Rebecca Walters, MS, LMHC, TEP
Hudson Valley Psychodrama Institute
New Paltz, NY
Dr. Baile: We're very gratified to have with us today Rebecca Walters who is a psychodramatist. So, you'll be hearing some different kind of stuff today, and director of the Hudson Valley Psychodrama Institute in New Platz, New York--New Paltz. Paltz 'cause Platz is something different. And, Rebecca is trained both as a mental health counselor and a creative arts therapist, as well as being certified as a--as a trainer, educator and practitioner in psychodrama. And, she's a fellow of the American Society of Group Psychotherapy and Psychodrama, and in 2010 received a Hannah Weiner Award for exceptional service to that organization. So, Rebecca travels around the world teaching people how to do psychodrama and using psychodrama techniques which she's going to be talking about today also called "action techniques" because instead of talking about things, she'll show what they look like and involve people to participate in some of the enactment of scenarios. So, we'll have a little bit of video to show you today also. So, Rebecca notably has served on the faculty of Gerry Spence's Trial Lawyer College. I know you've never heard about that probably but there is a college in Wyoming run by a very famous attorney, Gerry Spence, and he brings other attorneys there to learn how to use some of the techniques we'll be talking about in preparing witnesses for depositions and for trial and for selecting juries. So, it's all a very interesting kind of stuff. Rebecca has been working with us for the past two and a half years in conducting workshops using action techniques to teach communication skills, difficult conversations, how to resolve conflicts, how to talk to someone about their performance. So, today she's going to talk about some of these topics and she will show a little bit of video and maybe sort of do little exercises. And so, the title of her talk today is "Action, Methods in Developing Communication Skills". Rebecca, thank you for coming all the way down. By the way, Rebecca has had only about four hours of sleep because she got hung up in the thunderstorms along the East Coast. So, she was riding through Atlanta and got here at 3 AM. So, we especially thank her for doing this.
Rebecca Walters: Good. Well, first of all thank you for coming. Before I begin, I'm just wondering how many of people in this audience have been to the workshops that Dr. Baile [phonetic] and I had been doing for the last two years? Good, okay. Well, it's nice to see some familiar faces. So, really what this talk is about is why action methods. People who are working at cancer settings has many, many high stake interviews. You yourselves I'm sure have been involved with just that dealing with angry patients, giving bad news, dealing with one another over conflicts. The urgency of making sure the team functions well, talking to patients about clinical trials and other treatments, these are a myriad of high stake conversations that occur on a daily basis in a system like MD Anderson. How many of you received any training before you got to MD Anderson on how to communicate effectively? A smattering of hands. And yet, we all know that communication makes or breaks the kind of things that happen around here. There's been a lot of research that says that doctors who communicate well don't get sued as often as doctors who don't communicate well. You've all read that. That's been in popular press, right? Those of you who are nurses and social workers and patient advocates know the importance of communication. And yet, we really don't teach people very adequately how to do it. It leaves people floundering for what to say. For example, when a patient asks, "Well, how long do I have to live?" I'm sure that question gets asked around here a great deal. But most of you had not been taught effective ways of handling that question. Now, I know that doctors get communication skills training through various ways. I don't know whether or not it's true in other professions. They're given papers to read about communication but this has not been proven terribly effective because it doesn't allow for practice. They might--this may--they may discuss cases and if they're lucky, they have someone they can discuss the case with freely and openly. But that doesn't actually teach the skills. They may get some advice but it's not the same thing as having a chance to practice. Trainees may be supervised at a patient's bedside but once again, that allows your practice but it allows your practice in a--not in a very safe format because they're being observed often by the attending physician in the case of this fellow, or supervisor in the case of a nurse trainee or an employee, and because it's a very high stake situation. Most of us do not do our best when we're highly anxious, such as when our superior standing next to us taking notes and judging us. Yeah? Would you agree with me about that? That doesn't lead to feeling at ease and doing our best. Most people agree--would agree that actual practice is highly important in developing effective communication with--yeah? Thank you.
Without practice and coaching or feedback, one has no idea if one is communicating effectively, nor how to correct what they're doing. Now, one of those common methods of--that allows for practice is the use standardized patients or actors with scripts and then the student is coached while interacting with them. How many of you have experienced that, having standardized, working with standardized patients? Okay. So, is it clear what I'm talking about? You know about standardized patients? They hire an actor and they prepare them. And then they walk into a small group who work on communicating with them and a--and a senior person is coaching them. Well, it does give people a chance to practice but there are some downsides to it. The first is that it's extremely expensive. You have to pay somebody not only for their acting time, meeting with the students but you have to pay them for their preparation time. You have to prepare scripts. So, it's both costly and time consuming. And you could only reach a very small group of people because these are done in small groups with about 6 to 8 students at a time. With standardized patients, you also only get to practice on a limited number of issues. So, for example if your patient if what--people want to learn is how to deal with someone who is getting very distraught over being told there is no more clinical trials for them. That's what the students learn. They don't necessarily get given the skills to take that learning and generalize it to other situations. So, they don't get taught universal strategies of good communication; strategies that can be generalized, okay? Recently, in the last couple of years here at MD Anderson, we have been spearheading the use of action methods that come from psychodrama and sociodrama to teach these skills. Action methods make all the difference. They offer a way of learning skills needed to address difficult conversations, skills that get trans--can be transferred from one situation to another. I want to give you a little history of psychodrama so you understand its context. It was developed by a man named Jacob Levy Moreno who went to medical school in Vienna in the early part of the 20th century. He came to the United States in 1926 and he developed the idea of psychodrama. Psychodrama is a combination of the word psycho and drama. Psycho does not mean crazy. It's means the soul. So psychodrama means drama of the soul or drama of the mind. He believed that the ideal place to do therapy was in situ so that if you're having a problem in the family, that's where you do therapy. If you're having a problem in the workplace, that's where you address the issues. This was hugely--he was a huge forerunner to what happened in the psycho--psychotherapeutic arena in the late 20th century.
He developed psychodrama which is a way of using group members to enact situations in someone's life. And he--he did that when it would not be safe to do the work in actual placement. So, for example, if you're having a problem in the family, he said that's where you do family--family therapy. And--but if you can't because people are dead, they're absent, it's not safe, you use psychodrama. If you're having a problem in the workplace, the ideal thing is to address it with the people you're having problems with. However, I use--select this--my example, I used to give when I worked in the psychiatric hospital is if I told my boss what I really thought, I'd--I'd lose my job, right? So, but I could do it in a psychodrama state. So, that's why psychodrama was developed for, okay? It would give the participants an opportunity to achieve catharsis of bad reaction and emotional venting, but it would also offer what we call catharsis of integration, a chance to try out new behaviors that incorporate learning what happened in the psychodrama. So, the goal is not to just express yourself, the goal is to try to figure out how to be more effective which is what we bring to--to the work we're doing here.
Moreno had a huge influence on the field of psychology and sociology. He actually coined the word "psychotherapy". He invented something called sociometry which is the measurement of connections between people in a group which has been taken over by the sociology world. Many of the founders of various schools of psychotherapy trained with him or came and observed him. Virginia Satir who's the mother of family therapy watched him work, Eric Berne who developed transactional analysis that has its roots in psychodrama, Fritz Perls who is the father of Gestalt therapy who everybody thinks invented "empty chair" technique. Right before he died, he wrote a letter to Life Magazine where he gave credit to --to Moreno for developing the "empty chair" technique. Moreno was very interested in spontaneity and creativity and it gave birth to what we call spontaneity training. One person who attended a lot of his spontaneity training workshops was a man named Allen Funt. Okay, people know. And so Allen Funt went away from those experiences and developed something called Candid Microphone because this was in the '40s and which turned into Candid Camera. Moreno believed we could train people to be spontaneous. We could train people to be more adequate in their responses to situations. Psychodrama is used in many venues, not just psychotherapy. That's what it's known for the most but it's also used in--in industry and skill training and education. Now, if you can think back to your own experience in elementary school, the very best teachers most of you probably had aside from being kind and confident, also integrated drama into their classrooms or action into the classroom. I--I remember my daughter's third grade teacher was teaching about electricity. Now, I'm not a science person. I'm an artsy-fartsy kind of person. So, when I had to study--electricity when I was in high school, I didn't get it. Well, this teacher is doing wonderful. She had all the kids stand in a big circle and hold hands and be positive and negative and pass electricity around the room and then she had someone be a breaker. And I finally got it at the age of 47 at the time, alright? Because she did it in action and good teachers have always known that the more you put into action, the more people remember. My daughter--my daughter was in a science class where the teacher was teaching about solids, gases, and liquids. So, she had all the kids stand in--in the middle of the room and she said, okay, you're liquid and I'm going to turn the heat on, okay. And you start moving around and getting further and further away. So, the kids started jumping up and down as if they were molecules of water and they move further and further away. And then she said, okay, I'm going to put you on the--I'm going to put you in the freezer now. And the kids got really, really close together and became solid ice cubes. Trust me, those kids will always remember what happens to molecules when you heat them and when you freeze them. That's good teaching. Well, it's true for us too when we're teaching communication skills, okay.
The FBI uses psychodrama and socio--sociodrama to train hostage negotiators because they discovered if you sit and talk about it, you only get so far. But if you put people in simulations, people remember it and they develop their skills. It's used in nursing and education to help train people. Residential schools for troubled youths have used it to help their staff develop empathy and develop better skills of handling difficult situations. I personally work with hospice volunteers using psychodrama and sociodrama to teach them how to be compassionate and professional in their care for their clients. And as Dr. Baile said, it's been used extensively by Gerry Spence at the Trial Lawyers College in Wyoming to train trial attorneys in developing better skills both in terms of jury selection and presenting the--presenting stories to the jury and--and also working with preparing witnesses. So, I've been talking about psychodrama and sociodrama and I want to explain the difference. Psychodrama is one person's story. How many of you are parents? Okay. So, you know, we all struggle balancing work and family, right? And even if you're not a parent, we struggle with--struggling with the role of the professional when you have a personal life. So, a sociodrama, a psychodrama is one person's story and that person would come up to the stage and they would pick someone from the group to be their spouse or their kid, their boss, they might even pick somebody from the audience to represent MD Anderson, the whole hospital. And they get to show those actors how to be because it's their story. Sociodrama is different. In sociodrama, we look at the role. So, the group makes up the story. Excuse me, I've been told to stay out of that light. The group makes up the story, right? So, it isn't a specific person's story. It's a story of the role. So, it's what's it like to be a professional person, working in a place like MD Anderson, and have a personal life too, and the struggles between those two roles. And the group creates it and that's sociodrama. So, it's less personal. That reveals less about the individual and it's probably more appropriate for professional setting like this than for people who do their own personal work. Does that make sense to you guys? Yeah, okay.
The other thing that's--that's really cool about sociodrama is that everybody gets to have a--have a piece of the action, not just one person. So, all the participants can be involved with the creation of the scenario. Alright. So, Moreno's idea was that we could develop creativity and spontaneity in the many roles in our lives by literally stepping into another person's shoes by taking on the other's role and looking at ourselves through their eyes. This is the ultimate goal of sociodrama and psychodrama and it's called role reversal. And all of you have done it. I want you to think for a minute about a situation in your life with someone you've really cared a lot about. It could be someone from your family or someone at work. And you've had to negotiate something with them. And so, you sit and you try to figure out, okay, how are they going to best hear me? How many of you have done that? I do this in my car all the time, right? How was I going to--how can I be most effective talking to this person, right? That's role reversal. That's really basically it. It's not that complicated. How do we do it? In sociodrama, we physically move into the another chair, sitting like the other person, thinking about what that other person might be thinking about, getting into the shoes of the other, emersion into the role. It's the central skill and we use a particular kind of interviewing technique, which all of you can learn to do with some practice. It's not rocket science. We call it empathic interviewing. It's how we teach people in our workshops to get deeply into the role of the other, a series of simple questions that allows the participant to become fully immersed in the role of their patient for a short time to help figure out how the patient should best be approached.
Questions such as how old are you, what do--sort of work do you do? What are you wearing? How's your body feeling today? How are you sitting? Who is your biggest support? What are you most worried about today? Now you heard me mention two questions about how are you sitting and what--what is your body feeling like, okay? I worked a--many, many--I've had about 30 years of experience working inpatient psychiatric with adolescents, okay. So, if I'm trying to address an adolescent and I stand like this, that's not how the kid is standing. The kid is probably standing like this, right? So, if I'm going to try to figure out what's going on in that kid's mind and heart, standing like this is not going to do it. I've got to kinda go like that and sort of figure out, oh, I'm kinda partly keeping my distance from you, Rebecca. I'm not sure I trust you, right? So, literally getting into the person's body position gives us a lot of information. The other reason we do it is because it's really, really important that when you finish role reversal that you step back into your own role, okay. Nobody wants to walk out of a situation struggling with all the emotions of somebody else. So, by being able to go over here and become them and deal with their worries and their feelings, and then back to myself over here, that helps delineate the difference and people find it very helpful. We call it deroling. So, there are two techniques.
The other techniques that I want to talk about is the technique of doubling. Doubling is a technique that deepens the immersion by helping the professional uncover the deeper feelings the other person might have. And they do this by standing behind the chair of the other person and trying to uncover what's not being said. How many of you remember the film Annie Hall? I'm going back too far? Okay. Well, Annie Hall is a Woody Allen film and there's a scene on the balcony where the two of them are having this conversation. And they're, you know, they're kind of interested in each other so they're, you know, they're doing social chitchat. And underneath there are subtitles. Do you remember that? And they're saying things like, oh gosh, I hope--you know, I hope my breath doesn't smell and the other person saying things like, oh, I really like this person, I hope they're finding me attractive. That's the doubling. It's what's going on underneath what you see. Okay. When communication skills are taught via action method such as role reversal and doubling, participants get practical and useful techniques for developing the sort of empathy skills that they can transfer into any situation. So, the trick is you practice it in one situation and then you can take it wherever you go and use it in other situations. They can also--we can also stop the action in the middle of the sociodrama to identify what's working well or not. So, we have a couple of films that I want to--we're going to show you some clips from it. I want to speak about what they're about and who's in them. Danny, would you stand up and--this is Danny Epner who is an incredibly wonderful communicator. Danny has been working with Walter and me to develop some training--training videos. In this video, you're going to see him taking on the role of Dr. Jacobs who's not very good at communicating. That's not Danny, that's Dr. Jacobs. And you're going to--you're going to--we're going to be showing you role reversal through empathic interviewing.
[ Video ]
>> Good morning, Dr. Jacobs.
>> Hi, good morning.
>> What brings you here?
>> Well, I'm really worried about this conversation I'm going to have with a patient who's coming in today.
>> And what is her name?
>> Her name is Mrs. Jones.
>> Mrs. Jones, okay. And what are you concerned about?
>> Well, I'm really worried because I've given her a lot of chemotherapy. She's a breast cancer patient and she's had metastatic breast cancer for years and I've given her all this chemotherapy and I've basically gone through every chemotherapy I can think of and she's--the cancer has progressed. And now, I'm sort of at the end of my ideas now. I don't have any other chemotherapy to offer her.
>> Okay, and you're coming into this meeting with her to tell her that you have nothing left to offer her?
>> Right. So she had a CAT scan the other day and it was to check how the chem--the last chemotherapy worked. And it showed that it didn't work at all and now she is getting weaker and weaker. I'm going to have to tell her this.
>> Okay, come have a seat. What do you anticipate being hard about this conversation?
>> Well, you know I'm afraid that she's going to cry and maybe she'd be getting angry at me.
>> So, that's your worst fear? That she'll get angry or cry?
>> Yeah, when they get really emotional like that, it really--it really messes me up. I don't know how to respond to it.
>> Sure, sure, okay, good. I want you to come in to that chair, reverse roles and become Mrs. Jones. And Mrs. Jones, I want to know how old are you?
>> I'm 46.
>> And what are you wearing today?
>> Well, I'm wearing some--some jeans. I've been with my kids today. I've got a kid who's entering 8th grade, she's 13 and--and a little boy who is 9 and I'm kind of running around with them. I haven't been very active lately 'cause I've been pretty weak but--so I'm wearing jeans and just a shirt.
>> What kind of work do you do?
>> Well I was--I was a teacher, a part-time teacher but I haven't been able to work lately because of my treatment.
>> Because of your treatment. And are you in a relationship with somebody? Are you married?
>> Yeah, we've been happily married for 16 years. In fact, our anniversary is coming up.
>> Thank you.
>> And, Mrs. Jones how are you sitting right now?
>> What do you mean?
>> I want you to take on the way Mrs. Jones sits. So I want you feel her body, become her.
>> Well, I think this is how I would say it.
>> Okay. What does your body feel like right now Mrs. Jones?
>> I'm really nervous.
>> You're feeling really nervous? Okay, good. So, what brings you here to this meeting with Dr. Jacobs?
[ Inaudible Remark ]
>> Well, I'm expecting good news. I had a CAT scan the other day and I've been taking all this chemotherapy and I'm--I'm just--
[ End Video ]
Rebecca Walters: Okay, I want to point something out. So, Danny, this is not how Dr. Jacobs, the actor playing Dr. Jacobs sits. He comes over here and he goes like this, alright. And all of a sudden when I asked him that question, he realizes that he's nervous, he's holding himself together, alright and that's what I mean when I say it feels different when you step into someone's shoes. 'Cause when he was in Dr. Jacob's role, he was much more--his body was much more relaxed. Good, thank you.
[ Video ]
>> Sort of expecting you wanted to tell me things are going well.
[ Inaudible Remark ]
>> But you're nervous. So, you have some fear? What's--what's your big fear right now?
>> Well, I'm afraid that the things are not going as well and that maybe that chemo hasn't worked as well as I'm hoping.
>> And that would mean?
>> I'm not sure what that would mean because I've been through so much chemo already. I don't know how much more I can take.
>> Okay, good. And, what's the worst thing he could tell you at this meeting?
>> I think if he told me that, you know, I'm terminal. That would be horrible. I wouldn't know how to handle that.
>> That would be very difficult. So, if that turns out to be the case, what could he do to help you hear what you have to hear, what's the best way he could tell you that?
>> I think the only thing that would help me feel better is if he could tell me he could cure me and get rid of this problem so I could go on and raise my kids.
>> Right, that's really understandable, Mrs. Jones. And if he can't tell you that, then what would be most helpful to you in this conversation?
>> You know, I don't really know. I just want to get rid of this problem. I can't think of anything that he can tell me that would really help me feel good at all.
>> I'm not asking you so much about what he can tell you, so much as how can he tell you. Like what had--might you start to cry if he tells you that?
>> So, if you start to cry, what can Dr. Jacobs do that would be helpful to you?
>> Remember, that's Dr. Jacobs' fear, that she's going to start to cry.
>> Well, I can say what--what I really wouldn't like.
>> Okay, let's begin there, what wouldn't you like?
>> So I just--you know, I--I don't like--you know, I cried before and I don't like when people try to like calm me down right away. So, if he could just kinda give me some space for a few minutes and just, you know--
>> And while he's giving you space, so what do you want him to do? Do you want him to leave the room? Do you want him to sit there with you? What would be most helpful to you?
>> Sit there with me.
>> To sit there with you, okay. And is there anything he can say that would make this moment easier for you?
>> I'm not really sure. Maybe very little. Maybe something but not very much.
>> Something but not very much, okay. Good. I want you to reverse roles. And Dr. Jacobs, what did you learn--what did you learn from this about Mrs. Jones and how you could best handle the situation?
>> Well, it was really eye opening for me because, you know, she's really saying that she just needs a lot of space and--and I'm just thinking that she would want to talk about some other treatment options.
>> So, you learned to just be still with her?
>> Just kinda be there with her and not do very much of anything.
>> And if she starts to cry?
>> Well, I'm not exactly sure what to do based on what she told me so far but I know kinda what not to do and I think to just be there maybe give her a little reassuring touch or a few kind words but not too much at all.
>> Thank you, Dr. Jacobs.
[ End Video ]
Rebecca Walters: How many of you have somebody in your life that you wish would do that with you? Reverse roles and try to-- And try to step into your shoes. I'm seeing a lot of nodding heads, alright. Good, okay. Alright. So, the next clip I'm going to show you which is going to show you a piece of it is where we use doubling where Dr. Jacobs is bringing in a new patient to talk about and he's obviously found this method very helpful and he's come back and we're going to help him deepen it by having him double in the role.
[ Video ]
>> Welcome, Dr. Jacobs.
>> Thank you. Thanks. I haven't seen you for a while. Tell me what brings you here.
>> Well, I'm really worried, you know, we talked recently about some patient and--and that went pretty well but I've got another patient coming in that I'm really worried about talking to.
>> And what are you worried about?
>> Well, this gentleman, he's--he had colon cancer and it was resected. It's been almost four years ago now and now we're afraid that his cancer has come back.
>> Okay, so come sit down.
>> And Dr. Jacobs, talk a little bit about to me about your concerns.
>> Well, you know, I just feel so bad for this guy. I mean, it's stressful for him obviously but for me too because when he's coming to me and I've seen him every 3 to 4 months according to surveillance guidelines for all these years and, you know, he's been healthy and he's still pretty healthy actually. And getting all this blood work, CVAs every 3 to 4 months and, you know, surveillance and it's just really stressful for me now to have to tell him his cancer is back. I just--I feel like--like the bad guy.
>> I want you to stand behind your chair, okay, and I want you to double yourself, which means I want you to speak from your heart about some of those feelings you're having that maybe you're not saying aloud right now.
>> Well, you know, I can't--you know this job is like incredible. I mean it's like day in day out, you know. It'd be one thing if I had this conversation maybe every once in a while but it's just like you just counted away everyday. You know it's like one patient after another where we have to have these kind of conversations and I'm just so happy and relieved when somebody is in remission and they come back and, you know, they bring candy to the staff and everybody is happy but--but most of the time, it's the opposite. There is always bad news that has to fly around.
>> And what do you feel right now?
>> Just really stressed out and just worn out, you know.
>> Yeah, tired and it's just very exhausting. Yeah.
>> You're very tired. Okay. So, come back to your chair and I would like you to reverse roles and become this patient of yours. So come sit in that chair.
>> So, you want me to like pretend that I'm--
>> You're going to. You're going to get up.
>> Sit over there.
>> Okay. Have a seat.
>> So, I'm--
>> What is your name?
>> Okay, Mr. Barnes.
>> Mr. Barnes. I want you to sit like Mr. Barnes sits.
>> Okay, well--
>> Just like you feel it's like you're in his thoughts.
>> Yeah, usually he's kinda usually sitting down like that.
>> So, Mr. Barnes, can you describe what you look like?
>> Well, I'm kind of a big guy, you know.
>> Yeah, I see that.
>> Yeah, strong.
>> What kind of work do you do?
>> Well, I'm a--I'm a foreman, heavy equipment.
>> Heavy equipment. So, you're a pretty physical guy, physical guy?
>> Well, I don't do too much of that stuff anymore but I have through the years, yeah.
>> How old are you?
>> I'm 53.
>> And you married, with kids? Can you tell us about yourself a little bit?
>> Oh yeah, yeah. Well, I did a tour, you know, and then in the army and then I came back and we got married, Joan, and I and we have a 23-year-old and we have a--actually our oldest is fixing to have a baby.
>> Well, congratulations.
>> Thank you. He's 30.
>> You're going to be a grandpa. Yeah. I don't feel that old but, yeah.
>> Okay. So, what brings you here today?
>> Well, I'm here for my checkup. You know, I've been coming back here for years, good old Dr. Jacobs. He's a good--good guy and he gave me chemo and ever since then I've been just cruising right along.
>> Tell me more about Dr. Jacobs.
>> What do you want to know?
>> What kind of--what kind of guy is he when you--when you're in with him, is he warm, is he very, very distant, is he--like as if available to you.
>> He's--he's alright. I mean he's kind of one like East Coaster kind of guys, you know, he's trained at a really good--I think it was Harvard or something like that and so, he knows his stuff. I mean, he definitely knows his stuff.
>> And what's he like as a person?
>> He's pretty official, you know. He's very professional I guess I'd say.
>> Okay. So, as you walk in here today, what are some of your hopes and dreams? I'm sorry. What are some of your hopes and fears for this meeting?
>> I'm not really fearful. Just ready to get my checkup and get on back out to the site.
>> Okay, so stay behind your chair, Mr. Barnes. And I want you to let yourself drop into the feelings that you probably don't tell anybody. What has been life for you to have cancer?
>> It's like you're waiting for the shoe to drop. You know, you're waiting for that--that cancer to come back and for the doctor to say, it's come back 'cause you know when it's come back, it ain't going away.
>> And what's the feeling you have right now?
>> It's really, really scary.
[ End Video ]
Rebecca Walters: Good, come back and sit down. Okay.
Okay, I'll get to that in a second. Okay. So, that is just a piece of that second clip where you begin to see how doubling helps this Dr. Jacobs get more deeply both expressing his own inside feelings but also the patients. Alright. Traditional--so the traditional role play is also--used to teach communication skills, but without the use of role reversal, it's quite difficult for most people to develop the empathy for what the patient is going through. And without effective and empathic role reversal, it's hard to know what to say to a patient because you're not standing in their shoes. The feedback from peers or from standardized patients doesn't come close to finding out from within the role. What might work for one patient will not work for another. So, what's the solution? Reverse roles, role reversal. Learning how to step into the shoes of each patient will show you how to best respond to that individual patient. Now, we also work with large groups. We've had anywhere from 15 to 35 people in these groups. And the use of action methods with the whole group allows the entire group to participate in the experience of developing those empathy skills via tag teams where different people can get up to play into the role of the patient but also step into the role of the medical professional trying to communicate effectively and try out different techniques, try out different things that work.
It provides some opportunities for many group members to experience both the role of the patient and the role of the communicator. Or in the case of--we've done a lot of workshops for supervisors. It might be a supervisor and a supervisee. It might be peer to peer, two nurses on the floor. It might be looking at how to [inaudible] or how does a nurse tell a doctor you're not giving the patient realistic information, right? All that kind of stuff, you get to experiment with both roles. And we also give people the opportunity to practice these skills in dyads, learning--solidifying the learning through experiential exercises. So, I'm aware of what time it is and we need to give 10 minutes for questions. So, I think we might want to look at the slides, Walter.
Dr. Baile: So, kind of here--here's a representation of the different folks that we worked with at MD Anderson and various challenges, communication challenges that--and residents, fellows, staff of the Integrative Medicine program, patient advocates. And they all have somewhat different challenges, communication challenges. So, these techniques lets you tailor make the experience to what the different problems are because people can bring their own situation and challenges into the workshop. So it's-very unstructured and it's [inaudible] totally learner centered, so what are folks want to work on. So, I'm just going to go. So, here are some examples. Some of the nurses brought things about kind of dealing with a colleague physician who felt overwhelmed by his own discomfort in truth telling, managing grief over our patients that--who've died, dealing with family members who don't want to give up. When a patient for example is in the ICU and not doing well and is terminally ill. We had a very interesting one with the--with gynecology residents and fellows around cultural disparities when patients come from abroad and they have different expectations and cultural ways of talking to family members. We've worked with patient advocates who are often stuck in the middle between the patient and the doctor and trying to convince the physician sometimes what he needs to do. We used to have the wellness centers now Integrative Medicine but dealing with burnout issues and grief. And intensive care unit nurses who kind of--who often get caught in the middle between the primary team who wants to push ahead and the ICU team that says, you know, this patient is really not going to do well, we need to talk to the family about ventilation and coming off the ventilator. And medical oncology fellows who are dealing with patients in denial, and even faculty who have to supervise others underneath them, especially fellows and give feedback to the fellows on how you do that. And more recently, we've worked with a group of 70 community oncology physicians and research nurses on how to accrue patient's to clinical trials. So, this technique that Rebecca talked about is adaptable to a wide variety of situations because what we're really doing is getting folks to play their most difficult challenges and then role reverse and then reverse back again to try things out. So, I'm going to stop and did you want to let folks ask questions?
Well, I have a few more things I want to say and then we'll let people ask questions, okay?
Learning how to--learning how to step into the shoes of each--now, I've been saying patient but you can see from this, it's not just patients we're dealing with. Learning how to step into the shoes of the other--of each other really helps give people the skills to best respond to that individual. Techniques supplied in teaching communication skills in a hospital setting require a kind of empathy that allows one to step into the patient's role and then this is much very important. I mentioned it before, I want to underline it, to step back into your own role rather than get stuck in theirs. You've got a lot of people around here who are in despair and distress and it doesn't do anybody any good if you spend all day stuck in their feelings, right? When we--what we try to teach is that role reversal is empathy without being overwhelmed. So, I think that that's really all I have to say and I'm wondering if there are any--any questions that anybody has.
[ Inaudible Remark ]
>> My name is [inaudible], I'm coming from France in palliative care and then thank you for your very good presentation and the --the video that you have shown. One of my question is a question that some oncologists have asked me is that psychiatrists often are told--or say to have time to think and to take this time to think about what they feel and what the--the patient can feel. And most of the time, the same--you see 5, 6 patients in the morning. I see 20 patients in the morning, how can I take the time to--to know what I'm feeling and to experience how my patient can feel and do you have a quick form for the psychodrama that we can show it to the oncologists to allow them to use this technique in their daily practice, because this is something that require you a lot of time.
>> Do either of you want to answer that?
>> So, I think what Rebecca was talking about was if you're seeing 10 patients or 20 patients, okay, I don't think at that particular moment you can always be aware of what you're feeling or what the patient is feeling. But some patients are going to strike you as particularly challenging, okay? So, one of the things that we would do in a drama is to let you either bring your own patient, most challenging patient in and role reverse with them, get some experience of what they're going through and then have you get back as your doctor to attempt new communication with that person. The other thing that we might do is we might get a group of psychiatrists together and say, let's construct the patient--a typical patient. So, what's one of--a challenge somebody had this week. So, someone might say, well, this patient was resistant to doing, you know, taking this particular medication. So, let's give the patient a name, you know, how old are they, what is the medication in someone. So, you'd get a group composite of a challenging patient who might be resistant to medication. Someone would get into that role, okay, and then we'd interview them based upon what everybody said and then someone would try to attempt to communicate what that patient or role reverse with them. So, that's sociodrama and that's building a composite patient, okay. What you saw in this one was Dr. Jacobs was more of a psychodrama because he brought his own patient issue in. So, you can either build a typical--prototypical patient from the whole group contributing to the prototype or you can--that would be sociodrama or psychodrama where people bring their own cases.
>> But I think underlying what something that you said is that if you're seeing 20 patients in the--in the morning, you're not--you don't need to do this for the whole 20 patients. It may be one that you say, I'm not handling that well. You know, if you're a psychiatrist, I don't know in France. In America, most psychiatrists today are trained mostly in psychopharmacology. But when I was in graduate school, psychiatrists were trained in therapy and they had supervision. And this in a way is kind of like supervision around those types of issues. You don't need to do it with everybody. You need to do it with the people that you're having the most challenge with. Does that answer your question?
>> Your point about the--about the time is probably the most important question and it's the one that comes up. I think people are very skeptical. I think it--it boils down to the value proposition. I think we providers spend too much time. I know as a medical oncologist, we spend too much time talking. We need to be better listeners, and so it's true that if we're overwhelmed with--with patients, it's really difficult to do that but I think if we spent more time listening and less time talking, we are more efficient. We could--we can actually do this to some extent. Maybe it's a tiny bit, one phrase per patient. Maybe it's longer for another patient but it can be done.
>> Other questions, someone. Cathy is going to hand you a mic.
>> My name is Debbie Brown and I'm a case manager and I appreciated your--also, acknowledging that, yes, we're--we're stepping into the role in empathy for the patient, but then the fact that we need to also distance our self back for our own health and burnout and I'm sure that's an issue you hear all the time as well. Could you just speak a little bit more to that because I think that's something that so many of us need to find a healthy way to step back from and the process.
>> Well. Yes, I have heard that a lot in the two years that I've been coming down here. And one of the things that had seemed to be very meaningful to people is just being in a group and offering people a chance to say it to vent a little bit about what they're feeling. And people seemed--have said to me they feel a little relief knowing that they're not alone. That's a huge piece of it, to know that you're not the only person, that this is normal to feel this way--this way that that really helps people with the burnout. In terms of what we do in terms of this work is we very formally derole. So, what you saw in the film was Danny up there acting as this doctor, okay. So, what I would do with--if it was--if it had been Danny himself being in the role of that other person, I would have had him step back in his own role and I would have had him say, I'm Danny Epner, I'm not Mrs. Jones, I don't have this. I'm--this is my life. Sometimes we--people literally physically take the role off. It depends on how into the role they're--they are. I'm a group person and I really believe--I mean I can do this individually but I really believe that the power of doing it with a group of your peers where there's a certain amount of trust, comfort level with each other really helps with that. Because you know, you don't just forget your patients. I had a group of nurses very early on say, we've had so many people die and each one of them--I don't get to go to the funerals usually. There's no closure. So, you know, finding creative ways as a--as a community to create closure I think is also a really healthy way to be able to begin to let yourself let those feelings go. These are just some ideas. I think it's something that is--would be a very useful thing to think about on a deeper level at another time.
>> I think--I think also usually--well, you know, we have such high expectations of ourselves.
>> And often feel that when our patients don't do well or if we can't get them the right placement or something of that sort. But when you role reverse into your patient's role, you begin to experience as your patient how important the little things that you do are. So that when you get back into your own role, you know, you can sort of get a sense of the fact that a patient can appreciate you for being kind to them even if they didn't get the right placement. So, I think that's the power of role reversal. You really--we really work to get people immersed in the other person to character so that they can experience what is valuable to them and often it comes a surprise when you get back into your own role how little simple things make a big difference to patients.
>> Yeah, I want to add to that. Part of what exhausts us is feeling helpless like we can't make a difference. So, if you reverse roles like Dr. Jacobs did with Mrs. Jones and discover that he doesn't really need to do anything, all she needed him to do was kinda sit there while she cried and not take off, right? And actually I'll get--I'll get the nurse, right? But you just sit there for 3 minutes. You know, people don't cry for--people think they're going to cry forever, they don't. So, now Dr Jones knows. Dr.--Dr. Jacobs knows that he has something he can actually do that will be helpful. It isn't what he thought was going to be helpful which is to give her a list of other options. It's just to sit with her and let her have her feelings. Then, he doesn't feel so helpless and there's less burn out. It's easier just go back to your own role when you're not feeling helpless. You're not getting sucked into their helplessness.
>> So just--just to underline what the key component of role reversal is, is that your belief that you can help someone step into the role of their patient and actually become their patient for a period of time and suspend the reality of the fact that they're not their patient but to be them. And so, this interviewing that you saw Rebecca do with Dr. Jacobs, immersing him in the role of the patient is extraordinarily powerful and you'd be surprised how many people can become someone else when you immerse them in it. And that's the power of it all. Yes? We have--
>> What can go wrong with it? What can go wrong with it? Well, someone cannot--someone could not play. Someone can get into the role and not be able to do it, okay? I don't know, I haven't seen anything go wrong with it. What have you guys seen, 'cause I--I mean a big piece of it is how much warm up there is and when I run--when I run workshops here, we have enough time to warm people up. Without that warm up, it's hard to teach them the skills. Okay.
>> I'm Ellen Gritz and I was wondering it relates to this what can go wrong question. If you don't know your patient very well, if you don't know anything about their emotional life or their family life or their ways of reacting to things, can you genuinely become your patient in that role? I mean what if the fact that I'm so afraid of my cancer recurring is because I had a parent who died of cancer but you don't know that as a physician. So, I guess my question is, how much can the person who is doing the role reversal project themselves into the role in a way that will make them be better as their doctor talking [inaudible].
>> This is a very good question and I have an answer to it. Okay, the answer is this. Do you remember Dr. Jones I asked him--Dr. Jacobs, I asked him what are you most afraid of. What he was most afraid of was that that they would--the patient would cry or get angry. So, if their big fear is the patient is going to cry, the content about what makes the patient cry is not necessarily all that important. What we're going to do is get the patient to the point where they have to cry and then ask Dr. Jacobs to see what feels, you know, to see if he can try something out and reverse roles, does that feel like it's working. So, all that information, all the background information is a way to get Dr. J--Dr. Jacobs more into the role. If he doesn't know, I'm going to--I can say make it up. What would make you frightened? What's--what might be making you nervous? What might make you want to get angry right now? So that we can teach them the skill without having all the content.
>> Any last questions? Okay, I want to thank Rebecca for that wonderful lecture and demonstration.
[ Applause ]
>> Thank you.
>> Thank you.
[ Applause ]
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