Cinema, aesthetics and narrative: Cinema as therapy in substance use disorders

Accepted Manuscript Title: Cinema, Aesthetics and Narrative: Cinema as Therapy in Substance Use Disorders Authors: Ana Filipa Correia, Sofia Barbosa PII: DOI: Reference:

S0197-4556(17)30249-6 https://doi.org/10.1016/j.aip.2018.07.001 AIP 1523

To appear in:

The Arts in Psychotherapy

Received date: Revised date: Accepted date:

9-12-2017 29-6-2018 13-7-2018

Please cite this article as: Correia AF, Barbosa S, Cinema, Aesthetics and Narrative: Cinema as Therapy in Substance Use Disorders, The Arts in Psychotherapy (2018), https://doi.org/10.1016/j.aip.2018.07.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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CINEMA, AESTHETICS AND NARRATIVE

Cinema, Aesthetics and Narrative: Cinema as Therapy in Substance Use Disorders Ana Filipa Correia and Sofia Barbosa Hospital Prof. Doutor Fernando Fonseca, E.P.E., Amadora, Portugal

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Author Note

Ana Filipa Correia, Department of Psychiatry, Hospital Prof. Doutor Fernando

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Fonseca, E.P.E.; Sofia Barbosa, Department of Psychiatry, Hospital Prof. Doutor Fernando Fonseca, E.P.E..

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The authors would like to express their deepest gratitude to elements of the technical

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team of the institution where this work was performed, for all the help provided during the

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development and application of the therapeutic activity described in this paper; to Dulce

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Neves, for the help in analysing the data; and to José Ramos, Pedro Mourão-Ferreira and Teresa Maia, for the critical review of this article. Both authors contributed equally to this

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work.

This research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors. Conflicts of interest: none for any author.

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Correspondence concerning this article should be addressed to Ana Filipa Correia,

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Department of Psychiatry, Hospital Prof. Doutor Fernando Fonseca, E.P.E., IC19, 2720-276

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Amadora, Portugal. E-mail: [email protected]

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CINEMA, AESTHETICS AND NARRATIVE Highlights  Cinema as a mediator in therapeutic settings has been considered advantageous.  Few works have been written on cinematherapy in substance use disorders.  A review about cinema-mediated interventions in substance use disorders is made.  The narrative and aesthetic dimensions of cinema are studied.  Results conclude for the therapeutic potential of cinema-mediated interventions. Abstract

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The use of cinema as a mediator in therapeutic settings has been considered advantageous; however, few works have been published regarding this subject (Dermer & Hutchings, 2000;

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Eğeci & Gençöz, 2017; Hesley & Hesley, 1998; Poltrum, 2009; Schulenberg, 2003; Wolz, 2005). The aim of this work was to explore the therapeutic potential of cinema, especially

when applied to the treatment of substance use disorders, and to study the hypothesis that the

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narrative and aesthetic dimensions of cinema are primordial to its therapeutic properties. The

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authors first describe their clinical experience with a therapeutic activity specifically

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conceived to use cinema and its narrative and aesthetic dimensions in a therapeutic way, and

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then explore the proposed hypothesis by analysing and discussing its results. The authors

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found that cinema appears as a language of possibilities in the psychotherapeutic setting: not only the movies appeal to the patients’ inner world and to the reflection on their previous life experiences, but also provide a safe and creative space for change. Also, movies take the

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patients to talk and elaborate on their thoughts, feelings and life stories, allowing a different look at the future, acting as inductors of hope. This work may be seen as an innovative

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contribution to further discussion about the clinical benefits of cinematographic art as a therapeutic mediator.

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Keywords: Substance use disorders; Cinema; Narrative; Aesthetics; Cinematherapy.

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CINEMA, AESTHETICS AND NARRATIVE Cinema, Aesthetics and Narrative: Cinema as Therapy in Substance Use Disorders The interest for the therapeutic dimension of art dates back to classic antiquity. Aristotle, Greek philosopher and scientist, saw in the theatre plays the ability to purify the spirit and to help people to deal with aspects of their lives with which rational reconciliation was not possible (Poltrum & Leitner, 2009).

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The use of cinema as therapy take up all this knowledge and develops it, with some authors pointing, as ultimate aim, the possibility of satisfying a basic human need, the love

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for life (Grafl, 2008, p.63; Poltrum & Leitner, 2009). Several authors sought to demonstrate the potential of cinema, and what it can do for people, especially in the construction of

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meaning, from a self-consciousness that shapes personal identity (Clotas I Perpinyà &

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Florenza I Canals, 2012, p. 16). The same authors argue that the film visualization can

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culminate in a collision between the emerging and the settled self, allowing psychological

Florenza I Canals, 2012, p. 18).

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experiences of various intensity and duration, catalysts of change (Clotas I Perpinyà &

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There are also some advantages in choosing cinema: it not only provides a common language between therapists and clients (Dermer & Hutchings, 2000), but also makes it possible for the patient to change through a non-threatening way, within what some authors

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have named as safe distance (Dermer & Hutchings, 2000; Wolz, 2005). It also has the

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advantages of introducing new options of action (Hesley & Hesley, 1998), and connecting people not only through cognition and behaviour but also through emotions (Dermer &

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Hutchings, 2000), the latter referring to the emotional expression that movies can allow. In fact, many people who have difficulty understanding and expressing what they feel, sometimes need to see to feel (Poltrum & Leitner, 2009; Zur, 2005). For example, people who cry uncontrollably in the movies, when in real life they were not able to do it (Mangin, 1999). Indeed, difficult or unclear emotions are more easily expressed using metaphors

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CINEMA, AESTHETICS AND NARRATIVE (Schulenberg, 2003), often by identification with the protagonists of the films (Poltrum & Leitner, 2009). On the other hand, the multidimensional language of cinema, not only using a narrative, but also a visual and musical communication (Poltrum & Leitner, 2009; Wolz, 2005), facilitates the transmission of ideas not only through the intellect, but also through emotions. Besides, most patients will certainly be more likely to watch a movie than to

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engage in other forms of art, such as read a book (Hesley & Hesley, 1998; Poltrum & Leitner, 2009), even if it is only for the shortest reception time (Grafl, 2008; Poltrum & Leitner,

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2009).

Another important concept underlying the use of cinema in therapeutic settings has to

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do with the salutogenic quality of this type of therapy (Antonovsky, 1987); one that focuses

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not only on the disease, but rather on what promotes well-being. On a salutogenic

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perspective, it’s important to evoke the possibility of using films as inducers of hope (Hesley

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& Hesley, 1998), allowing the management of chaotic experiences and the identification of new coping resources, that act as catalysts of a positive change.

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A recent study from Eğeci and Gençöz (2017), on the use of cinematherapy in dealing with relationship problems, starts from the theoretical four-stage process outlined while watching a movie – identification, catharsis, insight and universalization – and concludes that

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the movie discussions, more that its visualization, appear to have helped the participants gain

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a different perspective and initiated a change process. In the field of substance use disorders, the use of art therapy dates back to the 1950s

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(Aletraris, Paino, Edmond, Roman, & Bride, 2014, p. 2; Moore, 1983). More recently, the authors highlight the work of the Anton Proksch Institute, and The Orpheus Program specifically. This program “seeks to empower addicts to live their lives in a way that is so exciting, pleasurable and joyful that the addictive substance loses its overpowering appeal” (The Anton Proksch Institute’s Orpheus Programme, 2015, p.1). One of its modules,

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CINEMA, AESTHETICS AND NARRATIVE Philosophic Cinema Therapy, includes therapeutic intervention through the visualization of films and is well described in the work of Poltrum and Leitner (2009). Substance use disorders have many expressions, each patient being unique in the experience of the disease. However, it is perhaps worth mentioning that the issue of emptiness is frequently present in the population of patients with this diagnosis, and that the

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addictive disorder may, to a certain extent, be understood as a disease of emptiness. This

means that many of the patients with substance use problems experience states of internal

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emotional emptiness, which can be transposed onto an existential plane; this emptiness is somehow filled with the addictive behaviour.

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In fact, from a phenomenological point of view, some authors, as Di Petta (2014),

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argue that all addictions lead to the final collapse of the Dasein structure, the constitution of

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the being-in-the-world-with-others, which makes impossible for them to stay in a space-with-

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others and to project themselves in time, resulting in the feelings of emptiness described above (Di Petta, 2014, p. 471). The author describes this existential situation as very difficult

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to treat, characterizing it “by patients frequently dropping out of conventional treatment, the loss of the being-in-the-world structure, boredom, emptiness, dread, anger, lack of meaning, loneliness and isolation” (Di Petta, 2014, p. 471).

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In continuity with these states of internal emotional emptiness, it is also frequent to

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find patients with very negative, pessimistic and even nihilistic cognitive patterns (Poltrum & Leitner, 2009). In many of these patients, the human sense of identity is lost even where there

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is no psychotic symptomatology, and some authors have been arguing that the only way to survive is to “achieve vital contact with another person, feeling empathy for the emotional, affective dimension of another person” (Di Petta, 2014, p. 477), or searching for therapies to re-encounter the meaning of life (Poltrum & Leitner, 2009).

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CINEMA, AESTHETICS AND NARRATIVE In this group of patients, the therapeutic use of cinema aims to contribute, within the framework of a wider therapeutic project, to change this experience of reality. Therefore, the authors believe that cinema can catalyse subjectively satisfying and fruitful changes in the way patients experience the present moment, and at the same time positively serve their expectations about their future and the meaning of their lives.

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In this paper, the authors pretend to explore the hypothesis that the narrative and aesthetic dimensions of cinema are primordial to its therapeutic properties in a group of

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patients with substance use disorders. Aiming that, the authors will first describe their clinical experience with a therapeutic activity specifically conceived to use cinema and its narrative

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and aesthetic dimensions in a therapeutic way, and then will explore the proposed hypothesis

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by analysing and discussing its results.

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Methods

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Context and Setting

A therapeutic activity was conceived upon both the theoretical framework and the

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hypothesis presented above, being named by the authors of Cinema, Aesthetics and Narrative. The conception and application of this activity happened in the context of a clinical rotation in Addictive Disorders, within the scope of the psychiatry residency program

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in Portugal, that the authors of this article were completing at the time. Cinema, Aesthetics

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and Narrative was an initiative of the authors, as part of the activities to be carried out during this clinical rotation. Approval and supervision were fully obtained from the technical team

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of the institution where it was performed. Cinema, Aesthetics and Narrative was performed in a therapeutic community located

in Lisbon, Portugal, between February and April 2016. This therapeutic community’s mission is the treatment and psychosocial rehabilitation of patients with addictive disorders. It is a specialized unit for long-term residential treatment and uses a group treatment method, with a

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CINEMA, AESTHETICS AND NARRATIVE resident hierarchy and treatment phases. It has capacity for 21 residents, of both genders and coming from any geographical point of the country. The minimum age for admission is 18 years. The technical team is multidisciplinary, consisting of a psychiatrist, four psychologists, a nurse, and a social worker; also, the unit receives trainees regularly. Participants

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The inclusion criterion was to be a resident admitted to the therapeutic community at the time the therapeutic activity was performed. There were no exclusion criteria. All

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participants provided their written informed consent for the participation and use of the data obtained for scientific purposes, after a briefing session about the characteristics of the

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activity, its schedule and duration, the purpose of the notes and forms, and the extent of

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confidentiality of personal identification.

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A total of 17 residents participated in at least one of the sessions of the therapeutic

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activity (see Appendix A for demographic and clinical characteristics of the participants). The activity started with a group of 15 participants; two patients dropped-out because they

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abandoned the treatment in the therapeutic community and one patient participated only intermittently in the sessions; two patients were admitted to the community at the end of the activity, only participating in the final sessions.

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Instruments

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Movies. The movies’ selection took into account the objectives of the therapeutic activity, the narrative and aesthetic dimensions of the films, and the target population.

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Regarding the objectives of the therapeutic activity, we searched for movies that would: metaphorically appeal to the patients’ inner world and to the reflection on their previous life experiences, making them accessible and communicable to themselves and to the other; provide a safe and creative space for change; positively serve the expectations of the patients about their future.

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CINEMA, AESTHETICS AND NARRATIVE On the narrative and aesthetic dimensions of cinema, the authors looked for films that had significant narrative and aesthetic properties, and that way would: enable processes of identification; contain dynamic or changeable narratives and characters; allow patients to feel and experience through aesthetic attention, by means of image, soundtrack and text; help bring the aesthetic dimension into the therapeutic setting.

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Finally, the movies selection took into account the target population: remembering that everything that moves people may have potential harmful side effects, which were

film, in an attempt to favour a metaphorical therapeutic work.

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prevented, and avoiding a direct approach of substance use disorders in the content of the

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The selected movies were: Garden State (Director: Zach Braff, 2004), Eternal

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Sunshine Of The Spotless Mind (Director: Michel Gondry, 2004), Gravity (Director: Alfonso

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Cuarón, 2013), Catch Me If You Can (Director: Steven Spielberg, 2002), The Thin Red Line

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(Director: Terrence Malick, 2008), and Amélie (Director: Jean-Pierre Jeunet, 2001). The movie Garden State tells the story of a young man who returns to his homeland

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after his mother's death; throughout the film, a change occurs in the main character, from a state of initial apathy to one of life affirmation in the end; interpersonal relationships are essential to this transformation. With this movie the authors intended to address the issue of

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the internal emotional emptiness, as seen in addictive disorders, and the possibility to change

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to a life with meaning, as a result of the therapeutic process. Also, the relevance of relationships in life - family, friendship and love - its complexity, as well as its transforming

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properties, affecting overall well-being, the disease experience and the treatment process. Eternal Sunshine of the Spotless Mind tells the story of a company that erases bad

memories from people as a way to deal with situations that cause suffering; in relation to this, it also brings the story of a couple experiencing troubles in their relationship and how it’s possible to rediscover mutual understanding. With this movie the authors intended to

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CINEMA, AESTHETICS AND NARRATIVE particularly address the issue of recurring behavioural patterns, repeatedly leading to the same results, as frequently seen in people with substance use disorders. Also, the importance of change in order to achieve a different result, referring to the possibilities brought about by the treatment. Finally, the importance to think and elaborate on the suffering in opposition to erase it, for instance, with the substance misuse.

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Gravity tells the story of an astronaut who suffers a life-threatening accident in space; although the main character is in distress and disconnected from life at the beginning of the

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storyline, she eventually realizes she wants to survive and struggles alone in space to return

to Earth. The authors chose this movie because of its aesthetic elements and language, mainly

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the image and the intense soundtrack. Also, it was again intended to address the issue of

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losing the attachment to life and the possibility of rediscover the will to live, but emphasizing

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that the elements that cling people to life, and the potential to change, exist within each

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individual. Finally, the authors intended to explore the space experience as a metaphor for the importance of an outside perspective in this process of discovery and change, as it happens in

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therapy.

Catch Me If You Can is based on the true story of a young boy who runs away from his idealized parents’ house when they decide to divorce, and then successfully, but

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criminally, poses as an airplane pilot, a doctor and a lawyer, thus earning a lot of money;

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throughout the film there is a policeman who tries to catch him, but who ends up becoming a container figure and making reparation possible in this man’s life. With this movie the

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authors intended to approach the issue of idealization of significant figures and the consequences of living accordingly to the expectations of the others, in dialogue with the importance of interpersonal relationships as a place where individuals can find security, limits and identification figures.

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CINEMA, AESTHETICS AND NARRATIVE The movie The Thin Red Line tells the story of a group of soldiers and the way they live together a physically and emotionally intense war experience. With this film the authors intended to address the war experience as metaphor for the substance use disorder, one in which may occur a total loss of references, but also for the group treatment in the therapeutic community, referring to the strong connections between people that become possible and

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helpful within these intense and peculiar experiences. Also, because of its strong aesthetic

elements and the underlying idea that looking for beauty is simultaneously an important but

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complex task.

The movie Amélie tells the story of a young girl living in Paris; during childhood she

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was very protected by her father, leading her to a solitary life in which imagination and

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fantasy have come to play a fundamental role; one day she decides to help those around her,

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but along the way her actions start to return to her in a mysterious and beautiful way. The

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authors chose this movie because of its aesthetic elements, seeking to provide a lighter and pleasant atmosphere of experience during the film viewing. Also, because the film refers to

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the possibility of positive transformation, with emphasis on the function of repairing actions, which are important elements of the therapeutic process in substance use disorders. Evaluation form. In the last session, anonymously, participants completed a two-part

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self-completion evaluation form. The aim of this was to obtain the participants’ evaluation of

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the therapeutic activity. The first part of the form was quantitative, and the participants were instructed to respond to a total of 18 statements (see Appendix B for content) using a

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predefined range of options, according to their level of agreement with it: 1 (strongly disagree), 2 (disagree), 3 (somewhat disagree), 4 (neither agree or disagree), 5 (somewhat agree), 6 (agree), 7 (strongly agree). The second part of the form included a total of seven open-ended and free response questions (see Appendix C for content), urging the patients to share some of their personal reflections on the therapeutic activity.

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CINEMA, AESTHETICS AND NARRATIVE Procedure The conceptualization of the therapeutic activity took into account the theoretical framework and the hypothesis presented above, but also the therapeutic model of the therapeutic community where it was performed and the specific needs of the group of patients in the community at that time.

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An intervention in eight sessions was developed. The first session aimed to present the therapeutic activity to the patients; in this introductory session, a group dynamics was

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also performed, that is, a discussion group where several questions regarding cinema and

cinema-related experiences were posed and discussed with the participants. All participants

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completed a written informed consent at the end of this first session, in which all

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clarifications were given about the activity and the use of data for scientific purposes. Six

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weekly sessions were then performed: in each session the participants watched a movie, and

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later a discussion group was held on the same day; the fourth session included an additional narrative exercise, in which participants were urged to use their imaginations and to write a

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short text in relation to one of the scenes of the movie viewed on that session. A closing session was performed, with the aim of holding a final discussion group, and the completion of the therapeutic activity evaluation forms. The discussion groups were always moderated

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by two mental health technicians: one of the authors of this article, alternately, and one

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element of the therapeutic community technical team. In all these sessions, the other author, who was not moderating the group, was dedicated to taking handwritten notes about the

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verbal and non-verbal participation of each participant or moderator of the group. Data analysis Quantitative data were obtained from the first part of the therapeutic activity’s evaluation forms. It should be noted that only the forms of the patients who most assertively participated in the whole therapeutic activity were counted (N=12); that is, it was not possible

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CINEMA, AESTHETICS AND NARRATIVE to obtain the results of the two participants who dropped-out because they abandoned the treatment in the therapeutic community, neither of the patient who participated only intermittently in the sessions, and that the forms of the two patients who only participated in the final sessions of the activity were not counted. Qualitative data were gathered through participant’s free written answers to the

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second part of the therapeutic activity’s evaluation forms, the handwritten notes taken by the authors in each discussion group session, and other field notes taken by the authors during

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their participant observation, having the status of addiction therapy trainees during internship. It should be noted that, since about two months prior to the application of the therapeutic

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activity, the authors were already attending the therapeutic community daily, on working

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days, which made possible to develop a relationship with both the providers and the service

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users, and reduced any unease regarding the presence of both of the authors.

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The content of the qualitative data was analysed through thematic analysis (Braun & Clarke, 2006; Vaismoradi, Turunen, & Bondas, 2013) by an analytic team composed by the

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two authors of this paper, both medical doctors and psychiatry residents with previous experience in qualitative research methods. The authors began by transcribing the data, and initial thoughts and ideas were noted down. The data were then read and re-read several

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times, and then the authors advanced to the coding phase, trying to identify features of the

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data appreciated as pertinent to the aim of the therapeutic activity and the hypothesis in test. The next stage involved searching for themes; these explained larger sections of the data by

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combining different codes that may have been very similar or may have been considered the same aspect within the data. The authors used thematic maps to aid the generation of themes, as suggested by Braun and Clarke (2006), which helped to visualize and consider the links between themes and to take into account the biases that we brought to bear on our theoretical background. At this point the themes that did not have enough data to support them were

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CINEMA, AESTHETICS AND NARRATIVE placed aside. This refinement of the themes was first performed separately, first attending to the responses to the therapeutic activity’s evaluation forms and then to the field notes, trying to find a coherent pattern within each group of data, and then they were considered as a whole. Both authors coded the material independently and classified it and then discussed it together. Once a clear idea of the various themes and how they fitted together emerged, the

sentences from participants to illustrate elements of the themes.

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Results

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authors start defining and naming the themes. Finally, the authors chose examples of

Regarding the quantitative part of the therapeutic activity’s evaluation form, all

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patients (N=12) agreed or strongly agreed that they enjoyed participating in the therapeutic

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activity Cinema, Aesthetics and Narrative. The majority of the participants (n=11) agreed or

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strongly agreed that they believed this therapeutic activity benefited their overall therapeutic

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project, and that participating in this therapeutic activity gave them a sense of overall wellbeing. Two-thirds of participants (n=9) agreed or strongly agreed that the characters’

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narrative helped them think better about certain aspects of themselves, and that watching movies helped them to better understand certain feelings. Again, a great part (n=11) of participants stated that the music, the image, the text and the narrative of the films allowed

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them to experience aesthetic pleasure, and that participating in this therapeutic activity helped

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them to feel life as more rewarding. See Appendix B for the complete results of the quantitative part of the evaluation form.

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The thematic analysis of the qualitative data led to four main themes that seem to be

essential in this group of patients regarding the therapeutic activity. These have been labelled as Narrative, Treatment, Hope, and Aesthetics. The narrative dimension existing in the therapeutic activity was the one that most stood out in the results. In the Narrative theme, the authors included aspects related to the

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CINEMA, AESTHETICS AND NARRATIVE identification to the narrative elements of the film - characters, situations, life stories, transformations and re-directing the stories, or finding new perspectives - including narrative elements present in the multiple languages of cinema, such as images, sound and text. About this narrative dimension of cinema, and by way of example, participants stated that “I identified a lot [with some movies] and I went back to my past, I asked myself questions, I

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answered others I already had in my head, I learned to look more widely at the things in life”, “I identified with the characters and transported their stories to my own life story”, “several

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times I identified with the characters”, and “starting to feel and understand things made me

think about what I did and what I want to do now: different and better". In every discussion

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group, direct identifications appeared in relation to the experiences of the characters: one

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participant, about the Amélie movie, addressed the subject of emptiness that he identified

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with: “the emptiness is there… she [the main character] tried to fill it with the lives of

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others”. Other participants validated this statement: “when I stopped working, I was totally lost… because the void was there”. In the film The Thin Red Line, a participant identified

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“with [the] distress and [the] despair”, and other said that “the madness that sets in [describing a scene of violence in the movie] moments that keep us away from the divine ... like the madness of wanting the drug”. In the same movie, the participants also used the

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metaphor of war to describe their own path of suffering: “it is a time to survive [the war]… in

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my life I also tried to survive... and the line that separates despair and life is really very tenuous… when you are there, you question everything… if it will return to be as it was ... if

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you will feel certain things again”. Other patients identified similar feelings after watching the movie Catch Me if You

Can, in which two participants were moved by the arresting scene of the main character; one of these participants said “I also felt like that before: a frightened and distressed child”. Other identified to the same character, stating that “[the drug use was] an escape from facing

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CINEMA, AESTHETICS AND NARRATIVE reality, not to have to decide, just as he [the main character] ran away so he did not have to decide about his parents”. In the various narratives present in the information analysed, subjects associated with interpersonal relations often arise, which is also in agreement with the existing literature on the therapeutic benefits of cinematherapy (Eğeci & Gençöz, 2017). For example, in the group

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discussion of the movie Garden State, some participants mentioned the feeling of guilt

associated with a loss and how this may affect relationships; on the other hand, in the group

fear of connecting with the other and then “getting tired”.

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discussion of the film Eternal Sunshine of The Spotless Mind, other residents reported to the

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The other theme more consistently found in the data analysis was Treatment, meaning

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all the elements that valued group treatment in the therapeutic community as well as the

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global therapeutic project, for example by facilitating the process of getting to know and

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connect to other participants and technical team members, and by facilitating the therapeutic work and the connection to the treatment process itself. This theme is also related to the

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appreciation of the treatment process in a way that is positive; and to the cinematherapeutic activity being seen as something that benefits the global therapeutic project. Beyond what the authors had foreseen, in all the discussion groups several analogies appeared with the

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therapeutic process, from the decision to initiate a treatment to the therapeutic interventions

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of the therapeutic community, and even to the symbolic and transitive moments of the project of each one. Several metaphors emerged from the films, many of them closely related to a

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global therapeutic project designed for each resident. A significant example was the metaphor proposed by one of the elements of the therapeutic team during the discussion of the film The Thin Red Line, referring to the ascent of the mountain by the soldiers as an analogy to the therapeutic process that is done in the therapeutic community: “to reach the top of the mountain, the hard trek to climb... the obstacles, the difficulties, those who are staying on the

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CINEMA, AESTHETICS AND NARRATIVE path... in hardness... the humanity that is discovered… the strength of a look... even in the enemy… the look of being human”. Another important metaphor came from the movie Eternal Sunshine of The Spotless Mind, with one of the participants suggesting that the treatment process is the discover of new connections, as in the film the mother memory is extinguished and the characters are forced to find new connections. One aspect that was also

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included in this theme was the feeling of greater connection with the other participants and with the elements of the technical team; relating to this, one participant stated that "I got to

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know other residents better… this activity helped me to expose myself to the group and the technicians”; another patient added that “it was also an opportunity for the group to get to

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know me better and for me to get to know them, to feel more at ease in talking and exposing

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my emotions”.

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Regarding the contribution of this therapeutic activity in the way the future is

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understood and perceived, participants stated that “there have been moments in some of the films that I found myself imagining the future with a stable life”, “I really enjoyed the hope

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that the films transmitted”, “some of the films influenced me to look for a more pleasant way of living”, and that “this activity has helped me to simplify the way I look at life and to value a little more who I am and what I want”. These and many other statements throughout the

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discussion groups and in the written responses on the evaluation forms have surprisingly led

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to the categorization of the theme Hope as one of the most important in the analysis performed, meaning the hope that the future may be different and better. Although the

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authors did not expect this to be one of the main themes, the truth is that, as suggested in the literature and previously discussed in the introduction of this text, hope seems to be an important element in the choice of films with therapeutic impact, which is reinforced by the words of the participants in this therapeutic activity. However, unlike the themes Narrative and Treatment, that appear in all the films and their respective discussion groups, and also in

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CINEMA, AESTHETICS AND NARRATIVE the global context, the theme Hope is mentioned in relation to the global activity and mainly related to the movies Garden State and Gravity. The same is true for the last theme that emerged from the thematic analysis, Aesthetics. This theme refers to the identification of aesthetic, meaning beautiful, elements of the films, and to the pre-reflective experiences of positive emotions and reactions to things in

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the ambience. For example, the way the participants saw some movies or reacted to some

scenes or moments, not always measurable in their answers to the evaluation forms, but more

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in the field notes of nonverbal aspects. This theme is mentioned by the participants in the

overall appreciation of the activity and also in their reflections on concrete films, especially

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The Thin Red Line, Gravity and Amélie. Regarding the overall activity, the authors highlight a

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patient’s statement that “[participating in the therapeutic activity] awakened in me very

A

pleasant sensations”, and that another participant wrote that “I paid much more attention to

M

details, landscapes, images and movement, songs… it was quite different". With the film Gravity, several aesthetic experiences were mentioned, expressions like "space” and “beauty"

TE D

often appeared, and several images of the film were used either to refer to concrete experiences of the participants - one participant stated that the intensity of the soundtrack in one of the movie scenes reminded immediately of a previous drug overdose experience - or

EP

metaphors - two participants highlighted one of the movie’s frames, a image of the main

CC

character in fetal position resembling an embryo, as an analogy to the symbolism of being reborn through therapy. Other example indicated by another patient was invoked by the re-

A

entry into the Earth’s atmosphere scene, in which the vessel disintegrates: "I associated the vessel with me... with the feelings that are released ... leaving the old load… to carry only what is needed". In the movie The Thin Red Line the aesthetic experience was also very present, with participants stating that "the invoking of the nature ... the beautiful!" or "an image that is worth everything". In the film Amélie it was also possible to verify the

20

CINEMA, AESTHETICS AND NARRATIVE description of aesthetic experiences by the participants, for example in statements like "it was very good, I felt very good ... very beautiful music" or "an extremely beautiful film". In addition to the four main themes extracted from the data thematic analysis, there are some aspects that, although not so predominant, seem to deserve reference. One of them is the viability of the emotional expression referred to in the theoretical introduction of this

IP T

study and which was also spontaneously mentioned by several participants. In concern to the relation between the viewing of the films and the emotional expression, a participant stated

SC R

that “[this therapeutic activity] contributed to make me feel more connected to what I feel,

which is usual difficult for me”; others reported that “I felt varied forms of different feelings

U

from film to film”, and that “this activity helps me to feel more connected to what I feel”.

N

Another aspect referred to globally by almost all participants was the possibility of

A

“viewing the films in a different way”; one participant wrote that “my appreciation [of the

M

therapeutic activity] is very positive, because through it I was able to see films that I had already seen in a completely different way… with other eyes… to identify myself with many

TE D

attitudes, behaviours of the characters”; others added “I especially liked that, at the end of each one of them [the movies], I had the opportunity to reflect on them” and “expressing is different, from feeling to speaking is different”, referring to the importance of the discussion

EP

and reflection about the film for its therapeutic action, as it was also recently shown by Eğeci

CC

and Gençöz (2017).

Discussion

A

The main goal of the current study was to examine the experiences that the

participants had while watching and reflecting on the assigned movies, and to determine the main therapeutic elements identified by this group of patients with substance use pathology, placing as hypothesis the importance of the narrative and aesthetic dimensions of cinema.

21

CINEMA, AESTHETICS AND NARRATIVE The results of this work are in agreement with those described in the literature, favouring the use of art mediators in therapeutic settings. This type of therapy evokes the possibility to patients express themselves through a non-verbal and creative way, not only creating art, but also interpreting and contemplating established works of art (Aletraris et al., 2014; Feen-Calligan, Washington, & Moxley, 2008). As suggested above, both in the mental

IP T

processes evoked by the sessions and in the results of the therapeutic activity evaluation

forms, this exploratory work highlights the therapeutic benefit of choosing an art mediator as

SC R

cinema. It seems to allow patients to better access their own internal experience, giving them the chance to rediscover parts of them, still alive and fulfilled with meaning, as opposed to

U

the emptiness feelings frequently found in the experience of people with addictive pathology.

N

In fact, although there are few studies on the use of cinematherapy in addictive and substance

A

use disorders (Poltrum & Leitner, 2009; Pur, 2009), we can find others with favourable

M

results applied to patients with pathologies as anxiety (Dumtrache, 2014), eating disorders (Gramaglia et al., 2011) and depression (Bowen, 2006).

TE D

As pointed out in results, the theme of Narrative was the most evident in all data analysis, so the authors chose to contextualize the elements that are thought to be associated with the therapeutic potential of narrative interventions. A narrative is the dimension of

EP

meaning in building a story, which underlies the relation between culture and experience

CC

(Good, 1994). It is important every time we want to tell a story; thus, it describes events from the perspective of the present moment, never being complete, having a plot and seeking that

A

meaning within a particular explanatory logic (Good, 1994). The main advantage of narrative therapies is to create a humanized consideration of

suffering. Also, narrative therapies may contribute to clarify the systemic origins of problems (Russell & van den Broek, 1992; Witztum & Goodman, 1999), and allow identifying potential paths of change, to reconstruct history in another direction (White & Epston, 1990;

22

CINEMA, AESTHETICS AND NARRATIVE Witztum & Goodman, 1999). Through narrative, individuals construct a morally valued and conceptually coherent identity and sense of self (Kirmayer, 2000, p. 3); when reconstructed, narrative exerts effects that move backward in time to reshape memories (Kirmayer, 2000, p. 3). In fact, narratives are the principal means to integrate alterity into autobiographical memory, combining personal experiences into a coherent story related to the self

IP T

(Stanghellini, 2017, p. 1-2). They may allow us to articulate the motives for our dispositions and character, as well as the meaning of the events that we encounter in life, helping to

SC R

unfold the dynamics of our identity (Stanghellini, 2017, p. 23). Thus, in the narrative aspect of cinema, it is intended that the entanglements and the stories of the characters allow

U

processes of identification by the individuals, enabling the creation of metaphors that best

N

suit the history of each one, and allowing each individual to externalize his own experience in

A

order to understand it and reflect on it. The expressions of the participants presented in the

M

results section clearly show how these processes occurred during this activity. As Ricoeur (1997) has shown, metaphor is literary work “in miniature” (Kirmayer, 2000, p. 4), and even

TE D

a few words can invoke “a whole conceptual space or world” (Kirmayer, 2000, p. 4), presenting narrative possibilities that can be extended to create more complex stories. “A person is what we are (e.g., our past), but also how we make sense of what we are through the

EP

stories we tell about ourselves, and who we want to become (our project)” (Stanghellini,

CC

2017, p. 24). The narrative power that can be transmitted in cinematographic poetry can certainly allow not only emotional reactions, but also identifications and metaphorical

A

processes capable of allowing a reconciliation with alterity imposed by the events present in the life of a patient with a substance use disorder. Through identification with the narratives transmitted in the movie viewing and reflection, patients can be aware of how they came to such behaviour dispositions, instead of merely accepting that, in the end, this is just how they

23

CINEMA, AESTHETICS AND NARRATIVE are. This may allow a work to build a sense of events involving the body, the world and other people, and meaningfully integrate it in their personal identity (Stanghellini, 2017). We can say that in cinema there is an emphasis on images and fragments, rather than on extended narratives, reflecting more closely the basic vision of everyday thinking “as rooted in poetic refigurations of the world” (Kirmayer, 2000, p. 26).

IP T

It is also added that, for the authors' understanding, the narrative dimension of cinema exists in close relation with its aesthetic dimension, as manifested in the words of Ferreira

SC R

(2004) in his book on the poetics of cinema: “Even when disconnected from the word, in

particular the sung word, music has its own process of producing meaning” (Ferreira, 2004,

U

p. 100). This observation may also be related to the not so obvious manifestation of aesthetic

N

phenomena in the thematic analysis carried out, which may be related to the less explicit and

A

pre-reflexive nature of aesthetic experience.

M

Another aspect that places cinema as a stream of narratives and metaphors relates to its symbolic language as transitional phenomena (Winnicott, 1958): not only through the

TE D

powerful experience that mediates between reality and imagination/fiction, in analogy to an intermediate domain similar to the playful world of children (Witztum & Goodman, 1999); but also as a symbolic space, which allows the metaphorical expression, indicator of the core

EP

emotional meaning of the narrative (Meichenbaum, 1995; Witztum & Goodman, 1999).

CC

These metaphorical and symbolic aspects made possible by cinematherapy, above all in the reflexive component embodied in the discussion groups, were mainly evident in the

A

results presented in one of the primordial themes enabled by the thematic analysis, Treatment, being one of the unexpected and significant results of the data analysis performed. This result may be important if we consider the reinforcement of the overall therapeutic project that could be made possible by an activity such as cinematherapy in the context of a

24

CINEMA, AESTHETICS AND NARRATIVE treatment plan directed towards the treatment of addictive behaviours, namely in the setting of a therapeutic community context. Another theme that deserves our best reflection, especially since it was an element predicted by the authors as relevant for the therapeutic effect of cinematherapy in the context of substance use pathology, is the aesthetic dimension of cinema. Aesthetics, although treated

IP T

by so many authors from antiquity under different denominations, is a term first proposed by Baumgarten in 1750 (as cited in Ferreira, 2004), deriving from the Greek word aesthesis,

SC R

meaning sense-perception. Baumgarten defined it as the science of sensitive cognition

(Baumgarten, von Mirbach, & Meiner, 2009). Aesthetics is still very neglected in the field of

U

philosophy of medicine today (Musalek, 2010, p. 1). However, we can say that modern

N

conception of aesthetics does not only deal with works of art, but to a great extent also with

A

what is beautiful, or ugly, in the natural reality, of our daily life (Musalek, 2010, p. 2). It is,

M

therefore, part of the lived experience of the human, in its relation with the world, in its relationship with others and in the relation of the Self to itself (Ferreira, 2004). Thus, the

TE D

aesthetic experience, in its various manifestations, among which is the filmic, is part of a more or less ritualized daily practice, and also involves affective and experiential levels that involve the body of each of us (Ferreira, 2004, p. 15).

EP

In medicine, and particularly in psychiatry, aesthetics is mainly concerned with

CC

interpersonal behaviour and the atmospheres in which behaviours manifest themselves (Musalek, 2010, p. 2). And its use presupposes the idea that aesthetics elements are always

A

present and relevant (Jacobsen, 2010; Munt & Hargreaves, 2009; Musalek, 2010), even if the patient or the clinician are not aware of it. In this sense, it is possible to become more aware, and cultivate and intensify the aesthetic perception in the clinical encounter. And therefore, the main use of aesthetics in a medical and therapeutic program is through the creation of aesthetic situations (Musalek, 2010), helping to bring this dimension into the clinical

25

CINEMA, AESTHETICS AND NARRATIVE encounter (Costa, Carmenates, Madeira, & Stanghellini, 2014). We emphasize that, in addictive disorders, the major reason underlying therapeutic failure is actually low adherence rates to treatment programs (Musalek, 2010, p. 1). Some studies have pointed out that perhaps one of the reasons for this is that the aims and forms of treatment are not attractive enough (Miller & Miller, 2009; Musalek, 2010). This leads to the idea of reorient treatment

IP T

programs from methods based on resistance and perseverance to programs focused in

overcoming, and re-encounter with beauty. In fact, many people with addiction disorders

SC R

suffer from a lack of opportunity for the aesthetic experience; in other words, a lack of

contact with experiences such as fascination, enthusiasm, sublime, moving and beautiful

U

(Musalek, 2010, p. 4). Then, the purpose of this type of therapy, such as cinematherapy, is

N

also to provide creative opportunities to people, so that they can enjoy a happy, fascinating

A

and appealing life, in such a way that the addictive behaviour loses its seductive power

M

(Musalek, 2010, p. 5). It was also on the basis of these assumptions that the authors chose the films. The thematic analysis of the data obtained was not as consistent for the theme of

TE D

Aesthetics as for the theme Narrative, possibly not only to a greater difficulty in measuring aesthetic experiences, but also to the fact that they are not so clearly present in all the films. However, the results presented, not only in the thematic analysis of qualitative information

EP

but also in the more quantitative results of the questionnaires, point to an impact of these

CC

aesthetic experiences on the overall experience of the participants in the proposed activity. One last note for the fourth theme found in the thematic analysis performed, Hope. In

A

fact, although this component was theoretically predicted to be significant in the choice of films made by the authors, the preponderance of this experience in the participants' descriptions was an unexpected result, but it seems to the authors of significant importance, specially if we consider the relevance of these elements in the therapeutic path of the patients with substance use pathology.

26

CINEMA, AESTHETICS AND NARRATIVE Throughout the sessions, the authors found that cinema appears as a language of possibilities in the therapeutic group setting. Movies appealed to the participants’ inner world and to the reflection on their previous life experiences, taking them to talk and elaborate on their thoughts, feelings and life stories. Also, cinema enabled a safe and creative mediation between the patients’ past and present experiences, including those related to the substance

IP T

use disorder and the treatment, and contributed to the participants´ expectations about their future in a hopefully and positive way.

SC R

Limitations and Implications for Future Research

The work described in this paper is exploratory, aiming to substantiate and contribute

U

to future research on the use of cinematherapy interventions in patients with substance use

N

disorders. Therefore, future research investigating the efficacy of these interventions should

A

be systematic, and would benefit of a larger number of participants and of using an enhanced

M

study design. Recording of the discussion sessions, with subsequent transcription, and application of an evaluation form in each of the sessions are two elements that seem essential

TE D

to the authors, and which were not carried out in this study, since the activity was designed with a therapeutic intent and considering the particular characteristics of the group of participants. The unavailability of a comparison group, varied enrolment time and the

EP

absence of a follow-up period are also limitations of this work that should be addressed in

CC

further studies.

Conclusions

A

The possibilities provided for the use of a multidimensional mediator, such as cinema,

may be helpful within the therapeutic work in patients with substance use disorders. This may happen not only by narrative means, but also by the hope and the aesthetic opportunity provided by the film visualization. On the other hand, movies seem to help clarify treatment paths and metaphorically help do link the patients to the therapeutic process. Further study is

27

CINEMA, AESTHETICS AND NARRATIVE needed to evaluate the cost-effectiveness of therapeutic interventions using cinema in patients

A

CC

EP

TE D

M

A

N

U

SC R

IP T

with substance use disorders.

28

CINEMA, AESTHETICS AND NARRATIVE References Aletraris, L., Paino, M., Edmond, M. B., Roman, P. M., & Bride, B. E. (2014). The use of art and music therapy in substance abuse treatment programs. Journal of Addictions Nursing, 25(4), 190–196. Antonovsky, A. (1987). Unraveling the mystery of health. How people manage stress and

IP T

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German in 2 volumes [in German]. Hamburg: Meiner.

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Baumgarten, A.G., von Mirbach, D., & Meiner, F. (2009). Ästhetik. Aesthetics. Latin–

Bowen, E. E. F. (2006). The power of film: A model for the use of group cinematherapy in the

U

therapeutic treatment of clinically depressed adolescents (Unpublished Master

N

thesis). University of New Hampshire, New Hampshire.

A

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research

M

in psychology, 3(2), 77-101.

Clotas I Perpinyà, J., & Florenza I Canals, J. (2012). Cine: autoconciencia e identidade.

TE D

Almería: Editorial Círculo Rojo.

Costa, C., Carmenates, S., Madeira, L., & Stanghellini, G. (2014). Phenomenology of atmospheres. The felt meanings of clinical encounters. Journal of Psychopathology,

EP

20, 351-357.

CC

Dermer, S. B., & Hutchings, J. B. (2000). Utilizing movies in family therapy: Applications for individuals, couples, and families. The American Journal of Family Therapy,

A

28(2), 163-180.

Di Petta, G. (2014). Psychopathology of addictions. Journal of Psychopathology, 20, 471– 479. Dumtrache, S. D. (2014). The effects of a cinema-therapy group on diminishing anxiety in young people. Procedia-Social and Behavioral Sciences, 127, 717-721.

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CINEMA, AESTHETICS AND NARRATIVE Eğeci, İ. S., & Gençöz, F. (2017). Use of cinematherapy in dealing with relationship problems. The Arts in Psychotherapy, 53, 64-71. Feen-Calligan, H., Washington, O. G., & Moxley, D. P. (2008). Use of artwork as a visual processing modality in group treatment of chemically dependent minority women. The Arts in Psychotherapy, 35(4), 287-295.

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Ferreira, C. M. (2004). As poéticas do cinema: a poética da terra e os rumos do Humano na ordem do fílmico. Porto: Edições Afrontamento.

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Good, B. J. (1994). Medicine, rationality, and experience: an anthropological perspective. New York: Cambridge University Press.

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Grafl, F. (2008). Lust am Schauen & Freude am Lesen? Zur Rezeptionsästhetik zweier

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Gramaglia, C., Abbate-Daga, G., Amianto, F., Brustolin, A., Campisi, S., De-Bacco, C., &

M

Fassino, S. (2011). Cinematherapy in the day hospital treatment of patients with eating disorders. Case study and clinical considerations. The Arts in

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Psychotherapy, 38(4), 261-266.

Hesley, J. W., & Hesley, J. G. (1998). Rent two films and let’s talk in the morning: using popular movies in psychotherapy. New York: Wiley.

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Jacobsen, T. (2010). Beauty and the brain: culture, history and individual differences in

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experience. In C. Mattingly & L. Garro (Eds.), Narrative and the cultural construction of illness and healing (pp. 153–180). Berkeley, CA: University of California Press.

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CINEMA, AESTHETICS AND NARRATIVE Mangin, D. (1999). Cinema therapy: How some shrinks are using movies to help their clients cope with life and just feel better. Health and body. Retrieved from http://www.salon.com/health/feature/1999/05/27/film_therapy/index.html. Meichenbaum, D. (1995). Changing conceptions of cognitive behavior modification. In M. J. Mahoney (Ed.), Retrospect and prospect in cognitive and constructive

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psychotherapies: theory, research and practice (pp. 20-26), New York: Springer. Miller, P.G., & Miller, W.R. (2009). What should we be aiming for in the treatment of

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addiction? Addiction, 104, 685–686.

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in Psychotherapy, 10(4), 251-260.

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Analysis, 17(4), 285-295.

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Psychiatry, 23, 530–535.

Poltrum, M., & Leitner, R. (2009). Existenzanalytische Kinotherapie Filme als Balsam der Seele. Wiener Zeitschrift für Suchtforschung, 32(1), 47-52.

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Pur, Ġ. G. (2009). Cinematherapy for alcohol dependent patients (Unpublished Master

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CINEMA, AESTHETICS AND NARRATIVE Schulenberg, S. (2003). Psychotherapy and Movies: On using films in clinical practice. Journal of Contemporary Psychotherapy, 33(1), 35-48. The Anton Proksch Institute’s Orpheus Programme. (2015). http://api.or.at/PDF/161108_eng_130_Informationsblatt_Orpheusprogramm_S.aspx. Accessed 3 January 2016.

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sciences, 15(3), 398-405.

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Witztum, E., & Goodman, Y. (1999). Narrative construction of distress and therapy: a model based on work with ultra-Orthodox Jews. Transcultural Psychiatry, 36(4), 403-436.

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Wolz, B. (2005). E-motion picture magic. A movie lover’s guide to healing and transformation. Centennial: Glenbridge Publishing Ltd. Zur, O. (2005). Cinema therapy: Harnessing the power of movies for therapeutic gain.

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Retrieved from http://www.zurinstitute.com/cinematherapy_clinicalupdate.html

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CINEMA, AESTHETICS AND NARRATIVE Appendix A Demographic and clinical characteristics of the participants in the therapeutic activity Cinema, Aesthetics and Narrative (N=17) Variable

n

%

Male

9

52.9

Female

8

SC R

Age

IP T

Gender

30-39

47.1

4

23.5

9

52.9

4

23.5

1

5.9

6

35.3

7

41.2

3

17.7

10

58.8

7

41.2

F10 - Mental and behavioural disorders due to use of alcohol

8

47.1

F11 - Mental and behavioural disorders due to use of opioids

1

5,9

F19 - Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances

8

47.1

40-49

U

50-59

N

School years completed ≤ 4 years

A

5-9 years

M

10-12 years

Marital status Single Divorced

TE D

>12 years

A

CC

EP

Current diagnosis (using the ICD-10 criteria)

33

CINEMA, AESTHETICS AND NARRATIVE Appendix B Content and complete results of the quantitative part of the evaluation form of the therapeutic activity Cinema, Aesthetics and Narrative (N=12) Level of agreement

Disagree (n)

Somewhat disagree (n)

Neither agree or disagree (n)

Somewhat agree (n)

Agrees (n)

Strongly agree (n)

Null or invalid answers (n)

I enjoyed participating in the therapeutic activity Cinema, Aesthetics and Narrative

0

0

0

0

0

4

8

0

I feel that the therapeutic activity has benefited my overall therapeutic project

0

0

0

0

1

8

3

0

Participating in the therapeutic activity has given me a sense of well-being

0

0

0

0

5

6

1

I have identified with the characters of the films included in the therapeutic activity

0

0

0

0

4

4

4

0

I have identified with the characters’ stories

0

0

0

1

3

4

4

0

The characters’ narrative helped me to recognize certain aspects of myself

0

0

0

1

1

9

1

0

The characters’ narrative helped me to think better about certain aspects of myself

0

0

0

0

3

6

3

0

The therapeutic activity allowed me to show aspects of me to the other patients

0

0

0

0

2

6

3

1

The therapeutic activity allowed me to get to know better the other patients

0

0

0

2

3

5

2

0

Watching the included movies

0

0

0

0

3

3

5

1

U N A

0

M

TE D

EP

CC

A

SC R

Statement

IP T

Strongly disagree (n)

34

CINEMA, AESTHETICS AND NARRATIVE

in the therapeutic activity helped me to feel 0

0

0

0

3

7

2

0

I was moved by the the films included in the therapeutic activity

0

0

0

1

1

4

6

0

Watching the movies brought me hope

0

0

0

0

1

8

3

0

Watching the movies helped me to value positive experiences and emotions

0

0

0

0

2

4

6

0

The music, the image, the text and the narrative of the films allowed me to experience beauty

0

0

0

0

1

4

7

0

Participating in the therapeutic activity helped me to feel life as more rewarding

0

0

0

0

1

9

2

0

Participating in the therapeutic activity helped me feel more involved with life

0

0

0

0

3

6

3

0

Participating in the therapeutic activity opened up my life and meaning possibilities

0

0

0

6

2

4

0

SC R

U

N A

M

TE D

EP CC A

IP T

Watching the movies helped me to better understand certain feelings

0

35

CINEMA, AESTHETICS AND NARRATIVE Appendix C Content of the questionnaire of the qualitative part of the evaluation form of the therapeutic activity Cinema, Aesthetics and Narrative

What is your general reflection about the participation in this therapeutic activity?

IP T

Do you consider that this activity contributed to or influenced the way you have thought about the events of your life?

making, change and re-encounter of meaning in your life?

SC R

Do you consider that this activity may have led to some hope for the possibilities of decision

U

Has there been any aspect of this activity with which you have not identified or caused

N

displeasure?

A

What movie did impact you the most? Why?

M

Have you ever seen any of the movies included in this activity? If so, do you consider that the experience of reviewing them in this activity was different or similar? Why?

A

CC

EP

TE D

What suggestions would you make to improve this activity?