Hello, I'm Dr. Walter Baile, Director of the I*CARE Program on interpersonal communication and relationship enhancement. In the following scenarios, you will see examples of 2 action techniques derived from psychodrama and sociodrama. As they use in enactment by a physician actor who takes the part of an oncologist who wants to better handle difficult conversations. He is coached by an experienced psychodramatist to help him find the best way to handle several patient discussions. First, you will see the coach interview the doctor in the role of his patient. Then you will see him doubling himself and reversing roles with his patient. In this first scene, the doctor comes for help with a problem. The coach interviews him and the role of the patient to help him step in to her shoes. So he can better understand his patient's issues.
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 is 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 have given her a lot of chemotherapy. She's a breast cancer patient and she's had metastatic breast cancer for years and I have given her all this chemotherapy and I have 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 and I--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 that 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. So we 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 is going to get angry at me.
But that's your worst fear that she'll get angry or cry?
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?
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 is entering 8th grade. She's 13 and a little boy who is 9 and I'm kind of running around with them. I haven't been really active lately 'cause I'm in 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, 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.
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 to feel your body, become her.
Well, I think this is how I would sit.
Okay. And what is your body feel like right now, Mrs. Jones?
I'm really nervous.
You feel really nervous, okay, good. So what brings you here to this meeting with Dr. Jacobs?
Well, I'm expecting good news. I had a CAT scan the other day and I've been taking all those chemotherapy and I'm sort of expecting him to tell me that things are going well.
But you're nervous. So you have some fear? What--what's your big fear right now?
Well, I'm afraid that things are not going as well and that maybe the 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--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 don't--I wouldn't know how to handle that.
That'd 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?
You know, 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--I just want to get rid of this problem. I--I don't--can't think of anything 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 is how can he tell you? Like what--how--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 while you're sitting there crying?
Well, I can--I can say what--what I really wouldn't like.
Okay, let's begin there. What would you know?
So I--I just--you know, 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 kind of give me some space for a few minutes and just--you know.
And while he's giving you space, 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 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 I was thinking that she would want to talk about some other treatment options.
So you learned to just be still with her?
Just kind of 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 kind of 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.
Good. Thank you Dr. Jacobs.
In this scene, you'll see the doctor double himself by standing behind his chair to delve deeper into his feelings about his conversation with the patient. You'll then see the coach use role reversal as the doctor switches roles with his patient and also double him in order to help him find the right words to say in response to his patient's feelings. Finally, he tries out his insights in an empty chair conversation with his patient.
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 that went pretty well, but I've got another patient coming in that I'm really worried about talking to.
What are you worried about?
Well, This gentleman, he had colon cancer and it was resected. It's been almost 4 years ago now, and now, I'm afraid that his cancer has come back.
Okay, so come sit down. And Dr. Jacobs talk a little bit 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, you know, 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 is still pretty healthy actually. And getting all this blood work CEAs 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.
Okay, I want you to stand behind your chair, okay, and I want you double yourself which means I want you to speak from your heart about some of the 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 would be one thing if I had this conversation maybe every once in a while when it's just like you could count it away everyday, you know, it's like one patient after another where we have to have this kind of conversations. And I'm just so happy and relieved when somebody's in remission and they come back and, you know, they bring candy to the staff and everybody's happy, but--but most of the time, it's the opposite. There's all this 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, its just very exhausting.
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.
Have a seat.
What is your name?
Okay, Mr. Barnes.
Mr. Barnes. I want you to sit like Mr. Barnes sits.
Just like you feel as if you're in his body.
Yeah. Usually, he's--kind of usually sits kind of like that.
So Mr. Barnes, can you describe what you look like?
Well, I'm kind of a big guy.
Yeah, I see that.
What kind of work do you do?
Well, I'm a foreman--heavy equipment.
Heavy equipment. So you're a pretty physical guy.
Well, I don't do too much of that stuff anymore, but I have through the years, yeah.
How old are you?
And are you married, with kids, can you tell us about yourself a little bit?
Oh 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.
Thank you. He's 30.
You're going to be a grandpa.
Yeah, but I don't feel that old, but yeah.
[Laughs] Okay, so what brings you here today?
Well, I'm here for my check up--you know, I've been coming back here for years. Good old Dr. Jacobs, he's good--good guy and he gave me chemo, and ever since that 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 is he available to you?
He's--he's alright, I mean he's kind of one of 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 person?
He's pretty official, you know, he is 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. I'm just ready to get my check up. Get on, back out to the site.
Okay, so stand behind your chair Mr. Barnes and I want you to let yourself drop into the feelings that you probably don't tell anybody. What's it been like 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 doc 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.
Good. Come back and sit down. So, Mr. Barnes, if Dr. Jacobs has to tell you that the cancer comes back, what do you need from him?
Well, I want to know how he's going to cure it.
Okay, and what else do you need from him?
If he can give me that, I won't need anything else.
And if he can't, how do you think you're going to react?
Probably be pretty mad about it, and I mean, it's like we've been checking every--what, 3 to 4 months, isn't that supposed to keep it from coming back?
So if you're very mad about it, what is the--what would be most helpful to you from Dr. Jacobs?
I'll tell you what, the last thing I want is some smarty pants doctor to be--you know, trying to calm me down and everything. So maybe just I think he should just kind of let me be a little bit--
You know, lets you just talk about how angry you are?
Okay, alright. Good, thank you Mr. Barnes, reverse roles.
Have a seat.
Yeah. So what did you learn from that?
Wow, gosh. That was, that was surprising.
What was surprising about it, Dr. Jacobs?
Well, it's just--you know, when I really--when I pretend like I'm him, it sort of makes me really get into his shoes and think about what's it like to be a patient.
I never really thought of it that way.
You know, when I'm sitting here, I'm Dr. Jacobs. It's like I'm thinking about how difficult it is for me and how stressful it is and how much work it is, but I never really thought of it that way.
So with that in mind, do you have any ideas about how to address Mr. Barnes?
Well, I think--that's kind of a hard questions because I think when I start the conversation, you know he's, he was telling me that he wants a cure and I think it's going to be really hard for me because I'm not going to be able to give him that.
So stand behind your chair right now. I want you to double yourself Dr. Jacobs.
Okay, so I'm sort of like go into my own feelings.
Go back into your feelings. Speak from your heart.
Speak from you're heart right now.
We'll, you know, I really feel sorry for Mr. Barnes. You know, I feel sorry for him because you know he's been in remission this whole time and he's a strong man and he's got a nice family, and I just feel horrible that I have to give him this bad news.
Okay. So come on back and sit down. With that in mind, with hearing that he is angry, probably going to be angry. And needs you to give him some space and allow that anger, and the fact that you can feel how deeply sorry you are that he--that this is the situation. What do you imagine might be useful?
You know, as we talk I think I really need to kind of slow the conversation down and I think I need to start with something I've never really done before. But I think I'm going to start by telling kind of warning him about what's happening and what's going to happen. I think I want to set him up so that he's kind of emotionally prepared for the bad news that I have to give him. So I'm going to--I think I'm going to tell him basically say something like, "Well, Mr. Barnes--"
Here he is, tell him.
Okay. So Mr. Barnes, "Hi, it's good to see you again. I know you're worried about the results of your tests and, you know, I'm afraid I have something really serious to talk with you about today and I hate to have to talk--you know, serious things with you after all this time. But I really think it's important that we do so and I wish I could give you better news."
How does that feel?
Little awkward, you know, I haven't really done that before.
But I think if I could think of some way of kind of warning him to kind of prepare him for the bad news, I think that will be a good thing for me to do.
Okay, turn and face me and one of the concerns you had was that he might get angry and if he's angry and expresses the anger, what have you learned from this about how to deal with that?
I think just giving him space and just letting him, you know--and showing that I care about him and--
And how can you do that?
Just validate and say, you know, this must be really difficult for you and you have every reason to be angry. I can understand why I'd be really angry myself.
Beautiful. Thank you.
In teaching communication skills, creating empathy for another's feelings allows learners to better understand how emotions play an important role as a subtext in influencing social interactions including those between healthcare professionals and their patients and family members.
Moreover, identifying and responding to these emotions is an important expression of empathy and compassion. This can go a long way to solidifying the trust that is so important in the relationship with our patients and their families. We hope that you'll have an opportunity to try out these techniques in your own teaching and find them useful in advancing the communication skills of those with whom you work.
©2012 The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd, Houston, TX 77030
800-392-1611 (USA) / 713-792-6161