key: cord-0796234-8615iodo authors: Davidson, Stephanie M.; Benson, Nicole M.; Beach, Scott R. title: Drawn Together: a Curriculum for Art as a Tool in Training date: 2020-11-16 journal: Acad Psychiatry DOI: 10.1007/s40596-020-01345-3 sha: a13e334c6df245359233677195b48aa9bef87392 doc_id: 796234 cord_uid: 8615iodo nan Historically, the arts and humanities were closely intertwined with medical practice, diverging over the last century as medicine viewed the humanities discordant with evidence-based medicine. The importance of the arts and humanities in medicine has recently been rediscovered and gained momentum, with increased integration of the arts into training curricula [1] . Recognition of the ways art can facilitate medical trainee learning is evident in the Association of American Medical Colleges' initiative to integrate arts and humanities throughout medical education [2, 3] . The Accreditation Council for Graduate Medical Education delineates milestones for psychiatric residency training for which art education tools could be beneficial. Art education has the potential to help trainees learn the value of the clinician's emotional response in the psychiatric evaluation (PCI), assist in self-reflection to allow for management of emotional content from difficult therapy sessions (PC4), and promote curiosity and openness to different points of view (PROF1) [4] . This article discusses simple methods of integrating the arts into psychiatric residency education, in order to facilitate reflection and provide tools for potential applications to patient care. Adoption of arts and humanities programs into medical education has demonstrated improvement in students' clinical observation and diagnostic skills as well as interpersonal and communication abilities [2] . Furthermore, the use of art-based education tools provides a unique frame to engage learners through a focus on self-discovery and tolerating the discomfort of unfamiliar topics in a safe space [2, 5, 6] . Art-based tools have been shown to foster resiliency and mitigate burnout [7, 8] . In certain studied patient populations, using these tools has resulted in improved quality of life [9] . As such, art-based education tools have an increasing role in psychiatric residency training. Having more specific knowledge and hands-on experience of these activities may strengthen trainees' ability to engage with patients, express curiosity, and support patients in different ways [3] . Psychiatry residencies have initiated book clubs and psychiatry in cinema events, encouraged mentored writing about artwork, and used popular television shows to teach residents [10] [11] [12] . These activities provide a forum for peer support, togetherness, and collaboration, as well as possible benefits from engaging in these art-based activities while learning about them. Further, with the current physical distancing guidelines due to the coronavirus disease 2019 (COVID-19) pandemic, art-based sessions may allow for increased social connectedness. In this educational case report, we describe an art-based education curriculum within a psychiatry residency program, which in its second implementation transitioned into a virtual format amidst the COVID-19 pandemic. The explicit goals of the curriculum were to develop specific clinical skills, selfawareness, and perspective taking, and to improve resident wellness by providing a safe and collaborative space for increased peer communication and shared vulnerability. It was specifically designed so any interested educator could facilitate these sessions without additional training. Here we describe the curriculum in its first in-person iteration, as well as the second iteration and how it was redesigned for a virtual format. This curriculum comprised eight-sessions incorporating artbased education tools and activities to teach skills to trainees applicable to their clinical work and to encourage supportive discussions about residents' challenging experiences (Table 1) . Each session, the facilitator presented the activity and provided necessary materials. Residents spent the first half of the sessions engaging in an activity and the second half sharing their experiences of the activity and discussing [18] potential applications to clinical practice. These activities enabled residents to process the trainee experience, with the art activities facilitating the sharing of vulnerability. Relevant articles to the activities were emailed to trainees after the sessions for future use (Table 1) . In one session, residents were given the prompt, "draw a person in the rain." After completing the activity, the research behind this projective assessment was explained, including how components of the completed artwork correlate with validated measures of stress and perceived coping resources (e.g., presence/absence of rain apparel, intensity of rain in the drawing) [13] . Residents could then share their artwork with each other and discussed their reactions to this experience and ways they could use this tool in their clinical work (Table 1) . After discussing the session's specific goals (Table 1 ) and applications to clinical care, residents were provided guidance about appropriate uses of this tool in psychotherapy, distinction from art therapy, and how to interpret and manage emotions that may arise during such an activity. While some of the activities, e.g. the bridge drawing (Table 1) , were more structured, other sessions were more spontaneous, allowing for direct processing of day-to-day experiences and clinical work. In another session, for example, residents were asked to draw an image inspired by a difficult clinical interaction. The artwork residents created varied from literal representations of the emergency room to abstract representations of their emotions at the time. Residents were encouraged to consider how one could process difficult or challenging material through artwork, a medium they may not have previously considered using. In the initial year of this curriculum, all sessions were held during a weekly one-hour conference, optional for trainees on the hospital campus (approximately 20 total possible attendees). Attendance varied from 6 to 15 [20] participants. Although systematic data were not collected regarding outcomes of this curriculum, attendance at this series surpassed attendance for other types of sessions within this conference hour that year. Residents expressed excitement for upcoming sessions, disappointment when unable to attend, and enthusiasm for continuing the sessions after the series had ended. Residents provided the most spontaneous positive feedback about Box Making and Shared Comic Creation (Table 1) . We hypothesize these activities may have been particularly useful to residents due to the focus on boundaries and privacy in the former and collaboration in the latter, all of which have direct applicability to residency training in psychiatry. This series (Table 1 ) was scheduled to be repeated during the winter-spring of 2020, and we sought to measure the impact via brief pre-and post-surveys for each session. The Institutional Review Board at our institution determined this study to be exempt. One in-person session (Shared Comic Creation, Table 1 ) was held before the COVID-19 pandemic began and residency didactics were shifted to a virtual platform. Initially, the curriculum continued in a virtual format, however, after two virtual art-based curriculum sessions, all non-essential residency didactics were canceled, including this series. The facilitator met with residents through a virtual video platform and followed the same session structure as the original series. Content was adapted to require only paper and pencil or tools available within the virtual video platform (e.g. whiteboard feature). In one virtual session, residents engaged in a collaborative drawing experience for 40 min. Residents were given prompts to draw (for example, "draw something scary," Fig. 1 ) and created images together using the shared whiteboard feature through the virtual video platform. Participants were able to draw their own images and modify those drawn by their peers simultaneously, facilitating collaboration and discussion as residents realized similarities in what they had chosen to draw. For example, residents noted how, when prompted to "draw something scary," multiple participants chose to draw images inspired by COVID-19 (e.g., masks, virus, uncertainty; Fig. 1) . As was the average in the first iteration, the in-person session had nine attendees. After the transition to the virtual format, six residents attended the first session; three attended the second session, consistent with what was seen in virtual didactics across the residency program. Surveys were provided to attendees of the sessions at the start and end of each session and comprised of 3-4 Likert scale questions asking about level of stress in that moment, level of feeling supported by peers, and comfort level in participating in the activity. An additional question on the post-survey addressed likelihood of using the activity in the future. In surveys obtained immediately prior to sessions, 11/17 residents (64.7%) reported their overall stress level was high (described as 4 or 5 on a 5-point scale), whereas only 3/17 residents (17.6%) described their current stress level as high immediately after concluding the activity. Prior to Fig. 1 "Draw something scary"collaborative digital drawing by four trainees engaging in the activities, 12/17 residents (70.6%) thought they would feel comfortable engaging in the activity (described as 4 or 5 on a 5-point scale), but all 17 residents reported feeling comfortable with the activities after completion. In both the pre-and post-surveys, all residents reported feeling supported by their peers (described as 4 or 5 on a 5-point scale). While some academic psychiatrists might worry that specialized training or knowledge of these techniques is necessary in order to teach or use these tools, creating the space and understanding the activities (Table 1) is likely sufficient. The activities used in this curriculum were specifically chosen because, while they are powerful means of communication and engagement for both patients and peers, they require only brief preparation and no specialized knowledge. In particular, many of the activities in this curriculum rely more on creativity than skill. The open-endedness of prompts allows residents to tailor their work to their own skill level. An unexpected benefit of using the virtual whiteboard was its ability to equalize the skill level of all participants, given the imprecise nature of the device and relative unfamiliarity of all users. To maximize participation and benefits of this curriculum when held in-person, art supplies should be provided to participants. There are many ways to mitigate costs and supplies can be re-used from session to session. In this curriculum, few supplies were needed; for the entire series of the in-person curriculum, the total supplies cost under $30. For virtual sessions, most participants will have some writing implements and paper available. No art supplies are needed for sessions using the virtual whiteboard feature, though using smartphones, tablets, or computers each have their own challenges. A final key component of the success of such a program is support from the institution and residency leadership. This series of sessions was possible as the Massachusetts General Hospital-McLean Hospital residency program had a flexible noon conference hour. Protected time for learning is highly valued in residency programs, and leadership must prioritize art activities in the same way that they would for a traditional didactic if such a program is to be successful. If residents are obligated to use their own free time in order to participate, the experience adds a burden to already busy schedules and is likely to be less embraced and valued. Unfortunately, these sessions were unable to be protected during the COVID-19 pandemic due to factors beyond the facilitator's control. As many programs continue to focus on resident wellness, incorporating such a program into the curriculum may allow residents to engage with peers to think creatively and foster social connectedness. This report and the curriculum, itself, have several limitations. Due to the structure of the clinical sites at this institution, as well as vacation and post-call days, the residents in attendance at each in-person session varied. This may have changed the dynamics within the group for each session and did not allow every resident to complete the full curriculum. While much of this is unavoidable, ensuring that clinical responsibilities do not impede the didactic hour when residents participate is critical. However, the transition to a virtual format allowed some to attend who would not have been able to make an in-person session. For example, one intern who was actively working on a COVID-19 unit was able to participate during her lunch break. Though we were unable to obtain feedback on this curriculum during its first implementation, we collected some data the second year, prior to the cancelation of the series. Further, the observed decrease in stress from the start to the end of the sessions cannot be extrapolated because of low numbers of participants and inability to account for other factors impacting stress. We are encouraged by the initial results; however, because formal feedback is not typically solicited for these types of conferences, we could not compare the impact of this curriculum to that of other sessions. This curriculum was specifically designed to allow for replication by an educator without a background in the arts and could be facilitated by any level of educator interested in promoting experiential learning and community in trainees. Although these tools are adapted from the art therapy field, it is not meant to be an art therapy curriculum and the authors, themselves, are not proficient in art therapy. In general, these activities work best in small groups; however, they could be applied in a large group setting or even one-on-one. Further, we adapted to the virtual format by necessity, which proved a valuable means of creating community and support amongst peers in different clinical settings. While not all the activities in the original curriculum would work in a virtual format, all of them would be feasible with slight adaptations ( Table 1) . As clinical and didactic requirements for psychiatry residency training have increased significantly over the past decades, residency programs have struggled to find ways to integrate additional perspectives from the arts without overburdening or overscheduling residents. Art provides residents a unique way to process their emotions and the experiences they have throughout their training. The activities described in this curriculum are applicable not only to the residents themselves, but also are tools they can bring to their clinical work. Through sharing in art activities, residents may create community with each other, learn from each other's struggles and successes, and share in ways that might not have been possible otherwise. Funding Dr. Benson received support from the National Library of Medicine Biomedical Informatics and Data Science Research Training Grant (BIRT) T15 LM007092. This work was conducted with support from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL 1TR002541) and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health. Ethical Considerations The Institutional Review Board at our institution determined that this study was exempt. On behalf of all authors, the corresponding author states that there is no conflict of interest. Medical Students' exposure to the humanities correlates with positive personal qualities and reduced burnout: a multi-institutional U.S. survey Association of American Medical Colleges. 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