Using Action Methods to Improve Communication Skills in Oncology

Action methods are techniques derived from psychodrama and sociodrama which enhance role plays often used to teach communication skills in the medical setting. They were developed by Dr. Jacob L. Moreno, a psychiatrist who used group enactments of life situations aimed at helping clients deepen their understanding of and resolve interpersonal conflicts or mental problems such as addictions, post-traumatic stress disorder, and the effects of traumatic experiences. While psychodrama focuses on intrapersonal challenges such as dealing with grief over the loss of a patient sociodramatic portrayals focus on challenges of a particular group such as how clinicians can more effectively give bad news.

Both of these methods can be used to teach communication skills to medical professionals. They differ from more conventional approaches to communication skills teaching in medicine, such as case discussions in that they utilize the added dimensions of space, movement and imagination. That is, their objective of is to portray social situations rather than merely describe them. Thus psychodramas and sociodramas are group activities in which many members of a group participate. In addition certain techniques used in the dramas permit participants to take on the role of another. These include interviewing for role, role-reversal and doubling which we will see in the following videos. These techniques allow participants to develop an empathic understanding of another person's point of view or feelings. Thus, for example, a doctor assuming the role of a nurse might better understand how that nurse might become frustrated and angry when the medical teams caring for a terminally ill patient in the ICU are communicating different goals of care to the patient's family.

One application of psychodrama and sociodrama is "role-training," which focuses on preparing individuals for professional roles and responsibilities. Thus they have been used in business management and education and in the legal setting to enhance leadership and presentation skills of executives, teachers, and trial lawyers. In the following videos you will see an example of how dramatic action techniques can be used to train health care providers to exercise the interpersonal skills needed in their professional roles, especially in challenging conversations with patients and families where many pitfalls exist around communication. We hope you will find this demonstration using a physician actor and a trained psychodramatist useful in thinking about how you teach communication skills.

         View full-size video   (20:48 - opens in new window)


Action Methods Up Close

In this next video series, we illustrate the use of these methods in helping a practitioner, Dr. Jacobs (played by Dr. Daniel Epner) deal with a common problem seen in busy oncology practices. In these portrayals we use rather than role-play the language of theatre and refer to the portrayals as enactments. In this enactment Dr. Jacobs describes his frustration in dealing with patients who complain of having to wait a long time in the waiting room before they get to see him. These enactments occur in a group setting where members of the group take part in the dramatic portrayal as auxiliaries, either taking the part of a character in Dr. Jacob's scenario or by doubling, giving voice to the unspoken feelings, attitudes or thoughts of the characters in the role play.

Dr. Jacobs is interviewed about this problem by Rebecca Walters, a facilitator trained in the use of action methods who is familiar with the communication issues common to oncology practice. In the following presentation, we will follow Rebecca as she seeks to reveal the complex social and communication issues underlying Dr. Jacob's dilemma and help him deal with them. The presentation is broken down into a series of video clips, each one with a description of the action technique used and how it helps to better understand the communication issues involved (to see complete unsegmented video, view Action Methods  Up Close (19:25 - opens in new window).

To note is the fact that this scenario was not rehearsed but was spontaneously enacted in the portrayal of a case demonstrating how a facilitator might work with a learner's communication dilemma.

Scene 1 - The Opening Interview   Top of Page

In the opening of this dramatic portrayal of Dr. Jacob's dilemma, Dr. Jacobs first describes his difficulty to the facilitator. Since action techniques are part of an enactment where colleagues often participate, the facilitator asks Dr. Jacobs to select a group member to help him in showing rather than just telling about his dilemma.

         View full-size video   (opens in new window)


Scene 2 - Doubling by Group Members   Top of Page

Dr. Jacobs is "doubled" by group members. Doubling is a technique the purpose of which is to deepen Dr. Jacob's role and to make it more authentic by revealing unspoken feelings, attitudes or thoughts. In doubling, the facilitator invites group members to contribute to the understanding of the dynamics of the interaction by asking them to imagine what other feelings might underlie Dr. Jacob's frustration. In doubling, group members are invited to come up onto the stage and stand behind Dr. Jacobs and speak for him, articulating thoughts or feelings he might not be saying but otherwise could be feeling. Doubling relies on the universal ability we all have to put ourselves in the shoes of someone else and imagine what is going on inside them. In doubling, Dr. Jacobs always has the final say as to whether the person doubling is correct in representing his true feelings and affirms the double's words by nodding his head. Doubling also serves to bring other members of the group into the enactment, reinforcing the group work and deepening the understanding of Dr. Jacob's dilemma.

         View full-size video   (opens in new window)


Scene 3 - Role Reversal and Interviewing for Role   Top of Page

In this scene, you see the first use of "role-reversal" a technique in which a person assumes the persona of someone else, usually someone whom he or she knows, in order to "get in their shoes" and experience what they might be thinking or feeling. Role reversal is possible because all of us can imagine what others might be experiencing in different situations especially if we know them and are intimately involved with an interaction with them. Role reversal is useful to create an "empathic understanding" of the other so we can better tune in to them and appropriately respond to them. Role reversal does not happen automatically but must be facilitated by "interviewing for role" which allows the person who is reversing to drop into the role of another character. In this scenario, the facilitator interviews the doctor as his patient to allow the audience to understand details of her illness and also her possible point of view. In this video, watch how Dr. Jacob's gets into the role of his patient assisted by the facilitator.

         View full-size video   (opens in new window)


Scene 4 - Doubling of Dr. Jacobs in the Reversed Role   Top of Page

Here we again see the use of "doubling" by the group.  In order to reveal "hidden" feelings, attitudes and emotions which a person may not be saying or even be necessarily aware of, the facilitator invites the group to come up and stand this time behind Dr. Jacobs in the role of his patient, Betty saying what the group members think are unspoken feelings.  Doubling depends upon the same ability to empathize with others and approximate how they might be thinking or feeling as does role-reversal…that is stepping into another person's shoes. Thus, doubling is also a form of role reversal. In doubling the person doubling does not have to be "proper" because our feelings are not always proper. This does not mean that we would necessarily say them but might be thinking of them. The important thing is that our thoughts, attitudes and feelings often determine our behavior so that knowing what they are can help us choose how we want to act. 

         View full-size video   (opens in new window)


Scene 5 - Doubling of Dr. Jacobs by the Facilitator While Dr. Jacobs is in the Role of Betty   Top of Page

An experienced facilitator in doubling can often "zoom in on" key feelings of Dr. Jacobs whether in their own role or the reversed role. They can also serve as a role model for the group as to how to double.

         View full-size video   (opens in new window)


Scene 6 - Facilitator Encourages a More "Genuine" Expression of Feelings   Top of Page

What makes role taking so powerful is that you can express feelings that you might otherwise be inhibited about. That is, while Betty might not ordinarily feel safe in expressing these feelings to her doctor, it is ok now to do so and the facilitator now encourages this. In this way, the protagonist in Betty's role might get a better idea of not only how frustrating it is for him having patients annoyed at him for their waiting, but also how inconvenient and frustrating it is for the patient. Experiencing this also plants the seed of how to eventually respond to Betty's frustration.

         View full-size video   (opens in new window)


Scene 7 - Dr. Jacobs Leaves the Role of Betty and Reverses Back into His Original and Natural Role to Hear His Own Words  Top of Page

When Susan exchanged roles with Dr. Jacobs, she was able to hear and learn the responses of Dr. Jacobs in the role of his patient, Betty. Now when reversed into Dr. Jacob's patient's role she was able to repeat these same words.  Here Dr. Jacobs not only hears the words of Betty, but responds to them with an empathic statement and regret, "Betty, I'm so sorry..."

         View full-size video   (opens in new window)


Scene 8 - Dr. Jacobs Responds to Betty's Anger with an Empathic Statement   Top of Page

Finally, as Betty, Dr. Jacobs can hear his own Empathic statement and now, as Betty, he can experience its emotional impact on him.  

         View full-size video   (opens in new window)


Scene 9 - Debriefing   Top of Page

In this scene, Dr. Jacobs and the group are debriefed as to what they took away from the experience.

         View full-size video   (opens in new window)