In this article, six psychiatric educators will describe educational vignettes in which they incorporate the arts into teaching psychiatry. Each educator focuses upon a different aspect of psychiatric phenomena in a problem-based learning format. "The teacher's role in problem-based learning is to act as a metacognitive coach by asking questions, helping students plan their work, guiding them toward the questions they need to pursue, and assessing their progress. In this format, the teacher is more of a guide than a provider of information" (1).

Dr. Dianne Trumbull, from West Virginia University, uses fairy tales (Box 1) to teach development in her resident course on psychodynamic psychotherapies. Because fairy tales are repositories of archetypal experiences for children, Dr. Trumbull uses them to help residents time-travel back to the early challenges of childhood in order to see healthy and pathological solutions. Both Freud (2) and Jung (3) saw the merits of using fairy tales to illuminate aspects of early childhood. Bettelheim noted: "Which story is most important to a particular child at a particular age depends entirely on his psychological stage of development, and the problems which are most pressing to him at the moment" (4).

Dr. Trumbull asks residents to imagine a child's possible repertoire of adaptive and maladaptive responses to narcissistic injury. She asks them to step into this fairy tale a second time to write an ending in which Max returns to find no mother ready and willing to take him back. In other words, what happens if Max returns to a cold, empty space; how does he manage?

One resident answered: "Max returned from ‘Where the Wild Things Are’ expecting a different outcome, in spite of the fact that his homecoming had been exactly the same the past dozen or more times. Once again, he found himself locked in his room without any supper. His mother once again left for the night, not to return until early daybreak. After a time, Human Services became involved. Soon it was a series of foster homes for Max. Some were okay, but most were bad. Max coped by maintaining his amazing ability "to go to far-away places." This resident's story goes on to show Max evolving into a someone with a personality disorder complicated by addiction and dissociative elements.

Dr. Trumbull also works with the first author, who developed a generic script (Box 2) to use in a psychotherapy course to illustrate the power of implicit communication.

The teachers ask two residents to participate, using the same script in two different readings. Although the explicit content does not change; that is, the words remain the same, the meaning unfolds in different directions as the performers alter intentions. For the first read, a resident may be instructed to read the lines as a former lover hoping for reconciliation, but, on the second read, looking for revenge. The resident may read the lines about the tree that has been through hurricanes as a means to show compassion and sensitivity, but, on the second read, as an analogy of hurt and bitterness. The residents invariably find that when they infuse the same lines with different intentions, they alter the meaning of the explicit communications. They can apply this understanding to psychodynamic psychotherapeutic processes.

Dr. Allan D. Peterkin, from the University of Toronto, uses written narratives to teach professionalism. Dr. Peterkin relates that all residents witness or experience clinical and academic encounters during which something "unprofessional" or even unethical happens. Many are reluctant to report or discuss such incidents, and thus their experiences remain unprocessed and may color attitudes about work, colleagues, and patients. This approach allows for shared reflection and problem-solving. Dr. Peterkin engages trainees in lively discussions about what medical professionalism "in the real world" means and to reflect on apparent breaches by having them write about specific situations.

He uses a one-time writing prompt with both family-medicine and psychiatric residents in one of their scheduled core seminars. Dr. Peterkin asks residents to: "write about an experience that felt unprofessional" and gives them 5–20 minutes to write a draft onsite. He suggests that they choose a specific incident and write a personal story, in the first person, with a beginning, middle, and end, in a way that conveys not only what happened, but how they felt about it emotionally. This instruction, informed by narrative theory, is more structured than usual assignments for "critical incident reports" (6, 7). He instructs residents to "write the way you would speak if telling this to a friend or trusted colleague" and not to worry about spelling, grammar, or syntax. He asks one or two volunteers to read their pieces aloud and to then remain silent as their peers comment, share feelings, or ask questions. This allows readers to hear and appreciate differing and sometimes surprising views and interpretations in response to what they have shared. Dr. Peterkin sets group-feedback parameters, which include not interrupting the reader, emphasizing strengths of the piece, and providing helpful edits in a respectful manner. When he invites the readers back into the discussions, they have the right to say as little or as much about the stories as they want, remaining in full control of what is elaborated. The importance of maintaining confidentiality around these written incidents is emphasized, because some of these experiences will not have yet been shared elsewhere.

Sample Discussion Questions

At the end of the session, Dr. Peterkin asks those who did not read to summarize their stories in a few lines.

Dr. Jeff Katzman, from The University of New Mexico, utilizes improvisational theater to train psychiatry residents in the art of psychotherapy. The University of New Mexico invited three professional improvisationalists to a 4-hour retreat to work with psychiatry residents. The format of improvisational theater dates back to the works of Viola Spolin (8) and generally involves at least two actors without a script, who must work cooperatively to tell a story. Actors create characters together and listen actively while jointly embracing the unfolding of a tale. They are generally offered little help in this endeavor other than audience suggestions such as a location or types of relationships.

The improvisationalists follow a code:

Trainees (new therapists) often struggle with improvisations. They often sit quietly without movement in the chair, burdened as they try to be experts, removing themselves from the immediacy of the relationships. Patients often comment about the removed style of new therapists, longing for more genuine experiences from their therapists. Trainees often focus on what to say next, so busy "writing their scripts" that they miss reality as it presents itself. Trainees often respond from a place of seemingly knowing, blocking the reality of the patient as interactions unfold. Improvisationalists refer to this as slowing the story and relationship by responding with "yes, but" as opposed to "yes, and." In some sense, the art of "yes, and" as presented in the world of improvisational theater is a window to Kohut's concept of empathy. Both improvisationalists and therapists must embrace a sense of spontaneity, careful listening, openness to any material that comes forth, and an immersion in the present moment joined by the relationships in the room. Phillip Rinstrom wrote of the similarity of these processes and the potential for improvisational theater to teach therapists about the "yes, and" processes as well as an immersion in a current moment of time (9).

Dr. Bruce Ballon, from the University of Toronto, uses theatrical magic to teach empathy (Box 3), understanding, and professional approaches for addressing mental health conditions, including psychotic, anxiety, and mood disorders. The use of magic goes back to the dawn of time, when shamans and witch doctors used magic to promote understanding of the world around us. All human beings develop magical thinking processes as part of their development, which never completely go away and actually becomes more active in times of stress. By use of magic, trainees can travel back to childhood and reexperience what it is like to view our world with a magical eye or with the emotions and thinking of people with psychoses. The art of mystery entertainment is a form of experiential learning using simulation. Attitudinal factors have an impact on professionalism, communication, scholarship, and collaborational capacities in a learner. Providing students with the opportunity to experience what it is like to feel the perceptions of a mental health disorder without knowing the exact method (i.e., the secrets behind the magic), brings to life the unsettling nature of psychiatric conditions. In teaching about the cognitive and emotional processes within someone suffering from pathological gambling, Dr. Ballon demonstrated there is no such thing as "100%" certainty.

Besides learning about cognitive distortions, psychogenic needs, and the ambiguity of healthcare decision-making in general, Dr. Ballon ends with a final learning-point: "It's not wise to bet against someone who carries his own deck of cards."

With a deck of cards, one can replicate many psychiatric conditions; however, when one pulls in the art of mentalism and other magical gadgets, one can simulate or approximate experience, and create a window into what it might be like to be suffering from a mental condition. Many people assume there's "magic" at work whenever they can't explain something. Mystery immerses us in the dreaded unknown or exposes gaps in our understanding of our world. Uninvited mystery is often the key issue underlying many psychiatric conditions.

Dr. Robert Averbuch, from The University of Florida, uses video segments from movies, TV programs, and the Internet to teach about psychiatric symptoms. In the Psychiatry Clerkship and Human Behavior Course, Dr. Averbuch incorporates video clips into classroom lectures. During a Forensic Psychiatry talk, he highlights the controversies surrounding "criminal insanity."

Dr. Averbuch allows students to ponder the scene while he discusses a variety of forensic issues. The clip and discussion draw in students, setting the stage to focus students' attention on a second scene from the same "ER" episode, an episode that reveals what had actually transpired.

This concluding scene is more dramatic and powerful than the opening scene and routinely evokes strong emotions from the students. Dr. Averbuch opens the discussion by asking, "How many people think the mother should be put in prison?" "How many believe she should not be held responsible for her actions?" He follows by introducing the full verbiage of the McNaughton Rule and Insanity Defense.

The emotional valence of the clip clearly focuses their attention; the lively discussion that ensues makes them active participants in their own learning.

The first author, from West Virginia University, uses both amateur and professional theater techniques for teaching psychiatry to health-science students. Dr. Fidler assigns residents to act out one-page scripts (Box 6) before a class of peers. The scripts focus on professionalism, and they are followed by discussions.

Additional scripts deal with staff conflicts, sexual-boundary issues, and financial-boundary issues.

Dr. Fidler also invites WVU Theater students to perform detailed, scripted roles of patients with psychiatric disorders (Box 7) for health-sciences students to interview in large or small classes and discuss.

Dr. Fidler encourages students to venture into asking daring questions, since the simulated patients or teachers can stop and guide students to reflect about the appropriateness of questions.

The collective aim of the six psychiatric educators is to encourage creative thinking in a psychiatric residency culture that has become largely about the dispersal of medical information, with little room for thoughtful consideration about matters that make us human. The authors offer examples of using the arts to highlight different aspects of psychiatric phenomena in a problem-based learning format. Although the educators have consistent feedback that illustrates residents' satisfaction with these teaching methods, the authors need a means of formal assessment to support their hypothesis that this experiential format succeeds in its aim of enhancing creative problem-solving skills in the clinical setting.

At the time of submission, the authors reported no competing interests.