‘The Wounded Healer’ — Harnessing the Power of the Performing Arts to Reduce Mental Health Related Stigma in Healthcare Professionals and Students
Not so invincible after all…
“Why am I as I am? To understand that of any person, his whole life, from
birth must be reviewed. All of our experiences fuse into our personality. Everything that ever happened to us is an ingredient.”
The Autobiography of Malcolm X
I want to begin by sharing my own personal story with you which, I hope, will provide an insight into who I am, what I stand for and why I feel so passionate about harnessing the power of the performing arts to challenge mental health related stigma.
I left my family behind me in Lebanon when I was 17 years old. The brutal and bloody civil war in the Lebanon in the 1980s had far-reaching ramifications so much so that even decades after the conflict was over prospects in the country were not looking favourable. So I packed my bags and took a one-way flight to England with high hopes for a better future. It’s not easy saying goodbye to your parents and I will never forget the sombre look on my mother’s face as I was bidding her farewell in Beirut International Airport. This may very well shatter my masculine bravado but I’d be lying if I said that I didn’t shed a tear or two…
Almost immediately after my arrival on British shores, I started working as a janitor cleaning floors. The callouses on my hands were testament to the toil of my labour. I worked 70 hours a week on minimum wage to sustain myself. Being far removed from my family meant that I could not derive comfort from their immediate presence. Naturally I felt melancholic when I saw other teenagers my age living with their parents preparing for the A-Level exams to gain entry into medical school without having to work full-time. These were trying times no doubt but I never gave up hope that one day I would realise my dream of qualifying as a doctor, no matter how far fetched it seemed. The subsequent year I enrolled into a Sixth Form College and continued to work full-time hours. I remember when the Head of the Sixth Form at the time laughed at my face after I told her that my intention was to apply to read medicine at university. ‘It’s too competitive’ she instantly retorted ‘you’ll never receive an offer’. She had this ability to make me feel like I was this dirty little immigrant with delusions of grandeur and that I would never amount to anything in life. I refused to allow her to diminish my resolve however. I dug deep and, somehow, managed to secure the A-Level grades necessary to matriculate into Manchester Medical School despite working full-time hours. It seemed that my dream to one day qualify as a doctor was starting to become true…
In 2006, when I was a third year medical student, I woke up one morning to discover that my hometown in Lebanon was bombed and that hundreds of people were killed overnight. I saw live footage of bombs being dropped on buildings and horrifying images of dismembered civilian corpses (including babies) strewn on the streets. I remember feeling utterly powerless as the death toll continued the rise and the destruction continued to spread. Fearing that my family were among the dead, I frantically tried to call them however I wasn’t able to get through (unbeknown to me at the time, my family were evacuated by the British Government).
The stress from the war in Lebanon precipitated an episode of psychological distress. My world had turned upside down and, in my despair, I contemplated suicide. I would stare at the buses speeding past me and think about which one I would throw myself under. I, however, resisted the urge to act upon these thoughts since I was a practising Muslim and suicide is forbidden in Islam.
Between 1,100 to 1,300 Lebanese people and 165 Israelis are believed to have been killed in the 2006 Lebanon war. The conflict severely damaged Lebanese civil infrastructure (opposite are buildings in Beirut that were reduced to rubble during the war).
Debilitating though the symptoms of mental illness were, I soon discovered that the stigma of mental illness was far worse. I was ostracised, dehumanised and shunned by the very people who, at the time, I thought were my closest companions. I was rendered impoverished and homeless and my mental health rapidly deteriorated. These were the darkest days of my life. I look back and think how on earth did I manage to emerge from that seemingly bottomless abyss? What made the situation even worse was that I was in complete denial that I had developed a mental illness. ‘Going mad’ is not something that happens to people who are robust enough to study medicine, but to other people, or so at least I thought. This state of denial was one of the main reasons why I did not seek help. Also, I did not find the thought of taking psychiatric medication (or ‘chemical cosh’ as it is referred to by members of the anti-psychiatry community) too appealing. What I did gravitate towards, however, was the power of film, literature and poetry. I remember how deeply therapeutic and profoundly cathartic it was for me to watch movies at the cinema (hence the term, ‘cinematherapy’ has been coined to reflect this), read novels (mostly fiction of the magical realism variety from Gabriel Garcia Marquez) and recite verses conceived by Dylan Thomas and Rudyard Kipling. Moreover, there were no ‘adverse effects’ associated with these activities. I started to exercise more and I noticed that slowly, but surely, my mental health started to improve without the help of psychotropic medication or therapy.
Prayer, the power of the performing arts and exercise were all factors that played crucial roles in my recovery from mental illness. These factors continue to contribute to my resilience.
Recovery and discovery…
I gradually recovered and resumed medical school with a renewed resilience and determination. There was a ‘fire burning in my belly’ and a ‘thunder in my heart’ to realise my potential and to make meaningful and important contributions to our world. I had been dis-empowered for so long and ridiculed and rejected by society and so redemption became my driving force. When I qualified as a doctor, I felt that it was incumbent upon me to challenge the stigma attached to mental illness in medical students, indeed I felt like this was ‘my calling’. After all, a recent systematic review and meta-analysis on the prevalence of depression, depressive symptoms and suicidal ideation in medical students published in JAMA in 2016 revealed that 27% of the 120,000 respondents reported depressive symptoms and 11% experienced suicidal ideation. I was clearly not alone. However, although effective treatment is available, stigma and ‘a culture of shame’ are formidable barriers to mental health services. My ‘mission’ therefore, was to break down those barriers so that medical students and doctors with mental health difficulties could access and receive the treatment they need and no longer continue to suffer in silence.
Despite the perception that medical students and doctors should be ‘invincible’ the reality is that we are human beings and are vulnerable to developing psychological distress like everyone else. Picture taken at a Mental Health Fight Club event in Dragon Café, London.
Genesis of the Wounded Healer
In 2014, I responded to my calling and pioneered the Wounded Healer under the direct supervision of my mentor Dr Rashid Zaman FRCPsych, a Consultant Psychiatrist based at Cambridge University and Director of the International Conference on Mental Health at Cambridge University. I must take this opportunity to pay tribute to Dr Zaman. It is no exaggeration to state that he is truly one of a kind. Never, throughout the 10 years that I have been fortunate to know him, has Dr Zaman EVER uttered a single negative word towards me. Dr Zaman has been with me every step of the way, the highs and lows, the failures and successes and he provided me (and continues to provide me) with unwavering support. I would never have achieved my goals if it wasn’t for him. Simply put, Dr Zaman is the ultimate mentor and I am so blessed to have him in my life.
The Wounded Healer is an innovative method of teaching that blends the performing arts with psychiatry. The main aims of the Wounded Healer are to engage, entertain, enthral and to educate to debunk myths about mental illness, encourage care-seeking and challenge mental health relate stigma. The Wounded Healer also harnesses the power of storytelling; it traces my recovery journey from homeless and impoverished ‘service-user’ to receiving the 2013 Royal College of Psychiatrists Foundation Doctor of the Year Award and, later, the 2018 RCPsych Core Psychiatric Trainee of the Year Award (the RCPsych Awards mark the highest level of achievement in psychiatry in the UK — not bad for a ‘madman’ even if I say so myself!).
I was inspired to conceive the Wounded Healer because not only did I believe that the mental health of medical students is not spoken about as often as it should be but also most (if not all) the talks that were given on this topic were soporific. My argument was, and remains, that in order to educate an audience you must first be able to engage them. The Wounded Healer is a highly theatrical intervention that disrupts conventional educational approaches and seldom elicits indifference. In the Wounded Healer, I re-enact scenes from famous films and recite poetry to engage audiences and, once engaged, I educate them with the facts. If Ezekial 25:17 from Pulp Fiction does not galvanise audiences, I don’t know what will! I also find delivering the Wounded Healer empowering and that it continues to contribute to my resilience.
In the Wounded Healer I re-enact scenes from famous films to engage audiences. The above picture was taken when I was delivering the Wounded Healer to 1000 medical students in Lisbon, Portugal.
‘Nothing about us without us: Experts by Experience as Educators…’
I had so much faith in the Wounded Healer that I took three years out of my clinical training to promote it. I initially reached out to medical school psychiatry societies in the UK and have since expanded operations internationally. Since its inception in 2014, I have been fortunate to deliver the Wounded Healer to over 75,000 people in 15 countries in five continents worldwide. The Wounded Healer has also been integrated into the medical school curriculum of four UK universities. In recognition for my services to public engagement and education, I was honoured to be a Finalist of the 2015 and 2017 Royal College of Psychiatrists Psychiatric Communicator of the Year Award.
The Wounded Healer: Evidence, not just Anecdote
The Wounded Healer is data-driven and evidence-based; it contains all six key ingredients of effective anti-stigma programmes targeting healthcare providers as identified by Stephanie Knaak and colleagues at the University of Calgary. The main strength of the Wounded Healer is that it is delivered by an Expert by Experience. We know from the results of multiple meta-analyses that the most effective way of reducing mental health related stigma in adults is through social contact with someone who has recovered from mental illness.
We conducted a pilot study with King’s College London Undergraduate Psychiatry Society to assess the effectiveness of the Wounded Healer at reducing mental health related stigma in healthcare students (this was a single-arm, pre- post comparison study). We administered validated psychometric stigma scales on participants before and after exposure to the programme and the results of our study showed statistically significant reductions in stigma variables (knowledge, attitude and behaviour).
Leveraging the power of film and digital technology to challenge mental health related stigma
I was extremely fortunate to receive invitations to deliver the Wounded Healer to audiences nationally and internationally however there were only so many talks that I could give (and only so much time, energy and resources that I had). In 2015, like a manna from the heavens, filmmakers from the London College of Communication approached me and offered to commission the production of the Wounded Healer film. We know from multiples studies on healthcare providers that virtual (i.e. video) contact with an Expert by Lived Experience is effective at reducing mental health related stigma so I embraced this opportunity. The Wounded Healer film has since been screened at the Psychiatry and Arts Section of the World Psychiatry Association World Congress in Berlin and the Australasian Physician’s Health Conference in Sydney. The results of a pilot study conducted by University College London Psychiatry Society on the effectiveness of the Wounded Healer film at reducing mental health related stigma in medical students were also encouraging.
The Wounded Healer Film Screening at the London College of Communication, London.
Afterthought…
Despite the perception that medical students and doctors should be ‘invincible’ the reality is that we are human beings and so we are vulnerable to developing mental illness just like everyone else is. Many medical students and doctors with mental illness continue to suffer in silence even though effective treatment is available and the consequences of this can be fatal. Indeed, Dr Daksha Emson, a multi-award winning psychiatrist with bipolar affective disorder, tragically killed herself and her three month old baby daughter during a psychotic episode. An independent inquiry into Dr Emson’s death concluded that she was the victim of stigma in the National Health Service. Succinctly put: stigma is killing people.
I have learned, through lived experience, that stigma and a ‘culture of shame’ are formidable barriers to mental health services. The Canadian Psychiatry Association reported that conventional education alone will not reduce mental health related stigma in medical students. We must pioneer innovative programmes that break down the barriers to mental health services for medical students and doctors who urgently need them. We must embrace our vulnerability, be honest and open about our mental health and instigate a cultural revolution.
According to Professor Brian Hurwitz, an eminent scholar in the health humanities based at King’s College London, there is a growing perception that science alone provides overall insufficient foundation for the holistic understanding of the interaction between health, illness and disease. The health humanities, therefore, emerged as a distinct entity in attempts to ameliorate the limitations in the provision of healthcare services and can be broadly described as the application of art and literature to medicine.
The performing arts and storytelling both possess an extraordinary power and must be utilised to reduce mental health related stigma and as a tool to promote recovery from mental illness. The evidence is clear, Experts by Experience have the power to reduce mental health related stigma and must operate at the vanguard of any anti-stigma initiative.
The Wounded Healer is an innovative anti-stigma programme that blends the performing arts with psychiatry that is delivered by an expert by both personal and professional experience and has been shown to reduce mental health related stigma in medical students. More research in this area must be conducted (and resources allocated) if we are serious about improving the mental health of medical students and doctors.
For those of you experiencing psychological distress in any of its many forms, I know that the world can be a dark and lonely place, believe me I know. But please, don’t give up hope. Effective treatment is available and recovery can be a reality for the many, not for the few. If I can recover and realise my dreams, other people out there with mental health difficulties can realise their dreams too…
Twitter: Dr Hankir Tweets as, ‘The Wounded Healer’ @ahmedhankir
NOTE FROM THE EDITORS: We are so excited to have Dr Ahmed Hankir writing for InSPIre the Mind. Ahmed has used his lived experience and channelled performing arts to challenge stigma and we are very thankful that he was willing to share his story with us.