Introduction
This article focuses on a course about pathographies of mental illness that is taught to fourth-year medical students, and it is a follow-up to Nathan Carlin’s Element, Pathographies of Mental Illness.
Footnote
1 When Carlin first designed the course over ten years ago, it included clinical information related to mental illnesses, drawing attention to the point that psychiatric research, being empirically oriented and evidence based, aims to produce generalizable knowledge (i.e., trends), while the reading of pathographies can yield useful experiential insights. The mental illnesses discussed included depression, bipolar disorder, schizophrenia, substance-use disorders, borderline personality disorder, conduct disorder, antisocial personality disorder, autism spectrum disorder, and anorexia nervosa and bulimia nervosa from the perspective of classic (and some contemporary) memoirs in the field. More recently, based on student feedback via course evaluations, the course has been redesigned to focus mainly on women and persons of color. This article describes the details of the course, discusses its evaluation, and also sets out the difference that a focus on diversity can make.
What is pathography?
The classic text on pathography is Anne Hunsaker Hawkins’s Reconstructing Illness.
Footnote
2 She defines “pathography” as autobiographies and biographies (i.e., life stories or narratives) of illness: path (= illness) + graphy (= narrative). Hawkins was first introduced to the term “pathography” when she read Oliver Sacks’ Awakenings,Footnote
3 who took the term from Sigmund Freud.Footnote
4 The term today can be used more broadly than narrative, including, for instance, art and poetry. Pathography is closely related to the fields of literature and medicine as well as narrative medicine. Because Hawkins taught in the Humanities Department at the Pennsylvania State University College of Medicine, she also believed that teaching pathography to medical students can make better doctors:
It is in restoring the patient’s voice to the medical enterprise that the study of pathography has its greatest importance and offers its greatest promise. For, as everyone realizes, we face a major crisis in medical practice at this moment. And this crisis, whose economic, political, and social dimensions are becoming familiar as they are challenging, has a less recognized human dimension. It is surely no accident that the appearance of pathography coincides with the triumph of scientific technological medicine.Footnote
5
She adds: “Pathographies make such problems vividly and immediately real for us, and thus they have a significant part to play in the movement towards a patient-centered medicine.”Footnote
6
About the course
The course is a seminar that lasts for four weeks, consisting of eight sessions: two sessions per week (each three hours). It is offered virtually so that medical students may attend residency interviews during the month. The sessions focus on the class readings and other materials, and each class meeting is discussion based (no lectures). Also, the class is divided into two groups where students lead the discussions, while faculty help to facilitate the discussion, ask questions, and make clarifying or contextualizing comments.
The course objectives include the following:
-
(1) articulating the significance of a “pathography approach” to understanding mental illness; and
-
(2) analyzing, via class presentations, ethical, existential, and clinical issues in various pathographies of mental illness.
To achieve these objectives, students are asked to create three one-page handouts for each mental illness.
The first handout focuses on pathography, where students are asked to (1) provide a brief overview of the book(s) and the article(s)/chapter(s) for the session; (2) raise at least six questions for discussion; and (3) identify key themes in the reading, listing striking passages. Table 1 offers a sample list of core texts.
Table 1.
Sample texts, 2023–2024
The second handout asks students to look up clinical information about the mental illness: (1) research the latest clinical information (e.g., findings related to diagnosis, prognosis, and epidemiology) relevant to the mental illness(es) for the day, drawing from the DSM-5-TR; (2) research the latest pharmacological interventions, drawing from UpToDate (an app that contains clinical information); and (3) describe how therapy can help a patient with this mental illness.
The third handout asks students to find other relevant resources of interest: (1) create a list of other pathographies related to the mental illness(es) for the day; (2) create a list of audio/visual resources related to the mental illness(es) for the day (e.g., TedTalks, podcasts, interviews, songs, and YouTube clips); and (3) create a bibliography of other useful resources.
Course evaluations
Each year, an evaluation survey is conducted with students after they complete the course.Footnote
7 The course was originally offered in Spring 2012, and it has been offered every year except Spring 2019. The course evaluations presented here include every year that the course was taught. The questions have remained consistent, informing revisions within the course over time. The evaluation is divided into four topic sections: learning objectives, course design, the readings (i.e., pathographies), and personal comments. Questions are closed- and open-ended. For the closed-ended questions, students rate their level of agreement with 13 statements, using a five-point Likert scale of (1) strongly disagree, (2) disagree, (3) neutral, (4) agree, and (5) strongly agree. Open-ended comments to two questions comprise the fourth and final section. Presented from both quantitative and qualitative perspectives are 113 students’ feedback. The quantitative results are described in terms of percent agreement with the rating statements, and qualitative responses are organized thematically.
Learning objectives and course design
Overall, students rated statements in the first two sections favorably. As described earlier, there are two objectives for the course, which were addressed in two rating questions aimed at understanding whether students perceive they developed skills in articulating the significance of a “pathography approach” and analyzing issues in pathographies of mental illness. There were three additional outcomes included in the section, relating in particular to their skills in applying, writing, and reflecting on pathographies. The statements prompted students to consider whether they achieved the objectives or outcomes as a result of the course, serving as a self-assessment of their learning. Students’ responses to the five statements were overwhelmingly positive, with 97% or more of them agreeing with each.
For both course objectives, 99.1% of students agreed they achieved them. Indeed, only a single student did not rate these items a four (agree) or five (strongly agree). A similar percentage of students rated that the course helped their abilities to “apply theoretical insights from medical humanities to a pathography of mental illness” and “describe how writing about mental illness helps sufferers to make meaning of mental illness.” The final statement in this section asked students to answer whether they could reflect on how reading pathographies of mental illness will affect their clinical skills. Again, agreement was high, with over 97% of students rating this as agree or strongly agree.
In addition to the objectives, students’ feedback about the course design was obtained. The statements were aimed at evaluating the discussions, their engagement, and the course overall. First, students agreed (rated a four or five) that the discussions were interesting (98.2%) and well facilitated (99.1%). They also expressed that their peers were engaged in the mental illnesses and issues presented (94.7%). Another attribute of the course that students were asked about related to the learning environment, specifically the course being offered in a humanities and ethics center, as being a comfortable setting for discussing humanistic topics. More than 97% of students agreed with this statement. Finally, nearly all of the students (99.1%) felt the course was well designed overall.
Considering the positive levels of agreement across these statements about the course, from learning objectives and outcomes to its design, these findings speak to students’ satisfaction with the course more broadly. However, it is the final two sections in the course evaluation that provide further insight into their perceptions about the readings and experiences with the pathography approach. These will be presented separately, with particular attention paid to students’ free responses.
The readings
The evaluation included four questions about their perceptions of the readings as contributing to their learning. First, students considered whether the readings promoted their understanding of mental illness. Then, they rated statements about the usefulness of the material conveyed and the concepts introduced to them. Finally, students responded to a question about the amount of reading they had. Across all four questions, agreement levels were, again, high, as in previous sections. Students rated highest that the readings introduced concepts that were new, understandable, but not too simplistic (99.2%). Further, they perceived the reading material as being useful (98.2%) and, overall, as contributing to their understanding of mental illness (98.3%). The least favorable item, in terms of rating, was the amount of reading (93.8%), which could be perceived as substantial by some students, with 14 texts assigned in addition to the DSM-5-TR in the present course offering.
Personal comments
While the quantitative evaluation items convey favorable perceptions about the course, the qualitative questions allow for a deeper understanding of their experiences. There are two questions in this section, which asked students to share what they considered the best part of the course and suggestions for improvement. Students’ responses to these questions were reviewed and analyzed qualitatively using coding. The first cycle helped to identify descriptive categories, looking at commonalities across responses. The second cycle organized the categories into broader themes to contribute to general interpretations of their perceptions. The themes shared for both questions start with the broader themes and include descriptors in students’ language to contextualize these.
When asked to share about the best part of the course, 106 students responded. Their answers fell into five themes that related to the course overall, discussions, mental illness, readings, and their experiences. The most frequently mentioned response among 32.1% of students was about the course discussions. Students described the discussions as the best part of the course for being good, using language like “enjoyable,” “excellent,” and “great,” but the bulk of their descriptions focused on the quality of the discussions, such as their value and ability to influence their thinking. One student described the discussions as “fruitful” for facilitating sharing of “the different ways people interpreted and experienced these works.” Another described the discussions as “socially relevant,” with another elaborating on a similar point, sharing that the discussions provided “insight and perspective” while “giving an opportunity for everyone to speak out, from the women in the group about hardships experienced as a woman … to personal stories or experiences with racial/cultural prejudice or LGBTQ perspectives.” The student credits the sensitivity with which such diverse viewpoints and complex topics were tackled. Still, other students characterized the discussions as being supportive of their experiences, allowing sharing with peers, but also as being engaging, meaningful, thought-provoking, and contributing to their medical education.
Though the remaining four themes were not mentioned as often as the discussions were, there was insight found in these. For instance, for those who cited the course in general as being the best, there was appreciation for its virtual format and flexibility for its attendance and makeup policies. One student also explained that the course “provided me with new perspectives and will help me care for patients in the future,” while another connected the course to appreciation for its medical humanities perspective. And, still, two students referenced the course environment, calling it “comfortable” and “empathetic.” Regarding the readings, students often described these in terms of their enjoyment, but also for their uniqueness, ability to “shine light on different experiences,” and being eye-opening as memoirs with “the perspectives of people who come from all different backgrounds and have been diagnosed with a spectrum of disorders.” There was also mention of being exposed to books they might not have ever read if it were not for the course.
Several students noted the topic of mental illness as being the best part of the course, crediting it with giving them new perspectives or insights about patients’ struggles. They found it helpful in preparing them to interact with patients, enhancing their understanding of “diagnostic criteria beyond what is written in the DSM.” The final theme about students’ experiences was the least mentioned (7.6%) but was no less impactful. For instance, students described their personal experiences as enhanced by sharing among peers, especially because of their openness. Another explained the experience was influential on their perspectives and future practice. Yet another student linked the other themes to their experiences, explaining that reading the pathographies, which prompted discussion of peers’ experiences and sufferers’ perspectives, related to “our future as clinicians and current experiences as medical students.”
In the second open-ended question, 43 students offered suggestions for improving the course. There were three themes identified among their comments: recommendations about the readings, discussions, and course practices. The majority of suggestions (86.0%) related to the readings, such as wanting fewer assigned books, with one student each stating they “had to rush through the readings […] and missed some important parts,” thought “14 books [were] a lot to get through,” and requested to “shorten readings.” Aside from these comments about the amount, one student noted the readings could be “pretty heavy” and “affected class morale” due to the subject matter. Others expressed desires to eliminate specific texts and, in one case, choosing different books that would “add more to the conversation.” Additional responses asked for “changing some of the readings,” though none in particular were mentioned, and a handful of students suggested supplementing the readings with “more contemporary pieces” or adding movies, documentaries, or art.
Two suggestions focused on the theme of discussion, particularly about strengthening connections between the pathographies and clinical material in discussion and including a free or open-topic session not directly connected to an assigned pathography or mental illness. The final theme was course practices, wherein students offered ideas about how to improve the course more generally, rather than specifically within the readings or discussions. For two students, the recommendations were linked to their personal experiences of sharing and vulnerability. One student noted that asking too many questions could make it difficult to share and be vulnerable, leading to situations in which “no one wanted to share anything,” and another wanted fewer questions to allow the conversation to flow freely. Conversely, a student credited the virtual format as enabling conversations that might be too difficult to have in person; their suggestion was to retain this feature. A student also commented on the makeup policy, requesting it be more lenient, while another hoped for more mental health topics to be included, and still another suggested participation be less prescriptive to allow students to participate when they chose. A final suggestion to improve the course was about limiting how many students would lead each session. The concern shared by this student was about ensuring those who were assigned to lead a session in partnership with others participated equally in the work.
For both free-response questions, the themes were few and touched upon different, yet similar, dimensions of Pathographies of Mental Illness. At times, there was appreciation expressed for the exposure to different and diverse readings as well as sharing personal experiences. Other times in their suggestions, students voiced interest in changing some of the pathographies or expanding the types of media used in the course. Still, students’ comments offered insight into how they perceived and experienced the course, but also hinted toward ways in which the course could practically be enhanced.
The difference that diversity makes: two perspectives on depression
The most notable way that the course has changed over the years, based on student feedback, has to do with the readings. The readings have become more diverse. Especially after the Black Lives Matter movement in 2020, students became more vocal about including perspectives from non-white persons. The change in readings, naturally, has affected the substance of the conversations in the seminar. We’ll lift up one such change to demonstrate the difference that diversity makes.
As noted, Darkness Visible is a classic in the field, a memoir about depression written by William Styron (1925–2006). Regarded as one of the greatest American writers of the twentieth century, Styron was most well known for three of his novels: Lie Down in Darkness, The Confessions of Nat Turner, and Sophie’s Choice. In Pathographies of Mental Illness, Carlin noted that the key objective of Darkness Visible was to destigmatize death by suicide, to make the point that, when people die this way, it is because they are in pain, not because they are weak, selfish, or immoral. Dying this way, Styron suggests, should not be viewed any differently from death caused by cancer.
Another important feature of Darkness Visible is that Styron, because he was a professional writer, paints a vivid picture of the experience of depression. He corrects the common, but incorrect, assumption that depression is just a more extreme form of sadness or “the blues.” He lifts up how active the experience of depression is, how close it is to physical sensations of pain, things like drowning or suffocation. He writes:
It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.Footnote
8
Styron noted that he experienced many of the symptoms of depression, as described in the DSM, including the inability to concentrate, the loss of rational thought and perspective, confusion, memory problems, panic, difficulty speaking, loss of libido, and an inability to experience pleasure or joy. In reflecting on the “cause” of his depression, he notes that the best one can do is “wise conjecture,” and he attributed his own to a mix of genetics, childhood experience, dissatisfaction with his work, turning age 60, and alcohol withdrawal (he was forced to quit drinking due to stomach problems). Drinking was important to him, as a writer, because it seemed to calm a constant anxiety that he lived with (perhaps lifelong depression) and it stimulated his creativity. Styron attributes his recovery not to therapy or medication, but to a lengthy stay in a psychiatric hospital. Thus, his message to his readers suffering from depression is to do everything that they can to hold on, as the depression will pass.
Meri Nana-Ama Danquah (b. 1967) offers a different perspective on depression in Willow Weep for Me.
Footnote
9 Born in Accra, Ghana, she moved to the United States at the age of six. Her parents divorced when she was eleven, thus creating financial difficulties. These difficulties were exacerbated for her when she became a single mother in 1991. For a significant number of years, work was unsteady for Danquah as she pursued a career as a writer, while also completing her education. So, if Styron offers a perspective on depression as a successful white male in his 60s, Danquah’s account of depression is written from the perspective of a young, single, Black, immigrant mother struggling to build a career. Danquah contrasts herself directly with Styron:
Styron and I would [n]ever have the same angle on anything. We had the same illness; the similarities end there. The way I did depression was a-whole-nother bag of beans. I’m a single Black mother about a half paycheck away from the government cheese line.Footnote
10
Access to care for Styron is an act of the will. His most restrictive barrier to care was the realization that he needed intense, inpatient care: He just had to convince himself—or be convinced by his family—that he needed care beyond the regular outpatient therapeutic and pharmacological care he had already been receiving. He shows no concern of financial difficulty or clinging responsibilities. Danquah, in contrast, had to navigate this illness with strained finances, significant parenting responsibilities, and limited social support.
Danquah also emphasizes that “culture plays an important role in both the patient’s illness and treatment. I am Black; I am female; I am an immigrant. Every one of these labels plays an equally significant part in my perception of myself and the world around me.”Footnote
11 For a financially struggling single mother like Danquah, inpatient therapies, or even the expense of medication, may not be feasible. Finding a therapist who could understand her life experiences, too, provided difficulty, which she detailed in her memoir. Realizing that the very different circumstances of each patient may require very different approaches to care is a major lesson in contrasting these narratives.
Also, these memoirs offer different writing styles because they attempt to reach different audiences. Styron’s more poetic, descriptive reflections on depression—with references to literary greats like Albert Camus—are not a style that is easily understood by all. It is cerebral and philosophical. Darkness Visible is written for an elite audience, originally published in Vanity Fair. There is not much about Styron’s family in it. One almost gets the sense that he faced his depression alone, while this was clearly not the case.Footnote
12
Danquah’s pathography, in contrast, is a novel-like chronicle of her experience—complete with characters immersed in a more relatable plot that is meant to also include a less literary and privileged audience, and in order to convey hope and offer solace, and to empower others in situations like hers to begin the work of recovery. With Danquah, we immerse ourselves in the midst of her story to become witnesses to the experiences and circumstances through her “thick lengthy periods” of depression.Footnote
13 To read about her depression is to read about her relationships.
Styron and Danquah agree that depression is not a choice; it is an illness. Styron writes: “Never let it be doubted that depression, in its extreme form is madness … from an aberrant biochemical process,” and that “such madness is chemically induced.”Footnote
14 Likewise, Danquah writes, depression is not “a character flaw or an insignificant bout with the blues that an individual can ‘snap out of’ at will.”Footnote
15 Yet, despite this agreement, Danquah lifts up that Black women experience this illness differently than white men:
I have noticed that the mental illness that affects white men is often characterized, if not glamorized, as a sign of genius, a burden of cerebral superiority, artistic eccentricity—as if their depression is somewhat heroic. White women who suffer from mental illness are depicted as idle, spoiled, or just plain hysterical. Black men are demonized and pathologized. … When a Black woman suffers from a mental disorder, the overwhelming opinion is that she is weak. And weakness in Black women is intolerable.Footnote
16
“Emotional hardship,” she writes, “is supposed to be built into the structure of our [Black women] lives.”Footnote
17 She adds: “I’ve frequently been told things like: ‘Girl, you’ve been hanging out with too many white folk’; ‘What do you have to be depressed about? If our people could make it through slavery, we can make it through anything’.”Footnote
18
Given this contrast with Styron, questions to discuss with medical students include the following:
-
1. Have you noticed differences related to race, gender, and class when talking with patients about mental illness?
-
2. How should we talk with patients from various cultural backgrounds?
-
3. What are the pros and cons of “race pairing” (i.e., matching patients and clinicians according to race)?
-
4. What resources are available for persons from less privileged backgrounds? How can we connect them to those resources?
Discussion
Over the many years the course has been offered, revisions have been informed by students’ feedback. One such example is the pivot to online learning, which was initiated because of the COVID-19 pandemic, but remains for its advantages in meeting students’ needs for flexibility around residency interviews, and, as one student explained, “it was easier to partake in discussions over WebEx compared to an in-person discussion,” referencing it as an effective approach to engaging conversation.
Other takeaways influenced reworking the class presentations and handouts to make each student responsible for their own assignment, addressing unintentional, yet unequal, participation among them. More has also been done to address students’ concerns about sharing experiences and vulnerability. The learning environment requires trust and building a safe space for discussion. Students’ awareness of their own vulnerability in tandem with recognizing that comfort with being vulnerable can be complicated, even leading students who were once forthcoming to stop sharing, as two students expressed. Discussions are sometimes best structured to a point but left to evolve organically. Thus, while conversations delve into personal experiences or focus on the stories of the pathographies’ authors, a delicate balance must be struck. In that respect, only through these evaluations could changes be made to cultivate safety and students’ vulnerability to facilitate sharing. Otherwise, we might not know this was needed.
Compared to earlier years, the course has become more engaging for students as drivers of their learning, leading in the discussions and questioning their peers. Strategies also address these needs while incorporating elements from the “best part” and “suggestions” comments, aiming to capitalize on what works. Including a trigger warning in course materials to alert students to the often difficult readings they will be exposed to, leading to equally sensitive conversations, was appreciated by at least one student who shared this. Allowing the makeup policy as a way not only to remain engaged in one’s absence but also to share more private or closely held views about a pathography or mental illness gives the student a receptive space to share without feeling forced when they might otherwise feel too vulnerable or uncomfortable to do so. This was mentioned as one student’s strategy for being present in the discussions while engaging in self-protection.
Perhaps the readings, the very vehicle inherent in the “pathography approach,” are the element of the course that has endured the most change and reflect students’ input. Readings have been reduced from as many as 20 texts at one time to fewer than 15 in their current form. And some of the very texts that students wanted to see changed have, indeed, been swapped for more contemporary pathographies. Other changes have included adding different topics that reflect more diverse viewpoints in terms of both the mental illnesses presented and the identities of sufferers of various mental illnesses. And, within the discussions, the shift to more diverse readings has created connections for students to make, allowing them to share their perspectives and exposing their peers to experiences they did not have themselves. Expanding medical students’ training in this way helps inform their future practice, yet has the added benefit of enabling them to identify with the authors’ stories and, by proxy, their patients’ stories as well as their peers’. With greater representation across the pathographies, there is also the ability for students to relate and see themselves reflected. Diversity among pathography authors matters, and exposing students to contrasting perspectives, sometimes of the same mental illness, is important to engage them in thinking and reflecting critically on what that means for patient care.
So, while one might take away from this discussion that student perceptions of the course were very positive, the truth is that they attained knowledge and acquired theoretical insights that they did not previously have. The distinction of Pathographies of Mental Illness being held like a graduate-level humanities course (in which discussion is the method) is that it engages them to not only think critically through a humanistic lens but also to communicate. What the evaluations impart is that students find value in studying pathographies of mental illness, especially those from diverse perspectives, because it enables them to reflect on their practice of medicine.
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Introduction
This article focuses on a course about pathographies of mental illness that is taught to fourth-year medical students, and it is a follow-up to Nathan Carlin’s Element, Pathographies of Mental Illness. Footnote 1 When Carlin first designed the course over ten years ago, it included clinical information related to mental illnesses, drawing attention to the point that psychiatric research, being empirically oriented and evidence based, aims to produce generalizable knowledge (i.e., trends), while the reading of pathographies can yield useful experiential insights. The mental illnesses discussed included depression, bipolar disorder, schizophrenia, substance-use disorders, borderline personality disorder, conduct disorder, antisocial personality disorder, autism spectrum disorder, and anorexia nervosa and bulimia nervosa from the perspective of classic (and some contemporary) memoirs in the field. More recently, based on student feedback via course evaluations, the course has been redesigned to focus mainly on women and persons of color. This article describes the details of the course, discusses its evaluation, and also sets out the difference that a focus on diversity can make.
What is pathography?
The classic text on pathography is Anne Hunsaker Hawkins’s Reconstructing Illness. Footnote 2 She defines “pathography” as autobiographies and biographies (i.e., life stories or narratives) of illness: path (= illness) + graphy (= narrative). Hawkins was first introduced to the term “pathography” when she read Oliver Sacks’ Awakenings,Footnote 3 who took the term from Sigmund Freud.Footnote 4 The term today can be used more broadly than narrative, including, for instance, art and poetry. Pathography is closely related to the fields of literature and medicine as well as narrative medicine. Because Hawkins taught in the Humanities Department at the Pennsylvania State University College of Medicine, she also believed that teaching pathography to medical students can make better doctors:
It is in restoring the patient’s voice to the medical enterprise that the study of pathography has its greatest importance and offers its greatest promise. For, as everyone realizes, we face a major crisis in medical practice at this moment. And this crisis, whose economic, political, and social dimensions are becoming familiar as they are challenging, has a less recognized human dimension. It is surely no accident that the appearance of pathography coincides with the triumph of scientific technological medicine.Footnote 5
She adds: “Pathographies make such problems vividly and immediately real for us, and thus they have a significant part to play in the movement towards a patient-centered medicine.”Footnote 6
About the course
The course is a seminar that lasts for four weeks, consisting of eight sessions: two sessions per week (each three hours). It is offered virtually so that medical students may attend residency interviews during the month. The sessions focus on the class readings and other materials, and each class meeting is discussion based (no lectures). Also, the class is divided into two groups where students lead the discussions, while faculty help to facilitate the discussion, ask questions, and make clarifying or contextualizing comments.
The course objectives include the following:
(1) articulating the significance of a “pathography approach” to understanding mental illness; and
(2) analyzing, via class presentations, ethical, existential, and clinical issues in various pathographies of mental illness.
To achieve these objectives, students are asked to create three one-page handouts for each mental illness.
The first handout focuses on pathography, where students are asked to (1) provide a brief overview of the book(s) and the article(s)/chapter(s) for the session; (2) raise at least six questions for discussion; and (3) identify key themes in the reading, listing striking passages. Table 1 offers a sample list of core texts.
Sample texts, 2023–2024
The second handout asks students to look up clinical information about the mental illness: (1) research the latest clinical information (e.g., findings related to diagnosis, prognosis, and epidemiology) relevant to the mental illness(es) for the day, drawing from the DSM-5-TR; (2) research the latest pharmacological interventions, drawing from UpToDate (an app that contains clinical information); and (3) describe how therapy can help a patient with this mental illness.
The third handout asks students to find other relevant resources of interest: (1) create a list of other pathographies related to the mental illness(es) for the day; (2) create a list of audio/visual resources related to the mental illness(es) for the day (e.g., TedTalks, podcasts, interviews, songs, and YouTube clips); and (3) create a bibliography of other useful resources.
Course evaluations
Each year, an evaluation survey is conducted with students after they complete the course.Footnote 7 The course was originally offered in Spring 2012, and it has been offered every year except Spring 2019. The course evaluations presented here include every year that the course was taught. The questions have remained consistent, informing revisions within the course over time. The evaluation is divided into four topic sections: learning objectives, course design, the readings (i.e., pathographies), and personal comments. Questions are closed- and open-ended. For the closed-ended questions, students rate their level of agreement with 13 statements, using a five-point Likert scale of (1) strongly disagree, (2) disagree, (3) neutral, (4) agree, and (5) strongly agree. Open-ended comments to two questions comprise the fourth and final section. Presented from both quantitative and qualitative perspectives are 113 students’ feedback. The quantitative results are described in terms of percent agreement with the rating statements, and qualitative responses are organized thematically.
Learning objectives and course design
Overall, students rated statements in the first two sections favorably. As described earlier, there are two objectives for the course, which were addressed in two rating questions aimed at understanding whether students perceive they developed skills in articulating the significance of a “pathography approach” and analyzing issues in pathographies of mental illness. There were three additional outcomes included in the section, relating in particular to their skills in applying, writing, and reflecting on pathographies. The statements prompted students to consider whether they achieved the objectives or outcomes as a result of the course, serving as a self-assessment of their learning. Students’ responses to the five statements were overwhelmingly positive, with 97% or more of them agreeing with each.
For both course objectives, 99.1% of students agreed they achieved them. Indeed, only a single student did not rate these items a four (agree) or five (strongly agree). A similar percentage of students rated that the course helped their abilities to “apply theoretical insights from medical humanities to a pathography of mental illness” and “describe how writing about mental illness helps sufferers to make meaning of mental illness.” The final statement in this section asked students to answer whether they could reflect on how reading pathographies of mental illness will affect their clinical skills. Again, agreement was high, with over 97% of students rating this as agree or strongly agree.
In addition to the objectives, students’ feedback about the course design was obtained. The statements were aimed at evaluating the discussions, their engagement, and the course overall. First, students agreed (rated a four or five) that the discussions were interesting (98.2%) and well facilitated (99.1%). They also expressed that their peers were engaged in the mental illnesses and issues presented (94.7%). Another attribute of the course that students were asked about related to the learning environment, specifically the course being offered in a humanities and ethics center, as being a comfortable setting for discussing humanistic topics. More than 97% of students agreed with this statement. Finally, nearly all of the students (99.1%) felt the course was well designed overall.
Considering the positive levels of agreement across these statements about the course, from learning objectives and outcomes to its design, these findings speak to students’ satisfaction with the course more broadly. However, it is the final two sections in the course evaluation that provide further insight into their perceptions about the readings and experiences with the pathography approach. These will be presented separately, with particular attention paid to students’ free responses.
The readings
The evaluation included four questions about their perceptions of the readings as contributing to their learning. First, students considered whether the readings promoted their understanding of mental illness. Then, they rated statements about the usefulness of the material conveyed and the concepts introduced to them. Finally, students responded to a question about the amount of reading they had. Across all four questions, agreement levels were, again, high, as in previous sections. Students rated highest that the readings introduced concepts that were new, understandable, but not too simplistic (99.2%). Further, they perceived the reading material as being useful (98.2%) and, overall, as contributing to their understanding of mental illness (98.3%). The least favorable item, in terms of rating, was the amount of reading (93.8%), which could be perceived as substantial by some students, with 14 texts assigned in addition to the DSM-5-TR in the present course offering.
Personal comments
While the quantitative evaluation items convey favorable perceptions about the course, the qualitative questions allow for a deeper understanding of their experiences. There are two questions in this section, which asked students to share what they considered the best part of the course and suggestions for improvement. Students’ responses to these questions were reviewed and analyzed qualitatively using coding. The first cycle helped to identify descriptive categories, looking at commonalities across responses. The second cycle organized the categories into broader themes to contribute to general interpretations of their perceptions. The themes shared for both questions start with the broader themes and include descriptors in students’ language to contextualize these.
When asked to share about the best part of the course, 106 students responded. Their answers fell into five themes that related to the course overall, discussions, mental illness, readings, and their experiences. The most frequently mentioned response among 32.1% of students was about the course discussions. Students described the discussions as the best part of the course for being good, using language like “enjoyable,” “excellent,” and “great,” but the bulk of their descriptions focused on the quality of the discussions, such as their value and ability to influence their thinking. One student described the discussions as “fruitful” for facilitating sharing of “the different ways people interpreted and experienced these works.” Another described the discussions as “socially relevant,” with another elaborating on a similar point, sharing that the discussions provided “insight and perspective” while “giving an opportunity for everyone to speak out, from the women in the group about hardships experienced as a woman … to personal stories or experiences with racial/cultural prejudice or LGBTQ perspectives.” The student credits the sensitivity with which such diverse viewpoints and complex topics were tackled. Still, other students characterized the discussions as being supportive of their experiences, allowing sharing with peers, but also as being engaging, meaningful, thought-provoking, and contributing to their medical education.
Though the remaining four themes were not mentioned as often as the discussions were, there was insight found in these. For instance, for those who cited the course in general as being the best, there was appreciation for its virtual format and flexibility for its attendance and makeup policies. One student also explained that the course “provided me with new perspectives and will help me care for patients in the future,” while another connected the course to appreciation for its medical humanities perspective. And, still, two students referenced the course environment, calling it “comfortable” and “empathetic.” Regarding the readings, students often described these in terms of their enjoyment, but also for their uniqueness, ability to “shine light on different experiences,” and being eye-opening as memoirs with “the perspectives of people who come from all different backgrounds and have been diagnosed with a spectrum of disorders.” There was also mention of being exposed to books they might not have ever read if it were not for the course.
Several students noted the topic of mental illness as being the best part of the course, crediting it with giving them new perspectives or insights about patients’ struggles. They found it helpful in preparing them to interact with patients, enhancing their understanding of “diagnostic criteria beyond what is written in the DSM.” The final theme about students’ experiences was the least mentioned (7.6%) but was no less impactful. For instance, students described their personal experiences as enhanced by sharing among peers, especially because of their openness. Another explained the experience was influential on their perspectives and future practice. Yet another student linked the other themes to their experiences, explaining that reading the pathographies, which prompted discussion of peers’ experiences and sufferers’ perspectives, related to “our future as clinicians and current experiences as medical students.”
In the second open-ended question, 43 students offered suggestions for improving the course. There were three themes identified among their comments: recommendations about the readings, discussions, and course practices. The majority of suggestions (86.0%) related to the readings, such as wanting fewer assigned books, with one student each stating they “had to rush through the readings […] and missed some important parts,” thought “14 books [were] a lot to get through,” and requested to “shorten readings.” Aside from these comments about the amount, one student noted the readings could be “pretty heavy” and “affected class morale” due to the subject matter. Others expressed desires to eliminate specific texts and, in one case, choosing different books that would “add more to the conversation.” Additional responses asked for “changing some of the readings,” though none in particular were mentioned, and a handful of students suggested supplementing the readings with “more contemporary pieces” or adding movies, documentaries, or art.
Two suggestions focused on the theme of discussion, particularly about strengthening connections between the pathographies and clinical material in discussion and including a free or open-topic session not directly connected to an assigned pathography or mental illness. The final theme was course practices, wherein students offered ideas about how to improve the course more generally, rather than specifically within the readings or discussions. For two students, the recommendations were linked to their personal experiences of sharing and vulnerability. One student noted that asking too many questions could make it difficult to share and be vulnerable, leading to situations in which “no one wanted to share anything,” and another wanted fewer questions to allow the conversation to flow freely. Conversely, a student credited the virtual format as enabling conversations that might be too difficult to have in person; their suggestion was to retain this feature. A student also commented on the makeup policy, requesting it be more lenient, while another hoped for more mental health topics to be included, and still another suggested participation be less prescriptive to allow students to participate when they chose. A final suggestion to improve the course was about limiting how many students would lead each session. The concern shared by this student was about ensuring those who were assigned to lead a session in partnership with others participated equally in the work.
For both free-response questions, the themes were few and touched upon different, yet similar, dimensions of Pathographies of Mental Illness. At times, there was appreciation expressed for the exposure to different and diverse readings as well as sharing personal experiences. Other times in their suggestions, students voiced interest in changing some of the pathographies or expanding the types of media used in the course. Still, students’ comments offered insight into how they perceived and experienced the course, but also hinted toward ways in which the course could practically be enhanced.
The difference that diversity makes: two perspectives on depression
The most notable way that the course has changed over the years, based on student feedback, has to do with the readings. The readings have become more diverse. Especially after the Black Lives Matter movement in 2020, students became more vocal about including perspectives from non-white persons. The change in readings, naturally, has affected the substance of the conversations in the seminar. We’ll lift up one such change to demonstrate the difference that diversity makes.
As noted, Darkness Visible is a classic in the field, a memoir about depression written by William Styron (1925–2006). Regarded as one of the greatest American writers of the twentieth century, Styron was most well known for three of his novels: Lie Down in Darkness, The Confessions of Nat Turner, and Sophie’s Choice. In Pathographies of Mental Illness, Carlin noted that the key objective of Darkness Visible was to destigmatize death by suicide, to make the point that, when people die this way, it is because they are in pain, not because they are weak, selfish, or immoral. Dying this way, Styron suggests, should not be viewed any differently from death caused by cancer.
Another important feature of Darkness Visible is that Styron, because he was a professional writer, paints a vivid picture of the experience of depression. He corrects the common, but incorrect, assumption that depression is just a more extreme form of sadness or “the blues.” He lifts up how active the experience of depression is, how close it is to physical sensations of pain, things like drowning or suffocation. He writes:
It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.Footnote 8
Styron noted that he experienced many of the symptoms of depression, as described in the DSM, including the inability to concentrate, the loss of rational thought and perspective, confusion, memory problems, panic, difficulty speaking, loss of libido, and an inability to experience pleasure or joy. In reflecting on the “cause” of his depression, he notes that the best one can do is “wise conjecture,” and he attributed his own to a mix of genetics, childhood experience, dissatisfaction with his work, turning age 60, and alcohol withdrawal (he was forced to quit drinking due to stomach problems). Drinking was important to him, as a writer, because it seemed to calm a constant anxiety that he lived with (perhaps lifelong depression) and it stimulated his creativity. Styron attributes his recovery not to therapy or medication, but to a lengthy stay in a psychiatric hospital. Thus, his message to his readers suffering from depression is to do everything that they can to hold on, as the depression will pass.
Meri Nana-Ama Danquah (b. 1967) offers a different perspective on depression in Willow Weep for Me. Footnote 9 Born in Accra, Ghana, she moved to the United States at the age of six. Her parents divorced when she was eleven, thus creating financial difficulties. These difficulties were exacerbated for her when she became a single mother in 1991. For a significant number of years, work was unsteady for Danquah as she pursued a career as a writer, while also completing her education. So, if Styron offers a perspective on depression as a successful white male in his 60s, Danquah’s account of depression is written from the perspective of a young, single, Black, immigrant mother struggling to build a career. Danquah contrasts herself directly with Styron:
Styron and I would [n]ever have the same angle on anything. We had the same illness; the similarities end there. The way I did depression was a-whole-nother bag of beans. I’m a single Black mother about a half paycheck away from the government cheese line.Footnote 10
Access to care for Styron is an act of the will. His most restrictive barrier to care was the realization that he needed intense, inpatient care: He just had to convince himself—or be convinced by his family—that he needed care beyond the regular outpatient therapeutic and pharmacological care he had already been receiving. He shows no concern of financial difficulty or clinging responsibilities. Danquah, in contrast, had to navigate this illness with strained finances, significant parenting responsibilities, and limited social support.
Danquah also emphasizes that “culture plays an important role in both the patient’s illness and treatment. I am Black; I am female; I am an immigrant. Every one of these labels plays an equally significant part in my perception of myself and the world around me.”Footnote 11 For a financially struggling single mother like Danquah, inpatient therapies, or even the expense of medication, may not be feasible. Finding a therapist who could understand her life experiences, too, provided difficulty, which she detailed in her memoir. Realizing that the very different circumstances of each patient may require very different approaches to care is a major lesson in contrasting these narratives.
Also, these memoirs offer different writing styles because they attempt to reach different audiences. Styron’s more poetic, descriptive reflections on depression—with references to literary greats like Albert Camus—are not a style that is easily understood by all. It is cerebral and philosophical. Darkness Visible is written for an elite audience, originally published in Vanity Fair. There is not much about Styron’s family in it. One almost gets the sense that he faced his depression alone, while this was clearly not the case.Footnote 12
Danquah’s pathography, in contrast, is a novel-like chronicle of her experience—complete with characters immersed in a more relatable plot that is meant to also include a less literary and privileged audience, and in order to convey hope and offer solace, and to empower others in situations like hers to begin the work of recovery. With Danquah, we immerse ourselves in the midst of her story to become witnesses to the experiences and circumstances through her “thick lengthy periods” of depression.Footnote 13 To read about her depression is to read about her relationships.
Styron and Danquah agree that depression is not a choice; it is an illness. Styron writes: “Never let it be doubted that depression, in its extreme form is madness … from an aberrant biochemical process,” and that “such madness is chemically induced.”Footnote 14 Likewise, Danquah writes, depression is not “a character flaw or an insignificant bout with the blues that an individual can ‘snap out of’ at will.”Footnote 15 Yet, despite this agreement, Danquah lifts up that Black women experience this illness differently than white men:
I have noticed that the mental illness that affects white men is often characterized, if not glamorized, as a sign of genius, a burden of cerebral superiority, artistic eccentricity—as if their depression is somewhat heroic. White women who suffer from mental illness are depicted as idle, spoiled, or just plain hysterical. Black men are demonized and pathologized. … When a Black woman suffers from a mental disorder, the overwhelming opinion is that she is weak. And weakness in Black women is intolerable.Footnote 16
“Emotional hardship,” she writes, “is supposed to be built into the structure of our [Black women] lives.”Footnote 17 She adds: “I’ve frequently been told things like: ‘Girl, you’ve been hanging out with too many white folk’; ‘What do you have to be depressed about? If our people could make it through slavery, we can make it through anything’.”Footnote 18
Given this contrast with Styron, questions to discuss with medical students include the following:
1. Have you noticed differences related to race, gender, and class when talking with patients about mental illness?
2. How should we talk with patients from various cultural backgrounds?
3. What are the pros and cons of “race pairing” (i.e., matching patients and clinicians according to race)?
4. What resources are available for persons from less privileged backgrounds? How can we connect them to those resources?
Discussion
Over the many years the course has been offered, revisions have been informed by students’ feedback. One such example is the pivot to online learning, which was initiated because of the COVID-19 pandemic, but remains for its advantages in meeting students’ needs for flexibility around residency interviews, and, as one student explained, “it was easier to partake in discussions over WebEx compared to an in-person discussion,” referencing it as an effective approach to engaging conversation.
Other takeaways influenced reworking the class presentations and handouts to make each student responsible for their own assignment, addressing unintentional, yet unequal, participation among them. More has also been done to address students’ concerns about sharing experiences and vulnerability. The learning environment requires trust and building a safe space for discussion. Students’ awareness of their own vulnerability in tandem with recognizing that comfort with being vulnerable can be complicated, even leading students who were once forthcoming to stop sharing, as two students expressed. Discussions are sometimes best structured to a point but left to evolve organically. Thus, while conversations delve into personal experiences or focus on the stories of the pathographies’ authors, a delicate balance must be struck. In that respect, only through these evaluations could changes be made to cultivate safety and students’ vulnerability to facilitate sharing. Otherwise, we might not know this was needed.
Compared to earlier years, the course has become more engaging for students as drivers of their learning, leading in the discussions and questioning their peers. Strategies also address these needs while incorporating elements from the “best part” and “suggestions” comments, aiming to capitalize on what works. Including a trigger warning in course materials to alert students to the often difficult readings they will be exposed to, leading to equally sensitive conversations, was appreciated by at least one student who shared this. Allowing the makeup policy as a way not only to remain engaged in one’s absence but also to share more private or closely held views about a pathography or mental illness gives the student a receptive space to share without feeling forced when they might otherwise feel too vulnerable or uncomfortable to do so. This was mentioned as one student’s strategy for being present in the discussions while engaging in self-protection.
Perhaps the readings, the very vehicle inherent in the “pathography approach,” are the element of the course that has endured the most change and reflect students’ input. Readings have been reduced from as many as 20 texts at one time to fewer than 15 in their current form. And some of the very texts that students wanted to see changed have, indeed, been swapped for more contemporary pathographies. Other changes have included adding different topics that reflect more diverse viewpoints in terms of both the mental illnesses presented and the identities of sufferers of various mental illnesses. And, within the discussions, the shift to more diverse readings has created connections for students to make, allowing them to share their perspectives and exposing their peers to experiences they did not have themselves. Expanding medical students’ training in this way helps inform their future practice, yet has the added benefit of enabling them to identify with the authors’ stories and, by proxy, their patients’ stories as well as their peers’. With greater representation across the pathographies, there is also the ability for students to relate and see themselves reflected. Diversity among pathography authors matters, and exposing students to contrasting perspectives, sometimes of the same mental illness, is important to engage them in thinking and reflecting critically on what that means for patient care.
So, while one might take away from this discussion that student perceptions of the course were very positive, the truth is that they attained knowledge and acquired theoretical insights that they did not previously have. The distinction of Pathographies of Mental Illness being held like a graduate-level humanities course (in which discussion is the method) is that it engages them to not only think critically through a humanistic lens but also to communicate. What the evaluations impart is that students find value in studying pathographies of mental illness, especially those from diverse perspectives, because it enables them to reflect on their practice of medicine.