The silver screen, printed page and cultural competence

In a multicultural society, cultural competence in assessing and managing patients is essential. If government proclamations are to be believed (e.g. Department of Health, 2003), such training could even become mandatory for mental health professionals. Could guidance be found in the cinema and the library?

Using a number of personal choices, we will illustrate the possibility of using films and novels to teach psychology students and trainees about other cultures, their developmental aspects and dynamics of individuals. We argue that they can be a rich source for illustrations of psychopathology, treatment and the way that different cultures deal with mental illness and abnormal behaviours.

In the 1940s and 1950s, the government often made use of educational documentaries to promote health and prevent the spread of disease. But the use of mainstream Hollywood cinema in educating trainees in medicine, psychiatry and psychology is a relatively recent phenomenon, only really taking off in the USA in the last 30 years or so. One of the first to comment, Nissim-Sabat (1979), argued that Hollywood producers have consistently shown an interest in the working of the mind, the abnormal mind and abnormal behaviour, which can be employed for illustrating psychopathology in training or teaching sessions. Such ideas are now beginning to be discussed in academic circles in the UK (see Bhugra 2003a, 2003b).

Cinema, used sensibly and not relying on its entertainment value solely, helps broaden trainee perspectives to include humanistic, social and philosophical components. The trainee is encouraged to challenge stereotypes and develop an empathic awareness of similarities and differences across cultures that will enable them to work within a cultural framework and formulation. Watching films will not by itself make any trainee more culturally competent, but it will certainly open windows for further discussion, in a non-threatening context.

Films and literature are both useful in that they not only reflect the interactions between therapist and the patient, they also set these in specific cultures to provide an insight into the milieu. They highlight customs, rituals, legends, folklores – all the components that define culture. Using the audiovisual medium also means that for training purposes both verbal and nonverbal communications can be studied and viewed as a social activity, allowing the audience to understand intracultural nuances.  

Both books and the cinema can illustrate individual concerns, anxieties and worries in the context of cultural nuances and expectations. They can also demonstrate cognitive schemas of the individual, interactions with their families and whether the individual cultures are sociocentric or egocentric. Similarly the impact of factors such as slavery or indentured labour on the individual's psyche in terms of isolation, alienation, anger and resentment can be observed and taken into account when any therapeutic interventions are being considered.

Of course, for trainees it is useful if the training in cultural competence is embedded in the broader perspectives of training and learning. As Roderhauser and Leetz (1987) have illustrated, the use of literature and films together sets the scene in the context not only of religious themes, existential struggles, epistemological considerations, ethical and moral principles, portrayals of ethnic and cultural factors, but also of social, political and historical issues and influences. Hyler and Moore (1996) advise that commercial films can be used to illustrate various possible aspects of suicidal behaviour including depression, post-traumatic stress disorder, adolescent pressures and the spiritual and philosophical aspects of suicide. They do caution that not all films will portray the mental health professional sympathetically or seriously, and may well end up stigmatising the professions and patients. In any discussion careful attention needs to be paid to individual portrayal and stigmatising influences.

From the psychological perspective, films can be used to demonstrate mental state examination, therapist–patient interactions (especially transference and countertransference), personality disorders, other psychiatric/psychological conditions such as obsessive compulsive disorders, phobias and common mental disorders.

We will now turn to some of our suggested films that you can call on to demonstrate various aspects of psychopathology. Of course these are personal choices – readers are encouraged to come back with better recommendations, to build their own library and share films and fiction accordingly. Indeed, involving the trainees themselves is an essential step if the process of learning is to succeed. The target audiences for most films are teenagers or young adults.

You need to let the trainees identify their favourite films, and discuss what struck them as unusual in these films and what the relevant lessons for dealing with cultures are.

Mental state examination 

Clips can be used to demonstrate existing psychopathology through the behaviour. For psychosis, films like The Shining, The Madness of King George, King of Comedy, Taxi Driver, Shine and Twelve Monkeys can be used, along with an introduction to appropriate professional literature. The students can be shown a short clip of 5–15 minutes duration and then asked to describe appearance, behaviour, abnormal experiences and perceptions. This information can then be used to produce not only specific formulations of diagnosis and management but also inherent problems of diagnosis. The trainees can then be asked to produce a list of questions they would like answered from third-party informants and what their management plans will be. Often the diagnosis is not very clear, but it should be possible to use differential diagnosis to illustrate key features.

Therapist–patient interactions

The role of therapist and patient expectations can be easily illustrated using films. For example Ordinary People illustrates not only family dysfunction but also the act of attempted suicide related to underlying depression and post-traumatic stress disorder. However, the film also demonstrates effectively the WASP (White Anglo Saxon Protestant)?values on East Coast America. The portrayal of cold mother and warm therapist can be used to discuss therapist–family interactions. Other films can be used to demonstrate therapist–patient interaction, the control of the interview, the arrogant therapist, an all-forgiving psychotherapist and patients' responses to these stereotypes. Making students look at reasons why therapists behave in an arrogant or insensitive manner can be used to thereby illustrate specific defence mechanisms.

Common mental disorders

Anxiety and depression related to stress are commonplace portrayals in the cinema. Personality disorders are more interesting, and are often employed to great effect as a mechanism for character development and interesting interactions.

Patricia Highsmith has written about psychopathic characters in an interesting manner. In The Talented Mr Ripley, Tom Ripley is a classic charming, cold, suave psychopath who manages to survive in a different cultural setting. Similarly Bruno Anthony in Strangers on a Train is a classic charmer, subtle, irritable at times but always focused on himself, bullying yet guiltless and a cold-blooded psychopath. Bogart played a paranoid captain in the Caine Mutiny. Fatal Attraction, Frances, Single White Female and Play Misty for Me can be used to illustrate borderline personality disorder, and Jezebel for narcissistic personality disorder.

Phobias

A horror flick like Arachnophobia and Hitchcock's classic Vertigo both illustrate the fears effectively. Of course, because of their frightening nature, phobias can be a candidate for extreme portrayal, and both teacher and student need to be aware of the problems inherent in such an approach.

Obsessive compulsive disorder

The character played by Jack Nicholson in the film As Good as it Gets is a good example. His rituals of switching on the lights five times, using unopened soaps and avoiding cracks in the pavement can be used to teach the role such routines play. The scene where he goes to buy a suit but, looking at the floor of the shop, decides not to go in is a good example to illustrate rituals and magical thinking as well as avoidance. Trainees can be asked to develop treatment plans, think of the role of possible co-therapists and set strategy in place.

Substance abuse

The most significant contribution that Hollywood cinema has made to psychiatry and psychology is in the field of substance abuse; in psychopathology and to a lesser degree in the management of such conditions.

The film Harvey is an old classic with James Stewart as an alcoholic accompanied by a six-foot-tall invisible rabbit. The role of the sister in getting the chief protagonist compulsorily admitted illustrates the role of the next of kin in this process, and the associated guilt. The Lost Weekend, Leaving Las Vegas and others can be used to discuss alcohol dependence, withdrawal, alcoholic hallucinosis and its impact on those around the user.

Similarly films like The Naked Lunch and Trainspotting can be used to discuss and illustrate chemical dependence and its impact on day-to-day living. For example, the desperate need for money in Trainspotting, which leads its characters to shoplift, can be used to illustrate the social chaos that drug dependence can cause.

The role of social and cultural factors in the aetiology, maintenance and treatment of substance abuse has to be observed and discussed where relevant. Cinema and literature may well both take an easy romantic option that the love of a good man or woman can help people overcome their habits, but trainees need to be guided through various coping and management strategies.

Specific cultures

Although discussion of the cultural context of the above behaviours and disorders would be an important part of their use in seminars, such as the WASP culture in Ordinary People, the emphasis is on the behaviour. For comprehensive cultural competence training you should therefore also include some films and texts where culture is addressed more explicitly. Relevant books are illustrated in Table 1 (overleaf). Again these are personal choices, and the reader may have better options.

For an understanding of Indian culture there are several authors who write in English. Vikram Seth's magnum opus A Suitable Boy presents the story of a Punjabi family in Uttar Pradesh, in the 1950s and their search for a groom for the youngest unmarried daughter. This will also allow the students to understand the complexity of the Indian family system. Rohinton Mistry's novels, especially his most recent Family Matters, also illustrate the role of the family in complex kinship situations as well as focusing on fast-disappearing Parsi (Zoroastrian) family traditions – most of his other work has also focused on Parsi traditions and families. Among other easily available and readable authors are Amit Chaudlhuri, Amitav Ghosh, Vikram Chandra and others. The latest by Vikram Chandra, Sacred Games, illustrates the social milieu in the economic capital of India, Mumbai, extremely well.

For Chinese culture, read Amy Tan's novel Joy Luck Club, and for an excellent description of Maoist cultural reorganisation the novel Balzac and the Chinese Seamstress provides a thought-provoking insight. Similarly, although Farewell My Concubine is set in a different era, the descriptions and the described environment are superb. For Latin American cultures Isabel Allende and Mario Vergas are useful. For African American family set-up and the role of slavery Alex Haley's Roots and Toni Morrison and Alice Walker's works are simply superb. The Color Purple not only deals with sexual abuse and domestic violence but also focuses on slavery in a wonderful manner. For learning about Sri Lanka, the novels of Romesh Gunasekara, Shyam Selvadurai and others are of interest. Carl Muller's writings about the Burgher community in Sri Lanka add another dimension to the understanding
of that culture.

For Trinidad, V.S. Naipaul's novel A House for Mr Biswas provides an extremely helpful and useful insight into the mind and functioning of an Indo-Trinidadian family. The story, said to be based on his father's life, is poignant and moving and yet illustrates various aspects of culture extremely successfully.

Most of these books deal with people in their culture of origin, though recent work such as Brick Lane, White Teeth and Londonstani reflect acculturative changes in populations.  

Suggested homework

Trainees can be asked to identify cultural similarities and differences, and discuss how these can be used to strengthen the therapeutic relationships. They should identify specific diagnostic and management issues relevant to psychological practice, as well as the delivery of care in the mental health care system. They can be encouraged to inspect their own cultural values and how these have influenced their prejudices. Last but not least, students should be encouraged to consider their own interpretations of the film or book, and to put forward their own choices.

Underused media

The advantages and disadvantages of the use of films and literature for cultural competence training are many (see also Bhugra, 2003a, 2003b, 2006). Films and books are powerful and yet underused media for training and teaching psychology trainees. There is evidence in the literature to suggest that medical students do respond to learning about various medical conditions through literature (Hampshire & Avery, 2001), and these authors recommend that students should be given the opportunity to study medicine in literature throughout their clinical years.?We believe the same could and should apply in psychology, providing students with the chance to reflect on their clinical experience in a cultural and historical context. This knowledge can then, with care, be applied to modify, implement and review treatment strategies.

Professor Dinesh Bhugra and Padmal De Silva are at the Institute of Psychiatry. E-mail: [email protected].

Weblinks

Films with psychiatric, mental health and substance abuse themes: www.psychflix.com
The Internet Movie Database: www.imdb.com
Indian film: www.indiafm.com
World/domestic cinema: www.atkinsononfilm.com

References

Bhugra, D. (2003a). Teaching psychiatry through cinema. Psychiatric Bulletin, 27(11), 429–430.
Bhugra, D. (2003b). Using film and literature for cultural competence training. Psychiatric Bulletin, 27(11), 427–428.
Bhugra, D. (2006). Mad tales from Bollywood. Hove: Psychology Press.
Department of Health (2003). Inside outside: Improving mental health services for black and minority ethnic communities in England. London:?Author. See tinyurl.com/34zt6g.
Hampshire, A. & Avery, A. (2001). What can students learn from studying medicine in literature? Medical Education, 35, 657–690.
Hyler, S. & Moore, J. (1996). Teaching psychiatry: Let Hollywood help. Academic Psychiatry, 20(4), 212–219.
Nissim-Sabat, D.E. (1979). The teaching of abnormal psychology through cinema. Teaching of Psychology, 6(2), 121–123.
Rodenhauser, P. & Leetz, K.L. (1987). Complementing the education of psychiatry residents. Journal of Psychiatry, Ed II, 243–249.