Despite the neurobiological revolution in psychiatry, case formulation, and especially psychosocial case formulation, remains important in the training of psychiatry residents (R1Y19041,R1Y19042). Indeed, a true commitment to biopsychosocial psychiatry underscores the importance of a multidimensional understanding of psychiatric patients, one that encompasses the many complex and interrelated paradigms that help to explain why people think, feel, and behave as they do (R1Y19043—R1Y19046).

Nevertheless, as neurobiological paradigms of mental illness have become more prominent and captured increasing curricular time in psychiatry residency training programs, the "psychosocial" portion of biopsychosocial case formulation has correspondingly withered in the hands of psychiatry trainees. The reduction of teaching hours devoted to psychosocial formulation has underscored the necessity of time-efficient educational efforts in this arena; psychiatry residents must develop competence in psychosocial formulation, as before, but they must do so with less training time. Furthermore, in psychiatry's "Decade of the Brain," (R1Y19046) psychiatric educators often find themselves having to explain and promote something that in earlier times seemed self-evident—the value of psychosocial formulation in the understanding and treatment of patients.

The deficiency in the ability of psychiatry residents to concisely and accurately conceptualize patients' psychopathology from nonbiological perspectives has been exacerbated by other factors as well: less time with individual patients resulting from shorter hospitalizations and restricted numbers of outpatient visits, less psychodynamic and psychosocial training in residency programs, and declining numbers of residents electing to undergo personal psychotherapy. All of these factors have combined to make today's typical psychiatry resident much less competent and comfortable than his or her forebears in the psychosocial aspects of case conceptualization.

The Traditional Approach to Teaching Psychosocial Formulation

The traditional approach to teaching psychosocial formulation has involved didactic presentation of relevant reading materials followed by patient case conferences in which a group of trainees attempts to formulate, biopsychosocially, a patient's difficulties on the basis of the presentation of the case by one of the trainees. The latter activity, although useful, often suffers from the relative paucity of information presentable in a typical 60—90 minute format as well as the reality that usually only the presenting resident knows enough about the patient to produce a cogent formulation. More useful, perhaps, are continuing case conferences where psychiatry trainees come to know an individual patient more deeply over the course of numerous presentations or discussions. Even in these settings, however, it is still relatively unusual for the group as a whole to join together in the construction of a full-bodied case formulation. Finally, whereas most training programs expect residents to create formulations for their inpatients and outpatients, the superficial nature of these current attempts at formulation are glaringly apparent, especially with respect to psychosocial issues. Indeed, current psychosocial formulations often consist of no more than a restatement of a patient's personal or family history. In order to address the problem of declining psychosocial formulation skills in the context of increasing neurobiological demands on psychiatry residents' time and attention, we have elected to complement the traditional teaching approach with formal use of an already-popular, but usually loosely structured teaching format in psychiatry: the "Movie Club."

A Complementary Approach to Teaching Psychosocial Formulation

The idea of using commercial films as a teaching device in and about psychiatry is hardly a new one. Glen and Kris Gabbard (R1Y19047), Steven Hyler et al. (R1Y19048), and Irving Schneider (R1Y19049) have reviewed the general depiction of mental illness and psychiatry in the cinema. Similarly, various authors have commented upon the movies' portrayal of psychiatrists (R1Y19049—R1Y190414), specific mental disorders or psychopathology (R1Y190415—R1Y190417), and suicide (R1Y190418). More generally, Gabbard (R1Y190419) has elaborated on the psychological approach to movie interpretation. Although the literature specifically addressing the use of commercial films to teach neophyte mental health professionals about psychiatry is limited, Wedding and Boyd (R1Y190420) have published a very useful book in this regard, and Fritz and Poe (R1Y190421) have explored the particular use of a cinema seminar in psychiatric education. In order to facilitate patients' exploration of important issues, Hesley and Hesley (R1Y190422) have even presented specific recommendations for the use of commercial films in psychotherapy itself. Thus, although the "Movie Club" is not a newly discovered methodology in psychiatry and psychiatric education, we have integrated this teaching device as a formal component into the psychosocial formulation training curriculum for our psychiatry residents. The format has proven to be challenging, effective, efficient, and fun.

As our residents are didactically and clinically exposed to the various leading psychiatric paradigms of the day, for example, neurobiological (R1Y190423,R1Y190424), cognitive/behavioral (R1Y190425), and psychodynamic (R1Y190426—R1Y190433), we begin, as do most programs, with preparatory didactic materials from the relevant psychiatric literature (R1Y19042,R1Y190434—R1Y190442) on the value, construction, and treatment implications of biopsychosocial formulation. This traditional approach is followed by the presentation of a series of movie videotapes as a basis for group formulation of psychosocial issues. Although some residents may elect to watch the selected movie on their own earlier in the week, most prefer to watch the movie as a group. The videotapes are often presented over a 2- or 3-hour period, including the lunch hour. Trainees typically bring lunch, popcorn, and other forms of oral gratification to the meetings. A faculty facilitator then helps the group to begin formulating the case. As ideas are generated, they are put on the blackboard, allowing a visual representation of the evolving formulation. Whatever theoretical paradigm(s) is/are used, an attempt is made to construct as complete a psychosocial formulation as possible, so that residents have some notion of the structure and content of a fully fashioned case conceptualization. Although our emphasis is on psychosocial issues in psychopathology, nevertheless, in the final formulation, we expect residents to include significant biological factors, as well. The session concludes with a concise restatement of the completed formulation, emphasizing a coherent, cohesive, comprehensive, and cogent description of why a particular person is suffering from specific difficulties in thinking, feeling, or behaving at a given time and in a given context. The process is repeated every 1—2 months. In between times, residents may be asked to read more about specific approaches or issues in psychosocial formulation, thus preparing themselves for increasingly sophisticated case conceptualizations as the academic year progresses.

Although there are innumerable commercial films that are useful for this purpose, we have found that the film Ordinary People is an excellent movie with which to begin because it offers a wealth of material upon which to base psychosocial formulations, from psychodynamic (ego psychology, object relations, and self-psychology) and cognitive/behavioral to systems (family) perspectives. Indeed, we have used Ordinary People sequentially, over the course of 2 years, to teach ego-psychological, self-psychological, and systems case conceptualizations during the respective didactic presentations of these theoretical paradigms. Similarly, each principal character (Conrad, Beth, and Calvin) may be the subject of case formulation. The virtually limitless number of commercial films available on videotape ensures that residents will have opportunities to make use of each major theoretical paradigm and to formulate the psychopathology of many and varied persons in a multitude of situations.

Although movies specifically about mental illness (R1Y19047—R1Y19049,R1Y190415) and/or mental health professionals (R1Y19047,R1Y19049,R1Y190419,R1Y190443; e.g., One Flew Over the Cuckoo's Nest, The Prince of Tides, Mr. Jones, etc.) are often used for teaching various aspects of psychiatry, we frequently use films that are not specifically targeted to the field of psychiatry (R1Y19047,R1Y190415—R1Y190418,R1Y190420,R1Y190422; e.g., A Perfect World, Anne of the Thousand Days, Annie Hall, Good Will Hunting, The Dead Poet's Society, Death of a Salesman, East of Eden, The Great Santini, Hannah and Her Sisters, Saturday Night Fever, A Streetcar Named Desire, To Die For, and even The Wizard of Oz). Psychopathology and mental illness are not simply office, clinic, or hospital phenomena; they are ubiquitous in the everyday, real lives of ordinary people. By choosing films that depict typical situations or experiences of typical people, the concept of psychopathology moves from the realm of rarified intellectual theory to everyday reality and practicality. Trainees are reminded that psychodynamics and psychopathology are all around us, if we are interested and willing to look for them.

Opportunities and Benefits of the Complementary Approach

The use of commercially available films ensures that all trainees have the same database on which to found their formulations, rather than having only one trainee with sufficient information with which to formulate. Everyone sees the same scenes, from the same perspectives, and is equally able to contribute to the discussion. At the same time, however, it is very instructive for trainees to note how differently each one of them remembers, assesses, and interprets the data presented by the film. This disparity often provides a good opportunity to underscore the difference between the related but distinct processes of accurate data acquisition vs. inference based on the available data. It enables residents to hone their observational skills so that they develop precision in their collection and reporting of data.

Although it may seem initially counterintuitive, movies fairly faithfully represent the kinds of data available to psychiatrists in their daily work. In films, just as in the psychiatrist's office, aspects of an individual's or family's life are presented in a series of snapshots or vignettes. Analogous to the situation in actual psychiatric practice, the information presented in films is always incomplete; certain scenes are chosen for inclusion over others. Just as a patient decides which of his or her thoughts, feelings, behaviors, life events, or memories to relate to the psychiatrist, so, too, does the movie, through the choices of the screenwriters and director. This selectivity provides an opening for the faculty facilitator to underscore that psychiatrists always have to deal with incomplete data and to ask the residents what additional information would be helpful and how that information might be obtained.

Also, residents can be reminded that it is often just as important what a patient, and, analogously, a screenwriter or movie director, elects not to present as it is what he or she chooses to present; the "missing data" often shed light on troublesome, conflictual, or avoided areas in an individual's life.

Finally, a third aspect of the analogy between the way data are presented in a movie and the way patients present data to psychiatrists is that information is invariably provided from a particular point of view or perspective. In that respect, films "distort" the data just as patients and/or individual family members give "their side of the story." Thus, the use of movies allows psychiatric trainees to consider the importance of the perspective from which the data are reported as well as to consider how the same event or situation might be viewed from another perspective. (Akira Kurosawa's classic film Rashomon is a prime example of this phenomenon.) In sum, psychiatry residents, whether viewing movies or working with patients, must decide which information is important and which is not, what data are missing and what information is needed, which "facts" are trustworthy, and which are suspect.

In contrast to the usual clinical case conference, movies allow psychiatry residents to see, rather than simply hear about, psychopathology. Cognitive distortions, defense mechanisms, impulsivity, narcissism, object relations, empathic failures—all are presented in visual and auditory modalities that are affectively charged and more accurately reflect their occurrence in everyday life. The intellectual theory behind various paradigms of normal and abnormal psychology comes alive in movies. Residents are able to see psychopathology in situ, rather than simply hear about it in condensed, clinical, and not infrequently sterile, case presentations. Similarly, the use of commercial films places psychosocial formulation in everyday contexts (rather than in the rarified atmosphere of often severely mentally ill patients). This reinforces the important reality that the world of the psychiatric patient is still an "outpatient" real world, and not simply the 30—60 minutes-or-so per week that he or she might spend with the psychiatrist.

From the practical standpoint, another advantage to this approach to teaching psychosocial formulation is that the commercial films have "good production values." Whereas the typical clinical videotape of a patient interview or psychotherapy session is frequently inaudible, and the participants are partially obscured in awkward positions, movie videotapes are specifically constructed so as to be seen and heard. The frequent lament at clinical case presentations—"I know that it's going to be a little hard to hear this."—is a rare occurrence when commercial films are used. A second practical advantage: movies present important information in condensed form. A coherent and fairly inclusive story is typically told in 90—120 minutes. In contrast, the usual patient videotape, unless specifically edited for this purpose, is much slower to evolve and laden with "dead time" that is not educationally efficient.

As already noted, the use of commercial films ensures that all participants in the group have access to the same database and are equally able to contribute. Furthermore, in contrast to the situation in individual supervisor—supervisee situations, the diversity of participants results in a multiplicity of perspectives, opinions, and ideas. The threatening aspects of psychosocial formulation in individual supervision are also minimized by the group setting; no single individual is on the spot, either with respect to presenting or formulating the case. Indeed, resident teamwork is specifically promoted through the process of group formulation; and any resident, no matter what his or her training level, can safely and enjoyably participate.

Finally, perhaps the most significant advantage to this approach is that it is fun. Today's psychiatry resident is often a member of the video generation, and even those who are older enjoy a good movie. Indeed, the perpetual problem of trainee attendance at didactic exercises is virtually nonexistent in this setting; residents, medical students, and interested others (including faculty) frequently attend even if they are not formal members of the class in question. The setting is relaxed and nonthreatening; and, when coupled with implementation of the universal educational axiom "feed them and they will come," the format of film, food, formulation, and fun is highly engaging.

Evaluation of the Complementary Approach

We have not conducted a formal evaluation of this approach to the teaching of psychosocial formulation to psychiatry residents. Nevertheless, it has been very well received. Residents' enthusiastic endorsement of the program is demonstrated by their request for more such sessions as well as their belief that the method has been highly effective (many residents have said, the most effective method) in teaching psychosocial aspects of formulation. Residents and faculty alike have enjoyed the low-key, collegial atmosphere that fosters learning in a nonthreatening fashion. Although more rigorous study of the effectiveness of the method has yet to be completed, observations by faculty members support the residents' contention that it has been an effective means of teaching this particular skill.

We have modified the traditional approach to teaching psychosocial formulation by incorporating the use of commercial films into the curriculum. Movie videotapes present information in a manner that often reflects the realities of actual psychiatric practice, but they do so in an affectively-charged, invigorating, and time-efficient way that helps psychiatry residents to recognize psychopathology in the context of the everyday lives of ordinary people. It also allows residents to see the data directly (not filtered through a trainee presenter) and to learn to make inferences from thoughts, feelings, and behavior as demonstrated in the video. Participants in this teaching modality all operate from the same database, and all are equally able to contribute to the discussion. The use of videotapes in psychiatric education is a format that is familiar, enjoyable, and stimulating (R1Y190443) as well as one that, in conjunction with a nonthreatening, collegial atmosphere, results in a satisfying and effective learning experience.