Maria Grazia Turri, Lecturer in creative arts and mental health, Queen Mary University of London

Gregory Hilton, Filmmaker, musician, postgraduate researcher at the University of Sheffield medical department.

Published in JHH18.1 – Flourishing in Medical Education

As a medical student and junior psychiatrist, I kept my artistic interests well separated from my clinical career. In my heart I always knew that reading Dostoevsky and Chekov had made me a better doctor, but I felt ashamed of admitting that in my free time I was a theatre maker. I now research and teach about the intrinsic connection between the arts and mental health, in the hope of contributing to a re-appropriation and celebration of the art of medicine.

I am an artist who uses film to communicate with myself and others. I am currently managing a project at Sheffield University’s School of Health and Related Research which will design complex suicide interventions for men. I see no valuable distinction between my lifelong artistic practice and my academic work, as they function together as a holistic feedback loop of discovery and analysis.

Prologue

I (MGT) enter the foyer of the Ashmolean Museum and sit on one of the benches in the ground floor gallery. While I wait for the continuing professional development (CPD) session to start, I check my email, aware that a row of marble Roman statues are looking on. Soon other colleagues gather nearby. We are the group of psychiatrists who signed up for a two-hour CPD session with Dr Jim Harris, teaching curator at the museum. I know a few participants quite well: some are consultants I worked with as a trainee, some are colleagues with whom I trained. Others I don’t know. In this particular session there are six of us, at other sessions it may be any number from three to ten.

At 2.05pm Jim joins us with his familiar smile. The theme for today’s session is ‘grief’ and he will take us to see a selection of objects that he has chosen in preparation for our meeting. We will start with some objects in the galleries open to the public and, as usual, we will spend the second half of the session in the New Douce Room, for a private viewing.

Jim invites us to follow him. As we move through the corridors and reach the Weldon Gallery on the second floor, we catch up with each other, chatting about work or perhaps the weather. We gather round a painting by Matthias Stom titled Blowing Hot, Blowing Cold (The Peasant and the Satyr).

Most of us are used to the format of the sessions. We know that one of the things we are expected to do is to watch the object. Jim asks: ‘What can you see?’ He doesn’t always ask that; sometimes he starts by telling us about the painter and the historical context is. At other times, he just waits for us to break the silence.

In front of the artwork, anything can happen. Some of us may venture an educated or uneducated guess. I recognise the Satyr from his pointed ears. Someone else notes the sadness on the face of the man eating. Someone asks Jim a question about medium perhaps, or where the painting may have been originally displayed or who may have commissioned it. One of us talks about a patient they saw recently who lost their mother. Silence may ensue, or sounds of recognition. The conversation may spiral off in talking (or grumbling) about the constraints to which guidelines or budgets confine us, or we may respond with a giggle to a witty comment. Sometimes we are at odds with each other, but usually open to listen to what is unfamiliar or even disagreeable. Sometimes we reach a kind of consensus, or new insights. Sometimes we are left confused or unconvinced. In all cases, Jim’s open attitude allows for a playful ‘third’ space to be created, a transitional space (Winnicott, 2005a) where conversations with art objects become conversations about ourselves, our clinical practice, our personal experience, the territory where our professional and personal values meet or clash.

The Art of Medicine: perceived impact

The Art of Medicine, described in more detail elsewhere (Allen et al, 2016), is a programme of CPD sessions for psychiatrists and part of the Ashmolean Museum outreach strategy. It paused in early 2020, following restricted access to public spaces during the Covid-19 pandemic. Funded by the museum, it is a gift that we were privileged to receive for a number of years, while remaining acutely aware of the risk of its coming to an end at the end of each funding cycle.

The scope of the project is to provide an opportunity for arts[1]based reflective practice. A group of co-convenors, of whom I am one, collaborate with Dr Jim Harris to select the themes for each session, agree calendar dates and manage bookings. Themes guide Jim in the selection of the art objects to show us at each session. As the programme evolved, themes have expanded from subjects that refer to the presentation of mental distress (for example, emotions like anger, grief or envy) to a focus on psychiatry subspecialties (like child and family, old age, hunger and greed) or service organisation (like community, hierarchies of power and the figure of the doctor). The potential for choice is almost infinite.

As co-convenor of The Art of Medicine, I have been in the privileged position to partake in many conversations with colleagues present at one or more sessions. I have heard first-hand how much the sessions are valued by those attending, although I have also heard senior colleagues calling them, with a raised eyebrow, a ‘waste of time’. When I became lecturer at Queen Mary, I grasped the opportunity to do a small qualitative study of psychiatrists’ perceived impact of the project on their clinical practice. Gregory Hilton carried out interviews with five psychiatrists who were regular participants. All had attended more than five sessions, with four out of five having in fact attended more than ten. Three interviewees were consultants at different stages of their career, a fourth psychiatrist was an associate specialist, and the fifth was a specialty trainee. There were three females and two males.

The study obtained ethics approval from Queen Mary University of London (QMREC1830). What follows is a summary of the themes emerging from the thematic analysis of the interviews.

Reflective practice

Perhaps unsurprisingly all psychiatrists described the sessions as reflective practice. Some drew an explicit parallel with Balint groups they had attended as trainees. Reflective practice is a complex task and it has been defined as comprising several components: (1) mindful presence and awareness, noticing and curiosity, (2) recognition of dilemma, (3) emotional intelligence and insight, (4) challenging assumptions, and (5) appreciating multiple perspectives (Wald, 2020, p746–747).

These qualities were consistently reported by our respondents as attributes of The Art of Medicine programme. The non-judgemental atmosphere of the sessions was noted as an essential element of the experience, which supported openness and honesty. The art objects invited a process of observation where all contributions were valued. As one participant remarked: ‘We’re all curious and listening to each other’s perspectives.’ This allowed for being reminded ‘of the bigger picture of what we’re doing’ in clinical practice, and broadening the horizons of what several respondents described as a narrow, ‘superficial’ or ‘judgemental’ view of patient care. Although psychiatrists did not necessarily expect sessions to be directly relevant to their clinical practice, ultimately they found them useful in a number of ways.

Cultural and historical contextualization

Discussion of the objects in their historical context fostered an awareness of cultural and historical frame[1]works. Participants described how the encounter with works of art, from ancient history to the modern era, allowed for the affirmation of the importance of cultural norms, personal beliefs and the complexity of the human experience. On the one side, objects showed a continuity of emotional experience across the ages. As a psychiatrist put it: ‘It’s a constant reminder that actually things haven’t changed that much. Human beings are still trying to regulate their emotions.’ And yet, the objects invited awareness of the importance of ‘exploring the cultural and the personal beliefs of the people that we see in clinic’.

Shared experience and bonding

Psychiatrists emphasised the importance of the group setting and its ‘supportive culture’. There was praise for the flattening of hierarchies that the sessions engendered: this allowed for a sense of mutual understanding and bonding. It also mirrored in a favourable way the kind of conversations that may be conducive to good teamwork, a real exchange whereby ‘we gain from each other, as well as gaining from … Jim’s perspective too’. A psychiatrist used a business metaphor to describe the value of the process: ‘You’re kind of investing in your experience bank. With deposits made by other people, because their experience becomes yours.’

…conversations with art objects become conversations about ourselves

Some respondents linked this process of sharing to the engendering of empathy, described by one participant as an attitude through which ‘we understand our own views as well as putting ourselves in other people’s shoes’. As shown by neuroscience research (Vessel et al, 2012), aesthetic experience engages neural processes which link self-awareness with the perception of objects that have salient personal meaning. For the psychoanalyst Donald Winnicott (2005b), cultural experience, like children’s play, happens within a transitional space where the mind negotiates the encounter between subjectivity and reality as ‘objectively’ perceived. Conversations about artworks during The Art of Medicine sessions may foster the creative tension between self-awareness and the inhabiting of other positions, which is characteristic of the transitional space.

The importance of facilitation

There was a unanimous consensus about the importance of the role of the teaching curator and of the benefits of his style of facilitation. Jim Harris was described as both very knowledgeable about the artworks, and yet genuinely curious about others’ contributions. He was the guarantor of the open and non-judgemental quality of the space. His skill and expertise about the artworks was deemed essential in ‘facilitating the interpretation, and also facilitating the discussion’. Yet, as one respondent pointed out, ‘his naivety about psychiatry actually is very helpful too. He’s a very curious person, and he respects our knowledge about the clinical issues, and is very keen on hearing how what we see ties to what we’re doing’.

There was a unanimous consensus about the importance of the role of the teaching curator.

The attitude of ‘not knowing’, which tends to be disowned in mainstream clinical practice, can be harnessed as a source of narrative humility (DasGupta, 2008) resisting the pull towards epistemic injustice intrinsic to medical care, ‘whereby a patient suffers an unfair credibility deficit, by virtue of being a patient’ (Younie & Swinglehurst, 2020, p27). Jim’s facilitation of our conversations with art objects holds together the tension between a position of technical knowledge and an openness to personal meaning.

Art-based reflective practice and meaning-making in psychiatry

Psychiatric patients come to clinical consultations imbued with personal meaning. And yet in the last 50 years psychiatry has striven to confine mental illness to lists of dry symptoms that are of poor value to clinicians and patients (Johnstone & Boyle, 2018a). Attempts at resisting this reductionist practice have been many. In January 2018 the British Psychological Society published The Power Threat Meaning Framework (Johnstone & Boyle, 2018b), a radically different perspective on psychiatric diagnosis. The framework amasses the rich evidence base for the psychosocial determinants of mental distress and provides a concrete tool for assessing and diagnosing through a contextual evaluation of the patient’s history. Besides affirming the role of social oppression and trauma in the making of mental distress, the framework gives due prominence to the role of personal meaning.

Danese & Widom (2020) studied the link of psychopathology and childhood trauma in a cohort of 2,000 children and found that mental illness is strongly mediated by the subjective experience of trauma. This is of little surprise to those like me who have practised psychotherapy, and yet diagnostic practice in psychiatry, submitting itself to the Diagnostic and Statistical Manual of Mental Disorders, is unwisely pressed towards the methodical marginalisation of patients’ narratives.

In a study (Turri et al, 2020) evaluating a new model of psychiatric assessment, we found that patients assessed following the principles of family therapy and dialogical practice, foregrounding patient and family’s personal accounts of the problem, were significantly less likely to become ‘revolving door’ patients, as they did not need further referrals to psychiatric care once discharged. Open dialogue (Razzaque & Stockmann, 2016) is an innovative approach to mental healthcare which focuses on communication and meaning as the ground that both sustains mental distress and provides its solutions. The expertise of mental health professionals is put into constructive dialogue with the voices of the patient and their family, so that all perspectives can be attended to. Significantly, open dialogue’s principles are not dissimilar to those of reflective practice: dialogism, polyphony and tolerance of uncertainty.

The General Medical Council considers reflective practice essential to professional development and quality of patient care. It has made it a requirement at all steps of doctors’ professional journey, from medical school to consultants’ appraisal and revalidation process. While doctors are required to produce ‘reflections’ at regular intervals, opportunities for developing reflective skills are rare, and the more so once specialty training has been completed.

The expertise of mental health professionals is put into constructive dialogue with the voices of the patient.

Art-based reflective practice, with its focus on shared meaning-making, may function as embodied metaphor for the complex meaning-making necessary to good mental healthcare. Central to such care is the necessity to create a space where the patient’s story is heard from a position of openness and genuine curiosity. A non-judgemental attitude will encourage the kind of honesty and emotional engagement that brings the patient’s subjective experience to the fore. The patient will have a story to tell, including contingent and contextual factors that make it unique and can point us to that basic question that good clinicians always ask: why now? There is also the clinician’s expertise of course, their acquaintance with types of suffering, other stories of low mood, phobias, grandiose beliefs. If such expertise is put to the service of epistemic justice, a genuine process of co-production can sustain the patient’s journey towards recovery. Psychiatrists (and other doctors and health professionals too) can thus be said to work like those artists who apply their knowledge of colour and light to understanding their subjects, rather than exploiting their subjects to display their technical knowledge of colour and light. The art of medicine, indeed.

Coda

At about 3.45pm we become aware that the Ashmolean session on grief is about to end. We are now in the New Douce Room, taking turns to look closely at a drawing by Michelangelo of The Descent from the Cross.

With white gloves, Jim has been busy taking drawings out of their boxes and placing them on wooden stands on one of the long tables. The space is tighter than in the open galleries and we shuffle around to make sure that everyone can reach a good view of the prints and drawings. I find the smell of wood and old paper mildly inebriating.

As we leave the session, I, like one of the interviewees, feel that I have recharged my batteries. The encounter with the beautiful objects, in a space which has valued my personal meaning-making and has allowed me to share it with a group of colleagues, has now become a third space inside me, a space that I will make available when I welcome my next patient.

We warmly thank Dr Jim Harris for advice and providing one of the images for this paper, the Ashmolean Museum for granting permission to use the second image, and the psychiatrists-interviewees for giving their time for the qualitative study.

References

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