Acad Psychiatry DOI 10.1007/s40596-014-0159-y
IN BRIEF REPORT
Teaching an Experiential Mind–Body Method to Medical Students to Increase Interpersonal Skills: A Pilot Study Cara Alexander & Robert D. Sheeler & Norman H. Rasmussen & Lucinda Hayden
Received: 22 August 2013 / Accepted: 1 May 2014 # Academic Psychiatry 2014
Abstract Objective The authors investigate whether inner relationship focusing increases self-awareness in medical students and, in the process, to give them experience with empathic listening. Methods Thirteen second-year medical students were randomized into experimental and control groups and surveyed pre-course and post-course about their self-awareness and perceived comfort with clinical interpersonal skills. Subjects attended a 20-h course on inner relationship focusing, followed by 5 months of weekly sessions. Pre-course and postcourse survey scores were averaged by group, and mean differences were calculated and compared using the twosample t test. Results The experimental group showed improvement in all areas compared to the control group. Improvement in one area (comfort talking to patients about how recurring symptoms might relate to issues in their lives) reached statistical significance (P=0.05). Conclusions Inner relationship focusing is a potential tool to increase self-awareness and empathic listening in medical students.
Keywords Empathic listening . Experiential learning . Focusing . Medical student wellness . Mindfulness . Reflective listening
C. Alexander : R. D. Sheeler (*) : N. H. Rasmussen Mayo Clinic, Rochester, MN, USA e-mail: [email protected]
L. Hayden Focusing Resources, Berkeley, CA, USA
The medical literature suggests that physician empathy is based primarily on a combination of reflective listening and mindfulness. In a large study on empathy, Winseman et al.  identified listening as among the top factors helping medical students develop a deeper understanding of patients. Mindfulness-based interventions also promote physician empathy . Thus, we decided to offer a novel elective on mind– body awareness that included an empathic listening technique called inner relationship focusing (IRF). We were curious about its impact on second-year medical students, especially in light of Hojat and colleagues’  controversial results showing that empathy begins to plummet in the third year of medical school. Our main interest was to determine whether offering an elective to students that incorporated elements of self-reflection and empathic listening would attract and engage students to invest in such processes early in their medical careers. IRF is unique because it combines mind–body awareness with empathic listening. Mind–body awareness is a key skill in developing empathy and compassion. Empathic listening essentially involves summarizing another person’s feelings and reflecting them back to that person. When done effectively, it conveys an understanding of the person’s experience . It allows students to depart from intellectual discussion and didactic learning to delve into more personal experience. The Box provides a brief case example of the process. Originally developed by a philosopher and psychotherapist Eugene Gendlin , who called it “experiential psychotherapy,” IRF was later adapted and renamed by Gendlin’s student, Ann Weiser Cornell . The method arose from Gendlin’s research question: “What makes psychotherapy helpful to some people and not others?” [7, 8] (Box). Of all the processes that occur in psychotherapy, the experiential moments, which Gendlin postulated were moments where
patients have contact with a felt sensation or image relating to their dilemma, are thought to be the most reliable predictors of lifestyle change and symptom relief . Gendlin’s research team developed an Experiencing Scale and correlated high experiencing scores with eventual success in therapy . Describing bodily felt experiences can awaken emotions that may not be available through intellectual or linguistic pathways. Gendlin collaborator, Carl Rogers, emphasized empathic listening as the core component of trust and healing. Once a strong alliance, such as between client and clinician, is established through empathy, it becomes a foundation for behavioral change . Empathy and listening are central to the physician–patient relationship. To the extent that IRF teaches these skill sets, it could potentially be of value to physicians in many fields.
Methods After obtaining approval from the Mayo Clinic Institutional Review Board, we recruited second-year medical students at our college of medicine for possible participation in an IRF elective course. We chose the second year because this is when students start performing some clinical work. To control for self-selection bias, we administered a brief five-item survey that scores openness to new experience to the entire 50 members of the second-year medical school class. The fiveitem Brief Openness Scale (BOS-5) (Table 1), designed specifically for this study to measure appreciation of new experience, was adapted from the full Openness to Experience scale of the Revised Neuroticism, Extraversion, Openness to Experience Personality Inventory, a highly regarded assessment of personality with established construct validity and internal consistency. The BOS-5 has never been separately validated, but the larger instrument from which it was derived has been. Each item is scored on a five-point rating scale. Higher scores correspond to higher levels of openness. Some items are reverse-scored (items 1, 3, and 5).
Consent was obtained from the entire 50-student medical school class, and all completed the BOS-5. Of the 13 students who scored on the high openness end of the BOS-5, 11 were interested in taking the elective. A random number generator was used to select six students for the IRF group. Seven other students (five who wanted to take the course and two who did not; all seven of whom were in the group of 13 with the highest BOS scores) agreed to participate in the control group. This was a highly select group, as all six of the students who took the elective were in the group of 13 representing the upper quartile of the BOS-5 scores. There was no significant difference in BOS-5 scores or in outcome measures between the experimental and control groups prior to the course intervention. The IRF group participated in a 20-h 1-week elective with daily requirements as follows: a 2-h didactic time, 1-h partner practice, and 1-h reading. An instructor from Focusing Resources in Berkeley, California, taught the course via teleconference. The students continued with weekly sessions for 5 months: half with a partner and half with an instructor. These sessions consisted of each partner being the active participant for 30 to 60 min while the other partner was the listener, then switching so that each student experienced both roles over a 1to 2-h session. All participants and controls completed a precourse survey 2 to 4 weeks prior to the course and a postcourse survey at the end of the 5-month course. The survey assessed perceived self-awareness and comfort with clinical interactions on a five-point numerical rating scale. Pre-course and post-course survey scores were averaged for each group on each item. The mean difference was calculated for each group on each item, and the mean differences were compared between the two groups using the two-sample t test. Both raw differences and percentage differences were calculated. Effect sizes were calculated using a pooled SD. The IRF group also completed a written course evaluation.
Results Raw mean differences between survey scores are listed in Table 2. Only one area, “comfort in talking to patients about how a
Table 1 Five-item Brief Openness Scalea BOS-5 item
I try to keep my thoughts directed along realistic lines and avoid flights of fancy How I feel about things is important to me I seldom pay much attention to my feelings of the moment I often notice the moods or feelings that different environments produce
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
I’m pretty set in my ways
The items are rated on a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Items 1, 3, and 5 are reverse-scored. A total score is computed ranging from 5 to 25. Higher scores are associated with greater openness. a BOS-5 five-item Brief Openness Scale
Acad Psychiatry Table 2 Comparison of responses of experimental group to control group before and after completion of inner relationship focusing course Course objective: comfort with…
Experimental group mean SEM Control group mean SEM P valuea Effect size raw difference (n=6) raw difference (n=7)
Using intuition in combination with clinical data Relating recurrent physical/emotional symptoms to patients’ life issues Accessing one’s own experience Being a fully present listener Reflective listening to help patients de-identify with problem Guiding patients in accessing their own experience Guiding patients in maintaining presence with self
1.00 0.17 0.33 0.33 0.83
0.73 0.43 0.88 0.33 0.54
−0.29 −0.14 0.29 0.29 0.43
0.14 0.11 0.27 0.27 0.15
0.09 0.16 0.96 0.93 0.47
1.03 0.86 0.03 0.06 0.42
SEM standard error of the mean By the two-sample t test
recurring non-organic symptom might be related to an issue in that patient’s life,” reached statistical significance (P=0.05). Some scores actually declined in the control group. Subjective responses were positive overall. Student evaluation comments included the following: (1) “I learned a lot more about myself than I would in a normal week of medical school.” (2) “My initial response to the technique was that of skepticism and discomfort.” (3) “My cerebral and analytical tendencies, which have been nurtured throughout medical school, impeded my willingness to embrace the abstract mindset.” (4) “[IRF] helped me in handling stress, frustration, and loss.” (5) “I have read about focusing and mindfulness before, but [this course] explained how to be successful and diligent about the practice.” (6) “Understanding my own thought processes, values, and emotions allows me to become more personally present and available for my relationships with my patients.”
Discussion We believe that the inclusion of high-level empathic listening and mind–body awareness skills are of potential benefit in medical education. IRF is elegantly simple and experiential. Our review of the medical literature identified no previous reports on IRF in medical education. However, many student wellness courses teach mindfulness-based skills. In medical and nursing students, teaching mindfulness has been found to lead to considerable improvement in anxiety, depression, empathy, self-awareness, relationships, academic performance, and communication skills . Similar effects have been observed in physicians participating in a 52-h program on meditating, communicating burnout feelings, and empathic
listening , with substantial improvement in burnout, empathy, mood, and fatigue. We elected to study IRF instead of mindfulness training because it also teaches empathic listening through direct experience. Our study adds to the existing literature on teaching mindfulness and empathic listening methods in medical education. It also provides preliminary data on teaching both skills at the same time through the novel IRF technique. In this small proof-of-concept study, we were encouraged to see statistical significance achieved in one of seven areas, although the other six did not reach significance. We believe our study was likely poorly powered to detect such differences. Conclusions were limited by our small sample size. It would be more appropriate to draw specific conclusions from a larger group in which more items might reach statistical significance. The data are also limited by relying on student self-reports soon after the end of the intervention as the primary outcome measure. We tried to control for selfselection bias by using the BOS-5 and by determining that most of the control group also wanted to take the course as well as by taking into consideration the fact that after any psychotherapeutic intervention, subjects will report a positive change in the direction desired by the interviewer. We realize that the specific facets of what was actually taught to the students were not finely delineated in relation to what we were able to test, and that the outcome measures were not validated. Yet we do believe that the skills involved in IRF that involve attention to one’s own and another person’s feeling state are important and that further and more precise study would be warranted. Further study of the use of IRF in a medical school curriculum might involve several steps. These could include a large enough sample to adequately power the study to detect moderate differences in which the following could be studied: (1) determining whether any statistically significant changes noted in the experimental group persisted over time; (2) investigating whether the control group and the
class at large gained similar skills through the standard curriculum; (3) using other more objective outcome measures to validate results, such as blinded reports from medical school instructors or patients’ perspectives on whether IRF-trained students were different from those not IRF-trained; and (4) determining whether the results could be replicated in a nonselect group of students rather than just in those with expressed interest. Teaching IRF can potentially introduce students to the value of developing mind–body skills within an empathic relationship. IRF is a novel psychodynamic skill tool that we have initially tested in a limited fashion in a medical school environment. We are hopeful that further study will show a possible role for this or other related techniques in the training of medical professionals.
Acknowledgments Dr Cara Alexander had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Statistical Analysis: This was not an industry-sponsored study. Authors’ Contributions: Drs Alexander, Sheeler, and Rasmussen, as well as Ms Hayden, participated in the design of the study, including the content of the teaching curriculum. Drs Alexander and Sheeler and Ms Hayden did the teaching of the students. Drs Alexander, Sheeler, and Rasmussen participated in the collection, management, and analysis of the data. Drs Alexander, Sheeler, and Rasmussen participated in the interpretation of the data. Drs Alexander, Sheeler, and Rasmussen and Ms Hayden participated in the preparation, review, and approval of the manuscript. Sponsors’ Role: There were no sponsors. Supported in part by an institutional research grant from the Department of Family Medicine, Mayo Clinic, Rochester, Minnesota.
Box. A Simulated Segment of an Inner Relationship Focusing Session.
Focuser leads himself or herself through a brief body scan exercise. Partner: Now that you are fully sensing into your body, if you notice any emotions or body sensations, you might let me know. Focuser: Something in my chest. I feel like I have a sinking feeling right in the center of my chest. Partner: Uh-huh. So you are sensing something in the center of your chest, like a sinking sensation. You might take that word “sinking” and check to see if that describes it well, or if another word fits better. Focuser (after some silence): It’s more of an emptiness in my chest. It’s a lonely empty feeling. Partner: Uh-huh. You’re sensing it’s lonely… and empty…. You might see if it’s okay to just be with that, keep it company. Focuser (after a pause): I didn’t realize how often I feel this in my chest; how long I’ve been feeling this way. (Begins to weep.) Partner: Yeah, it’s really letting you know how lonely it’s been feeling for so long. Focuser: And I never really check in with myself like this…just to be with myself. Partner: It’s really clear now how much this has been needing your attention and care. Focuser: I’m letting it know I hear it… wow… it started to feel lighter. It’s like it smiled at me! It feels much better now that it’s been recognized. Partner: Maybe you could take time to enjoy that lighter feeling!
Adapted from Cornell . Used with permission.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
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