Dark side of the moon: a course in mental health and the arts

In 2005 clinicians were invited to submit proposals for Student Selected Components (SSC) for third and fourth year students at the new Hull and York Medical School. As a consultant psychiatrist with an interest in the arts I proposed a 3-week course in mental health and the arts. I wanted to find ways of promoting psychiatry as an interesting and valid subject for study and practice – as described in a recent Psychiatric Bulletin article (Eagles et al, 2007), medical students’ attitudes to psychiatry could be influenced by their undergraduate experience. Eighteen months later, 15 students have completed the course.

The course

The course was briefly described on the medical school website. I also prepared an introductory leaflet presenting the different art genres and giving examples of the links between mental illness and the arts and some questions that could be asked. The course was to be run twice a year in blocks of 3 weeks. The weekly seminars lasted 1.5 hours (but there were other teaching sessions) with a maximum student number of four at a time. The students were expected to study for a minimum of 40 hours per week, including private study. I divided the options to study into four main areas: literature, painting, film and music. While looking for mental illness themes in literary works, I came across a few useful reference books and articles (Jamison, 1993; McGrath, 2002; Oyebode, 2002; Bloch, 2005; Gabbard & Gabbard, 2005). The British Journal of Psychiatry series ‘Psychiatry in Pictures’ was also a good source of ideas. My knowledge on the relationship between arts and psychiatry has developed further with the help of the students keeping pace with some of the subjects they chose to study.

The title of the course should be obvious to all those around in the 1970s – Dark Side of the Moon is a Pink Floyd's 1973 album with a mental illness theme brought about by the psychotic breakdown of their founder member, Syd Barrett, who died in 2006. I was hoping that a catchy title would help attract students as they explored options for their SSC. The aims of the course, namely enhancing students’ understanding of mental illness and promoting psychiatry as a chosen specialty, were kept open to allow students to come up with their own topics and themes.

The course needed to have a clinical component and the students met a patient who used art as a self-treatment. They also had a session with an art therapist and were encouraged to join in with creative art and writing sessions at the local psychiatric hospital. At the end of the course students had to produce a 2500-word essay on their chosen topic.

Fifteen students completed the course in 4 blocks over 2 years.

The subjects chosen are outlined in Box 1.

Box 1. Subjects chosen

Books/writers

Sylvia Plath The Bell Jar

Ian McEwan Enduring Love

Patrick McGrath Asylum

Edgar Allan Poe, various books and stories (from Selected Tales, Oxford University Press, 1980)

The war poets: Siegfried Sassoon and Wilfred Owen, selected works

Artists

Richard Dadd

Van Gogh

Stephen Wiltshire

Film/TV

A general review of films, including A Beautiful Mind, The Snake Pit, Repulsion, Girl Interrupted, etc.

Comedians: Spike Milligan and Rowan Atkinson

Music

The Argentinian tango

Robert Schumann

Jazz and drug addiction

Manic Street Preachers

Matt Savage

How the course developed

The majority of the students found themselves getting fully absorbed in their chosen subject. Most easily covered the minimum required 40 hours per week spending their time reading articles and books, watching films and doing internet research. Medical students rarely have the time to investigate a subject in this way having spent their school years studying mainly science subjects and then getting caught up in the medical curriculum, and I felt that they appreciated this opportunity. Students were encouraged to critically investigate their chosen topic and original ideas were welcomed. Some came with ideas fully formed, whereas others spent the first week searching a vast field to narrow down in the second week to a topic they could study in more depth. Some of the themes chosen are outlined in Box 2.

Box 2. Chosen themes (examples)

Books/writers

1. • Is The Bell Jar relevant to psychiatry today?

2. • Can reading certain literature help us understand mental illness?

3. • Can we recognise contemporary descriptions of mental illness in Edgar Allan Poe's work?

4. • How did the war poets Owen and Sassoon portray shell shock in their poems?

Artists

1. • Did his mental illness influence the art of Richard Dadd?

2. • What type of mental illness did Van Gogh suffer from and was his artwork a therapy for his illness or a reaction to it?

3. • Can studying the artwork of autistic savants (Wiltshire and Savage) help us to understand autism?

Film/TV

1. • What can we learn from films portraying mental illness?

2. • Are there differences between Eastern and Western views on mental illness as portrayed in film?

3. • Does tragedy and sadness underlie the humour of certain comedians?

Music

1. • Exploring the tango as an expression of Argentine insanity

2. • How can mental illness affect the creativity of composers?

3. • Studying the link between drug misuse and jazz performers (1945–1960)

4. • Investigating the disappearance of Richey Edwards (Manic Street Preachers)

Emerging themes

Influence of mental illness on art

Bipolar affective disorder can enhance artistic expression by increasing productivity and creativity. Examples here are Robert Schumann's music and Spike Milligan's comedy. Sadly, schizophrenia does not always enhance creative ability, but it may change it. This is illustrated in the work of artists such as Richard Dadd and Louis Wain. Dadd produced more obsessive paintings with greater attention to detail following his admission to mental hospital, whereas Wain's paintings of cats became more psychedelic after he developed schizophrenia.

Enhancing understanding of mental illness

Studying creative arts can help medical students understand what it is like to have mental illness. The Bell Jar by Sylvia Plath (1971) gives a superb description of a descent into severe depression, a suicide attempt and recovery after electroconvulsive therapy (ECT) treatment. Some of Edgar Allan Poe's works are also evocative in this sense – one of his short stories, The Black Cat (1843), clearly describes the development of a paranoid psychosis. The film, A Beautiful Mind (2001), is another example. As we watch it we are taken on a journey into a delusional state with a lack of insight, which is only gained with the commencement of treatment. There is always a risk of relapse and we witness the devastating effect on the patient (the film's protagonist) and carer (the protagonist's wife) of a major mental illness.

Reading poems by Siegfried Sassoon and Wilfred Owen and their experiences of treatment at Craiglockhart Hospital near Edinburgh during the First World War gives remarkable insights into the horrors of war, subsequent trauma-related symptoms and treatment approaches that are still valid today. Pat Barker describes this eloquently in her novel Regeneration (1991).

Stigma

Unfortunately some art can potentially have the effect of increasing stigma by exaggerating the risk of harm to others and can put people off seeking help for their illness for fear of the treatments. A possible example here is the novel Enduring Love by Ian McEwan (1997). Although it gives a good description of de Clerambault's syndrome (delusional love), it may have the effect of exaggerating the risk to others from people with mental illness as perceived by the general public. Sensational events, such as an attempted murder by a person with mental illness, may help sell a novel or a film, but they may also contribute to creating a distorted image of mental illness. The films One Flew Over the Cuckoo's Nest (1975) and Shock Corridor (1963) did much to increase fear of ECT; a more recent film Gothika (2003) is no better. In those films, psychiatric hospitals are depicted as dark, frightening places with bare walls and corridors, communal showers and intimidating nurses in white uniforms jangling their keys ominously.

Bedside manner

Familiarising themselves with accounts given by people with mental illness can give medical students an experience of what it is like to be on the ‘other side,’ thus increasing their empathic skills as future doctors. For example, The Bell Jar describes two different approaches by psychiatrists treating patients in a psychiatric hospital and it is not hard to decide which approach is preferred by the patient; whether that of Dr Gordon asking questions from the other side of his acre of polished desk or that of Dr Nolan who takes a personal interest in her patients and supports them through the whole process of ECT treatment. This book also describes a successful course of ECT, unusual in literature and film. Mandatory reading in my view.

Art as a therapy

Art can be used as a therapy, a way of coping with symptoms and achieving better understanding of the illness. Van Gogh appeared to use his paintings as a way of coping with inner feelings, although not always successfully. One student suggested that the tango helped the Argentinians deal with the stress of the social and political changes in their country. The students met a patient who explained how paintings helped her to make sense of terrible early life experiences and they saw how an art therapist carried out her work.

Illicit drugs and alcohol

Finally, students gained understanding of how illicit drugs and alcohol can affect the mind and in some cases enhance creative experience but not without cost. One student studied the influence of illicit drug misuse (heroin) on the life and works of Charlie Parker and Miles Davis with the suggestion that the unique quality of their music may have been enhanced by their drug misuse. It is well known that Van Gogh regularly used absinthe but it is unlikely, however, that this enhanced his art.

Conclusions

Studying mental illness through art certainly aids understanding of both symptoms and treatment, and it is a valid subject for medical students to study. Students went away with a better understanding of mental illness and hopefully some resistance to the stigmatising influences they will encounter in their later experiences in medicine. When I made the decision to apply for psychiatry training my supervisor, a physician, was not slow to point out that I was wasting my career. Psychiatrists who will not remove a difficult patient from a medical ward may face anger from other staff. All these influences take their toll with the inevitable result in future choice of specialty.

One of the potential problems with this type of course is how to evaluate the students. Since the medical school requires a mark, I chose to use an essay as well as assessing the student's performance in the tutorials. The aim was to teach the students to critically evaluate information not directly related to a science subject and formulate their own opinion. Marks were given for the ability to produce a readable and interesting piece of work. However, not all students find this easy and some may have been put off applying for the course for this reason.

Now that Hull and York Medical School is more established I have concerns that some students may now not apply to do what they perceive as ‘soft’ SSCs and will concentrate instead on more clinically orientated subjects with the aim of securing future jobs. However, as long as students continue to apply for the course I will continue to run it.

At this stage it is too early to predict whether doing the course will have any influence on the student's future choice of specialty. I am considering doing a follow-up study in 5 years time, which may throw more light on this. At the very least the opportunity to study an art subject in more depth could benefit students’ use of leisure time.

Declaration of interest

None.