Chapter 08: Teaching Communications to Larger Groups

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Chapter 08: Teaching Communications to Larger Groups

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In this chapter, Dr. Baile talks about how he spent the next seven years developing strategies to teach communications to larger groups, basing his approach on the work of Rebecca Walters and John Nolte’s use of psychodrama and sociodrama to explore communcations and emotional issues. Dr. Baile illustrates his approach by talking about psychodrama retreats he held in Italy, in particular a workshop for forty hospice workers addressing end of life communications. He discusses the warm up exercises needed and the way that psychodrama techniques are based on role-reversals. Next, he describes challenges that participants confront and the opportunities for transformation that psychodrama offers –experiences that he finds very gratifying to offer to clients. Dr. Baile then talks through how psychodrama works, using the example of a nurse who was taken off a case without any explanation for why. Dr. Baile then talks about differences between teaching in Italy, where participants can come for multi-day retreats, and the more skill-based approach he takes at MD Anderson, where participants can only spend an hour or two.

Identifier

BaileW_02_20160823_C08

Publication Date

9-1-2016

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - The Researcher; The Researcher; Discovery and Success; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Discovery, Creativity and Innovation; Evolution of Career; Professional Practice; The Professional at Work; Overview; Definitions, Explanations, Translations; Activities Outside Institution; Human Stories; Offering Care, Compassion, Help; Discovery and Success

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Walter F. Baile, MD:

So one thing that happened to me during this process is that we were working with one facilitator with five learners. And that didn’t seem to me to be as efficient as it could be. And so I thought a lot about how do you turn this into a situation for a larger group, when I got introduced to psychodrama and sociodrama. And so I was very interested in the methodology because it was group methodology. So over the course of the next seven years I developed a way to bring psychodrama and sociodrama techniques to teaching communication skills. And I’ve published three or four papers on that. And so every couple of months my colleague, a psychodramatist, comes down, and we run groups on end of life discussion for people, and dealing with angry family members, using—so instead of having standardized patients we create the characters as a group based upon what the challenges are of the learners. So they bring their dilemmas in. We create characters; we enact them, like acting.

T.A. Rosolowski, PhD:

Who is your collaborator from psychodrama?

Walter F. Baile, MD:

Rebecca Walters, who heads up the Hudson Valley Psychodrama Institute in New Paltz, New York. And she’s very extraordinarily talented. And I’ve taught her some oncology and she’s taught me how to do psychodrama. So I’ve gone up a tick and done my own psychodramas up with her, and with another person named John Nolte, who actually does—did you know that there’s something called a trial lawyers academy?

T.A. Rosolowski, PhD:

No, I didn’t know that.

Walter F. Baile, MD:

And it’s not academy. It’s trial lawyers something. And they teach attorneys how to use psychodrama techniques to select juries and to interview injured workers. It’s for plaintiffs’ attorneys.

T.A. Rosolowski, PhD:

I’m not surprised that they would do that kind of thing.

Walter F. Baile, MD:

It’s become very famous. And so Rebecca has taught there. And John Nolte has taught there. So Nolte has something every year in Round Top where he conducts a psychodrama training institute and people from Houston and San Antonio and Austin go. It’s a residential workshop. And so you get to see how good some of these attorneys are at doing psychodrama. It’s just amazing. And they have a lot of no fear in doing this. And some of them are very very competent. So I’ve done some psychodramas. But I’ve done a lot of sociodramas. Psychodrama is about you. Sociodrama is about the issue. So if you want to do your own psychodrama on stuff in your past or present or whatever, you can go and work with Rebecca and do your own work, and then you can learn how to teach psychodrama, rather facilitate psychodramas. And that’s been my evolution from doing small group work into doing larger group work where everyone gets to participate. So we have maybe 15. I’ve done a psychodrama with 40 hospice people in Italy in a basilica a couple of years ago. And so it’s a very creative process. So I had 40 people that were nurses, doctors, social workers, and two psychologists. And they came to this retreat house outside of Rome. And I think it was called Castelvecchio. I don’t recall. It was about an hour drive outside of Rome. And we had a three-day retreat. And the subject was communication at the end of life. So you can’t teach these things unless you do warm-up exercises with people because they’re not ready to jump right up and get into an enactment. So you’ve got to get them to relax a bit, lower their anxiety, and get them to be spontaneous rather than thinking before doing. So one warm-up exercise I did is I broke people into four groups. So we were in this big basilica. And there are four side chapels. You’ve been to basilicas, you know what I’m saying. So I sent an even number to each side chapel. And psychodrama is about imagining. So I said, “I want you to imagine that you are all either patients or family members of patients, and you’re sitting and waiting for the doctor to come. And I want you to talk amongst yourselves about your diseases and your family situation. Just make it up.” So they all got into these chapels and they were pretending. So it’s a lot about pretending. And they were good sports. They went with it. And then I got a colleague of mine who is a very glamorous Italian psychologist who teaches with me named Anna Costantini. And Anna put on her dark glasses and sashayed into each of these chapels and said, “Oh, ciao, everybody, I’m the doctor, and I’m here to address your concerns, I’ll be with you in 30 or 40 minutes, I’ve got an important phone call to make.” And then I had them all talk about what it was like to be a patient and a family member waiting and then have the doctor say that to them. So it was a warm-up. And that’s called role reversal. And so role reversal is the cornerstone of psychodrama. When you get into someone else’s shoes to understand how they think and feel. So it’s called the engine that drives the psychodrama. And so that was one warm-up exercise. Then in the other warm-up exercise I said, “I want you to form up in four groups and make the groups so that there’s an even number of doctors and nurses and psychologists. I don’t want everybody in one profession in one group.” And what I did is to say, “Want the doctors to imagine that they’re a nurse, and role-reverse into a nurse’s role. And be a nurse. And I want the nurses to be a doctor.” And then I said, “Pair up in twos with somebody from a different profession and tell them from the reversed role what you need from them.” So the doctors in the reversed role as a nurse would tell the nurse in the reversed role as a doctor what they need from them. So it’s tricky. So those are some of the warm-ups. And then we did a lot of enactments. We had people write down what their biggest challenges were. And then we had them role-play them. And we had three or four people at one time in a role-play because it was a home visit with a patient who didn’t want to know anything, how bad they were. And so we did enactments and we figured out what would work, what wouldn’t work. I brought different members of the group in. So there were 40 people.

T.A. Rosolowski, PhD:

So tell me about what some of these big challenges are for people. And actually hang on just a minute. I want to let these people know that we’re in here interviewing, because I’m a little worried that the machine is going to pick up these voices outside the door. I got to see Warren Holleman, who I haven’t seen in a while. So I wanted to ask you. What are some of the big challenges that are confronted?

Walter F. Baile, MD:

People in denial about death. People who are angry because they felt cheated out of some time of their life. People who are sad. Family members who don’t want to tell the patient how bad things are. So a lot of things involving affect and emotion.

T.A. Rosolowski, PhD:

Those are things that are coming from the patients. What kind of challenges come from inside the individuals that have to have these conversations?

Walter F. Baile, MD:

The desire to fix things. The biggest challenge. How to get people to be compassionate rather than try to fix it. That’s the biggest challenge. Or run away from it. Or deny their own anxieties. So you have to work on both sides. Have to work with the docs, you have to work with their own emotions, and you have to teach them how to work with the family and patient’s emotions. So that’s a big challenge.

T.A. Rosolowski, PhD:

I can imagine it would be incredibly transformative for someone going through the psychodrama process.

Walter F. Baile, MD:

Indeed, it’s transformative. Very transformative. Because when you discover—so if you go on my web site you’ll see some examples.

T.A. Rosolowski, PhD:

I will.

Walter F. Baile, MD:

So when people discover that they don’t need to listen to their own anxiety that tells them to do something that they think might work but to develop a technique in which they do something very different than the usual stuff, that it works with the patient, that’s transformative. So if I’m a doc, and I’m always trying to find a new treatment for people even at the end of life, but instead I say to the patient, “You know, any more treatment is going to do you more harm than good, and I know you want to spend time with your family, rather than stay in bed sick from the treatment, I don’t think that’s what you need or want.” And when they learn to say that and have the patient say, “Thank you for doing that, I was wondering how to refuse more treatment,” that’s transformative. And being a psychiatrist is actually one of the gifts that I’ve been able to bring to this teaching process using psychodrama and sociodrama, because this is all about knowing yourself, and being able to understand what the emotions are behind the anger and blaming and everything else that goes on. The bottom of the emotional jug as we call it. So it’s been very very enriching for me to have this work to do. And then we go out. We’ve been doing some training now of other people in learning how to use role reversal and doubling and some of the other psychodrama and sociodrama techniques in teaching communication skills. So I just came back from a hospice in Nashville where my colleague and I went for three days to teach people these techniques. And we’ve run workshops at the hospice and palliative care meetings on using these techniques to teach, and the Cleveland Clinic also. So this has been quite an adventure. For me it’s a shame, my only regret is that I didn’t get involved with this 25 years ago, because then I would have made my career out of it. But it evolved from using small group learning to larger group learning, and I’ve done these psychodrama and sociodrama workshops in Italy with these groups from a hospice in Rome and another group at the—what’s it called? It’s run by a medical oncologist. So it’s a group near Bologna that has an academy for hospice training. So I’ve gone and done this kind of work with them and that’s been very very interesting.

T.A. Rosolowski, PhD:

How so?

Walter F. Baile, MD:

Because of the situations arise—so I talk about a case. So I had one learner. I was trying to do a sociodrama. So sociodrama is about problems that the group creates. Like that what’s difficult is talking to patients around blah blah blah. So you create a scenario. The group creates a scenario. OK, make up a name of a patient. Make up the name of the situation. How old are they? Married? They have children? And then you have people come and say, “I have a problem,” which is their personal problem, that’s a psychodrama. So one time I was trying to do a sociodrama but a nurse said, “I need help with this issue.” “OK, what is it?” “Well, I’ve transferred from surgery into hospice care and I’m having a very hard time because I have a patient who is in hospice that I don’t know what to do about. And this is a patient who has had a stroke, so they can’t talk. But she also has a terminal illness. And she’s isolated because her husband comes to visit her and can’t talk to her, can’t communicate with her, because she can’t talk. Has aphasia. And so he stays five minutes and leaves. And she feels abandoned. And he feels frustrated.” And so we did a psychodrama in which I had her take on the role of this patient and I had her pick other people to be in the scenario. So she picked somebody to be the husband. And the way it works is, you see, only you as the protagonist know these other people. So I had to have her become the husband. And as the husband tell the group about himself. And then the person who is going to take that place knows enough to get into that role. So it was very very interesting.

T.A. Rosolowski, PhD:

So that whole thing itself is role reversal, which is very interesting.

Walter F. Baile, MD:

It’s all about role reversal. So she had somebody take the role of this patient and someone the husband. And it was very fascinating because these things always turn out to be more than what they seem. So I said, “What do you want to say here to this woman about her feeling abandoned?” And she said, “I don’t know.” And I said, “What’s stopping you?” And she said, “Well, this person reminds me of my Mamma Rosa.” I said, “Well, who’s Mamma Rosa?” She said, “She’s my grandmother who raised me. And I can’t stand the thought of losing her. And this person reminds me of her and she’s terminally ill.” And so I had her reverse roles into Mamma Rosa and she became her Mamma Rosa. And I said to her in that role, “What do you need to say to this nurse in order to help her understand, help her with her fears?” And she said, “I need you to know that I’ll always be with you no matter what.” And then reversed them back. And so we dealt with that thing. And then we had to deal with this other kind of drama. And so people came up with ideas. And one idea would be that the husband would come and read the newspaper to his wife. And so this whole drama unfolded in the space of two hours. So that was a psychodrama and it was about her identification with her own patient. And her then displacement of Mamma Rosa onto this patient. It was very very interesting psychodynamics.

T.A. Rosolowski, PhD:

Now how do you find that people apply that kind of complex knowledge that they would gather during a session like that and over the course of an entire retreat? Because I can imagine that from one perspective people who are more instrumental about these kinds of problems, they would say, “Well, just don’t identify with patients. That’s the solution to the problem.” Whereas here what you’re saying, the whole idea is people do identify with patients. And you have to actually process at multiple levels.

Walter F. Baile, MD:

Well, did you ever find it helpful that anyone ever told you not to do something?

T.A. Rosolowski, PhD:

Oh, no, no, I’m not saying that it would be helpful not to do anything. What I’m saying is that there are people who have a simple answer. And then this is a very complicated answer to a problem. And my question is How did the participants in the groups that you would run find that they could take that complicated information and then apply it in other situations once they left.

Walter F. Baile, MD:

Well, at the end of these things you process it. And you ask people, “What did this mean to you?” So you have this reflective exercise afterwards. You say to people, “What was it like for you to be in the role of the husband?” So people get insight. This is all about vicarious participation. Because all of us have been in positions at one time or another where we felt awkward doing something or interacting with someone because they reminded us of someone else. And it’s just bringing all this stuff out and the way you do it through enactments and getting people comfortable and role reversal and imagining and using creativity and spontaneity. Then there was another one I did. So there was a nurse who was very distressed because she had been taken off a case and didn’t know why. And so we did the enactment. So OK, let’s see what this looks like. Because, you see, Freud psychoanalyzed people by putting them on the couch and having them talk. Jacob Moreno, the founder of psychodrama, said, “No, let’s not talk about it, let’s see what it looks like.” That was the big contribution Moreno made. And so doing these dramatic enactments and getting into people’s feelings really gets at the bottom of the human experience, because we all act on the basis of our feelings, whether we’re aware of them or not. Our anxieties, our prejudices, whatever. And so we enacted this case. And she picked people to play the patient. Oh, here’s what the problem was. The problem was the patient had pancreatic cancer and the son didn’t want her to know. So someone played the patient, someone played the son. And so, you see, the way psychodrama works is that every time the protagonist asks a question of the patient, you have to role-reverse them and then answer that in the reversed role. So we were doing an enactment and it turns out that in the enactment the nurse started talking to the patient and the patient said, “Well, I’m not sure what’s wrong with me because they didn’t tell me.” And at that moment the son comes into the scenario and says, “I think she’s getting tired, and I think it’s probably a good time for you to leave.” And so this woman was very frustrated. And after that her manager pulled her off the case. So she was feeling very much as if she did something wrong. So we had two enactments. And I had her reverse into the role of the son. And as the son tell the group why he didn’t want mother to know. And she said in the reversed role that no, I’m gay, and I was in this relationship and I just lost my boyfriend, and I’m so aggrieved at the thought of losing my mother. And I don’t want all of us grieving at the same time. That’s what she said. Now who in God’s name would have known anything about this? But you let people imagine what it could be. And maybe it comes out of picking up stuff about the son. So then we reversed. I reversed her back. And we were able to process why people are in denial. Whatever reasons could it be. But that was very real for her. And then we had to do a second enactment. And then you could do resolutions. You could say, “Well, what might you tell the son that would help him with his reaction to his mother’s diagnosis and trying to protect her?” What kind of technique. You could empathize with him. And then I had her create a scene where she’s interacting with her supervisor. And so in the reversed role as the supervisor she said to her, “I think you’re just doing an absolutely magnificent job. However, I think in this instance we need someone more experienced to do it.” Or something like that it was. So those were our two psychodramas. So she was able to resolve her conflict about feeling as though she didn’t do an adequate job and at the same time understand what was below the surface in the son’s behavior. And that’s what it’s all about. What’s below the surface? What are people thinking and feeling that they’re not saying?

T.A. Rosolowski, PhD:

I imagine just going through that kind of process the participants get a lot more mental flexibility and creativity in imagining on the ground what patients might be going through.

Walter F. Baile, MD:

Well, you give permission for people to imagine what else might there be. And then we do didactic teaching in the middle of this. I might stop and teach about the emotional jug, which is what comes out at the top isn’t always what’s at the bottom. So part of sociodrama is that when we’re teaching—so sociodrama, our teaching here is based upon giving people skills. So I’ll teach people what empathy is and how to make an empathic response and we explore how it’s much better than a fix it response. And so our workshops here are very much skill-based. I want to teach five skills to people around how to deal with angry patients and things of that, through empathy and listening and blah blah blah. Psychodrama is a little bit different. You can teach some skills in psychodrama. But what might be better is well, try things out. And what you do then is, you see, you work with a learner and say, “What might you say to this angry patient who’s angry because this doctor never told him how bad it is?” So the person would say, “I might say, ‘You must have lost trust in your doctor.’” I said, “OK, why don’t you try it out?” And so the person then tries out. And then they reverse roles. And you have a person say to them in the role of their patient, “You must have lost trust in your doctor.” Because then they can experience what it feels like in the reversed role. That’s why role reversal is the engine that drives psychodrama, and to an extent sociodrama. The other technique we use is doubling. So let’s go back to this case of—so a lot of it is about getting feelings out, because you can’t reverse role when you’re full of feelings. So this woman who was going to be her supervisor, who’s interacting with the supervisor, who told her—took her off the case. So what we would say to the group is “Who can imagine what Barbara must have felt when her supervisor said, ‘I’m taking you off the case’?”. And you have people come up and stand behind the person one by one and speak as if they’re her. And speak what she’s not saying. “I am so furious. I feel so incompetent. I’m just puzzled. I’ve been a nurse for 20 years. Why in God’s name are they doing this with no explanation?” Because you’ve got to get those emotions out before you can allow her to reverse role in a supervisor. Because people cannot role-reverse when they’re angry or full of emotion. Because they’re still in themselves. But once you get that stuff on the table it doesn’t become an elephant in the room anymore. And then it’s easier for them to role-reverse. So these are very very very powerful tools. And you can use them anytime. So if I’m doing couples therapy and I have John and Jane, I say, “Now Jane, I’d like you to reverse roles with John. Now as John tell me about yourself.” So she gets immersed into the role. “Now as John I want you to tell me about Jane.” So people are telling you effectively about themselves as perceived by another person. And that’s very very enlightening because people will admit things about themselves that they would never admit in their own role. And you can reverse them back and say, “You told me. And so what do you think about that? Is that true? Do you really monopolize John’s time when he comes home from work stressed? What about that? What’d that feel like to you?” So these are all extraordinarily powerful techniques that apply to everyday life too.

T.A. Rosolowski, PhD:

Now as you’ve been talking a couple things have occurred to me. One is a question. And that is the examples that you gave of psychodrama and sociodrama, were those all taken from teaching scenarios in Italy?

Walter F. Baile, MD:

Yes.

T.A. Rosolowski, PhD:

OK. And my question based on that is have you done the great majority of the psychodrama and sociodrama teaching overseas, or is that something—and I’m wondering if there’s a reason behind that.

Walter F. Baile, MD:

So these were three-day workshops. One was an all-day workshop. A couple were three-day workshops. But here people aren’t going to come to three-day workshops. So we’ve condensed it to four hours. And in four hours we teach very specific skills. How to deal with angry family members, how to deal with end of life discussions. And they’re much more skill-based.

T.A. Rosolowski, PhD:

That was what I was gathering.

Walter F. Baile, MD:

Yeah. In four hours you have to say, “Well, I can teach two things to people.”

T.A. Rosolowski, PhD:

Now what do you think is the source of that? That in Italy people are willing to go to a three-day workshop whereas in the US people want something that’s a lot more condensed.

Walter F. Baile, MD:

Well, the workshops in Italy were organized by the leaders of this hospice who said, “We can get people. How much time do you need? Well, let’s do something for a couple of days.” But here I’m at MD Anderson and I have colleagues taking care of patients and doing all sorts of stuff. And they can get away for four hours, but they can’t get away for three days. So that’s why we do it like that. We’ve done two workshops for family members on the stem cell transplant unit and we’re going to do two more for family members, because they need to deal with their own helplessness and anxieties as family members and as caregivers. And they don’t have a whole lot of support in doing that.

T.A. Rosolowski, PhD:

When was that workshop? Has that already been given?

Walter F. Baile, MD:

Couple months ago.

T.A. Rosolowski, PhD:

Couple months ago, so that’s really new.

Walter F. Baile, MD:

New. Just started it out. Just decided that this is something that we wanted to do.

T.A. Rosolowski, PhD:

And what’s the format for that? Is that a longer kind of—

Walter F. Baile, MD:

Two hours.

T.A. Rosolowski, PhD:

It’s two hours, OK.

Walter F. Baile, MD:

Yeah, you could just scratch the surface, give people some thoughts. And you don’t want them to do as much soul-searching as you do acknowledgment that this is a tough job. That it’s not very easy for people to do.

T.A. Rosolowski, PhD:

Am I correct in assuming that your heart is with the deeper teaching that you’re able to do in Italy?

Walter F. Baile, MD:

Well, I had no idea what I was going to do when I went over there. I had some warm-ups in mind that I was going to do, and I had a terrible cold too. I had laryngitis; I had to have somebody help me speak. But you have to trust yourself. There are a couple of basic techniques. The warm-ups you got to do. And so you have to have the warm-ups in mind, and you have to plan the warm-ups. And then you have to plan how to bring forward the issues. So you have people talk in small groups about stuff that’s bothered them in their interactions with patients and family members. Then you put them on the board, and then we vote on them. That’s how you get the material. It’s all learner-centered.

T.A. Rosolowski, PhD:

That’s very creative for you as the facilitator or the person who’s providing the tools.

Walter F. Baile, MD:

Yeah, we came up with this method. And then you’re dealing with what matters to people most, not what you think matters to them most. And so you put this on the board, and then you select cases, and you create a scenario. You invite people to come up and take on the role of a social worker or nurse. And people like to get in the role of other people. Because it’s creative and it’s challenging. And because we all have an idea of what other people must be going through. And so it’s fun. And you’ve got to have some fun in some of this stuff, especially the sociodramas. Psychodrama is a little more serious.

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Chapter 08: Teaching Communications to Larger Groups

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