “prescribed” for therapeutic purposes are also excellent resources for movies that can be used for teaching.
The Internet has spawned new resources. Lists of movies pertaining to mental health can be found on Joy’s Media File (www.frii.com/~parrot/films.html) and The Psychiatry On-line Web site (www.priory.com/ psych/psycineman.htm). Perhaps more important, the Internet provides a relatively easy way to undertake the following:
to obtain specific movie reviews (try the Movie Review Query Engine, http://www.mrqe.com) to identify and contact the distributor if public performance rights will need to be obtained (The Internet Movie Database http://www.imdb.com is probably the most comprehensive Web-based database.) to rent or purchase obscure movies (try the Facets multimedia Web site, www.facets.org).
Unfortunately, it is still challenging to start with a particular need—say, to teach about panic disorder—and then to find the movie that will best serve your teaching purposes. Ideally, one requires a searchable database of relevant movies. Although limited to documentaries, the Docuseek Web site (www.docuseek.com/wc.dll?docprocess~startsearch) is a search site for independent documentary, social issues and educational videos available in the United States and Canada. Other searchable sites for documentaries include Moving Images Distribution (www.movingimages.bc.ca), the National Film Board of Canada (www.nfb.ca) and Filmakers Library (www.filmakers.com). Local libraries (both university and public) should also be contacted to determine whether there are local collections of movie titles that can be searched and borrowed. If all else fails, try Google (www.google.ca) or a similar search engine. Increasing numbers of consumers with mental illness are establishing personal Web sites with resource information that includes relevant popular movies, often with an annotated perspective.
Finally, another important caveat: Hollywood films and other commercial movies are made primarily for entertainment and profit, not to educate. Before a film is screened or recommended, it should be personally critically appraised to ensure that it reflects the issues intended for instruction. To state the obvious, accurate portrayal of individuals with mental disorders, or their treatment, should not be assumed.
Enhancing the Learning Experience
Before a movie is screened or assigned, students should be primed with issues to consider while they view it. In this regard, Wedding and Boyd offer an excellent template (4). For example, here are some of their questions to consider while watching Hitchcock’s Psycho:
Is it an accurate presentation of mental illness? Do films like Psycho do a disservice to people with mental disorders by perpetuating the myth of the homicidal maniac? How often are paraphilias such as voyeurism linked with violence? Would you feel comfortable working with a patient like Norman Bates? Would you insist that security officers be present during your evaluation?
When film clips are used, Zazulak’s advice is first to describe the actions leading up to the selected clip and then to reinforce the learning objectives (5). After the clip has been viewed, Zazulak recommends asking a series of questions that require students to explore their reactions in a progressively more personal manner. Examples are as follows:
What did you see? What did you hear? What did you feel? What did you think?
Zazulak then suggests broadening the context to include questions on the potential impact of the viewing experience on subsequent clinical interactions.
One interesting and imaginative approach to supplement the experience of watching films is suggested by Wedding and Boyd (4). To stimulate discussion, these authors construct a history and mental status exam that is closely linked to the selected film character. As an example, they have used the film Psycho to teach the dissociative and somatoform disorders. They provide a script that begins with the court-appointed psychiatric evaluation of Mr. Norman Bates, who is awaiting sentencing on four counts of murder. His diagnosis is a dissociative identity disorder and his prognosis is viewed as bleak (a prognosis confirmed by the sequels Psycho 2, Psycho 3 and Bates Motel). Koren, on the other hand, takes a more factual approach, asking 10 questions about clinical pharmacology that students are to answer while watching the movie Awakenings (9).
Finally, viewing films primarily for entertainment is different from viewing films for educational purposes, and general viewing advice may enhance the learning experience for students. For example, Hesley and Hesley emphasize that casual moviegoers typically pay most attention to a film’s plot (10); however, depending on the specific learning objectives, it may be useful to remind students to concentrate more on the characters and their relationships.
Addressing Technical Issues
These issues will obviously vary, depending upon the instructional strategy. Some documentaries and historical films that are only available as film (16 or 35 mm) require a film projector—a rapidly vanishing piece of equipment. The more likely technical challenge occurs when only selected vignettes are required. In these circumstances, preselected scenes must be identified; a process facilitated by a “counter” on either a VHS or DVD machine. Although these clips can then be cued up for screening at the appropriate time, it will be tempting to copy the selected segment(s). Movie DVDs are currently copy-protected and preclude this process, but video segments can easily be transferred to blank videotape. Copying clips has several advantages: desired segments can be found with less difficulty; there is no need to repeatedly borrow and return the video(s); and when multiple clips are being shown, there is no awkward transport of several videos to educational presentations. The VHS transfer process itself is relatively straightforward and simply requires a second VHS machine. It is again worth emphasizing, however, that permission from the appropriate rights holder is required before a copy (or compilation of video clips) is made from an original source.
For various reasons, it may be even more tempting to digitize the video clips in question. This allows for their more seamless introduction into computer-based presentations (such as PowerPoint) and also avoids the need for television monitors and VHS recorders. However, using digitized video requires a certain degree of skill in editing as well as in circumnavigating a confusing number of hardware and software decisions. In brief, the process most commonly used to digitize video requires a computer with a soundcard and a video input card that, via an RCA jack, is able to accept the input from a VCR. Proper software must also be installed to convert the signal from analog to digital and to compress the file. The resulting digital file (which, depending on its size, may need to burned on to a CD-ROM or recordable DVD) can then be used as part of a PowerPoint presentation linked either as an external file (via a hyperlink) or embedded within the PowerPoint slide itself (provided the digital file format is AVI or MPEG). If that’s not confusing enough, the Copyright Act does not yet cover digital rights (although Phase III of the Copyright Act, now in development, will deal with digitization). Call your librarian (and your lawyer!).
Although beyond the scope of this present discussion, the digital format can also be used in Web-based presentations or within instructional CD-ROMs or DVDs, with the caveat that bandwidth is still a significant challenge to the delivery of video via Internet or Intranet.
Feature films can also be used as therapeutic tools for patients. Stay tuned for Part II!
References
1. Rabkin LY. The celluloid couch: an annotated international filmography of the mental health professional in the movies and television, from the beginning to 1990. Lanham (MD): The Scarecrow Press, Inc; 1998.
2. Gabbard GO, Gabbard K. Psychiatry and the cinema. 2nd ed. Washington (DC): American Psychiatric Press, Inc; 1999.
3. Vernet M. Freud: effects speciaux/mise en scene: U.S.A. Communications, 23, 223-34, 1975. (as quoted in Gabbard and Gabbard, 1999).
4. Wedding D, Boyd MA. Movies and mental illness. Using films to understand psychopathology. Boston (MA): McGraw-Hill College; 1999.
5. Zazulak J. Let hollywood help you teach. www.cfpc.ca/education/sot/sotnewsletter.asp
6. Alexander M, Hall MN, Pettice YJ. Cinemeducation: an innovative approach to teaching psychosocial medical care. Fam Med 1994;26:430 3.
7. Fritz G, Poe RO. The role of cinema seminar in psychiatric education. Am J Psychiatry 1979;136:207–10.
8. Kornfeld J, Mitter N. Langara College Copyright Guide August 2001. Revised ed. Vancouver (BC): Langara; 2001.
9. Koren G. Awakenings: using a popular movie to teach clinical pharmacology. Clin Pharmacol Ther 1993;53:3 5.
10. Hesley JW, Hesley JG. Rent two films and let’s talk in the morning. 2nd ed. New York: John Wiley and Sons; 2001.
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